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Uttley L, Scope A, Stevenson M, et al. Systematic review and economic modelling of the clinical effectiveness and cost-effectiveness of art therapy among people with non-psychotic mental health disorders. Southampton (UK): NIHR Journals Library; 2015 Mar. (Health Technology Assessment, No. 19.18.)

Systematic review and economic modelling of the clinical effectiveness and cost-effectiveness of art therapy among people with non-psychotic mental health disorders.

Chapter 2 clinical effectiveness of art therapy: quantitative systematic review.

This chapter aims to provide an overview of the evidence examining the clinical effectiveness of art therapy in people with non-psychotic mental health disorders.

• Literature search methods

Bibliographic database searching

Comprehensive literature searches were used to inform the quantitative, qualitative and cost-effectiveness reviews. A search strategy was developed to identify reviews, RCTs, economic evaluations, qualitative research and all other study types relating to art therapy. Methodological search filters were applied where appropriate. No other search limitations were used and all databases were searched from inception to present. Searches were conducted from May to July 2013. The full search strategies can be found in Appendix 2 .

To ensure that the full breadth of literature for the non-psychotic population was included, it was pragmatic to search for all art therapy studies and then subsequently exclude studies manually (through the sifting process) that were conducted in people with a psychotic disorder or a disorder in which symptoms of psychosis were reported. It is therefore possible for the reviewer to view all potentially relevant records available and manually exclude studies of samples with psychotic disorders. This method of searching through the literature is in contrast to an approach that uses a search strategy listing all possible mental health disorders that are considered to be ‘non-psychotic’ in the search terms. The latter method may not retrieve all relevant studies from populations that are not indexed under the named mental health disorders.

In addition to the range of conditions covered by the population, the evidence from the studies being generated was frequently not a clear-cut diagnosed ‘mental health disorder’ and the populations retrieved were not the clinical populations of common mental health problems that were first anticipated. At this point in the study identification process it would have been easy to exclude any study that did not include patients with a clinically diagnosed mental health disorder. If this approach had been taken, there would have been three studies in the quantitative review. Instead a pragmatic approach was taken by identifying, including and describing the populations that art therapy is being studied in, with reference to targeting mental health symptoms (see Chapter 1 , Non-psychotic mental health population: definition ).

Databases searched

• MEDLINE and MEDLINE In-Process & Other Non-Indexed citations (OvidSP).
• EMBASE (OvidSP).
• Cochrane Database of Systematic Reviews (The Cochrane Library).
• Cochrane Central Register of Controlled Trials (The Cochrane Library).
• Database of Abstracts of Review of Effects (The Cochrane Library).
• NHS Economic Evaluation Database (The Cochrane Library).
• Health Technology Assessment Database (The Cochrane Library).
• Science Citation Index (Web of Science via Web of Knowledge).
• Social Sciences Citation Index (Web of Science via Web of Knowledge).
• CINAHL: Cumulative Index to Nursing and Allied Health Literature (EBSCO host ).
• PsycINFO (OvidSP).
• AMED: Allied and Complementary Medicine Database (OvidSP).
• ASSIA: Applied Social Sciences Index and Abstracts (ProQuest).

Sensitive keyword strategies using free-text and, where available, thesaurus terms using Boolean operators and database-specific syntax were developed to search the electronic databases. Date limits or language restrictions were not used on any database. All resources were searched from inception to May 2013.

Grey literature searching

A number of sources were searched to identify any relevant grey literature. Relevant grey literature or unpublished evidence would include reports and dissertations that report sufficient details of the methods and results of the study to permit quality assessment. Conference proceedings without a corresponding final report (published or unpublished) would not qualify for inclusion, as they are unlikely to contain sufficient information to permit quality assessment and can often be different to results published in the final report. 39 , 40

Sources searched

• NHS Evidence (Guidelines): www.evidence.nhs.uk/ .
• The BAAT: www.baat.org/index.html .
• UK Clinical Research Network Portfolio Database: public.ukcrn.org.uk/Search/Portfolio.aspx .
• National Research Register Archive: www.nihr.ac.uk/Pages/NRRArchive.aspx .
• Current Controlled Trials: www.controlled-trials.com/ .
• OpenGrey: www.opengrey.eu/ .
• Google Scholar: scholar.google.co.uk/ .
• Mind: www.mind.org.uk/ .
• International Art Therapy Organisation: www.internationalarttherapy.org/ .
• National Coalition of Arts Therapies Associations: www.nccata.org/ .

Additional search methods

A hand search of the International Journal of Art Therapy (formerly Inscape ) was conducted. The additional search methods of reference list checking and citation searching of the included studies were utilised. Other complementary search methods were considered such as pearl growing; however, because the search method employed was considered to be very inclusive, such additional methods were unlikely to generate additional relevant records.

• Review methods

Screening and eligibility

The operational sifting criteria (eligibility criteria) were defined and verified by two reviewers (LU and AS). Titles and abstracts of all records generated from the searches were scrutinised by one assessor and checked by a second assessor to identify studies for possible inclusion into the quantitative review. All studies identified for inclusion at abstract stage were obtained in full text for more detailed appraisal. Non-English studies were translated and included if relevant. For conference abstracts or clinical trial records without study data, authors were contacted via e-mail; however, no additional data were retrieved by contacting study authors. There was no exclusion on the basis of quality. If closer assessment of studies at full text indicated that eligible studies were not RCTs, then the studies were excluded. Agreement on inclusion, for 20% of the total search results ( n  = 2015), was calculated at title/abstract sift demonstrating 0.93 agreement using the kappa statistic. If there was uncertainty regarding the inclusion of a study, the reviewers sought the opinion of the team members with the relevant clinical, methodological or subject expertise to guide the decision.

Accumulation of results

All references were accumulated in a database using Reference Manager Version 12 (Thomson Reuters, Philadelphia, PA, USA), enabling studies to be retrieved in categories by keyword searches and duplicates to be removed.

Study appraisal

Two reviewers (LU and AS) performed data extraction independently for all included papers and discrepancies were resolved by discussion between reviewers. When necessary, authors of the studies were contacted for further information. Data were input into a data extraction template using Microsoft Excel (Microsoft Corporation, Redmond, WA, USA), which was designed for the purpose of this review and verified by two reviewers. Information related to study population, sample size, intervention, comparators, potential biases in the conduct of the trial, outcomes including adverse events, follow-up and methods of statistical analysis was abstracted from the published papers directly into the electronic data extraction spreadsheet.

The evidence generated from the comprehensive searches highlighted that the majority of research in art therapy is conducted by or with art therapists. This indicates potential researcher allegiance towards the intervention in that art therapists are likely to have a vested interest in the output of the study. For this reason it was deemed important to focus on the highest quality evidence available from the study literature. Trials that were non-randomised (i.e. in which the researcher was able to select and allocate participants to treatment arms) were considered to be too low in methodological rigour to be included in this review. The consequence of including data from non-randomised studies into the review is that the resulting data are biased and therefore not robust or sufficient to inform and contribute to the evidence base. 41 , 42 The inclusion and exclusion criteria for the quantitative review are shown in Figure 2 .

Eligibility criteria for the quantitative review.

Studies could be conducted in any setting, including primary, secondary, community based or inpatient.

Study selection was not limited by the number of sessions, and studies that provided the intervention in a single session were included.

Timing of outcome assessment

Post-treatment outcomes and outcomes at reported follow-up points were extracted and summarised when reported.

Quality assessment strategy

Quality assessment of included RCTs was performed for all studies independently by two reviewers using quality assessment criteria adapted from the Cochrane risk of bias, 44 Centre for Reviews and Dissemination (CRD) guidance 45 and Critical Appraisal Skills Programme (CASP) 46 checklists to develop a modified tool for the purpose of this review. The modified tool was developed to incorporate relevant elements across several tools to allow comprehensive and relevant quality assessment for the included trials. Judgements and corresponding reasons for judgements for each quality criterion for all studies were stated explicitly and recorded. Risk of bias was assessed to be low, high or unclear. Where insufficient details were reported to make a judgement, risk of bias was stated to be unclear and authors were not contacted for further details. Discrepancies in judgements were resolved by discussion between the two reviewers.

• Results of the quantitative review

The total number of published articles yielded from electronic database searches after duplicates were removed was 10,073 (see Figure 3 ). An additional 197 records were identified from supplementary searches, resulting in a total of 10,270 records for screening. Of these, 10,221 records were excluded at title/abstract screening. Common reasons for exclusion from the review can be seen in Table 1 . A full list of the studies excluded from the quantitative review at full text stage (with reasons for exclusion) can be found in Appendix 3 .

Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) flow diagram of studies included in the quantitative review.

Common reasons for exclusion from the review

The grey literature searches yielded very few potentially relevant records that were not generated by the electronic searches. One record appeared highly relevant to the research question and related to a clinical trial record of and RCT of art therapy in personality disorder (CREATe) for which the status was ‘ongoing’. However, e-mail contact with the primary investigator of this trial confirmed that the trial had been terminated because of poor recruitment.

• Included studies: quantitative review

Fifteen RCTs were identified for inclusion into the review which were reported in 18 sources (see Table 2 ). For clarity in this comparison, where a study with multiple sources is discussed only one of the sources has been noted.

Description of 15 included RCTs

Ten out of the 15 included studies were conducted in the USA, while only one study was conducted in the UK (see Tables 2 and 3 ). Eleven of the studies were conducted in adults (who are the primary focus of this review) and four were conducted in children. All trials had small final sample sizes with the number of participants reported to be included in each study ranging between 18 and 111. The mean sample size was 52.

Comparators across the 15 included studies

Three studies are of patients from the target population of people with non-psychotic mental disorders. 47 – 49 Of these three studies, only one was conducted in adults. 47

In the remaining 12 studies, the study population comprised individuals without a formal mental health diagnosis. 49 – 59 , 61 , 62 The populations in these studies are, therefore, mainly people with long-term medical conditions which are not reported to be accompanied by a mental health diagnosis; however, outcomes targeted in these studies were mental health symptoms.

The total number of patients in the included studies is 777. Nine studies compared art therapy with an active control group and six studies compared art therapy with a wait-list control or treatment as usual.

Two studies were reported to be conducted in an inpatient setting 48 , 49 and one study was conducted in prison. 59 The majority of studies were conducted in community/outpatient setting, although the precise setting for conducting the intervention was not reported in six studies. 50 , 52 , 54 – 56 , 61

Brief descriptions of the art therapy interventions are provided in Tables 4 and 5 .

Description of intervention and control in studies with active control

Description of intervention in studies with non-active control

Study duration ranged between the 15 studies from 1 session to 40 sessions, with a mean number of nine sessions (see Tables 4 and 5 ). Most studies with an active control group were of ‘group’ art therapy. One study which was a ‘brief’ intervention consisting of one individual session per participant. 56 Two studies did not state explicitly if sessions were in a group or individual. 47 , 53 Three studies with no active control were group art therapy 58 , 59 , 61 and three studies were individual art therapy. 49 , 55 , 62

The symptoms or outcome domains under investigation and associated outcome measures are reported in Table 6 .

Outcome domains under investigation in the 15 included RCTs

• Data synthesis

Heterogeneity of the included studies

The study populations are heterogeneous ( Figure 4 ), highlighting the wide application of art therapy in this small number of included RCTs but also demonstrating the difficulty in obtaining a pooled estimate of treatment effect. In this respect the clinical profile of patients can be regarded as a potential treatment effect modifier.

Patient clinical profiles in the 15 included RCTs.

The control groups across the included studies are heterogeneous ( Figure 5 ); therefore, there may be different estimates of treatment effects depending on what art therapy is compared against. Creating a network meta-analysis, which would incorporate all relevant evidence for all the comparators, for all non-psychotic mental health disorders, would be beyond the remit for this research project.

Comparator arms in the 15 included RCTs.

In addition, despite common mental health symptoms being investigated across the included RCTs, the majority of studies were using different measurement scales to assess these outcomes ( Table 7 ). Therefore, as there are insufficient comparable data on outcome measure across studies, it is not possible to perform a formal pooled analysis.

Instruments used in the 15 included RCTs

Potential treatment effect modifiers in the included studies

As well as the patient’s clinical profile, several other treatment effect modifiers can be identified from the included studies.

Experience/qualification of the art therapist

Twelve of the 15 included studies stated that the art therapy was delivered by one or more art therapists. One study was reported in three sources to use a ‘trained’ art therapist. 62 – 64 One study reported the art therapist as ‘licensed’. 56 Two studies reported using a ‘qualified’ art therapist. 48 , 57 Two studies reported using a ‘certified’ art therapist. 50 , 53 One study was reported in two sources as using a ‘registered’ art therapist. 60 , 61 One study reported using ‘experienced art psychotherapists’. 47 Four studies simply stated ‘art therapist’ without reference to accreditation. 49 , 52 , 58 , 59 One study stated that the sessions were run by one artist and two speech therapists. 51 One study stated that the sessions were run by two mental health counsellors. 55 One study did not state whether or not an art therapist was involved. 54 While there was considerable variability in the reporting of the accreditation of the therapist, most studies were conducted by a person who was considered to be qualified as an art therapist.

Individual versus group art therapy

The majority of RCTs are of group art therapy with only 4 of the 15 RCTs examining individual art therapy. 49 , 55 , 56 , 62

Eleven RCTs are of adults and four RCTs are of children or adolescents. 48 , 49 , 50 , 58

Five RCTs involved only women, 47 , 54 , 55 , 61 , 62 and one RCT only men. 59 In the remaining nine RCTs the subjects were of mixed gender.

Pre-existing physical condition

In nine studies patients had pre-existing physical conditions. 50 , 51 , 54 – 58 , 61 , 62 The remaining six studies involved people who were depressed, 47 , 59 people with post-traumatic stress disorder (PTSD) 48 , 49 or older people. 52 , 53

Other potential treatment effect modifiers which are not fully explored in the included RCTs include duration of disease (mental or physical), underlying reason for mental health disorder and patient preference for art therapy.

Owing to the degree of clinical heterogeneity across the studies and the lack of comparable data on outcome measures, meta-analysis was not appropriate. Therefore, the synthesis of data is limited to a narrative review to analyse the robustness of the data, which includes trial summaries as well as tabulation of results.

Study summaries

This section provides short overviews of each study with reference to statistically significant differences between groups that were reported in each of the studies.

Beebe et al. 2010 58

This was a RCT in children ( n  = 22) with asthma of art therapy versus wait-list control. Sessions lasting 60 minutes were provided once a week for seven weeks. Outcomes were measured at baseline, immediately following completion of therapy and 6 months after the final session. Targeted variables were quality of life (QoL) and behavioural and emotional adaptation. Outcome measurement tools were the Paediatric QoL asthma module and Beck Youth Inventories. Pre- and post-test scores were compared between groups using analysis of variance (ANOVA) and Dunnett’s test. Compared with baseline scores, the intervention group showed a significant reduction in 4 out of 10 QoL items at 7 weeks and in 2 out of 10 QoL items at 6 months. Significant improvement relative to the control group was found in two out of five items of the Beck Youth Inventory at 7 weeks and in one out of five items at 6 months.

Broome et al. 2001 50

This was a three-arm RCT in children and adolescents ( n  = 97) with sickle cell disease of art therapy versus CBT (relaxation for pain) or attention control (fun activities). Group sessions were provided over 4 weeks. Outcomes were measured at baseline and at 4 weeks and 12 months. The targeted variable was coping and the authors hypothesised that coping strategies would increase after attending a self-care intervention. Outcome measures were the Schoolagers’ Coping Strategies Inventory and Adolescent Coping Orientation for Problem Experiences scores and numbers of emergency room visits, clinic visits and hospital admissions. The number of coping strategies used was analysed at three time points using Pearson’s correlations, independent t -tests and ANOVA. Coping strategies increased in children and adolescents in all three groups, but data regarding the difference between the intervention and control groups were not reported.

Chapman et al. 2001 49

This RCT of brief art therapy versus treatment as usual was carried out in children ( n  = 85) hospitalised with PTSD. A 1-hour individual session was provided but the number of sessions was not reported. Outcomes were measured at baseline and at 1 week, 1 month, and 6 and 12 months (in children who were still symptomatic). The targeted symptom was PTSD. The outcome measurement tool was Children’s Post Traumatic Stress Disorder Index (PTSD-I). The method of statistical analysis was not described. No significant differences were found between groups, but a non-significant trend towards greater reduction in PTSD-I scores was observed in the intervention group relative to the control group.

Gussak 2007 59

This was a RCT in incarcerated adult males ( n  = 44) of art therapy versus no treatment. Eight weekly group sessions were provided. Outcomes were measured pre- and post-test (exact time points not reported). The targeted symptom was depression. The outcome measure was the Beck Depression Inventory-Short Form (BDI-II). The change in BDI-II scores from pre-test to post test was calculated and differences between groups analysed using independent-samples t -tests. Depression was significantly lower in the intervention group than in the control group post test.

Hattori et al. 2011 51

This was a RCT in Alzheimer disease ( n  = 39) of art therapy versus a ‘simple calculation’ control group. Twelve 45-minute weekly sessions were provided (individual/group not reported). Outcomes were measured at baseline and at 12 weeks. Targeted variables were mood, vitality, behavioural impairment, QoL, activities of daily living and cognitive function. Outcome measures were the Mini Mental State Examination Score (MMSE), the Wechsler Memory Scale revised; the Geriatric Depression Scale (GDS); the Apathy Scale (Japanese version); Short Form questionnaire-8 items (SF-8) – Physical (PCS-8) and Mental (MCS-8) components; the Barthel Index; the Dementia Behaviour Disturbance Scale; and the Zarit Caregiver Burden Interview. Outcomes were measured at baseline and 12 weeks. The percentage of responders who showed a 10% or greater improvement relative to baseline score before the intervention was compared between groups using a chi-squared test. A significant improvement in the intervention group was seen in MCS-8 subscale of the SF-8 and the Apathy Scale. The control group showed a significant improvement in MMSE relative to the intervention group. No significant differences between groups in other items were reported.

Kim 2013 52

This RCT in older adults ( n  = 50) compared art therapy with regular programme activities. Between 8 and 12 sessions lasting 60–75 minutes were provided over 4 weeks. Targeted variables were positive/negative affect, state–trait anxiety and self-esteem. Outcomes were measured using the Positive & Negative Affect Schedule, the State–Trait Anxiety Inventory (STAI) and the Rosenberg Self-Esteem Scale. Time points for measurement were not reported (assumed 4 weeks). Independent group t -tests were performed to compare pre- and post-test scores between groups. Significant improvements in the intervention were seen in all three outcomes compared with the control group.

