History of Art Therapy Peer Reviewed Articles 2011

Introduction

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

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

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

Nonetheless, despite the to a higher place advantages, published systematically review on this topic is defective. Therefore, this review aims to explore its clinical applications and hereafter perspectives to summary its global pictures, so as to provide more than clinical treatment options and enquiry directions for therapists and researchers.

Publications of Art Therapy

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

A full of 652 records were plant. Then, we manually screened out the literatures that independent the word "art" but was not relevant with the subject of this report, such every bit country of the art therapy, antiretroviral therapy (Art), and assisted reproductive engineering science (Art). Finally, 479 records almost art therapy were identified. Since we aimed to focus on art therapy included painting and drawing as major media, nosotros screened out literatures deeper, and identified 413 (84%) literatures involved in painting and drawing (Figure 1).

Effigy 1. Number of publications about fine art therapy.

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

Overview of Art Therapy

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

Art Therapy for Mental Disorders

Based on the 413 searched literatures, nosotros farther express them to mental disorders using the following key words, respectively: Low OR anxiety OR Cognitive impairment OR dementia OR Alzheimer'due south affliction OR Autism OR Schizophrenia OR mental disorder. Every bit a result, a total of 23 studies (5%) (Table 1) were included and classified afterwards reading the abstract and the full text carefully. These studies include 9 articles on low and feet, 4 articles on cognitive impairment and dementia, 3 articles on Alzheimer'southward affliction, three articles on autism, and 4 articles on schizophrenia. In improver to the English literature, in fact, some Chinese literatures also described the application of art therapy in mental diseases, which were not listed only referred to in the following specific literatures.

Table 1. Studies of art therapy in mental diseases.

Depression Disorders and Feet

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

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

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

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

Cognitive Impairment, and Dementia

Dementia, a progressive clinical syndrome, is characterized by widespread cerebral impairment in memory, thinking, beliefs, emotion and performance, leading to worse daily living (Deshmukh et al., 2018). According to the Alzheimer'southward Disease International 2015, there is 46.8 million people suffered from dementia, and numbers well-nigh doubling every xx years, rising to 131.v 1000000 by 2050. Although art therapy has been used as an alternative handling for the dementia for long fourth dimension, the positive effects of painting therapy on cognitive office remain largely unknown. One intervention assigned older adults patients with dementia to a group-based fine art therapy (including painting) observed significant improvements in the clock drawing test (Motorway, 2013), whereas ii other randomized controlled trials (Hattori et al., 2011; Rusted et al., 2016) on patients with dementia have failed to obtain significant cognitive improvement in the painting group. Moreover, a cochrane systematic review (Deshmukh et al., 2018) included two clinical studies of art therapy for dementia revealed that at that place is no sufficient evidence most the efficacy of art therapy for dementia. This may be considering patients with severely cerebral impairment, who was unable to accurately call up or appraise their ain behavior or mental land, might lose the ability to enjoy the benefits of art therapy.

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

Alzheimer's Disease

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

Schizophrenia

Schizophrenia is a circuitous functional psychotic mental illness that affects nearly 1% of the population at some signal in their life (Kolliakou et al., 2011). Non only do sufferers feel "positive" symptoms such as hallucinations, delusions, but also experience negative symptoms such as varying degrees of anhedonia and asociality, dumb working memory and attention, poverty of voice communication, and lack of motivation (Andreasen and Olsen, 1982). Many patients with schizophrenia remain symptomatic despite pharmacotherapy, and fifty-fifty attempts to suicide with a rate of 10 to 50% (De Sousa et al., 2020). For these patients, fine art therapy is highly recommended to procedure emotional, cerebral and psychotic experiences to release symptoms. Indeed, many forms of art therapy have been successfully used in schizophrenia, whether and how painting may interfere with psychopathology to release symptoms remains largely unknown.

A contempo review including 20 studies overall was performed to summary findings, however, concluded that it is not clear whether art therapy leads to clinical comeback in schizophrenia with depression (Ruiz et al., 2017). Anyhow, many randomized clinical trials reported positive outcomes. For case, Richardson et al. (2007) conducted painting therapy for six months in patients with chronic schizophrenia and found that art therapy had a positive upshot on negative symptoms. Teglbjaerg (2011) examined experience of each patient using interviews and written evaluations before and after painting therapy and at a ane-year follow-up and constitute that group painting therapy in patients with schizophrenia could non but reduce psychotic symptoms, merely also heave cocky-esteem and amend social function.

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

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

Autism

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

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

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

In a word, art therapy plays a meaning function in children with ASD, not only as a method of treatment, simply too in understanding and investigating patients' problems.

Other Applications

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

In brief, these studies suggest that fine art therapy is meaningful and accepted by both patients and therapists. Near oft, fine art therapy could strengthen patient'south emotional expression, self-esteem, and self-awareness. However, our findings are based on relatively small samples and few adept-quality qualitative studies, and require cautious estimation.

The Application Prospects of Art Therapy

With the development of modern medical technology, life expectancy is besides increasing. At the same time, it likewise brings some side effects and psychological issues during the handling process, especially for patients with mental illness. Therefore, there is an increasing need for finding appropriate complementary therapies to better life quality of patients and psychological health. Fine art therapy is primarily offered as individual art therapy, in this review, we establish that fine art therapy was most ordinarily used for depression and anxiety.

Based on the in a higher place findings, art therapy, as a not-verbal psychotherapy method, not but serves as an auxiliary tool for diagnosing diseases, which helps medical specialists obtain much data that is difficult to proceeds from conventional tests, judge the severity and progression of diseases, and sympathise patients' psychological country from painting characteristics, merely besides is an useful therapeutic method, which helps patients open up upwards and share their feelings, views, and experiences. Additionally, the implementation of fine art therapy is not express past age, language, diseases or environment, and is easy to be accepted by patients.

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

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

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

In the future, art therapy may be more thoroughly investigated in the following directions. Offset, more than loftier-quality clinical trials should exist carried out to gain more reliable and rigorous evidence. Second, the evaluation methods for the effectiveness of art therapy need to be as diverse as possible. It is necessary for the investigation to include non simply subjective calibration evaluations, but also objective means such every bit encephalon imaging and hematological examinations to be more than disarming. Third, it volition be helpful to specify the details of the art therapy and patients for objective comparisons, including types of diseases, painting methods, required qualifications of the therapist to perform the fine art therapy, and the theoretical ground and mechanism of the therapy. This practice should be continuously promoted in both hospitals and communities. Fourth, guidelines well-nigh fine art therapy should be gradually formed on the basis of accumulated testify. Finally, mechanism of art therapy should exist farther investigated in a variety of ways, such every bit at the neurological, cellular, and molecular levels.

Writer Contributions

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

Funding

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

Conflict of Involvement

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

Publisher'south Note

All claims expressed in this article are solely those of the authors and exercise not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Whatever production that may exist evaluated in this article, or claim that may exist made past its manufacturer, is not guaranteed or endorsed past the publisher.

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