research about art therapy

• Open access
• 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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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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Lost for words? Research shows art therapy brings benefits for mental health

Academic, Master of Art Therapy Program, Western Sydney University

Senior Lecturer, Child and Adolescent Psychiatry, UNSW Sydney

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Sarah Versitano is a PhD Candidate at Western Sydney University and works for the Sydney Children's Hospitals Network, which is part of NSW Health. She has received funding from the Health Education and Training Institute (HETI) for the Mental Health Research Award. She is a Registered Art Therapist with the Australia, New Zealand and Asian Creative Arts Therapies Association (ANZACATA) and Registered Clinical Counsellor with the Psychotherapists and Counsellors Federation of Australia (PACFA). She has delivered art therapy and psychotherapy in public and private hospital settings.

Iain Perkes works for the University of New South Wales and the Sydney Children's Hospitals Network which is part of NSW Health. He has previously worked for numerous health services throughout NSW Health. He has received funding or awards from the Australian National Health and Medical Research Council (NHMRC), the International Association of Child and Adolescent and Allied Professions, (IACAPAP), the World Psychiatric Association (WPA), the Tourette's Association of America (TAA), Tourette Syndrome Association (TSA), the NSW Institute of Psychiatry, The University of Sydney, and the Sydney Partnership for Health, Education, Research and Enterprise (SPHERE). He is affiliated with Neuroscience Research Australia (NeuRA) and the Health Education and Training Institute (HETI, NSW Health).

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Creating art for healing purposes dates back tens of thousands of years , to the practices of First Nations people around the world. Art therapy uses creative processes, primarily visual art such as painting, drawing or sculpture, with a view to improving physical health and emotional wellbeing .

When people face significant physical or mental ill-health, it can be challenging to put their experiences into words . Art therapists support people to explore and process overwhelming thoughts, feelings and experiences through a reflective art-making process. This is distinct from art classes , which often focus on technical aspects of the artwork, or the aesthetics of the final product.

Art therapy can be used to support treatment for a wide range of physical and mental health conditions. It has been linked to benefits including improved self-awareness, social connection and emotional regulation, while lowering levels of distress, anxiety and even pain scores.

In a study published this week in the Journal of Mental Health , we found art therapy was associated with positive outcomes for children and adolescents in a hospital-based mental health unit.

An option for those who can’t find the words

While a person’s engagement in talk therapies may sometimes be affected by the nature of their illness, verbal reflection is optional in art therapy.

Where possible, after finishing an artwork, a person can explore the meaning of their work with the art therapist, translating unspoken symbolic material into verbal reflection.

However, as the talking component is less central to the therapeutic process, art therapy is an accessible option for people who may not be able to find the words to describe their experiences.

Read more: Creative arts therapies can help people with dementia socialise and express their grief

Art therapy has supported improved mental health outcomes for people who have experienced trauma , people with eating disorders , schizophrenia and dementia , as well as children with autism .

Art therapy has also been linked to improved outcomes for people with a range of physical health conditions . These include lower levels of anxiety, depression and fatigue among people with cancer , enhanced psychological stability for patients with heart disease , and improved social connection among people who have experienced a traumatic brain injury .

Art therapy has been associated with improved mood and anxiety levels for patients in hospital , and lower pain, tiredness and depression among palliative care patients .

Our research

Mental ill-health, including among children and young people , presents a major challenge for our society. While most care takes place in the community , a small proportion of young people require care in hospital to ensure their safety.

In this environment, practices that place even greater restriction, such as seclusion or physical restraint, may be used briefly as a last resort to ensure immediate physical safety. However, these “restrictive practices” are associated with negative effects such as post-traumatic stress for patients and health professionals .

Worryingly, staff report a lack of alternatives to keep patients safe . However, the elimination of restrictive practices is a major aim of mental health services in Australia and internationally.

Read more: 'An arts engagement that's changed their life': the magic of arts and health

Our research looked at more than six years of data from a child and adolescent mental health hospital ward in Australia. We sought to determine whether there was a reduction in restrictive practices during the periods when art therapy was offered on the unit, compared to times when it was absent.

We found a clear association between the provision of art therapy and reduced frequency of seclusion, physical restraint and injection of sedatives on the unit.

We don’t know the precise reason for this. However, art therapy may have lessened levels of severe distress among patients, thereby reducing the risk they would harm themselves or others, and the likelihood of staff using restrictive practices to prevent this.

That said, hospital admission involves multiple therapeutic interventions including talk-based therapies and medications. Confirming the effect of a therapeutic intervention requires controlled clinical trials where people are randomly assigned one treatment or another.

Although ours was an observational study, randomised controlled trials support the benefits of art therapy in youth mental health services. For instance, a 2011 hospital-based study showed reduced symptoms of post-traumatic stress disorder among adolescents randomised to trauma-focussed art therapy compared to a “control” arts and crafts group.

What do young people think?

In previous research we found art therapy was considered by adolescents in hospital-based mental health care to be the most helpful group therapy intervention compared to other talk-based therapy groups and creative activities.

In research not yet published, we’re speaking with young people to better understand their experiences of art therapy, and why it might reduce distress. One young person accessing art therapy in an acute mental health service shared:

[Art therapy] is a way of sort of letting out your emotions in a way that doesn’t involve being judged […] It let me release a lot of stuff that was bottling up and stuff that I couldn’t explain through words.

A promising area

The burgeoning research showing the benefits of art therapy for both physical and especially mental health highlights the value of creative and innovative approaches to treatment in health care .

There are opportunities to expand art therapy services in a range of health-care settings. Doing so would enable greater access to art therapy for people with a variety of physical and mental health conditions.