Lyshak-Stelzer et al. 2007 48

This RCT in adolescents ( n  = 29) with PTSD compared art therapy with arts and crafts activities. Sixteen weekly group sessions were provided. The targeted symptom was PTSD. Outcome measurement tools were the University of California, Los Angeles (UCLA) PTSD Reaction Index ( Diagnostic and Statistical Manual of Mental Disorders – Fourth Edition, Child Version) (primary measure) and milieu behavioural measures (e.g. use of restraints). Measurement time points were not reported, but data at two years were provided. Pre- and post-test scores were compared between groups using repeated-measures ANOVA. The intervention was significantly better than control at reducing PTSD symptoms, according to the UCLA PTSD Reaction Index.

McCaffrey et al. 2011 53

This was a RCT in older adults ( n  = 39) of art therapy versus garden walking (individual and group). Twelve 60-minute sessions (group/individual not reported) were provided over 6 weeks. The targeted symptom was depression. The outcome measurement tool was the GDS. Pre- and post-test scores were compared between groups using repeated-measures ANOVA. Measurement was at baseline and 6 weeks. Depression significantly improved from baseline in all three groups with no significant differences between groups.

Monti and Peterson 2004; 60 Monti et al. 2006 61

This RCT in women with cancer ( n  = 111) compared mindfulness-based art therapy with wait-list control. The trial was sized to have 80% power to detect a standardised effect size of 0.62. Eight 150-minute group sessions were provided over 8 weeks. Targeted variables were distress, depression, anxiety and QoL. Outcome measurement tools were the Symptom Checklist-90-Revised (SCL-90-R), the Global Severity Index (GSI) and the Short Form questionnaire-36 items (SF-36). Measurement was at baseline and at 8 weeks and 16 weeks. Pre-and post-test measures were compared between groups using mixed-effects repeated-measures ANOVA. A significant decrease in symptoms of distress and highly significant improvements in some areas of the QoL scale were observed in the intervention group compared with the control group.

Monti et al. 2012 54

This RCT of women with breast cancer ( n  = 18) compared mindfulness-based art therapy with educational support (control group). Eight 150-minute weekly group sessions were provided. The targeted symptom was anxiety but the authors were interested in whether or not cerebral blood flow (CBF) correlated with experimental condition. The primary outcome measurement was functional magnetic resonance imaging (fMRI) CBF and the correlation with anxiety using SCL-90-R. Measurement was at baseline and within 2 weeks of the end of the 8-week programme. The method of statistical analysis was not described and the effectiveness of the intervention was not the primary outcome. Anxiety was reduced in the intervention group but not in the control group. CBF on fMRI changed in certain brain areas in the art therapy group only. It should be noted that patients with a confirmed diagnosis of a psychiatric disorder were excluded from this study.

Puig et al. 2006 55

This was a RCT in women with breast cancer ( n  = 39) of art therapy versus delayed treatment. Four 60-minute weekly sessions were provided. Targeted symptoms were anger, confusion, depression, fatigue, anxiety, activity and coping. The outcomes, the Profile of Mood States and the Emotional Approach Coping Scale (EACS) scores, were measured before and 2 weeks after the intervention. Pre- and post-test scores were compared between groups using ANOVA. The intervention group showed significant improvements in the anger, confusion, depression and anxiety mood states but fatigue and activity were not significantly different between the groups. In the intervention group, EACS coping scores increased, but were not significantly different from those in the delayed treatment control group.

Rao et al. 2009 56

In this RCT in adults with HIV/AIDS ( n  = 79), the intervention group received brief art therapy while the controls watched a video tape on the uses of art therapy. Only one 60-minute session of individual art therapy was provided. Targeted symptoms were anxiety and physical symptoms, including pain. The outcome measures used were Edmonton Symptom Assessment Scale (ESAS) scores (primary outcome) and STAI scores. Pre-and post-test scores were compared between groups using analysis of covariance (ANCOVA) and adjusted for age, gender and ethnicity. Measurements were recorded before and immediately after the intervention or control session. The intervention group experienced significant improvements in physical symptoms (ESAS) compared with the control group, but anxiety was not significantly different between the groups.

Rusted et al. 2006 57

In this RCT in adults with dementia ( n  = 45), art therapy was compared with an activity group control. Forty 60-minute weekly group sessions were provided. Targeted symptoms were depression, mood, sociability and physical involvement. Outcome measures were the Cornell Scale for Depression in Dementia the Multi Observational Scale for the Elderly, MMSE, The Rivermead Behavioural Memory Test, Tests of Everyday Attention and the Benton Fluency Task. Measurements were recorded at baseline, 10 weeks, 20 weeks, 40 weeks and at follow-up at 44 and 56 weeks. Pre- and post-test scores were compared between groups using ANOVA with time of assessment as repeated measures. At 40 weeks, the intervention group was significantly more depressed than the control group, but this effect was reduced at follow-up. However, groups were not comparable at baseline, as the art therapy group were more depressed at the beginning of the study than the control group.

Thyme et al. 2007 47

This was a RCT in depressed female adults ( n  = 39) of psychodynamic art therapy versus verbal dynamic psychotherapy. Ten 60-minute weekly sessions (individual/group not reported) were provided. Targeted symptoms were stress reactions after a range of traumatic events, mental health symptoms and depression. Outcome measurements were Impact of Event Scale, Symptom-Checklist-90 (SCL-90), Beck Depression Inventory (BDI) and Hamilton Rating Scale of Depression scores. Measurements were recorded at baseline, at 10 weeks and at a 3-month follow-up. All patients improved from baseline on all scales ( p  < 0.001). There were no significant differences between groups so art therapy was not significantly different to the comparator at either time point.

Thyme et al. 2009; 62 Svensk et al. 2009; 63 Oster et al. 2006 64

This RCT in women with breast cancer ( n  = 41) compared art therapy with treatment as usual as a control. Five 60-minute weekly individual session were provided. Targeted symptoms were depression, anxiety, somatic, general symptoms, QoL and coping methods. Outcome measure tools were the Structural Analysis of Social Behavior, the GSI, the SCL-90, the World Health Organization (WHO) QoL instrument – Swedish version, the European Organization for Research and Treatment of Cancer (EORTC) QoL Questionnaire-BR23 and the Coping Resources Inventory (CRI). Measurements were recorded at baseline and at 2 months and 6 months. The intervention significantly improved depressive, anxiety, somatic and general symptoms compared with the control. Pre- and post-test scores were compared between groups using t -tests, ANOVA and linear regression. On the WHOQoL, scores on the overall, general health and environmental domains at 6 months were significantly higher in the intervention group than in the control group. There were no significant differences between groups on the EORTC. In the intervention group, the score on only the ‘social’ dimension of the CRI was increased relative to the control group.

Findings of the included studies

The directions of statistically significant results from the 15 included RCTs are summarised in Table 8 .

Summary of the direction of findings from the 15 included studies

As can be seen in Table 8 , in 14 of the 15 included studies there were improvements from baseline in some outcomes in the art therapy groups. However, both the intervention and the control groups improved from baseline in four studies, with no significant difference between the groups. 47 , 49 , 50 , 53 The control groups across these four studies were verbal psychodynamic psychotherapy, 47 treatment as usual, 49 CBT 50 and garden walking, 53 and verbal psychodynamic psychotherapy, respectively.

In eight studies, art therapy was significantly better than the control group for some but not all outcome measures. Table 9 shows the results according to the mean change from baseline between groups in these eight studies.

Nine included studies with statistically significant findings in the art therapy group in some but not all outcome measures

In one study, 52 all outcomes were significantly better in the art therapy intervention group than in the control group. Table 10 shows the results from the Kim 52 study.

One included study with statistically positive findings for all outcomes in the art therapy group

In one study 57 of a sample of people with dementia, outcomes were worse for the art therapy group than for the control group, which was an activity control group. An unusual pattern of results is presented, including a significant increase in anxious/depressed mood ( p  < 0.01) at 40 weeks which was not present at the 10- or 20-week time points and dissipated by 44 and 56 weeks. The authors discuss several reasons for this result including the high level of attrition; the reliance on observer ratings in the frail and elderly sample (and subsequent potential impact of observer bias); the increased depression as a response to the sessions ending; and the possibility that art therapy was contraindicated in this sample.

Narrative subgroup analysis of studies by mental health outcome domains

Table 11 presents the results for effectiveness of art therapy across relevant mental health outcome domains.

Effectiveness of art therapy across mental health outcome domains

Among the nine studies examining depression, 47 , 51 , 53 , 55 , 57 – 59 , 61 , 62 art therapy resulted in significant reduction in depression in six studies. 47 , 53 , 55 , 59 , 61 , 62 In four of these six studies, 55 , 59 , 61 , 62 art therapy was significantly more effective than the control. Data relating to significant differences are reported in Table 9 .

Among the seven studies examining anxiety, 52 , 54 – 56 , 58 , 61 , 62 art therapy resulted in significant reduction of anxiety in six studies. 52 , 54 , 55 , 58 , 61 , 62 In these six studies, art therapy was significantly more effective than the control. Data relating to significant differences are reported in Tables 8 and 9 .

Among the four studies examining mood or affect, 51 , 52 , 55 , 57 art therapy resulted in significant positive improvements to mood in three studies. 51 , 52 , 55 In these three studies, art therapy was significantly more effective than the control. Data relating to significant differences are reported in Tables 8 and 9 .

Among the three studies examining trauma, 47 – 49 art therapy resulted in significant reduction of symptoms of trauma in all studies. While trauma improved from baseline, there was no significant difference between the art therapy and control groups in any of the three studies.

Among the three studies examining distress, 47 , 61 , 62 art therapy resulted in significant reduction of distress in all studies. In two studies, 61 , 62 art therapy was significantly more effective than the control group. Data relating to significant differences are reported in Table 9 .

Quality of life

In the four studies examining QoL, 51 , 58 , 61 , 62 art therapy resulted in significant improvements to some but not all components of the QoL measures in all studies. In all studies, art therapy was significantly more effective than the control. Data relating to significant differences are reported in Table 9 .

Among the three studies examining coping, 50 , 55 , 62 art therapy resulted in significant improvements to coping resources in all studies. In one study, 62 art therapy was significantly more effective than the control. In another study, there was no difference between groups. 55 In the third study, significant differences between the art therapy and control groups were not reported. 50 Data relating to significant differences are reported in Table 9 .

In the one study examining cognition, 51 the control group (simple calculations) exhibited significant improvements in cognitive function relative to the art therapy group. Data relating to significant differences are reported in Table 9 .

Self-esteem

In the one study examining self-esteem, 52 art therapy resulted in significant improvements in self-esteem relative to the control group. Data relating to significant differences are reported in Tables 9 and 10 .

• Adverse events

Adverse events were not reported in any of the included RCTs. However, three studies reported outcomes that may be indirectly related to the safety of art therapy. The Lyshak-Stelzer et al. 48 study reported no significant differences between groups in the number of incidents, seclusions, restraints or ‘PRN [pro re nata, as needed] orders’. The Broome et al. 50 study reported a decrease in emergency room visits, clinic visits and hospital admissions over time in both the art therapy and control groups. In addition, the Beebe et al. 58 study reported equal asthma exacerbation numbers in each group but these occurred after the trial has finished.

The lack of adverse event data in the majority of included studies is not necessarily evidence that there were no adverse events in the included trials. It may indicate only that adverse events were not recorded. Potential harms and negative effects of art therapy are further explored in the qualitative review (see Chapter 3 ).

• Quality assessment: strength of the evidence

Table 12 illustrates the types of study designs and the number of studies included into the quantitative and qualitative reviews.

Study designs and their inclusion into the review

Critical appraisal of the potential sources of bias in the included studies

Method of recruitment.

Participants were typically convenience samples from existing clinical patient groups. Few details were provided on the inclusion/exclusion criteria of the patients in the studies, as can be seen from Table 13 .

Method of participant recruitment in the 15 included RCTs

Allocation bias: Method of randomisation

Table 14 shows the descriptions of randomisation from the included RCTs. Randomisation usually refers to the random assignment of participants to two or more groups. Randomisation was not described in seven studies. 48 – 50 , 54 , 55 , 58 , 59 This information could simply be missing from the published journal paper and, if benefit of the doubt were applied, it could be assumed that proper randomisation may have been done but not reported. This would represent an unclear risk of bias. However, it could also be assumed that proper randomisation did not take place and the method of selecting participants into the studies was flawed. This would represent a high risk of bias. Therefore, there is an unclear/high risk that randomisation was not adequately performed in these six studies.

Description of randomisation from the included RCTs

Allocation bias: allocation concealment

In order to ensure that the sequence of treatment allocation was concealed, a robust method of allocation to the study arms should be undertaken and documented. Allocation concealment was not reported in any of the included studies. Lack of allocation concealment can destroy the purpose of randomisation, as it can permit selective assignment to the study arms.

Appropriate randomisation for allocation to study arms includes undertaking ‘simple’ randomisation (e.g. tossing a coin), which avoids introducing excessive stratification to prevent imbalanced groups, and ‘distance’ randomisation so that researchers are unable to influence allocation (e.g. a central randomisation service which notes basic patient details and issues a treatment allocation). Several of the eight randomisation methods described are likely to be open to allocation bias either because they did not use distance randomisation or because the reports do not provide enough details about what measures were taken to ensure that allocation was truly concealed to the investigators. For example, the Hattori et al. 51 study describes stratification by three variables. Stratifying by more than one variable can be problematic, and stratifying by more than two variables is not advisable. 65 In addition, the Kim 52 study does not clearly describe how randomisation was undertaken. The sealed envelope technique employed in the McCaffrey et al. 53 study is intended to ensure that equal numbers receive the intervention and the control but is vulnerable to subterfuge. Few of the included RCTs reported adequate details of methods of randomisation and, consequently, these studies, as reported, had an unclear risk of allocation bias.

Performance bias: blinding

Blinding of participants was not conducted in any of the included RCTs. Blinding of participants to their experimental condition is understandably unfeasible in trials of psychological therapy as opposed to pharmacological interventions. Therefore, while lack of blinding across the included trials means that the trials are at risk of performance bias, the trials cannot be deemed to be of poor quality on this basis.

Performance bias: baseline comparability

Groups were reported to be comparable at baseline in 7 out of the 15 studies ( Table 15 ). 48 , 51 – 54 , 56 , 62 (Baseline comparability was unclear or not reported and therefore was unable to be assessed in five studies. 47 , 49 , 50 , 55 , 58 ) In three studies, 57 , 59 , 61 patients in the art therapy group appeared to have more severe illness at baseline. These differences could reflect a potential allocation bias resulting from flawed randomisation procedures in the studies.

Baseline comparability between intervention and control groups in the included 15 RCTs

Performance bias: groups treated equally

As blinding was not possible, all studies are at risk of performance bias. In the case of the six studies 49 , 55 , 58 , 59 , 61 , 62 that had wait-list/treatment as usual controls rather than an active comparator group, it can be argued that the groups were not treated equally, as the control groups were not given the time and attention that an active control group would receive. Therefore, the risk of performance bias in the art therapy group is higher in these six studies.

Reporting bias: selective outcome reporting

No studies appeared to have collected data on outcomes that were not reported in the results.

Reporting bias: incomplete outcome data

In three studies, 48 , 54 , 57 outcome data were incomplete, indicating a high risk of reporting bias. The reasons for this were: data on 20% completers only (80% of participants withdrew or were excluded); 48 actual data not provided (only p -values reported); 54 and group numbers not provided at any time point. 57 In four studies the risk of reporting bias was unclear because incomplete outcome data were reported. 49 , 50 , 58 , 59

Detection bias

Blinding of clinical outcome assessment was reported to be conducted in only one study. 58 Therefore, 14 out of the 15 included RCTs are at unclear to high risk of detection bias, as assessors may have influenced the recording of clinical outcomes.

Researcher allegiance

In the Kim 52 study there was only one author, and the two researchers are reported to be art therapists. The author is also a senior art therapist. The Gussak 2007 59 study also has only one author, who is a professor of art therapy. Trials that are published by one author are unlikely to have been conducted as collaborative projects adhering to standards of good clinical practice. The risk of researcher allegiance in these studies is, therefore, high.

The McCaffrey et al. 2011 53 study was funded by the owners of the gardens that were the basis of the comparator. The gardens are profit-making, and participants who completed the study were given 1 year’s free membership. The risk of researcher allegiance for the control group in this study, can, therefore, be considered to be high.

As can be seen from Table 16 , all studies were prone to many instances of unclear risk of bias. Some studies were prone to several instances of high risk of bias. In the context of this review, with the exception of blinding participants, all the risk of bias domains are important to be able to establish internal validity of these trials. Currently the only domain that is at low risk of bias is selective outcome reporting. Owing to the risks of bias highlighted by the critical appraisal of these studies, it can be concluded that the included RCTs are generally of low quality.

Summary of risk of bias (high, low or unclear) in the 15 included quantitative studies

Critical appraisal of other potential sources of confounding

Withdrawals and exclusions are reported in Table 17 .

Withdrawals from the study across the included RCTs

As can be seen from Table 17 , there were only four studies in which all participants completed the trial. 52 , 54 , 55 , 58 While several studies reported substantial numbers of dropouts, only one study reported to be sized with reference to effect size. 61 Considering that the sample sizes in the remaining 14 RCTs are small and not sufficiently powered to account for attrition, these dropouts have a significant impact on the reliability of these RCTs. For example, in the Rusted et al . 57 study, attrition was 53.3%, meaning that the final data are reported for 9 versus 12 people in the art therapy and activity control groups, respectively. This small number of completers calls into question the reliability of this study’s results.

Only 5 of the 11 studies in which dropouts occurred reported the breakdown of withdrawal between groups. Two studies 50 , 59 do not report the reasons for withdrawal in the dropouts that occurred. In addition, attrition was not handled appropriately in the included RCTs as imputation for missing data were generally not reported or were reported to be not conducted except in one study. 62 The risk of attrition bias in the 11 studies where dropouts occurred is, therefore, unclear.

Concomitant treatment

Co-therapy or concomitant medication was not reported in eight trials. 49 – 52 , 55 – 58 In a further two studies, 53 , 61 participants were eligible to take part if in receipt of mental health treatment but the actual data for concomitant therapy (overall or between groups) are not reported.

In the Gussak 59 study, 93% ( n  = 25/27) of participants in the intervention group were taking medication for a mental illness, compared with 27% ( n  = NR) in the control group. In the Thyme et al. 47 study, it was reported that psychopharmacological treatment was an exclusion criterion. It is subsequently stated that ‘in the [art therapy] group, one participant were [sic] prescribed antidepressants during therapy ( n  = 1) and one between termination of therapy and the 3-month follow-up ( n  = 1), and in the [verbal therapy] group three during therapy ( n  = 1) [sic] and two after ( n  = 2). Two participants in VT accepted Body Awareness as an additional treatment during psychotherapy.’ 47

In the Thyme et al. 2009 62 study the usage of antidepressants was self-reported, and therefore this information may be incomplete. In the Chapman et al. 49 study, ‘treatment as usual’ hospital care was defined as the normal and usual course of paediatric care including Child Life services, art therapy, and social work and psychiatric consultations. While only the Monti et al. 2012 54 study reports that use of psychotropic medication was an exclusion criterion, there is generally an unclear/high risk of confounding as a result permitted additional treatment across the included studies.

Treatment fidelity

Sufficient measures to ensure treatment fidelity would include monitoring the therapy sessions through audio or video tapes to allow independent checking. No such measures to ensure that the intervention was being delivered consistently were reported in any of the studies. However, one study 58 does provide an appendix of the content of each session. In addition, one study 61 provides the art therapy programme details in the first of the two resulting publications. 60 Most studies provided brief synopses of the intervention programme and content of the sessions. 48 , 50 , 52 , 54 – 56 , 62 However, some studies provided scant details of what took place in the sessions. 47 , 49 , 51 , 53 , 57 , 66 Moreover, Chapman et al. 49 do not even state how many sessions were provided. Therefore, the included RCTs have unclear risk of poor treatment fidelity.

The risk of bias assessment and the potential areas of confounding including attrition, concomitant treatment and treatment fidelity illustrate that the included trials are generally of low quality and, therefore, the results of the 15 RCTs that are included in the quantitative review should be interpreted with caution. Three studies 47 , 51 , 56 can be considered as being of slightly better quality because there are no instances of high risk of bias (other than blinding, which is a common hurdle in trials of psychological therapy) and at low risk of bias on at least four domains.

Discussion of the quantitative review

The aim of the quantitative systematic review was to assess the evidence of clinical effectiveness of art therapy compared with control for treating non-psychotic mental health disorders. The limited available evidence showed that patients receiving art therapy had significant positive improvements in 14 out of 15 RCTs. In 10 of these studies, art therapy resulted in significantly more improved outcomes than the control, while in four studies art therapy resulted in an improvement from baseline but the improvement in the intervention group was not significantly greater than in the control group. In one study, outcomes were better in the control group than in the art therapy group. Relevant mental health outcome domains that were targeted in the included studies were depression, anxiety, mood, trauma, distress, QoL, coping, cognition and self-esteem. Improvements were frequently reported in each of these symptoms except for cognition.

Limitations of the quantitative evidence

Despite every possible effort to identify all relevant trials, the number of studies that qualified for inclusion was small. Despite a large number of records on art therapy yielded from the searches, very few studies were RCTs, demonstrating a slow uptake of the evidence-based medicine model in this field. The study samples are heterogeneous and few samples can be regarded strictly as the target population for this review – people diagnosed with a mental health condition. The limited selection of mental health disorders in the included study samples means that the external validity to the population with non-psychotic mental health disorders is limited. In addition, the sample sizes are small, and as yet there are no large-scale RCTs of art therapy in non-psychotic mental health disorders. The paucity of RCT evidence means that it is not possible to make generalisations about specific disorders or population characteristics.

The risk assessment of bias highlighted that, although all studies were reported to be RCTs, few studies reported how patients were randomised, and in the majority of studies there were several instances of high risk of bias. Areas of potential confounding frequently associated with the studies included attrition, concomitant treatment and treatment fidelity. Consequently, the internal validity of the included studies is threatened. Owing to the low quality of the 15 RCTs, the results included in the quantitative review should be interpreted with caution. As this systematic review did not search for and include direct evidence about other interventions for non-psychotic mental health disorders, it has not been possible to identify indirect evidence for the effect of art therapy in a mixed treatment comparison within the scope of this research. Therefore, the effectiveness of art therapy compared with other commonly used treatments that have been shown to be effective is unknown. In addition, the underlying mechanisms of action in art therapy remain unclear from this evidence. The qualitative systematic review that is presented in the next chapters will explore the factors that may contribute to the therapeutic action in art therapy.

• Conclusions

From the limited number of studies identified, in patients with different clinical profiles, art therapy was reported to have statistically significant positive effects compared with control in a number of studies. The symptoms most relevant to the review question which were effectively targeted in these studies were depression, anxiety, low mood, trauma, distress, poor QoL, inability to cope and low self-esteem. The small evidence base, consisting of low-quality RCTs, indicated that art therapy was associated with an improvement from baseline in all but one study and was a more effective treatment for at least one outcome than the control groups in the majority of studies.

Included under terms of UK Non-commercial Government License .

• Cite this Page Uttley L, Scope A, Stevenson M, et al. Systematic review and economic modelling of the clinical effectiveness and cost-effectiveness of art therapy among people with non-psychotic mental health disorders. Southampton (UK): NIHR Journals Library; 2015 Mar. (Health Technology Assessment, No. 19.18.) Chapter 2, Clinical effectiveness of art therapy: quantitative systematic review.
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• Published: 16 May 2022

The effect of active visual art therapy on health outcomes: protocol of a systematic review of randomised controlled trials

• Ronja Joschko   ORCID: orcid.org/0000-0003-4450-254X 1 ,
• Stephanie Roll   ORCID: orcid.org/0000-0003-1191-3289 1 ,
• Stefan N. Willich 1 &
• Anne Berghöfer   ORCID: orcid.org/0000-0002-7897-6500 1  

Systematic Reviews volume  11 , Article number:  96 ( 2022 ) Cite this article

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Metrics details

Art therapy is a form of complementary therapy to treat a wide variety of health problems. Existing studies examining the effects of art therapy differ substantially regarding content and setting of the intervention, as well as their included populations, outcomes, and methodology. The aim of this review is to evaluate the overall effectiveness of active visual art therapy, used across different treatment indications and settings, on various patient outcomes.

We will include randomised controlled studies with an active art therapy intervention, defined as any form of creative expression involving a medium (such as paint etc.) to be actively applied or shaped by the patient in an artistic or expressive form, compared to any type of control. Any treatment indication and patient group will be included. A systematic literature search of the Cochrane Library, EMBASE (via Ovid), MEDLINE (via Ovid), CINAHL, ERIC, APA PsycArticles, APA PsycInfo, and PSYNDEX (all via EBSCOHost), ClinicalTrials.gov and the WHO’s International Clinical Trials Registry Platform (ICTRP) will be conducted. Psychological, cognitive, somatic and economic outcomes will be used. Based on the number, quality and outcome heterogeneity of the selected studies, a meta-analysis might be conducted, or the data synthesis will be performed narratively only. Heterogeneity will be assessed by calculating the p-value for the chi 2 test and the I 2 statistic. Subgroup analyses and meta-regressions are planned.

This systematic review will provide a concise overview of current knowledge of the effectiveness of art therapy. Results have the potential to (1) inform existing treatment guidelines and clinical practice decisions, (2) provide insights to the therapy’s mechanism of change, and (3) generate hypothesis that can serve as a starting point for future randomised controlled studies.

Systematic review registration

PROSPERO ID CRD42021233272

Peer Review reports

Complementary and integrative treatment methods can play an important role when treating various chronic conditions. Complementary medicine describes treatment methods that are added to the standard therapy regiment, thereby creating an integrative health approach, in the anticipation of better treatment effects and improved health outcomes [ 1 ]. Within a broad field of therapeutic approaches that are used complementarily, art therapy has long occupied a wide space. After an extensive sighting of the literature, we decided to differentiate between five clusters of art that are used in combination with standard therapies: visual arts, performing arts, music, literature, and architecture (Fig. 1 ). Each cluster can either be used actively or receptively.

The five clusters of art used in medicine for therapeutic purposes, with examples of active visual art forms (figure created by the authors)

Active visual art therapy (AVAT) is often used as a complementary therapy method, both in acute medicine and in rehabilitation. The use of AVAT is frequently associated with the treatment of psychiatric, psychosomatic, psychological, or neurological disorders, such as anxiety [ 2 ], depression [ 3 ], eating disorders [ 4 ], trauma [ 5 , 6 ], cognitive impairment, or dementia [ 7 ]. However, the application of AVAT extends beyond that, thereby broadening its potential benefits: it is also used to complement the treatment of cystic fibrosis [ 8 ] or cancer [ 9 , 10 ], to build up resilience and well-being [ 11 , 12 ], or to stop adolescents from smoking [ 13 ].

As a complementary intervention, AVAT aims at reducing symptom burden beyond the effect of the standard treatment alone. Since AVAT is thought to be side effect free [ 14 ] it could be a valuable addition to the standard treatment, offering symptom reduction with no increased risk of adverse events, as well as an potential improvement in quality of life [ 15 , 16 , 17 ].

The existing literature examining the effectiveness of art therapy has shown some positive results across a wide variety of treatment indications, such as the treatment of depression [ 3 , 18 ], anxiety [ 19 , 20 ], psychosis [ 21 ], the enhancement of mental wellbeing [ 22 ], and the complementary treatment of cancer [ 15 , 23 ]. However, the existing evidence is characterised by conflicting results. While some studies report favourable results and treatment successes through AVAT [ 17 , 24 , 25 , 26 ], many studies report mixed results [ 3 , 15 , 16 , 27 , 28 ]. There is a substantial number of systematic reviews which examine the effectiveness of art therapy regarding individual outcomes, such as trauma [ 29 , 30 , 31 , 32 , 33 ], anxiety [ 19 ] mental health in people who have cancer [ 23 , 34 , 35 ] dementia [ 7 ], and potential harms and benefits of the intervention [ 36 ]. The limited number of published studies, however, can make the creation of a systematic review difficult, especially when narrowing down additional factors, such as the desired study design [ 7 ].

Therefore, it might be helpful to combine all existing evidence on the therapeutic effects of AVAT in one review, to generate evidence regarding its overall effectiveness. To our knowledge, there is no systematic review that accumulates the data of all published RCTs on the topic of AVAT, while abiding to strict methodological standards, such as the Cochrane handbook [ 37 ] and the PRISMA statement [ 38 ]. We thus aim to establish and strengthen the existing evidence basis for AVAT, reflecting the clinical reality by including a wide variety of settings, populations, and treatment indications. Furthermore, we will try to identify characteristics of the setting and the intervention that may increase AVAT’s effectiveness, as well as differences in treatment success for different conditions or reasons for treatment.

Methods/Design

Registration and reporting.

We have submitted the protocol to PROSPERO (the International Prospective Register of Systematic Reviews) on February 9, 2021 (PROSPERO ID: CRD42021233272). In the writing of this protocol we have adhered to the adapted PRISMA-P (Preferred reporting items for systematic review and meta-analysis protocols, see Additional file 1 ) [ 39 ]. Important protocol amendments will be submitted to PROSPERO.

Eligibility criteria

Type of study.

We will include randomised controlled trials to minimise the sources of bias possibly arising from observational study designs.

Types of participants

As AVAT is used across many patient populations and settings, we will include patients across all treatment indications. Thus, we will include populations receiving curative, palliative, rehabilitative, or preventive care for a variety of reasons. Patients of all ages (including seniors, children and adolescents), all cultural backgrounds, and all living situations (inpatients, outpatients, prison, nursing homes etc.) will be included without further restrictions. The resulting diversity reflects the current treatment reality. Heterogeneity of included studies will be accounted for by subgroup analyses at the stage of data synthesis. Differences in treatment success depending on population characteristics are furthermore of special interest in this review.

Types of interventions

As the therapeutic mechanisms of AVAT are not yet unanimously agreed upon, we want to reduce the heterogeneity of treatment methods included by focusing on only one cluster of art activities (active visual art).

We define AVAT as any form of creative expression involving a medium such as paint, wax, charcoal, graphite, or any other form of colour pigments, clay, sand, or other materials that are applied or shaped by the individual in an artistic or expressive form.

The interventions must include a therapeutic element, such as the targeted guidance from an art therapist or a reflective element. Both, group and individual treatment in any setting are included.

Purely occupational activities not intended to have a therapeutic effect will not be considered.

All forms of music, dance, and performing art therapies, as well as poetry therapy and (expressive) writing interventions which focus on the content rather than appearance (like journal therapy) will not be included. Studies with mixed interventions will be included only if the effects of the AVAT can be separated from the effects of the other treatments. Furthermore, all passive forms of visual art therapy will be excluded, such as receptive viewings of paintings or pictures.

Comparison interventions

Depending on the treatment indication and setting, the control group design will likely vary. We will include studies with any type of control group, because art therapy research, just like psychotherapy research, must face the problem that there are usually no standard controls like, e.g. a placebo [ 40 ]. Therefore, we will include all control groups using treatment as usual (including usual care, standard of care etc.), no treatment (with or without waitlist control design), or any active control other than AVAT (such as attention placebo controls) as potential comparators.

Stakeholder involvement

Stakeholders will be involved to increase the relevance of the study design. Patients, art therapists, and physicians prescribing art therapy, all from a centre that uses AVAT regularly, will be interviewed using a semi structured questionnaire that captures the expert’s perspective on meaningful outcomes. Particularly, we are interested in the stakeholders’ opinions about which outcomes might be most affected by AVAT, which individual differences might be expected, and which other factors could affect the effectiveness of AVAT.

A second session might be held at the stage of result interpretation as the stakeholders’ perspective could be a valuable tool to make sense of the data.

As there is no universal standard regarding the outcomes of AVAT, we have based our choice of outcome measures on selected, high quality work on the subject [ 7 ], and on theoretical considerations.

Outcome measures will include general and disease specific quality of life, anxiety, depression, treatment satisfaction, adverse effects, health economic factors, and other disorder specific outcomes. The latter are of special relevance for the patients and have the potential to reflect the effectiveness of the therapy. The disorder specific outcomes will be further clustered into groups, such as treatment success, mental state, affect and psychological wellbeing, cognitive function, pain (medication), somatic effects, therapy compliance, and motivation/agency/autonomy regarding the underlying disease or its consequences. Depending on the included studies, we might re-evaluate these categories and modify the clusters if necessary.

Outcomes will be grouped into short-term and long-term outcomes, based on the available data. The same approach will be taken for dividing the treatment groups according to intensity, with the aim of observing the dose-response relationship.

Grouping for primary analysis comparisons

AVAT interventions and their comparison groups can be highly divers; therefore, we might group them into roughly similar intervention and comparison groups for the primary analysis, as indicated above. This will be done after the data extraction, but before data analysis, in order to minimise bias.

Search strategy

Based on the recommendations from the Cochrane Handbook we will systematically search the Cochrane Library, EMBASE (via Ovid), and MEDLINE (via Ovid) [ 41 ]. Furthermore, we will search CINAHL, ERIC, APA PsycArticles, APA PsycInfo, and PSYNDEX (all via EBSCOHost), as well as the ClinicalTrials.gov and the WHO’s International Clinical Trials Registry Platform (ICTRP), which includes various smaller and national registries, such as the EU Clinical Trials Register and the German Clinical Trials Register (DRKS).

The search strategy is comprised of three search components; one concerning the art component, one the therapy component and the last consists of a recommended RCT filter for EMBASE, optimised for sensitivity and specificity [ 42 , 43 , 44 ]. See Additional file 2 for the complete search strategy, exemplified for the Cochrane Library search interface. In addition, relevant hand selected articles from individual databank searches, or studies identified through the screening of reference lists will be included in the review. A handsearch of The Journal of Creative Arts Therapies will be conducted.

Results of all languages will be considered, and efforts undertaken to translate articles wherever necessary. There will be no limitation regarding the date of publication of the studies.

Data collection and data management

Study selection process.

Two reviewers will independently scan and select the studies, first by title screening, second by abstract screening, and in a third step by full text reading. The two sets of identified studies will then be compared between the two researchers. In case of disagreement that cannot be resolved through discussion, a third researcher will be consulted to decide whether the study in question is eligible for inclusion. The Covidence software will be used for the study selection process [ 45 ].

Data extraction

All relevant data concerning the outcomes, the participants, their condition, the intervention, the control group, the method of imputation of missing data, and the study design will be extracted by two researchers independently and then cross-checked, using a customised and piloted data extraction form. The chosen method of imputation for missing data (due to participant dropout or similar) will be extracted per outcome. Both, intention to treat (ITT) and per protocol (PP) data will be collected and analysed.

If crucial information will be missing from a study and its protocol, authors will be contacted for further details.

Risk of bias assessment for included studies

In line with the revised Cochrane risk of bias tool for randomised trials (RoB 2) [ 46 ], we will examine the internal bias in the included studies regarding their bias arising from the randomisation process, bias due to deviations from intended interventions, due to missing outcome data, bias in measurement of the outcome, and in selection of the reported result [ 47 ].

The risk will be assessed by two people independently from each other, only in cases of persisting disagreement a third person will be consulted.

If the final sample size allows, we will conduct an additional analysis in which the included studies are analysed separately by bias risk category.

Measures of treatment effect

If possible, we will conduct our main analyses using intention-to-treat data (ITT), but we will collect ITT and per-protocol (PP) data [ 48 ]. If for some studies ITT data is not reported, we will use the available PP data instead and perform a sensitivity analysis to see if that affects the results. Dichotomous data will be analysed using risk ratios with 95% confidence intervals, as they have been shown to be more intuitive to interpret than odds ratio for most people [ 49 ]. We will analyse continuous data using mean differences or standardised mean differences.

Unit of analysis issues

Cluster trials.

If original studies did not account for a cluster design, a unit of analysis error may be present. In this case, we will use appropriate techniques to account for the cluster design. Studies in which the authors have adjusted the analysis for cluster-randomisation will be used directly.

Cross-over trials

An inherent risk to cross-over trials is the carry-over effect.

This design is also problematic when measuring unstable conditions such as psychotic episodes, as the timing could account more for the treatment success than the treatment itself (period effect).

As art therapy is used frequently in the treatment of unstable conditions, such as mental health problems or neurodegenerative disorders (i.e. Alzheimer’s), we will include full cross-over trials only if chronic and stable concepts are measured (such as permanent physical disabilities or epilepsy) [ 50 ].

When including cross-over studies measuring stable conditions, we will include both periods of the study. To incorporate the results into a meta-analysis we will combine means, SD or SE from both study periods and analyse them like a parallel group trial [ 51 ]. For bias assessment we will use the risk of bias tool for crossover trials [ 47 ].

For cross-over studies that measure unstable or degenerative conditions of interest, we will only include the first phase of the study as parallel group comparison to minimise the risk of carry-over or period effects. We will evaluate the risk of bias for those cross-over trials using the same standard risk of bias tool as for the parallel group randomised trials [ 52 ]. We will critically evaluate studies that analyse first period data separately, as this might be a form of selective reporting and the inclusion of this data might result in bias due to baseline differences. We might exclude studies that use this kind of two-stage analysis if we suspect selective reporting or high risk for baseline differences [ 47 ].

Missing data

Studies with a total dropout rate of over 50% will be excluded. To account for attrition bias, studies will be downrated in the risk of bias assessment (RoB 2 tool) if the dropout rate is more than half for either the control or the intervention group. An overall dropout rate of 25–50% we will also be downrated.

Assessment of clinical, methodological, and statistical heterogeneity

We will discuss the included studies before calculating statistical comparisons and group them into subgroups to assess their clinical and methodological heterogeneity. Statistical heterogeneity will be assessed by calculating the p value for the chi 2 test. As few included studies may lead to insensitivity of the p value, we may adjust the cut-off of the p value if we only included a small amount of studies [ 49 ]. In addition, we will calculate the I 2 statistic and its confidence interval, based on the chi 2 statistic to assess statistical heterogeneity. We will explore possible reasons for observed heterogeneity, e.g. by conducting the planned subgroup analyses. Based on the amount and quality of included studies and their outcome heterogeneity, we will decide if a meta-analysis can be conducted. In case of high statistical heterogeneity, we first check for any potential errors during the data input stage of the review. In a second step, we evaluate if choosing a different effect measure, or if the justified removal of outliers will reduce heterogeneity. If the outcome heterogeneity of the selected studies is still too high, we will not conduct a meta-analysis. If clinical heterogeneity is high but can be reduced by adjusting our planned comparisons, we will do so.

Reporting bias

Funnel plot.

Funnel plots can be a useful tool in detecting a possible publication bias. However, we are aware, that asymmetrical funnel plots can potentially have other causes than an underlying publication bias. As a certain number of studies is needed in order to create a meaningful funnel plot, we will only create those plots, if more than about 10 studies are included in the review.

Data analysis and synthesis

Based on the amount and quality of included studies and their heterogeneity, we will decide if a meta-analysis is feasible.

If a meta-analysis can be conducted, we will be using the inverse variance method with random effects (to increase compatibility with the different identified effect measures and to account for the diversity of the included interventions). We would expect each study to measure a slightly different effect based on differing circumstances and differing intervention characteristics. Therefore, a random effects model is the most suitable option.

A disadvantage of the random effects model is that it does not give studies with large sample sizes enough weight when compared to studies with small sample sizes and therefore could lead to a small study effect. However, we expect to find studies with comparable study sizes with an N of 10–50, as very large trials are uncommon for art therapy research. If we include studies with a very large sample size, we might calculate a fixed effects model additionally, as sensitivity analysis, to assess if this would affect the results.

If the calculation of a meta-analysis is not advisable due to difficulties (such as a low number of included studies, low quality of included studies, high heterogeneity, incompletely reported outcome or effect estimates, differing effect measures that cannot be converted), we will choose the most appropriate method of narrative synthesis for our data, such as the ones described in the Cochrane Handbook (i.e. summarising effect estimates, combining p values or vote counting based on direction of effect) [ 53 ].

Subgroup analysis

If the number of included studies is large enough (around 10 or more [ 54 ]) and subgroups have an adequate size, we plan to compare subgroups based on the therapy setting (inpatient, outpatient, kind of institution), the intervention characteristics (the kind of AVAT, intensity of treatment, staff training, group size), the population (treatment indication, age, gender, country), or other study characteristics (e.g. bias category, publication date). If possible, we will also examine these factors by calculating meta-regressions.

Sensitivity analysis

Where possible, sensitivity analyses will be conducted using different methods to establish robustness of the overall results. Specifically, we will assess the robustness of the results regarding cluster randomisation and high risk of bias (RoB 2 tool).

AVAT encompasses a wide array of highly diverse treatment options for a multitude of treatment indications. Even though AVAT is a popular treatment method, the empirical base for its effectiveness is rather fragmented; many (often smaller) studies examined the effect of very specific kinds of AVATs, with a narrow focus on certain conditions [ 2 , 7 , 55 , 56 ]. Our review will give a current overview over the entire field, with the hope of estimating the magnitude of its effectiveness. Several clinical guidelines recommend art therapy based solely on clinical consensus [ 57 ]. By accumulating all empirical evidence, this systematic review could inform the creation of future guidelines and thereby facilitate clinical decision-making.

Understanding the benefits, limits, and mechanisms of change of AVAT is crucial to optimally apply and tailor it to different contexts and settings. Consequently, by better understanding this intervention, we could potentially increase its effectiveness and optimise its application, which would lead to improved patient outcomes. This would not only benefit each individual who is treated with AVAT, but also the health care provider, who could apply the intervention in its most efficient way, thereby using their resources optimally.

Furthermore, explorative findings regarding the characteristics of the treatment could generate new hypotheses for future RCTs, for example regarding the effectiveness of certain types of AVAT for specific treatment indications. Moreover, the emergence of certain patterns in effectiveness could inspire further research about possible mechanisms of change of AVAT.

Availability of data and materials

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

• Active visual art therapy

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols

Randomised controlled trial

Risk of Bias tool

Intention to treat

Per protocol

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Joschko, R., Roll, S., Willich, S.N. et al. The effect of active visual art therapy on health outcomes: protocol of a systematic review of randomised controlled trials. Syst Rev 11 , 96 (2022). https://doi.org/10.1186/s13643-022-01976-7

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Art therapy and art psychotherapy are often offered in Child and Adolescent Mental Health services (CAMHS). We aimed to review the evidence regarding art therapy and art psychotherapy in children attending mental health services. We searched PubMed, Web of Science, and EBSCO (CINHAL®Complete) following PRISMA guidelines, using the search terms (“creative therapy” OR “art therapy”) AND (child* OR adolescent OR teen*). We excluded review articles, articles which included adults, articles which were not written in English and articles without outcome measures. We identified 17 articles which are included in our review synthesis. We described these in two groups—ten articles regarding the treatment of children with a psychiatric diagnosis and seven regarding the treatment of children with psychiatric symptoms, but no formal diagnosis. The studies varied in terms of the type of art therapy/psychotherapy delivered, underlying conditions and outcome measures. Many were case studies/case series or small quasi-experimental studies; there were few randomised controlled trials and no replication studies. However, there was some evidence that art therapy or art psychotherapy may benefit children who have experienced trauma or who have post-traumatic stress disorder (PTSD) symptoms. There is extensive literature regarding art therapy/psychotherapy in children but limited empirical papers regarding its use in children attending mental health services. There is some evidence that art therapy or art psychotherapy may benefit children who have experienced trauma. Further research is required, and it may be beneficial if studies could be replicated in different locations.

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Introduction

Child and Adolescent Mental Health Services (CAMHS) often offer art therapy, as well as many other therapeutic approaches; we wished to review the literature regarding art therapy in CAMHS. Previous systematic reviews of art therapy were not specifically focused on the effectiveness in children [ 1 , 2 , 3 , 4 , 5 ] or were focused on the use of art therapy in children with physical conditions rather than with mental health conditions [ 6 ]. The use of art or doodling as a communication tool in CAMHS is long established—Donald Winnicott famously used “the Squiggle Game” to break boundaries between a patient and professional to narrate a story through a simple squiggle [ 7 ]. Art is particularly useful to build a rapport with a child who presents with an issue that is too difficult to verbalise or if the child does not have words to express a difficulty. The term art therapy was coined by the artist Adrian Hill in 1942 following admission to a sanatorium for the treatment of tuberculosis, where artwork eased his suffering. “Art psychotherapy” expands on this concept by incorporating psychoanalytic processes, seeking to access the unconscious. Jung influenced the development of art psychotherapy as a means to access the unconscious and stated that “by painting himself he gives shape to himself” [ 8 ]. Art psychotherapy often focuses on externalising the problem, reflecting on it and analysing it which may then give way to seeing a resolution.

The UK Joint Commissioning Panel for Mental Health 2013 recommends that psychotherapists and creative therapists are part of the CAMHS teams [ 9 ]. There is a specific UK recommendation that art therapy may be used in the treatment of children and young people recovering from psychosis, particularly those with negative symptoms [ 10 ], but no similar recommendation in the Irish HSE National Clinical Programme for Early Intervention in Psychosis [ 11 ]. There is less clarity about the use of art therapy in the treatment of depression in young people—arts therapies were previously recommended [ 12 ], but more recent NICE guidelines appear to have dropped this advice, though the recommendation for psychodynamic psychotherapy has remained [ 13 ]. Art therapy is often offered to treat traumatised children, but we note that current NICE guidelines on the management of PTSD do not include a recommendation for art therapy [ 14 ]. The Irish document “Vision for Change” did not include a recommendation regarding art psychotherapy or creative therapies [ 15 ]. Similarly, the document “Sharing the Vision” does not make any recommendation regarding creative or art therapies, though it recommends psychotherapy for adults and recommends arts activities as part of social prescribing for adults [ 16 ]. Meanwhile, it is not uncommon for there to be an art therapist in CAMHS inpatient units, working with those with the highest mental healthcare needs. We wished to find out more about the evidence for, or indeed against, the use of art therapy in CAMHS. We performed a systematic review which aimed to clarify if art psychotherapy is effective for use in children with mental health disorders. This review aimed to address the following questions: (1) Is art therapy/psychotherapy an effective treatment for children with mental health disorders? (2) What are the various methods of art therapy or art psychotherapy which have been used to treat children with mental health disorders and how do they differ in terms of (i) setting and duration, (ii) procedure of the sessions, and (iii) art activities details?

The Preferred Reporting Items for Systematic Reviews (PRISMA) statement for systematic reviews was followed. Searches and analysis were conducted between September 2016 and April 2020 using the following databases: PubMed, Web of Science and EBSCO (CINHAL®Complete). The following “medical subject terms” were utilized for searches: (“creative therapy” OR “art therapy”) AND (child* OR adolescent OR teen*). Review publications were excluded. Studies in the English language meeting the following inclusion criteria were selected: (i) use of art therapy/art psychotherapy, (ii) psychiatric disorder/diagnosis and/or mood disturbances and/or psychological symptoms, (iii) human participants aged 0–17 years inclusive. Articles investigating the efficiency of art therapy in children with medical conditions were included only if the measured outcome related to psychological well-being/symptoms. Exclusion criteria included: (i) application of therapies which do not involve art activities, (ii) application of a combination of therapies without individual results for art therapy, (iii) not clinical studies (review, meta-analysis, reports, others), (iv) studies which focused on the artwork itself/art therapy procedure and did not measure and publish any clinical outcomes, (v) absence of any pre psychiatric symptoms or comorbidity in the participant sample prior to art intervention. All articles were screened for inclusion by the authors (MA, TR, IB, AM, DB), unblinded to manuscript authorship.

Data extraction

The authors (IB, TR, AM, MA, DB) extracted all data independently (unblinded). Data were extracted and recorded in three tables with specific information from each study on (i) the study details, (ii) art therapy details and outcome measures and (iii) art therapy results. The following specific study details were extracted: author/journal, country, year of publication, study type (i.e. study design), study aims, study setting, participant details (number, age and gender), disease/disorder studied and inclusion criteria and exclusion criteria of the study. The following details were extracted regarding the art therapy provided and outcome measures : type of art therapy provided (individual or group therapy), the art therapy procedure and/or techniques used, the art therapy setting, therapy duration (including frequency and duration of each art therapy session), the type of outcome measure used, the investigated domains, the time points (for outcome measures) and the presence or absence of pre-/post-test statistical analysis. Finally, we extracted specific information on the art therapy results , including therapy group results, control group results, the number and percentage of who completed therapy, whether or not a pre-/post-test statistical difference was found and the general outcome of each study. Following the extraction of all data, studies included were divided into two groups: (1) children with psychiatric disorder diagnosis and (2) children with psychiatric symptoms. Finally, the QUADAS-2 tool was used to assess the risk of bias for each study, and a summary of the risk of bias for all data was calculated [ 17 ]. The QUADAS-2 is designed to assess and record selection bias, performance bias, detection bias, attrition bias, reporting bias and any other bias [ 17 ].

Study inclusion and assessment

A total of 1273 articles were initially identified (Fig.  1 ). After repeats and duplicates were removed, 1186 possible articles were identified and screened for inclusion/exclusion according to the title and abstract, which resulted in 1000 articles being excluded. The remaining 186 full articles were retrieved and full text considered. Following review of the full text, 70 articles were selected and further analysed. Fifty-three of them did not meet our criteria for review. Reasons for exclusion were grouped into four main categories: (1) not art therapy [ n  = 2]; (2) not mental health [ n  = 5]; (3) no outcome measured [ n  = 18]; (4) other reasons (i.e. descriptive texts, full article not available) [ n  = 28]. In conclusion, there were 17 articles remaining that met the full inclusion criteria, and further descriptive analysis was performed on these 17 studies. All the considered articles were produced in the twenty-first century, between 2001 and 2020, most in the USA (60%), followed by Canada (30%) and Italy (10%). The characteristics of studies included in our final synthesis are reported in Tables 1 and 2 .

PRISMA 2009 flow diagram

Participant characteristics

Participants in the 17 studies ranged from 2 to 17 years old inclusive. In ten articles, children with an established psychiatric diagnosis were included (Group 1, see Table 1 ). The type of psychiatric disorders as (i) PTSD, (ii) mood disorders (bipolar affective disorder, depressive disorders, anxiety disorder), (iii) self-harm behaviour, (iv) attachment disorder, (v) personality disorder and (vi) adjustment disorder. In seven articles, children with psychiatric symptoms were enrolled, usually referred by practitioners and school counsellors (Group 2, see Table 2 ). Participants had a wide variety of conditions including (i) symptoms of depression, anxiety, low mood, dysthymic features; (ii) attention and concentration disorder symptoms; (iii) socialisation problems and (iv) self-concept and self-image difficulties. Some children had medical conditions such as leukaemia requiring painful procedures, or glaucoma, cancer, seizures, acute surgery; others had experienced adversity such as parental divorce, physical, emotional and/or sexual abuse or had developed dangerous and promiscuous social habits (drugs, prostitution and gang involvement).

Study design: children with an established psychiatric diagnosis (Table 1 )

A summary of the ten studies on art therapy in children with a psychiatric diagnosis can be seen in Table 1 , with further information about each study. There are just two randomised controlled in this category, both treating PTSD in children [ 18 , 19 ]. Chapman et al. [ 18 ] provided individual art therapy to young children who had experienced trauma and assessed symptom response using the PTSD-I assessment of symptoms 1 week after injury and 1 month after hospital admission [ 18 ]. Their study included 85 children; 31 children received individual art therapy, 27 children received treatment as usual and 27 children did not meet criteria for PTSD on the initial PTSD-I assessment [ 18 ]. The art therapy group had a reduction in acute stress symptoms, but there was no significant difference in PTSD scores [ 18 ]. The second randomised controlled trial provided trauma-focused group art therapy in an inpatient setting and showed a significant reduction in PTSD symptoms in adolescents who attended art therapy in comparison to a control group who attended arts-and-crafts. However, this study had a high drop-out rate, with 142 patients referred to the study and just 29 patients who completed the study [ 19 ].

The remaining studies regarding art therapy or art psychotherapy in children with psychiatric disorders are case studies, case series or quasi experimental studies, most with less than five participants. All these studies reported positive effects of art therapy; we did not find any published negative studies. We can summarise that the studies differed greatly in the type of therapy delivered, in the setting (group or individual therapy) and in the types of disorders treated (Table 1 ).

Forms of art therapy intervention and assessment (Table 1 )

The various modalities and duration of art therapy described in the ten studies with children with psychiatric diagnoses are summarised in Table 1 . The treatment of PTSD was described in two studies, but each described a different art therapy protocol, and the studies varied in terms of setting and duration [ 18 , 19 ]. The Trauma Focused Art Therapy (TF-ART) study described 16 weekly in-patient group sessions [ 19 ], whereas the Chapman Art Therapy Treatment Intervention (CATTI) is a short-term individual therapy, lasting 1 h at the bedside of hospital inpatients [ 18 ]. Despite the differences, the methods have some common aspects. Both therapy methods focused on helping the individual express a narrative of his/her life story, supporting the individual to reflect on trauma-related experiences and to describe coping responses. Relaxation techniques were used, such as kinaesthetic activities [ 18 ] and “feelings check-ins” [ 19 ]. In the TF-ART protocol, each participant completed at least 13 collages or drawings and compiled in a hand-made book to describe his/her “life story” [ 19 ]. The use of art therapy in a traumatised child has also been described in a single case study [ 20 ].

Group art therapy has been described in the treatment of adolescent personality disorder, in an intervention where adolescents met weekly in two separate periods of 18 sessions over 6 months, with each session lasting 90 min, facilitated by a psychotherapist [ 21 ]. Sessions consisted of a short group conversation regarding events/issues during the previous week followed by a brief relaxing activity (e.g. listening to music), a period of art-making and an opportunity to explain their work, guided by the psychotherapist.

A long course of art psychotherapy over 3 years with a vulnerable female adolescent who presented with self-harm and later disclosed being a victim of a sexual assault has been described [ 22 ]. The young person described an “enemy” inside her which she had overcome in her testimony to her improvement, which was included in the published case study [ 22 ]. The approach of “art as therapy” has been described with children with bipolar disorder and other potential comorbidities, such as Asperger syndrome and attention deficit disorder, using the “naming the enemy” and “naming the friend” approaches [ 23 ].

The concept of the “transitional object”—a coping device for periods of separation in the mother–child dyad during infancy—has been considered in art therapy [ 24 ]. It was proposed that “transitional objects” could be used as bridging objects between a scary reality and the weak inner-self. Children brought their transitional objects to therapy sessions, and the therapy process aimed to detach the participant from his/her transitional object, giving him/her the strength to face life situations with his/her own capabilities [ 24 ].

Two studies of art therapy in children with adjustment disorders were included in our systematic review [ 25 , 26 ]. Children attended two or three video-recorded sessions and were encouraged to use art materials to explore daily life events. The child and therapist then watched the video-recorded session and participated in a semi-structured interview that employed video-stimulated recall. The therapy aimed to transport the participant to a comfortable imaginary world, giving the child the possibility to create powerful, strong characters in his/her story, thus enhancing the ability to cope with life’s challenges [ 25 , 26 ].

Outcome measures and statistical analysis (Table 1 )

Three articles on psychiatric disorders evaluated potential changes in outcome using an objective measure [ 18 , 19 , 22 ]. Two studies used the “The University of California at Los Angeles Children’s PTSD Index” (UCLA PTSD-I), which is a 20-item self-report tool [ 18 , 19 ]. Statistical differences were evaluated by calculating the mean percentage change [ 18 ] and the ANOVA [ 19 ]. The 12-item “MacKenzie’s Group Climate Questionnaire” was used to measure the outcome of group art therapy in adolescents with personality disorder, and a significant reduction in conflict in the group was found [ 21 ]. However, the sample size was small, and there was no control group [ 21 ]. Many studies did not use highly recognised measures of outcome but relied instead on a comprehensive description of outcome or change after art therapy/psychotherapy, in case studies or case series [ 20 , 22 , 23 , 24 , 25 , 26 , 27 ].

Study design: children with psychiatric symptoms (Table 2 )

We included seven studies in our review synthesis where art therapy or art psychotherapy was used as an intervention for psychiatric symptoms—many of these studies occurred in paediatric hospitals, where children were being treated for other conditions. Two of these studies were non-randomised controlled trials, one of which was waitlist controlled [ 28 , 29 ], and the other five were quasi-experimental studies [ 30 , 31 , 32 , 33 , 34 ].

Forms of intervention and assessment (Table 2 )

Three articles described art therapy in paediatric hospital patients but varied in terms of therapy and underlying condition [ 28 , 29 , 33 ]. The effectiveness of art therapy on self-esteem and symptoms of depression in children with glaucoma has been investigated; a number of sensory-stimulating art materials were introduced during six individual 1-h sessions [ 33 ]. Short-term or single individual art therapy sessions have also been used in hospital aiming to improve quality of life [ 28 , 29 ]. Art therapy has been provided to children with leukaemia; the children transformed unused socks into puppets called “healing sock creatures” [ 29 ]. Short-term art therapy prior to painful procedures, such as lumbar puncture or bone marrow aspiration, has also been described, using “visual imagination” and “medical play” with age-appropriate explanations about the procedure, with a cloth doll and medical instruments [ 28 ].

The remaining articles described the provision of art therapy to vulnerable patients, where the therapy aimed to increase self-confidence or address worries. Two studies focused on female self-esteem and self-concept, both using group activities [ 31 , 32 ]. Hartz and Thick [ 32 ] compared two different art therapy protocols: art psychotherapy, which employed a brief psychoeducational presentation and encouraged abstraction, symbolization and verbalization and an art as therapy approach, which highlighted design potentials, technique and the creative problem-solving process, trying to evoke artistic experimentation and accomplishment rather than different strengths and aspects of personality [ 32 ]. Participants completed a known questionnaire about self-esteem as well as a study-specific questionnaire.

Coholic and Eys [ 34 ] described the use of a 12-week arts-based mindfulness group programme with vulnerable children referred by mental health or child welfare services, with a combination of group work and individual sessions [ 34 ]. Children were given tasks which included the “thought jar” (filling an empty glass jar with water and various-shaped and coloured beads representing thoughts and feelings), the “me as a tree” activity, during which the participant drew him/herself as a tree, enabling the participant to introduce him/herself, the “emotion listen and draw” activity which provided the opportunity to draw/paint feelings while listening to five different songs and the “bad day better” activity which involved painting what a “bad day” looked like, and then to decorate it to turn it into a “good day”. The research included quantitative analysis and qualitative assessment using self-report Piers-Harris Children’s Self-Concept Scale and the Resiliency Scales for Children and Adolescents [ 37 , 38 ].

Kearns [ 30 ] described a single case study of art therapy with a child with a sensory integration difficulty, comparing teacher-reported behaviour patterns after art therapy sessions using kinaesthetic stimulation and visual stimulation with behaviour after 12 control sessions of non-art therapy; a greater improvement was reported with art therapy [ 30 ].

Outcome measures and statistical analysis (Table 2 )

Most of the studies on art therapy in children with psychiatric symptoms (but not confirmed disorders) used widely accepted outcome measures [ 29 , 30 , 31 , 32 , 33 , 34 ] (Table 2 ), such as self-report measurements including the 27-item symptom-orientated Children’s Depression Inventory or the Tennessee Self Concept Scale: Short Form [ 33 , 35 , 36 ]. The 60-item Piers-Harris Children’s Self-Concept Scale (2nd edition) and the Resiliency Scales for Children and Adolescents (RSCA) were used in a study on vulnerable children [ 34 , 37 , 38 ]. The Piers-Harris Children’s Self-Concept Scale is a widely used self-report measure of psychological health and self-concept in children and teens and consists of three global self-report scales presented in a 5-point Likert-type scale: sense of mastery (20 items), sense of relatedness (24 items) and emotional reactivity (20 items) [ 37 ]. A modified version of the Daley and Lecroy’s Go Grrrls Questionnaire was administered at group intake and follow-up, to rank various self-concept items including body image and self-esteem along a four-point ordinal scale in group therapy with young females [ 31 , 39 ].

Some researchers created their own outcome measures [ 28 , 29 , 30 , 33 ]. One study group created a mood questionnaire for young children—this was administered by a research assistant to patients before and after each therapy session, in their small wait-list controlled study [ 29 ]. Another group evaluated classroom performance using an observational system rated by the teacher for each 30-min block of time every day during the study [ 30 ]. The classroom study also used the “person picking an apple from a tree” (PPAT) drawing task—this was the only measurement tool in the studies we reviewed which assessed the features of the artworks themselves [ 30 , 40 ]. Pre- and post-test drawings were evaluated for evidence of changes in various qualities over the course of the research period [ 30 ].

Hartz and Thick [ 32 ] used both the 45-items Self-Perception Profile for Adolescents (SPPA) [ 41 ] which is widely used and considered reliable, as well as the Hartz Art Therapy Self-Esteem Questionnaire (Hartz AT-SEQ) [ 32 ], which is a 20-question post-treatment questionnaire designed by the author, to understand how specific aspects of art therapy treatment affect self-esteem in a quasi-experimental study with group art therapy. Four of the seven articles performed statistical analysis of the data collected, using the Wilcoxon signed-rank test [ 31 ], Fisher’s t [ 32 ], MANOVA [ 34 ], and two-tailed Student’s t test [ 29 ].

Assessment of bias

The QUADAS-2 assessment of bias for each study included in our systematic review synthesis can be seen in Table 3 , with a summary of the results of the QUADAS-2 assessment for all included studies in our review in Table 4 . Studies marked in green had a low risk of bias; those marked in red had a high risk of bias while those in yellow had an unclear risk of bias. Just two studies were found to have a low risk of bias [ 19 , 29 ].

We found extensive literature regarding the use of art therapy in children with mental health difficulties ( N  = 1273), with a large number of descriptive qualitative studies and cases studies, but a limited number of quantitative studies which we could include in our review synthesis ( N  = 17). The predominance of descriptive studies is not surprising considering that the field of art therapy and art psychotherapy has developed from the descriptive writings of Freud, Jung, Winnicott and others, and for many years, academic psychotherapy focused on detailed case descriptions rather than quantitative outcome studies. The numerous descriptive and qualitative publications generally described positive changes in participants undergoing art therapy, which may represent publication bias. Our aim was however to describe the quantitative evidence regarding the use of art therapy or art psychotherapy in children and adolescents with mental health difficulties, and we found a limited number of studies to include in our review synthesis. There were just two randomised controlled trials, no replication studies and insufficient information to allow for a meta-analysis. However, the articles in our review synthesis suggested that art therapy may have a positive outcome in various groups of patients, especially if the therapy lasts at least 8 weeks.

There is some evidence from controlled trials to support the use of art therapy in children who have experienced trauma [ 18 , 19 ]. It should be noted that art therapy or art psychotherapy was delivered as individual sessions in most of the studies in our review, especially for children with a psychiatric diagnosis. A group approach to art therapy was used in some studies with vulnerable children such as children in need, female adolescents with self-esteem issues and female offenders [ 22 , 31 , 34 ]. However, the studies on group art therapy or psychotherapy are quasi-experimental studies of limited size, and it would be useful if larger, more robust studies such as randomised controlled trials could study the efficacy of group art therapy or group art psychotherapy.

Many of the studies included in our review synthesis ranked low in the Cochrane Risk of Bias criteria, with a high risk of bias. Our review synthesis highlights the heterogeneity of the studies—various methods of individual or group art therapy were delivered, with some studies delivering psychoanalytic-type interventions while others delivered interventions resembling cognitive behaviour therapy, delivered via art. The literature also showed a general lack of standardisation with regard to the duration of art therapy and outcome measures used. Despite this, the authors of many of the studies described common themes and hypothesised about the value of art therapy or art psychotherapy in improving self-esteem, communication and integration. The interventions often encouraged the child to re-enact or to process trauma, and the authors described improved integration, and therapeutic change or transformation of the young person. It appears that there were varied interventions in the studies in the review synthesis but that many studies had theoretical similarities.

Strengths and limitations

We used clearly defined aims and followed PRISMA guidelines to perform this systematic review. However, we did not incorporate unpublished studies into our review and did not examine trial websites. By following strict exclusion criteria, we excluded studies on art psychotherapy and mental health where one or more participant commenced treatment before his/her eighteenth birthday and completed after the eighteenth birthday such as that by Lock et al. [ 42 ]. The Lock et al. [ 42 ] study may be of interest to those who are considering commissioning art therapy services for CAMHS, as it is a randomised controlled trial and suggests that art therapy may be a useful adjunct to Family-Based Treatment for adolescent anorexia nervosa in those with obsessive symptoms [ 42 ]. Our strict criteria also led us to exclude many studies where the primary focus was on educational issues including school behaviour or educational achievement—this is both a strength and limitation of our study. By excluding these studies, our systematic review can give useful information to CAMHS staff regarding the suitability of art therapy or art psychotherapy for children and adolescents with mental health difficulties. However, we note that a complete assessment of the effectiveness of art therapy or art psychotherapy in children would also include studies on the use of art therapy or art psychotherapy with children who have educational difficulties [ 43 , 44 ], those with physical illness or disability, as well as describing the many studies on art therapy or art psychotherapy in children who are refugees or living in emergency accommodation. We focused our review on quantitative research, but there are many mixed-methods studies in art therapy and art psychotherapy, where qualitative studies analysis may be used to generate hypotheses, and quantitative methods are used to test the hypothesis. A complete analysis of the effectiveness of art therapy or art psychotherapy in children could include summaries of qualitative or mixed-methods studies as well as quantitative studies.

Meanwhile, it should be noted that there is considerable evidence for the effectiveness of psychotherapy in general [ 45 , 46 ]. It has long been established that the common factors of alliance, empathy, expectations, cultural adaptation and therapist differences are important in the provision of effective psychotherapy [ 47 ]. Art therapy and art psychotherapy are more likely than the traditional talking therapies to provide these factors for those working with children.

Conclusions and future perspectives

There is extensive literature which suggests that art therapy or art psychotherapy provide a non-invasive therapeutic space for young children to work through and process their fears, trauma and difficulties. Art has been used to enhance the therapeutic relationship and provide a non-verbal means of communication for those unable to verbally describe their feelings or past experiences. We noted that there is considerably more qualitative and case description research than quantitative research regarding art therapy and art psychotherapy in children. We found some quantitative evidence that art therapy may be of benefit in the treatment of children who were exposed to trauma. However, while there are positive outcomes in many studies regarding art therapy for children with mental health difficulties, further robust research and randomised controlled trials are needed in order to define new and stronger evidence-based guidelines and to establish the true efficacy of art psychotherapy in this population. It would be helpful if there were studies with standardised outcome measures to facilitate cross comparison of results.

Availability of data and material

Data can be made available to reviewers if required.

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Acknowledgements

However we would like to acknowledge the support of the European Erasmus mobility scheme which allowed Dr. Irene Braito and Dr. Dicle Buyuktaskin to join the Department of Child and Adolescent Psychiatry, University College Dublin for placements. We would also like to acknowledge the summer student research scheme in University College Dublin which supported Mohammad Ahmed.

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Braito, I., Rudd, T., Buyuktaskin, D. et al. Review: systematic review of effectiveness of art psychotherapy in children with mental health disorders. Ir J Med Sci 191 , 1369–1383 (2022). https://doi.org/10.1007/s11845-021-02688-y

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SYSTEMATIC REVIEW article

A systematic review of empirical evidence on art therapy with traumatized refugee children and youth.

• 1 American University of Beirut, Beirut, Lebanon
• 2 Emirates College for Advanced Education, Abu Dhabi, United Arab Emirates

The current global refugee crisis revealed that refugee children, youth, and adults are uniquely vulnerable to traumatic events. Yet, there are only a few studies available that report robust systematic data on art therapy interventions with mental health in recent refugee populations. The purpose of the study is to synthesize and evaluate (a) the available research evidence on the use of art therapy in reducing post-traumatic stress disorder (PTSD) levels in refugees, and (b) the quality of empirical evidence for each of the reviewed studies. The authors adopted the Council for Exceptional Children (CEC) evidence-based practice (EBP) standards and quality indicators to evaluate the methodological soundness of the reviewed studies and the evidence-based classification of art therapy as a treatment intervention. We systematically searched electronic databases of pertinent review articles for the period from 2010 to 2020 using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Systematic searches identified 70 research articles but yielded eight eligible journals as per the inclusion criteria. Results indicated that, though considered a promising treatment approach, art therapy is presently classified as an intervention that falls under the category of practice with insufficient evidence. The findings suggest the need for further methodologically sound experimental studies to strengthen the evidence behind art therapy as an intervention to reduce PTSD symptoms in refugees around the world.

Introduction

Post-traumatic stress disorder (PTSD) is one of the common psychological and anxiety disorders that are present among refugees ( Khamis, 2019 ; Grasser et al., 2021 ). PTSD is characterized by severe symptoms of re-experiencing and avoidance due to traumatizing experiences and thus leading to impairment in important areas of functioning such as social areas, occupational areas, and other crucial areas ( American Psychiatric Association, 2013 ). Meta-analyses conducted by Lindert et al. (2017) , Blackmore et al. (2022) , and Henkelmann et al. (2020) showed that refugees have the highest PTSD prevalence rates, 32, 31.46, and 29% respectively. Systematic review research showed that refugees suffering from PTSD exhibited severe symptoms, such as intrusion, withdrawal, negative mood, alternations in arousal ( Ghumman et al., 2016 ), hypervigilance, difficulties falling asleep, irritability, outbursts of anger, self-destructive, reckless behavior ( Spiller et al., 2017 ), anxiety, depression, and somatization ( Lindert et al., 2017 ; Nesterko et al., 2020 ; Verhülsdonk et al., 2021 ). Moreover, when children are exposed to refugee conditions, the symptoms of their trauma might begin later in adolescence ( Cohen et al., 2006 ; Al-Hroub, 2014 ; Saab et al., 2019 ; Al-Hroub et al., 2020 ). In a systematic review conducted by Kien et al. (2019) on mental disorders in young refugees and asylum seekers in European countries, findings showed that the prevalence varied widely among 47 studies covered in 53 articles for the period from 1990 to 2017 for PTSD (19.0% and 52.7%), depression (10.3 and 32.8%), anxiety disorders (8.7% and 31.6%), and emotional and behavioral problems (19.8% and 35.0%).

Therefore, the role of psychosocial, therapeutic, and mental health interventions is found crucial in managing PTSD symptoms in refugee children and youth ( Giacaman et al., 2007 ; Al-Hroub, 2015 ; Almoshmosh, 2016 ; McLaughlin and Al-Hroub, 2016 ), and adults ( Palic and Elklit, 2011 ). Research showed that therapeutic practices that rely on non-verbal treatment, such as art therapy, may promote healing refugee learners affected by war ( Harris, 2009 ; Rowe et al., 2017 ; Zubala and Karkou, 2018 ).

The Role of Art Therapy

Art therapy is known as an interdisciplinary field where art therapist combines approaches from different fields such as art education, counseling, neuroscience, visual art, and others ( Bucciarelli, 2016 ). Art therapy has been employed as an intervention to reduce PTSD symptoms since it provides a non-threatening environment for refugee children and adolescents to facilitate the expression of feelings that are linked to trauma and identify some feelings that can lead to a sense of relief. Art therapy also provided the opportunity for refugee learners to tolerate their negative emotions when they become capable of regulating their emotions ( Sommers-Flanagan, 2007 ; Case and Dalley, 2014 ; Kalmanowitz and Ho, 2016 ; Akthar and Lovell, 2019 ; Wahlbeck et al., 2020 ). In addition, refugee learners who have difficulties in verbal expression find art therapy very effective ( Stuckey and Nobel, 2010 ).

Meta-analysis research has shown that the use of artwork applied by therapists and practitioners aids not only learners who have been diagnosed with PTSD ( Schouten et al., 2015 ), but also those with autism spectrum disorder ( Schweizer et al., 2014 ), depression ( Blomdahl et al., 2013 ), anxiety ( Abbing et al., 2018 ), and other mental illnesses ( Kaye-Huntington and Peterson, 2010 ). However, research results for policy decision-making and implementation processes regarding therapeutic procedures in art therapy are still limited ( Damianakis, 2007 ; Register and Hilliard, 2008 ; Schouten et al., 2015 ).

In practice, art therapy involves the product, the process, and the relationship between the counselee and the therapist. However, the diversity of approaches in art therapy due to several factors is reflected in the emergence of different titles and different approaches such as person-centered art therapists, group analytic art therapists, cognitive, gestalt, cognitive-behavioral art therapy, and studio approaches to art therapy ( Edwards, 2014 ). Although each approach has its theory and techniques, the use of art as the language of expression is what they have all in common.

The classification of art therapy distinguishes between three approaches: directive, non-directive, and combined. In a directive approach, the session usually starts with the therapist introducing themes to facilitate the creative activity. After an engagement in the creative activity, the session would end with a discussion as members in the group discuss, share thoughts and feelings, and share their work ( Edwards, 2014 ). In the non-directive approach, the therapist avoids giving directives or themes believing that imposed themes or structures may inhibit the natural discovery within the person ( McNeilly, 1983 ). Art, language, and literature from psychology can be combined in various ways to better affect positive change, and art by itself can be considered a language of expression ( Morrell, 2011 ). Regardless of the adopted approach, learners who are referred for art therapy do not necessarily have to be skillful in art as the aim is to offer the opportunity to express and not assess the art produced ( Case and Dalley, 2014 ).

The rationale of this research stems from the drastic increase of forcibly displaced refugees in the world and the increasing need for providing psychosocial non-verbal interventions to deal with their traumas globally. According to the United Nations High Commissioner for Refugees (UNHCR), more than 84 million people were forcibly displaced worldwide by the first half of 2021 as a result of persecution, conflict, violence, human rights violations, and events, of which 26.6 million have been acknowledged as refugees ( United Nations High Commissioner for Refugees, 2021 ). Over the period between 2010 and 2020, the population of refugees increased ~3.6 times [from 7.2 million ( United Nations High Commissioner for Refugees, 2010 ) to 26 million]. In parallel, there has been increasing attention in research in studying the effectiveness of alternative and creative art therapy on the social and emotional, and health wellbeing of learners since the beginning of the twentyfirst century, particularly in the past decade ( Clift et al., 2019 ). Therefore, this study explores, through a systematic review of empirical research, the use of art therapy in reducing PTSD levels in refugee children from 2010 to 2020.

Several systematic review studies have explored the effectiveness and contribution of art to children with clinical conditions, such as trauma, special education and disabilities, non-specific difficulties, medical conditions, and juvenile offenders (e.g., Cohen-Yatziv and Regev, 2019 ), children, and adolescents with psychosocial problems ( Bosgraaf et al., 2020 ), or traumatized adults ( Schouten et al., 2015 ), and adults with depression, borderline personality disorder, schizophrenia, and PTSD (e.g., Van Lith, 2016 ). Yet, none of these studies explored the effectiveness of art therapy on refugee children and adolescents with PTSD.

Thus, the present study aims to synthesize and evaluate the available research evidence on the use of art therapy in reducing PTSD levels in refugees over the years between the years 2010 and 2020. In addition, the study aims to evaluate the quality of empirical evidence for each of the reviewed studies by adopting highly regarded and reliable quantitative indicators. Given the research aims, a systematic review of the literature was warranted to address the following research questions:

a. What is the available research evidence on the use of art therapy in treating PTSD traumatic symptoms in refugees between the years 2010 and 2020?

b. What are the qualities of empirical evidence for available peer-reviewed studies on art therapy practices with traumatized refugees?

Research Design and Search Process

A systematic review of research related to the use of art therapy with traumatized refugee children, adolescents, and adults was conducted using Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA; Page et al., 2021 ). Peer-reviewed studies were identified through the following Boolean search terms entered in Education Research Complete, Education Research Complete, Academic Search Ultimate, Art and Architecture Source, APA PsychArticles, Web of Science (WOS), Scopus, and ERIC databases: (“trauma,” OR “PTSD,” OR “post-traumatic stress disorder,” OR “traumatized children”) AND (“refugee * ” OR “forced migration”) AND (“art therapy” OR “art”). The Boolean terms were entered into the mentioned databases and the search process continued across the three PRISMA phases (see Figure 1 ). The search was filtered to include articles published in English between the years 2010 and 2020. Two professors of special education reviewed the keywords and agreed on the list of terms that can be used during the search procedure. For relevance to the current review, the abstracts, as well as full-text peer-reviewed articles were obtained and screened. The systematic review focuses on experimental studies conducted from 2010 to 2020. Given that there are a limited number of studies on art therapy with refugee children, this topic was explored at a broader level with a focus on adults, adolescents, and children refugees.

Figure 1 . PRISMA flow diagram for systematic review. From: Page et al. (2021) .

Applying the Inclusion and Exclusion Criteria

In the first phase, databases were selected to search for the selected articles related to the psychology field. The reports obtained were then screened by examining the title and abstract of each article. Results obtained from the screening phase were then examined more closely (i.e., reading full text) and the following inclusion criteria were applied:

(a) Peer-reviewed journal articles,

(b) Published during 2010-2020,

(c) Art therapy intervention study (group design or single-subject research design),

(d) All study sample sizes,

(e) Intervention conducted with refugees diagnosed with PTSD, and

(f) A study published in the English language.

Systematic reviews, descriptive articles, book reviews, and qualitative studies were excluded. Additionally, studies that investigated the effects of expressive art therapy (e.g., dance, music, drama) and other therapeutic interventions that do not include art were removed from the list for potential inclusion. Dissertation and thesis studies were also excluded.

The literature search was conducted, independently, by three researchers (N.A. A.A, and F.Z), who also independently screened the identified peer-reviewed articles' titles and abstracts to assess their eligibility as per the inclusion criteria. If it was unclear whether a study was eligible, the study article was assessed in full. The two researchers concluded that eight research articles yielded eligible.

Coding Based on CEC Quality Indicators and Evidence-Based Classifications

The CEC quality indicators and evidence-based classifications were used to assess the certainty of the evidence for each of the reviewed studies ( Cook et al., 2014 ). The content-coding table was divided into eight areas presenting the quality indicators: (a) context and setting; (b) participants; (c) intervention agent; (d) description of practice; implementation fidelity; (f) internal validity; (g) outcome measures/independent variable; and (h) data analysis. Percentages to determine the quality indicators met are calculated after coding the elements across the studies. After reading the article and identifying the elements in each article, the element was coded as 1 if there is sufficient information regarding the indicator element and 0 if there is insufficient information for the indicator element by referring to the coding sheet based on the CEC standards ( Cook et al., 2014 ).

The CEC standards include 28 quality indicators. Eighteen of the quality indicators apply to group comparison and single-subject studies, six apply only to comparison studies and four are specific to single-subject studies ( Cook et al., 2014 ). The study is expected to describe the critical features regarding the context and setting. To understand the population that will benefit from the intervention, it is important to describe clearly the participants' demographics and define clearly the difficulty of focus or disability the criteria for determining the disability or the difficulty. Researchers also need to examine the role of the intervention agent and background variables. The study is also expected to provide a detailed description of the intervention procedures and intervention agents' actions. The practice also has to demonstrate the fidelity of implementation by using direct reliable measures. For internal validity, the study is expected to describe the baseline and provide a clear description of the assignment to groups. Researchers should include detailed information on the comparison/control group and how participants are assigned to ensure the comparison conditions are meaningful. The researchers are expected to consider the outcome as an indicator by examining how the study clearly defines and describes the measurement of variables and how the effects are reported on all measures of the outcome. Moreover, the researchers need to show the appropriateness of frequency and timing of outcome measures. Finally, data analysis should be conducted appropriately by examining the data analysis techniques such as effect size calculations to determine the amount of the effect of an intervention on the participants or the group.

The quality indicator for each element was calculated individually to determine the percentage met for each indicator across each study. To ensure reliability, two researchers read and coded each of the 8 elements to confirm the identified results and the information. A point-by-point method was used to establish interrater reliability for coding articles. All articles were double-coded by an independent researcher, and the percentage of agreement was calculated (i.e., agreements divided by agreements plus disagreements, multiplied by 100). The initial percentage of agreement was 93%. Coding results were communicated, inconsistencies were discussed, and a consensus was reached (i.e., 100% agreement).

Evidence-Based Classification

After assessing the reviewed studies for quality indicators, methodologically sound studies are then evaluated for evidence-based classifications. A study is considered for evidence-based classification only when they use group comparison designs (e.g., randomized or non-randomized quasi-experiments) or a single-subject research design ( Cook et al., 2014 ). Eligible studies are classified as (a) evidence-based, (b) potentially evidence-based, (c) mixed-effects, (d) insufficient evidence, or (e) negative effects based on the number of single subjects, and group comparison studies of strong and moderate methodological quality with positive, neutral, and negative effects ( Cook et al., 2014 ). Evidence-based practices (EBP) are supported by two group comparison studies with random assignment to groups and at least 60 participants across studies, four group comparison studies with the non-random assignment to groups, and at least 120 participants across studies, or five single-subject studies with at least 20 participants across studies. To be identified as EBP. The practice has to also meet 50 % of the criteria for two or more of the study designs. The group of studies on a given practice should not include any studies with negative effects and at least a 3:1 ratio of positive effects to neutral/mixed effects. Potentially evidence-based practices must be supported by one group comparison study with random assignment to groups and positive effects; two or three group comparison studies with no randomly assigned groups and positive effects; or two or four single-subject studies with positive effects. For this item, CEC considers group experimental, non-randomly assigned group comparison, and single-subject design studies collectively. Mixed-evidence practices must meet the criteria for evidence-based practice or potentially evidence-based practice and the ratio of studies with positive effects to studies with neutral/mixed-effects is <2:1 or one or more studies with negative effects if these studies do not outweigh studies with positive effects. Insufficient evidence exists when the literature is lacking all the other evidence-based criteria. Negative effects must include more than one sound study with negative effects, and the number of studies with negative effects outnumbers the sound studies with positive effects.

Initially, the Boolean search yielded two hundred thirty-two ( n = 232) results, from which seven duplicated records and three records not written in the English language were removed. Two hundred twenty-two ( n = 222) results were obtained before applying the inclusion criteria. After screening titles and abstracts, seventy ( n = 70) articles were considered for potential inclusion. The full texts of the seventy peer-reviewed articles ( n = 70) were read and examined. The application of the above-mentioned inclusion criteria yielded eight experimental studies for review (see Figure 1 ). The reviewed studies employed variations of group designs: quasi-experimental, pre-post group design without control, and within-group designs. Methodological soundness for each study was evaluated based on CEC quality indicators, and quantitative results are reported in Table 1 and explained below. Table 2 represents information about the intervention context, sample size, nationality, and age group of participants across reviewed studies. Participant age groups varied from 7 to 80 years, and the sample size ranged from 12 to 145 participants.

Table 1 . Methodological soundness by quality indicators.

Table 2 . Context and demographic information across reviewed studies.

The evidence so far supporting art therapy for treating PTSD in refugees includes: (a) two quasi-experimental design studies ( Meyer DeMott et al., 2017 ; Feen-Calligan et al., 2020 ), (b) five pre-test post-test group studies with no control ( Van Wyk et al., 2012 ; Ugurlu et al., 2016 ; Moosa et al., 2017 ; Rowe et al., 2017 ; Schouten et al., 2019 ); and (c) one within-subject group design with no control ( DroŽdek et al., 2014 ). Systematic coding of each of the eight articles based on CEC quality indicators indicated that none of the reviewed studies received a score that is below 50% with overall scores ranging from 59 to 86%. Detailed results in relation to our evaluation of quality indicators per study and evidence-based classification of the overall treatment practice are illustrated and justified below.

Results for Quality Indicators

Findings show that all reviewed studies met the criteria regarding describing the context and the setting explicitly. Studies took place in different locations such as Turkey, Sharam Vihar, Mehwath, Australia, and the United States. Similarly, all reviewed studies met the criteria related to providing sufficient information on participants' demographics. It is also critical to note that none of the studies that involved more than one group used random participant assignment to study groups ( DroŽdek et al., 2014 ; Meyer DeMott et al., 2017 ; Feen-Calligan et al., 2020 ). The sample size across studies varied from 12 to 145 participants, and the age of participants ranged from seven to 80 years.

Five articles met the criteria for both intervention agent quality indicator elements ( Van Wyk et al., 2012 ; Ugurlu et al., 2016 ; Meyer DeMott et al., 2017 ; Rowe et al., 2017 ; Feen-Calligan et al., 2020 ). In the studies conducted by Schouten et al. (2019) and by DroŽdek et al. (2014 ), the qualifications, certification, or description of the training of the art therapist were not mentioned. Similarly, the researcher's background or certification, or description of training was not included in the study conducted by Moosa et al. (2017) . In several studies, additional agents were included such as licensed art therapists, psychologists, psychiatrists, Syrian college students, graduate students, and translators.

Three out of the eight reviewed studies reported information related to both elements and met the requirement ( Meyer DeMott et al., 2017 ; Moosa et al., 2017 ; Feen-Calligan et al., 2020 ). The studies provided detailed information by stating the questions asked during the intervention and providing enough materials to clearly describe the dosage and content of the intervention. Ugurlu et al. (2016) provided sufficient information regarding what the art therapy session will include and described the time and dosage of intervention with pre and post-assessments. However, the authors did not provide enough information regarding the description of the materials. In the study conducted by Rowe et al. (2017) , the researchers provided sufficient information regarding dosage and the process evaluation framework during the intervention phase but there was insufficient information regarding the materials used and the detailed process was missing regarding the art therapy techniques used. Similarly, DroŽdek et al. (2014 ) provided a table showing the phases of intervention with the content but did not provide enough materials to describe the specificity of the intervention. In the study done by Schouten et al. (2019) , the researchers explained the sessions but the specific elements of art therapy were not evident and reported. Therefore, this study did not explicitly describe the intervention procedure and materials used, and the researchers provided only general information. In addition, the study that was conducted by Van Wyk et al. (2012) did not describe materials or provide accessible sources.

Five out of eight studies did not meet this criterion as no implementation fidelity data were collected ( Van Wyk et al., 2012 ; DroŽdek et al., 2014 ; Ugurlu et al., 2016 ; Meyer DeMott et al., 2017 ; Moosa et al., 2017 ). In article Rowe et al.'s article, the authors described how the therapists were able to follow the planned protocol for administering assessment tools and dose delivered but it did not clearly state the measures used such as observation checklists or self-reports of the implementation by unit analysis. Schouten et al. (2019) applied the protocol checklist that gave therapists ways to direct sessions and the patients reported satisfaction regarding the session. A checklist regarding treatment adherence was included in this study. However, the questionnaire developed by the author was not clearly described and explained thoroughly. In the article Feen-Calligan et al. (2020) , the study did not include measures or checklists to determine fidelity implementation but the study provided information regarding analyzing sessions by the team and refining sessions by adding recommendations and tracking changes to the following session or week. The observation checklists or self-reports in addition to the dosage were not present in the study.

None of the reviewed studies met all nine elements of the internal validity criterion. In the group design study conducted by Meyer DeMott et al. (2017) , the researchers reported information regarding the assignment of participants to groups but did not clarify if the control group had limited access to intervention. Moreover, in the same study, the differential attrition was less than 10 percent, but the overall attrition was higher than 30 percent. On the other hand, in the study conducted by Feen-Calligan et al. (2020) , the independent variable was controlled, control group conditions were described, and the study reported that the control group had no access to intervention. The study carried out by Feen-Calligan et al. (2020) clearly described how participants were assigned to either the treatment or the control group. In their study, Rowe et al. (2017) reported that participants had access to other mental health resources, which is a threat to internal validity. In four of the studies (i.e., 50%), researchers did not indicate whether participants in the baseline condition had access to any of the intervention components ( Van Wyk et al., 2012 ; Ugurlu et al., 2016 ; Moosa et al., 2017 ; Schouten et al., 2019 ). This may have presented a potential threat to the internal validity of the mentioned studies.

All studies that measured socially important outcomes provided clear operational definitions of the dependent variables and reported the effects of the intervention. The only study that met all elements related to the dependent variable(s) was the study conducted by DroŽdek et al. (2014 ) because in this study the tools used were validated across cultural settings and demonstrated good interrater and test-retest reliability. Rowe et al. (2017) reported that validated assessment tools were used in this study and measures of internal consistency among items for each of the scales were strong. Similarly, the measurement tools used in the study done by Schouten et al. (2019) and the study done by Van Wyk et al. (2012) had been validated and the reliability was good. In addition, Moosa et al. (2017) reported in the study that the measurement tools used were reliable with internal reliability higher than 80. Similarly, the study done by Ugurlu et al. (2016) provided evidence of internal reliability and the study done by Feen-Calligan et al. (2020) provided evidence of reliability and validity. The study that provided three data points was the study done by Meyer DeMott et al. (2017) provided an adequate description of the outcomes measures but did not provide information regarding the internal reliability and validity of the tools.

Regarding data analysis, all reviewed studies met the requirements for this quality indicator. Three elements are included in the data analysis criteria. For a group design study, the study is expected to report effect size statistics and data analysis techniques need to be provided to compare the change in the outcome of the groups ( Cook et al., 2014 ). All group comparison design studies employed appropriate statistical analysis methods that align with their research questions and data collection tools. Additionally, all reviewed studies provided clear descriptions of their data analysis techniques.

Upon evaluation of the methodological soundness of the reviewed studies based on CEC quality indicators and evidence-based classification ( Cook et al., 2014 ), we found that the practice of using art therapy for the treatment of PTSD in refugees falls under the “insufficient evidence” category. As mentioned earlier, according to CEC standards, a study can be considered for evidence-based classification only when they employ a group comparison design (e.g., randomized or quasi-experiment) or a single subject design ( Cook et al., 2014 ). The only two studies that were eligible for classification were the ones that employed quasi-experimental designs ( Meyer DeMott et al., 2017 ; Feen-Calligan et al., 2020 ). Both studies met more than 50% of quality indicators (see Table 1 ). However, upon examination of individual intervention results reported by the authors of both studies, we found that the art therapy intervention conducted by Feen-Calligan et al. (2020) yielded positive effects on participants' PTSD symptoms (i.e., the difference between groups was statistically significant in favor of the treatment group). On the other hand, the intervention implemented by Meyer DeMott et al. (2017) yielded neutral effects (i.e., the differences between groups were not statistically significant). This finding means that the ratio of methodologically sound studies with positive effects to methodologically sound studies with neutral/mixed-effects was <2:1, and thus places the treatment practice in the “insufficient evidence” classification.

This systematic review is the first to examine art therapy with a focus on refugees with PTSD symptoms from 2010 to 2020. After a systematic review of the literature and multi-step evaluation of studies for quality indicators, the findings revealed that art therapy as a treatment for PTSD in children and youth refugees meets the “insufficient evidence” classification as per CEC standards. The present systematic review found that the majority of art therapy intervention studies with refugees with PTSD employed a pre-test post-test group design with no control group. In some studies, art therapy has been used in the intervention as an independent component while in other studies art therapy has been used as part of expressive, creative, or group therapy. All studies met the quality indicators related to context and participants, and thus we can deduce that the studies described clearly the features of the context and setting studies provided enough information related to participants' demographics as well as a clear description of the status of participants. We also notice variation among results regarding the other quality indicators such as the description of practice, the fidelity of implementation, intervention agents, data analysis, internal validity, and outcome measures. Most of the studies (five out of eight studies) met the criteria related to intervention agents and most of the studies described the role of the therapist, qualifications, and the specific training. When examining the description of the intervention, only three studies met this quality indicator by providing a clear and detailed description of the intervention with sufficient materials to describe it specifically. Studies that did not meet this quality indicator lacked the element that is related to providing sufficient information on materials relevant to the intervention being examined. As for implementation fidelity, none of the articles fully met this quality indicator, and two articles did not even mention any effort to collect fidelity data. It is critical to note that this methodological limitation has the potential to pose a threat to internal reliability.

Furthermore, four studies did not meet the quality indicator when examining internal validity and two studies met half of the elements. Only two studies met four elements out of the six elements, and only one study met all the elements regarding internal validity ( Feen-Calligan et al., 2020 ). When examining the outcome measures/ dependent variables, we also notice variation among results. Only one study met all elements for this quality indicator and most of the studies did not provide a minimum of three data points per phase. As for the criteria related to data analysis, all the studies met CEC standards as data analysis was adequately conducted and reported. In conclusion, the lowest scores across studies were for meeting implementation fidelity (i.e., 21%) and internal validity criteria (i.e., 52%).

Limitations of the Study

Since the initial search yielded a very limited number of studies on children refugees, studies with participants of all ages were included in this review. Most of the studies located during the search procedure were qualitative case studies and this indicated that few experimental studies were conducted to test the efficacy of an intervention. This may reflect that researchers need to shift toward empirical evidence more than case studies or qualitative research. Second, the search is limited to peer-reviewed journal articles, and thus excluding dissertations or other types of publications may be a limitation. Another limitation, including peer-reviewed journal articles that are in the English language only may have left out findings from important work written in other languages. Consequently, it can be noted that the low number of articles included in this review may limit generalizing of the findings. Moreover, the number of studies located may be insufficient to present a statistical measurement or meta-analysis. Results and findings also show the importance and need for future studies and more experimental studies because it is essential to improve the practices and methods of implementation. Future systematic reviews may also need to improve search procedures by examining more databases or including additional resources to improve search procedures yielding results that are more accurate. It is also essential to examine these practices with other participants (military, participants who witnessed war but did not leave the country, and others) or participants suffering from other types of disorders or symptoms to compare the effectiveness of these practices.

Implications for Research, Practice, and Policy

The majority of reviewed studies used pre-post group designs with the absence of a control group, and very few articles employed experimental research methodology (e.g., group experiment, quasi-experimental, single-subject design). Knowing that intervention studies that employ single-group pre-post designs are limited by serious threats to internal validity ( Shadish, 2002 ), future research should focus on experimental methodology to investigate the effectiveness of art therapy on PTSD symptoms in refugees. We also suggest that more experimental studies are warranted across other different contexts to identify how art therapy approaches can be implemented effectively. Therefore, this field or area of practice needs to be further explored, developed, and enhanced since art therapy-based interventions may lead to positive effects on individuals suffering from PTSD, as shown in one methodologically sound study among the reviewed literature ( Feen-Calligan et al., 2020 ). Further systematic reviews that combine both qualitative and quantitative methodologies may be included to explore the elements that may affect and decrease traumatic symptoms. This review developed a bridge between what literature presents, what therapists know, and therapists' practice. To improve the transferability of practice, further quantitative studies are needed that aim at enhancing implementation fidelity and having sufficient information regarding internal validity. Future studies need to provide more detailed materials or resources when describing the practice in the studies. After examining the table and comparing the ages of participants, it is essential to improve practices in future studies by focusing on children as participants since most of the studies included adolescents or adults. Other factors may also have an impact on the effectiveness of the intervention and these variables should be taken into consideration when interpreting data. It may also be difficult to reach conclusions about the most effective interventions and practices because of the small sample groups. It would be important to conduct further comparative studies among different contexts and wider populations to draw firmer conclusions about the most effective interventions for traumatized children and adolescent refugees.

Data Availability Statement

The original contributions presented in the study are included in the article/supplementary material, further inquiries can be directed to the corresponding author/s.

Author Contributions

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

Conflict of Interest

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

Publisher's Note

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

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Meyer DeMott, M. A., Jakobsen, M., Wentzel-Larsen, T., and Heir, T. (2017). A controlled early group intervention study for unaccompanied minors: can Expressive Arts alleviate symptoms of trauma and enhance life satisfaction?. Scand. J. Psychol. 58, 510–518. doi: 10.1111/sjop.12395

Moosa, A., Koorankot, J., and Nigesh, K. (2017). Solution focused art therapy among refugee children. Indian J. Health Wellbeing 8, 811–816.

Morrell, M. (2011). Signs and symbols in art therapy. J. Clinic. Art Therap. 1, 25–32. Retrieved from: https://digitalcommons.lmu.edu/jcat/vol1/iss1/8

Nesterko, Y., Jäckle, D., Friedrich, M., Holzapfel, L., and Glaesmer, H. (2020). Prevalence of post-traumatic stress disorder, depression and somatisation in recently arrived refugees in Germany: an epidemiological study. Epidemiol. Psychiatric Sci. 29, 1–11. doi: 10.1017/S2045796019000325

Page, M. J., McKenzie, J. E., Bossuyt, P. M., Boutron, I., Hoffmann, T. C., Mulrow, C. D., et al. (2021). The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. Int. J. Surg. 88, 105906. doi: 10.1016/j.ijsu.2021.105906

Palic, S., and Elklit, A. (2011). Psychosocial treatment of posttraumatic stress disorder in adult refugees: a systematic review of prospective treatment outcome studies and a critique. J. Affect. Disord. 131, 8–23. doi: 10.1016/j.jad.2010.07.005

Register, D., and Hilliard, R. (2008). Using Orff-based techniques in children's bereavement groups: a cognitive-behavioural music therapy approach. Arts Psychotherap. 35, 162–170. doi: 10.1016/j.aip.2007.10.001

Rowe, C., Watson-Ormond, R., English, L., Rubesin, H., Marshall, A., Linton, K., et al. (2017). Evaluating art therapy to heal the effects of trauma among Refugee youth: The Burma art therapy program evaluation. Health Promot. Pract. 18, 26–33. doi: 10.1177/1524839915626413

Saab, C., Al-Hroub, A., and Vlaardingerbroek, B. (2019). Developing a policy for street children in Lebanon. Issam Fares Institute for Public Policy and International Affairs (IFI), American University of Beirut (AUB), Lebanon . Available online at: https://www.aub.edu.lb/ifi/Documents/publications/policy_briefs/2019-2020/20191008_developing_policy_educational_needs_street_children_lebanon.pdf

Schouten, K. A., Niet, G. J. D., Knipscheer, J. W., Kleber, R. J., and Hitschemaekers, G. J. M. (2015). The effectiveness of art therapy in the treatment of traumatized adults. a systematic review on art therapy and trauma. Trauma Violen. Abuse. 16, 220–228. doi: 10.1177/1524838014555032

Schouten, K. A., van Hooren, S., Knipscheer, J. W., Kleber, R. J., and Hutschemaekers, G. J. (2019). Trauma-focused art therapy in the treatment of posttraumatic stress disorder: a pilot study. J. Trauma Dissoc. 20, 114–130. doi: 10.1080/15299732.2018.1502712

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Wahlbeck, H., Kvist, L. J., and Landgren, K. (2020). Art therapy and counseling for fear of childbirth: a randomized controlled trial. Art Therap. 37, 123–130. doi: 10.1080/07421656.2020.1721399

Zubala, A., and Karkou, V. (2018). Arts Therapies in the Treatment of Depression: International Series of Arts Therapies Research. London: Routledge.

Keywords: art therapy, trauma, refugees, post-traumatic stress disorder, systematic review, evidence-based practice, quality indicators, mental health

Citation: Annous N, Al-Hroub A and El Zein F (2022) A Systematic Review of Empirical Evidence on Art Therapy With Traumatized Refugee Children and Youth. Front. Psychol. 13:811515. doi: 10.3389/fpsyg.2022.811515

Received: 08 November 2021; Accepted: 14 April 2022; Published: 18 May 2022.

Reviewed by:

Copyright © 2022 Annous, Al-Hroub and El Zein. 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: Anies Al-Hroub, aa111@aub.edu.lb

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

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Art Therapy, Research and Evidence-based Practice

• Andrea Gilroy - Goldsmiths College, University of London, UK
• Description

`This impressive book is lively, inspiring and innovative. Andrea Gilroy's energetic enthusiasm for her subject is infectious. She breathes life into the topics of research and EBP. This rich exploration combines a rigorous investigation of the existing literature with intelligent, original and practical suggestions. A thorough, informative approach that challenges existing thinking. This is a must for art therapists - at last a book that places art at the centre of our evidence in a convincingly argued, accessible and rewarding read' - Professor Joy Schaverien PhD

Art Therapy is under increasing pressure to become more "evidence-based". As a result, practitioners now need to get to grips with what constitutes "evidence", how to apply research in appropriate ways and also how to contribute to the body of evidence through their own research and other related activities.

Written specifically for art therapy practitioners and students, Art Therapy, Research & Evidence Based Practice :

" traces the background to EBP

" critically reviews the existing art therapy research

" explains the research process

" links research with the development of clinical guidelines, and

" describes the knowledge and skills needed to demonstrate efficacy.

Drawing on her own experience as a researcher, practitioner and lecturer, Andrea Gilroy looks at the implications of EBP for art therapy and examines common concerns about the threat it may pose to the future provision of art therapy within public services.

Art Therapy, Research Evidence-Based Practice addresses issues which are critical to the future development and even the survival of art therapy. Combining insightful analysis with practical guidance and examples, this is an ideal resource for practitioners and for those in training.

See what’s new to this edition by selecting the Features tab on this page. Should you need additional information or have questions regarding the HEOA information provided for this title, including what is new to this edition, please email [email protected] . Please include your name, contact information, and the name of the title for which you would like more information. For information on the HEOA, please go to http://ed.gov/policy/highered/leg/hea08/index.html .

For assistance with your order: Please email us at [email protected] or connect with your SAGE representative.

SAGE 2455 Teller Road Thousand Oaks, CA 91320 www.sagepub.com

`This is an important and topical book coming at a time when there is growing pressure to show evidence of good practice, in order to reassure the prospective client, and to demonstrate financial accountability. It gives valuable guidelines and examples for art therapists. The book is innovative and inspiring, and the author's enthusiasm shines through. I end with the last line of this topical, readable, relevant book - one that encapsulates its content: 'We need the facts, we need the figures, but we need the stories and the pictures, too' - Therapy Today

`This book brings makes a major contribution to the field of art therapy by reviewing, in an accessible and informed manner, the issues around the development of research-informed practice. The author offers an overview of different traditions of inquiry that will be of value to practitioners as well as those actually involved in carrying out research' - John McLeod, Tayside Institute for Health Studies, University of Abertay Dundee

Relevance, comprehensive, quality of evidence, easy to read

a useful text that guide the design and implementation of art therapy interventions with diverse populations. This text is not only a must read but an essential component and acquisition for practitioners, clinicians and academic alike

adopted as a recommended read for the Art Therapy Students undertaking the research module as it helps them apply theory of research to their own practice

a brilliant read

excellent comprehensive text. adopts balanced and well-argued position. provides a thorough review of art therapy research. a very good addition to the field. will recommend to PGT and PGR students undertaking research projects in art therapy.

Provides an excellent and timely introduction to the adoption of both qualitative and quantitative research methodologies within art therapy.

Preview this book

For instructors, select a purchasing option, related products.

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

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

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

SEEKING TO ADDRESS THE FOLLOWING RESEARCH QUESTIONS:

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

SUGGESTED POPULATIONS TO RESEARCH:

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

BIBLIOGRAPHIC SEARCH TOOL

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

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

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

Research and Evidence Base in ART

Art research bibliography:.

Peer-reviewed publications began in 2012 after completion of a prospective cohort study of 80 adults with symptoms of psychological trauma. Multiple peer-reviewed papers have been published on  ART  with many more in progress.

Evidence-Based:

ART  has been classified as an “ Effective ” intervention for the treatment of Depression and Depressive Symptoms, Trauma and Stress-Related Disorders, and Personal Resilience/Self-Concept.

Peer-Reviewed Publications:

Accelerated resolution therapy: randomized controlled trial of a complicated grief intervention..

Harleah G. Buck, PhD, RN, FPCN, FAHA, FAAN, Paula Cairns, PhD, RN, Nnadozie Emechebe BPharm, MPH, Diego F. Hernandez, PsyD, Tina M. Mason, MSN, APRN, AOCN, AOCNS, FCNS, Jesse Bell, MS, MPH, Kevin E. Kip, PhD, FAAS, Philip Barrison, BS, and Cindy Tofthagen, PhD, APRN, AOCNP, FAANP, FAAN. American Journal of Hospice & Palliative Medicine® 2020

Brief treatment of symptoms of post-traumatic stress disorder (PTSD) by use of Accelerated Resolution Therapy (ART)

Kip KE, Elk CA, Sullivan KL, Kadel R, Lengacher CA, Long CJ, Rosenzweig L, Shuman A, Hernandez DF, Street JD, Girling SA, Diamond DM. Behavioral Sciences 2012; 2(2): 115-134

Brief treatment of co-occurring post-traumatic stress and depressive symptoms by use of accelerated resolution therapy

Kip KE, Sullivan KL, Lengacher CA, Rosenzweig L, Hernandez DF, Kadel R, Kozel FA, Shuman A, Girling SA, Hardwick MJ, Diamond DM. Frontiers in Psychiatry 2013; 4(article 11):1-12. doi: 10.3389/fpsyt.2013.00011

Stress Management Intervention To Prevent Post–Intensive Care Syndrome–Family In Patients’ Spouses

Paula L. Cairns, Harleah G. Buck, Kevin E. Kip, Carmen S. Rodriguez, Zhan Liang and Cindy L. Munro. ©2019 American Association of Critical-Care Nurses; Am J Crit Care 471-476 28 2019; 10.4037/ajcc2019668

Randomized controlled trial of accelerated resolution therapy (ART) for symptoms of combat-related post-traumatic stress disorder (PTSD)

Kip, KE, Rosenzweig L, Hernandez DF, Shuman A, Sullivan KL., Long CJ, Taylor J, McGhee S, Girling SA, Wittenberg, T, Sahebzamani, FM, Lengacher CA, Kadel R, Diamond DM. Military Medicine 2013; 178: 1298-1309

Case report and theoretical description of Accelerated Resolution Therapy (ART) for military-related post-traumatic stress disorder

Case report and theoretical description of Accelerated Resolution Therapy (ART) for military-related post-traumatic stress disorder. Military Medicine 2014; 179:31-37

Accelerated resolution therapy (ART) for treatment of pain secondary to combat-related post-traumatic stress disorder (PTSD)

Kip KE, Rosenzweig L, Hernandez DF, Shuman A, Diamond DM, Girling SA, Sullivan KL, Wittenberg T, Witt A, Lengacher CA, Anderson B, McMillan SC. European Journal of Psychotraumatology 2014, 5: 24066 – http://dx.doi.org/10.3402/ejpt.v5.24066

Comparison of Accelerated Resolution Therapy (ART) for treatment of symptoms of PTSD and sexual trauma between civilian and military adults

Kip KE, Hernandez DF, Shuman A, Witt A, Diamond DM, Davis SE, Kip R, Abhayakumar A, Wittenberg T, Girling SA, Witt S, Rosenzweig J. Military Medicine, 180: 964-971

Accelerated resolution therapy: an innovative mental health intervention to treat post-traumatic stress disorder

Finnegan A, Kip K, Hernandez D, McGhee S, Rosenzweig L, Hynes C, Thomas M. Journal of the Royal Army Medical Corps 2015 Jul 3. pii: jramc-2015-000417. doi: 10.1136/jramc-2015-000417. [Epub ahead of print]

ART-Related Publications:

Posttraumatic stress disorder and related diseases in combat veterans.

Textbook Chapter: Waits WM, Kip KE, Hernandez DF. Accelerated Resolution Therapy. In Ritchie EC (ed). Springer International Publishing, Switzerland, 2015; pp 105-121

Interview with Dr. Charles Hoge on PTSD Treatments and a Novel Treatment, Accelerated Resolution Therapy

Other Publications: Hoge, C. Australasian Society of Traumatic Stress Studies, August, 2015

Posttraumatic Stress Disorder: Developments in Assessment and Treatment

Hoge CW, Lies J. Federal Practitioner, April 2015; 16S-20S

Accelerated Resolution Therapy (ART): Clinical Considerations, Cautions, and Informed Consent for Military Mental Health Clinicians

Hoge CW. Notes prepared by: Charles W. Hoge, M.D., Senior Scientist Walter Reed Army Institute of Research (WRAIR) Walter Reed National Military Medical Center (WRNMMC) Office of the Army Surgeon General (OTSG) (Cleared for public release February 12, 2015)

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For more information visit  www.husson.edu/ givingday

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Benefits of Art Therapy for Mental and Physical Health

Published on: February 28, 2024

Art therapy is a niche within the mental health care industry focused on encouraging individuals to rely on art to improve their outlook and reduce symptoms of anxiety and depression. According to the  American Art Therapy Association , art therapy can serve as a supplement to traditional mental health care treatment and work to boost cognitive function, emotional resilience and self-confidence. It can also help reduce stress and aid conflict resolution, making it a powerful tool for people of all ages and backgrounds.

Amid a widespread mental health crisis, the need for art therapy for mental health is obvious. Mental health care professionals who are passionate about art therapy and holistic wellness services may be interested in exploring the new Expressive Arts Therapy certificate program available at Husson University. This certificate program allows skilled professionals to use a variety of tools to help treat their patients. The art therapy courses teach how various forms of art, dance, drama, music, and writing can be used to benefit their patients.

Explore Our Degree and Certificate Programs

The Importance of Art Therapy for Mental Health

Art therapy as a practice is incredibly versatile and can be used in various ways to support mental health. Depending on the needs of the individual and their experiences with therapy, a mental health care provider may use different techniques to help their client.

According to  Very Well Mind , the purpose of art therapy is to help develop a greater sense of self-awareness through creative expression and, in turn, learn additional coping mechanisms that can help them lower stress levels or reduce feelings of depression or anxiety.

Some common art therapy techniques include coloring, drawing, music, photography, sculpture and writing. Not only do individuals benefit from the creative process of making art, but they may also gain further insight through reflection that can help them move forward in their lives.

The Connection Between Art and the Brain

Humans have long been drawn to art; they are moved to create it, and they are attracted to pieces that have been crafted by other artists. The truth of the matter is that this desire to be creative and appreciate art is rooted in science. There is a potent, biological connection between art and the brain, which is one of the reasons why art therapy can be so beneficial and effective.

According to the  American Congress of Rehabilitation Medicine , studies have shown that simply observing art can boost serotonin and increase blood flow to the brain. This natural connection between art and the brain confirms the numerous benefits of art therapy.

Research Supporting Art and Mental Health

During the growing mental health crisis, more researchers are beginning to look into the root causes of these struggles and the most effective treatments to help people suffering from mental health disorders and severe mental illnesses. A recent  study published in Cureus  reviewed the most recent art therapy treatments and determined that this practice—when used as a supplement to traditional treatments such as counseling or medication—can be a valuable component of a mental health care treatment plan.

Benefits of Art Therapy

Art therapy for mental health is considered an incredibly beneficial treatment option, especially when used in combination with other mental health care services. Art therapy has the power to:

Reduce Stress and Anxiety

The process of creating art can help naturally reduce stress levels and minimize anxiety, largely because it requires the individual to remain present and focused on the task at hand. Additionally, the creative arts allow for plenty of flexibility and an opportunity for people to express themselves in ways they may not be able to in other parts of their lives.

According to  Everyday Health , some studies have shown that individuals who take at least 45 minutes every day to create art are more likely to have reduced cortisol levels compared to those who do not reserve time for the creative arts.

Stimulate Cognitive Abilities

Research has revealed a direct correlation between art and brain function, which means art therapy may also help improve cognitive abilities. When an individual is engaged in the process of creating art, they are more likely to enter a deep flow state in which they are entirely present and focused on their work. During this time, they are allowing their brain to heal and restore itself. Most people who can enter this deep flow state report feeling almost euphoric—there is a sense of pleasure associated with the process of creating art that is entirely and uniquely theirs.

Help With Pain

Art therapy may be able to help ease pain because it allows individuals to explore their feelings and experiences creatively. Those experiencing chronic or traumatic pain may be able to use art as a way to manage the impact of that pain, and they can then reflect on their creations to better understand what they are going through. By focusing on their art, they may no longer be consumed or distracted by the pain they are experiencing.

Improve Self-Esteem and Self-Awareness

One of the most compelling benefits of art therapy is its ability to elevate self-esteem and self-awareness. Using a variety of mediums and techniques to create art, individuals are able to channel their emotions into their works. There is a natural sense of pride that develops as the person can overcome the challenges in art and produce a final piece, and they can also deepen their understanding of their feelings as they reflect upon the art.

Encourage Emotional Expression

Art provides a safe and creative space for emotional expression. One of the most difficult aspects of managing emotions is learning how to release them, especially when a person finds it challenging to talk about their experiences and put words to their feelings. Through art therapy, people can find distinct and innovative ways to express themselves and release those emotions. For many, art therapy techniques become a coping mechanism they rely on for years to come.

How Does Art Therapy Work?

Individuals who opt for art therapy treatment work in cooperation with a practicing art therapist who understands the most effective techniques and mediums to use. Art therapy is typically used as a supplement and can be combined with other mental health care treatment options.

According to  Psychology.org , art therapy involves:

• Establishing a defined goal for the art therapy program.
• Allowing the client to choose a medium that appeals to them.
• Providing the client with guidance about the process of creating art and how it can be constructed in a therapeutic way.
• Encouraging the client to reflect on the artwork they have created.
• Discussing the finished product with the client to better understand its relevance to their feelings and experiences.

Who Can Benefit From Art Therapy?

As a holistic treatment option, there are many types of clients who can benefit from art therapy. According to the  Sage Neuroscience Clinic , some groups that commonly benefit from art therapy include:

• Children – Young children who have experienced traumatic events benefit from art therapy as an outlet for their emotions, particularly when they may not have the words to express them. Art therapy for children also allows the provider to develop a better understanding of their client and their needs.
• Seniors – Elderly people are at a higher risk of cognitive decline, and art therapy can help them improve and restore cognitive function.

How to Incorporate Art Therapy in Daily Life

Art therapy techniques can often be incorporated into daily life, too. Many people who participate in art therapy find that they continue drawing, painting, sculpting and creating well after their therapy programs are complete. When art therapy techniques become part of the daily routine, they can help ward off ongoing feelings of anxiety, depression and stress.

Explore the Connection Between Art and Mental Health at Husson University

Combining the freedom of the creative arts with proven mindfulness techniques and healing strategies, the Expressive Arts Therapy certificate program at Husson University could equip you with the skills needed to pursue this niche career path. This new program adds to our growing collection of  online degree and certificate programs  that are designed to empower you and fuel your career.

Request more information  about our degree and certificate programs.

Select a Program

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Art Therapy, Research and Evidence-based Practice

• Andrea Gilroy - Goldsmiths College, University of London, UK
• Description

`This book makes a major contribution to the field of art therapy by reviewing, in an accessible and informed manner, the issues around the development of research-informed practice. The author offers an overview of different traditions of inquiry that will be of value to practitioners as well as those actually involved in carrying out research' - John McLeod, Tayside Institute for Health Studies, University of Abertay Dundee

`This impressive book is lively, inspiring and innovative. Andrea Gilroy's energetic enthusiasm for her subject is infectious. She breathes life into the topics of research and EBP. This rich exploration combines a rigorous investigation of the existing literature with intelligent, original and practical suggestions. A thorough, informative approach that challenges existing thinking. This is a must for art therapists - at last a book that places art at the centre of our evidence in a convincingly argued, accessible and rewarding read' - Professor Joy Schaverien PhD

Art Therapy around the world is under increasing pressure to become more "evidence-based". As a result, practitioners now need to get to grips with what constitutes "evidence", how to apply research in appropriate ways and also how to contribute to the body of evidence through their own research and other related activities.

Written specifically for art therapy practitioners and students, Art Therapy, Research & Evidence Based Practice :

" traces the background to EBP

" critically reviews the existing art therapy research

" explains the research process

" links research with the development of clinical guidelines, and

" describes the knowledge and skills needed to demonstrate efficacy.

Drawing on her own experience as a researcher, practitioner and lecturer, Andrea Gilroy looks at the implications of EBP for art therapy and examines common concerns about the threat it may pose to the future provision of art therapy within public services.

Art Therapy, Research Evidence-Based Practice addresses issues which are critical to the future development and even the survival of art therapy. Combining insightful analysis with practical guidance and examples, this is an ideal resource for practitioners and for those in training.

`This is an important and topical book coming at a time when there is growing pressure to show evidence of good practice, in order to reassure the prospective client, and to demonstrate financial accountability. It gives valuable guidelines and examples for art therapists. The book is innovative and inspiring, and the author's enthusiasm shines through. I end with the last line of this topical, readable, relevant book - one that encapsulates its content: 'We need the facts, we need the figures, but we need the stories and the pictures, too' - Therapy Today

`This book brings makes a major contribution to the field of art therapy by reviewing, in an accessible and informed manner, the issues around the development of research-informed practice. The author offers an overview of different traditions of inquiry that will be of value to practitioners as well as those actually involved in carrying out research' - John McLeod, Tayside Institute for Health Studies, University of Abertay Dundee

Relevance, comprehensive, quality of evidence, easy to read

a useful text that guide the design and implementation of art therapy interventions with diverse populations. This text is not only a must read but an essential component and acquisition for practitioners, clinicians and academic alike

adopted as a recommended read for the Art Therapy Students undertaking the research module as it helps them apply theory of research to their own practice

a brilliant read

excellent comprehensive text. adopts balanced and well-argued position. provides a thorough review of art therapy research. a very good addition to the field. will recommend to PGT and PGR students undertaking research projects in art therapy.

Provides an excellent and timely introduction to the adoption of both qualitative and quantitative research methodologies within art therapy.

Preview this book

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This is a mass-produced replica of a famous miracle-working icon of the Virgin and Child, brought to Russia from Byzatium in the 12th century, known as the "Virgin of Vladimir", and currently kept in Moscow (State Tretyakov Gallery). The Virgin and Child are each identified by abbreviated inscriptions.

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Henry Walters, Baltimore [date of acquisition unknown], by purchase; Walters Art Museum, 1931, by bequest.

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Acknowledgments, personalized cancer vaccines directed against tumor mutations: building evidence from mice to humans.

Cancer Res 2024;84:953–5

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• Version of Record April 1 2024

Edward F. Fritsch , Patrick A. Ott; Personalized Cancer Vaccines Directed against Tumor Mutations: Building Evidence from Mice to Humans. Cancer Res 1 April 2024; 84 (7): 953–955. https://doi.org/10.1158/0008-5472.CAN-24-0565

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Personalized vaccines directed to tumor mutations have recently gained significant momentum. On the basis of the concept of stimulating T-cell responses against neoantigens encoded by a tumor's host of personal mutations, these vaccines utilize genome or exome sequencing, mutation calling, and epitope prediction followed by manufacturing of a customized vaccine for each patient. In their 2012 Cancer Research publication, Castle and colleagues provided evidence that vaccinating with long peptide vaccines encompassing neoantigens can generate robust immune responses and induce antitumor activity in a mouse B16F10 melanoma. This approach, harnessing the exquisite specificity of mutations to the tumor and thus providing an effective target for cancer vaccines, was subsequently shown to be safe and immunogenic in a series of small first in man trials in patients with melanoma. The field has accelerated and expanded substantially over the last 5 years, propelled by increasing evidence for vaccine-mediated clinical efficacy, leading to ongoing registrational trials using personalized RNA neoantigen vaccines in patients with melanoma and several other malignancies.

See related article by Castle and colleagues, Cancer Res 2012;72:1081–91

By the early 2010s, the emergence of next-generation sequencing enabled the in-depth genetic characterization of cancer genomes from multiple individual tumors, revealing a mutational landscape characterized by mostly personal mutations, the tumor of each patient having its own unique set of mutations. Surprisingly, the vast majority of missense mutations in protein-coding regions were not in cancer driver genes, the classical targets to counteract cancer promoting pathways, but in many other expressed genes of unknown direct functional significance. However, the immunologic importance of such mutations was recognized on the basis of decades of work highlighting the favorable immunologic properties of “neoantigens”—mutation-based epitopes unique to tumor cells and able to overcome central immune tolerance to generate T cells capable of eliminating tumors expressing these antigens ( Fig. 1 ; ref. 1 ).

Targeting the cancer mutanome with T cells. The advent of next-generation sequencing has enabled rapid identification of a tumor's mutational landscape. Coupled with improved epitope prediction algorithms, these advances allow the identification of putatively immunogenic mutations in the tumor genomes of individual patients and the generation of personalized T cell–inducing vaccines.

The concept of a personalized cancer vaccine is based on the paradigm of sequencing the coding genomes or exomes of individual tumors to globally identify mutations that encode neoepitopes, predicting which neoepitopes are most likely to be presented to the host immune system and thus capable of triggering an immune response, and generating a vaccine based on these neoepitopes. Stimulating an immune response with a personalized vaccine that utilizes a broad spectrum of tumor specific antigens and is not affected by central immune tolerance addresses the challenges of clonal evolution and the resulting tumor heterogeneity. The publication by Ugur Sahin, John Castle, Sebastian Kreiter, and others describes using high-throughput next-generation exome sequencing to assess the mutational landscape of a mouse melanoma and to interrogate the immunogenic potential of a validated subset of these mutations by vaccinating with peptides encompassing such mutations ( 2 ).

Whole-exome sequencing of the B16F10 mouse melanoma model revealed 962 nonsynonymous point mutations, about half of which were expressed. Fifty of these mutations were selected based on quality metrics of the mutation call, abundant occurrence in the B16F10 transcriptome, and MHC peptide binding score, and then tested for immunogenicity. C57BL/6 mice were vaccinated with long peptides (27 amino acids including the predicted epitope and short surrounding native sequences on either side) plus the Toll-like receptor (TLR) 3 agonist poly(I:C). Sixteen of the 50 peptides induced T-cell responses as assessed by IFNγ ELISPOT utilizing bone marrow–derived dendritic cells (DC) pulsed with peptides. Eleven of these 16 mutations induced T-cell responses specific to mutated peptides. T-cell responses were also confirmed using in vitro –transcribed RNA coding for three of the 16 respective long peptides that induced a strong mutation-specific T-cell response. Importantly, vaccinating with long peptides encompassing either of 2 of the mutations adjuvanted with poly-IC delayed growth of B16F10 tumors. The study demonstrated that generating customized vaccines targeting a portion of personal mutations of a cancer genome can trigger robust antitumor responses in the B16F10 mouse model. Similar studies in other tumor models have corroborated and expanded on these results.

Surprisingly, a follow-up publication from the same group found that the B16F10 epitopes (and also similar mutation-based epitopes in two other murine models) predicted on the basis of MHC class I binding primarily generated MHC class II restricted (i.e., CD4 + ) T-cell responses ( 3 ). This discrepancy has extended to human neoantigen-based vaccination (see below) and still lacks a proven molecular basis. A critical role of CD4 + T cells has been established in the context of tumor-directed T-cell immunity ( 4 ) but whether the vaccine-induced CD4 + T cells arising from MHC class I–predicted epitopes contribute directly or indirectly to tumor control is still unclear.

Three subsequent studies—all conducted in patients with melanoma—demonstrated that personalized vaccines generated by processes fundamentally similar to those presented by Castle and colleagues (whole-exome sequencing for mutation identification, transcriptome analysis, and MHC class I epitope prediction) could be effectively produced and administered safely to patients with cancer. These studies differed in epitope design (predicted MHC class I binding peptide alone as the antigen or the predicted binding peptide included within a larger encoded context—“long peptides”) or whether peptides, peptide-loaded DCs, or lipid-encapsulated mRNA encoding the peptides were used as the delivery vehicle.

In the first of the three studies, three patients with stage III melanoma were treated intravenously with autologous, mature DC pulsed with 7 epitope-length peptides per patient. The vaccines generated de novo CD8 + T-cell responses against 6 immunizing neoantigens and augmented preexisting CD8 + T-cell responses against another 3 ( 5 ). In a clinical trial conducted by the group that performed the first mouse study discussed in this Landmark commentary, 13 patients with melanoma received intranodal injections with RNA vaccines encoding up to 10 neoantigens ( 6 ). Approximately 60% of the 125 vaccinating neoantigens across the 13 patients generated T-cell responses (20% of which were detected ex vivo ) with a predominance of CD4 + over CD8 + , as observed preclinically. Two-thirds of the neoantigens stimulated de novo responses. Initial signals of vaccine-mediated clinical antitumor activity were observed in this study: two patients with advanced melanoma had objective responses and a third one experienced a complete response after additional PD-1 inhibition; the rate of recurrences was substantially reduced postvaccination in patients who had no evidence of disease entering the trial. In the third melanoma trial, 8 patients with high-risk melanoma received up to 20 long peptides formulated with the TLR agonist poly-ICLC encoding personal neoantigens ( 7, 8 ). The vaccines were very well tolerated (no dose limiting toxicities) and induced strong ex vivo T-cell responses in all patients. Similar to the intranodal RNA vaccine, the majority of neoantigens contained in the vaccines stimulated T-cell responses with a predominance of vaccine-induced CD4 + compared with CD8 + T-cell responses. In a follow-up analysis of this trial, persistent vaccine-specific immunity was detected across all vaccinated patients at long-term time points up to 4.5 years postvaccination, and single-cell RNA sequencing and single-cell TCR sequencing studies on tetramer-sorted vaccine-specific CD4 + T cells revealed TCR repertoire diversification and the generation of a memory cell response. Furthermore, ongoing complete responses were observed in 2 patients who received PD-1 inhibition upon disease progression during or immediately after vaccination.

On the basis of these encouraging results, the investigation of personalized neoantigen vaccines in cancer patients has broadened substantially in scope—larger trials, an increasing number of tumor types, additional vaccine platforms, and inclusion of control arms. Beyond melanoma, personalized vaccine trials have been conducted in patients with non-small cell lung cancer, glioblastoma, pancreatic cancer, urothelial cancer, colorectal cancer, bladder cancer, and others. Across trials, neoantigen-directed vaccines have consistently been found to be safe and immunogenic in the majority of vaccinated patients; furthermore, signals of vaccine-induced antitumor activity have been seen. In one particularly impressive example, 16 patients with surgically resected pancreatic cancer were treated with one dose of the PD-L1–specific antibody atezolizumab, followed by vaccination with a personalized RNA vaccine targeting up to 20 neoantigens and subsequent standard-of-care chemotherapy ( 9 ). Half of the 16 patients developed vaccine-specific immunity as measured by ex vivo IFNγ ELISPOT and expansion of T-cell clones measured by TCR Vβ sequencing. No tumor recurrences were observed in this group over the course of the study, while patients who did not immunologically respond to the vaccine had recurrences at the expected rate for standard-of-care therapy. This accelerating pace of clinical development was boosted further by the recent report of prolonged recurrence-free survival in patients with high-risk stage III or IV melanoma randomized to receive a personalized RNA vaccine in combination with pembrolizumab compared with pembrolizumab alone ( 10 ). Phase III trials testing this vaccine in patients with melanoma and other cancers are underway.

In just under 15 years, the further development of personalized neoantigen vaccines has revitalized the field of cancer vaccines, with an expectation that such vaccines will be an important component of the cancer immunotherapy armamentarium. Furthermore, it brought neoantigens in the mechanistic spotlight for tumor-infiltrating lymphocyte and checkpoint blockade therapy. There are still logistic and technical hurdles ahead, as such vaccines are costly and slow to bespoke manufacture, and so far only utilize a subset of the potential neoantigen classes found in tumors. Broadening the use of personalized neoantigen vaccines will require innovative approaches that can build on the solid foundation established by these studies.

E.F. Fritsch reports other support from BioNTech and nonfinancial support from Dionis Therapeutics outside the submitted work; in addition, E.F. Fritsch has a patent for Compositions and methods for personalized neoplasia vaccines pending to BioNTech, a patent for Combination therapy for neoantigen vaccine pending to BioNTech, a patent for Multi-domain protein vaccine pending to Dionis Therapeutics, and a patent for Nucleic Acid Artificial Mini-Proteome Libraries pending to Dionis Therapeutics. P.A. Ott reports grants and personal fees from Bristol Myers Squibb and Genentech; grants from Celldex, Merck, Neon Therapeutics, and Evaxion; nonfinancial support from Immunetune; MyNeo; and personal fees from Servier and Phio outside the submitted work.

We thank Ute E. Burkhardt for support with generating Fig. 1. P.A. Ott is supported by NCI-R01 CA229261; Team Science Award from the Melanoma Research Alliance; the Francis and Adele Kittredge Family Immuno-Oncology and Melanoma Research Fund; the Susan and Bruce Hampton Research Fund; the Fisher Family Fund; and the Morgan Family Fund for Melanoma Research.

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• Exploiting the Mutanome for Tumor Vaccination

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