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What Is Art Therapy?

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Effectiveness

Things to consider, how to get started.

The use of artistic methods to treat psychological disorders and enhance mental health is known as art therapy. Art therapy is a technique rooted in the idea that creative expression can foster healing and mental well-being.

People have been relying on the arts for communication, self-expression, and healing for thousands of years. But art therapy didn't start to become a formal program until the 1940s.

Doctors noted that individuals living with mental illness often expressed themselves in drawings and other artworks, which led many to explore the use of art as a healing strategy. Since then, art has become an important part of the therapeutic field and is used in some assessment and treatment techniques.

Types of Creative Therapies

Art therapy is not the only type of creative art used in the treatment of mental illness. Other types of creative therapies include:

• Dance therapy
• Drama therapy
• Expressive therapy
• Music therapy
• Writing therapy

The goal of art therapy is to utilize the creative process to help people explore self-expression and, in doing so, find new ways to gain personal insight and develop new coping skills.

The creation or appreciation of art is used to help people explore emotions, develop self-awareness, cope with stress, boost self-esteem, and work on social skills.

Techniques used in art therapy can include:

• Doodling and scribbling
• Finger painting
• Photography
• Working with clay

As clients create art, they may analyze what they have made and how it makes them feel. Through exploring their art, people can look for themes and conflicts that may be affecting their thoughts, emotions, and behaviors.

What Art Therapy Can Help With

Art therapy can be used to treat a wide range of mental disorders and psychological distress . In many cases, it might be used in conjunction with other psychotherapy techniques such as group therapy or cognitive-behavioral therapy (CBT) .

Some conditions that art therapy may be used to treat include:

• Aging-related issues
• Eating disorders
• Emotional difficulties
• Family or relationship problems
• Medical conditions
• Psychological symptoms associated with other medical issues
• Post-traumatic stress disorder (PTSD)
• Psychosocial issues
• Substance use disorder

Benefits of Art Therapy

According to a 2016 study published in the  Journal of the American Art Therapy Association, less than an hour of creative activity can reduce your stress and have a positive effect on your mental health, regardless of artistic experience or talent.

An art therapist may use a variety of art methods, including drawing, painting, sculpture, and collage with clients ranging from young children to older adults.

Clients who have experienced emotional trauma, physical violence, domestic abuse, anxiety, depression, and other psychological issues can benefit from expressing themselves creatively.

Some situations in which art therapy might be utilized include:

• Adults experiencing severe stress
• Children experiencing behavioral or social problems at school or at home
• Children or adults who have experienced a traumatic event
• Children with learning disabilities
• Individuals living with a brain injury
• People experiencing mental health problems

While research suggests that art therapy may be beneficial, some of the findings on its effectiveness are mixed. Studies are often small and inconclusive, so further research is needed to explore how and when art therapy may be most beneficial.  

• In studies of adults who experienced trauma, art therapy was found to significantly reduce trauma symptoms and decrease levels of depression.
• One review of the effectiveness of art therapy found that this technique helped patients undergoing medical treatment for cancer improve their quality of life and alleviated a variety of psychological symptoms.
• One study found that art therapy reduced depression and increased self-esteem in older adults living in nursing homes.

If you or someone you love is thinking about art therapy, there are some common misconceptions and facts you should know.

You Don't Have to Be Artistic

People do not need to have artistic ability or special talent to participate in art therapy, and people of all ages including children, teens , and adults can benefit from it. Some research suggests that just the presence of art can play a part in boosting mental health.

A 2017 study found that art displayed in hospital settings contributed to an environment where patients felt safe. It also played a role in improving socialization and maintaining an identity outside of the hospital.

It's Not the Same as an Art Class

People often wonder how an art therapy session differs from an art class. Where an art class is focused on teaching technique or creating a specific finished product, art therapy is more about letting clients focus on their inner experience.

In creating art, people are able to focus on their own perceptions, imagination, and feelings. Clients are encouraged to create art that expresses their inner world more than making something that is an expression of the outer world.

Art Therapy Can Take Place in a Variety of Settings

Inpatient offices, private mental health offices, schools, and community organizations are all possible settings for art therapy services. Additionally, art therapy may be available in other settings such as:

• Art studios
• Colleges and universities
• Community centers
• Correctional facilities
• Elementary schools and high schools
• Group homes
• Homeless shelters
• Private therapy offices
• Residential treatment centers
• Senior centers
• Wellness center
• Women's shelters

If specialized media or equipment is required, however, finding a suitable setting may become challenging.

Art Therapy Is Not for Everyone

Art therapy isn’t for everyone. While high levels of creativity or artistic ability aren't necessary for art therapy to be successful, many adults who believe they are not creative or artistic might be resistant or skeptical of the process.

In addition, art therapy has not been found effective for all types of mental health conditions. For example, one meta-analysis found that art therapy is not effective in reducing positive or negative symptoms of schizophrenia.

If you think you or someone you love would benefit from art therapy, consider the following steps:

• Seek out a trained professional . Qualified art therapists will hold at least a master’s degree in psychotherapy with an additional art therapy credential. To find a qualified art therapist, consider searching the Art Therapy Credentials Board website .
• Call your health insurance . While art therapy may not be covered by your health insurance, there may be certain medical waivers to help fund part of the sessions. Your insurance may also be more likely to cover the sessions if your therapist is a certified psychologist or psychiatrist who offers creative therapies.
• Ask about their specialty . Not all art therapists specialize in all mental health conditions. Many specialize in working with people who have experienced trauma or individuals with substance use disorders, for example.
• Know what to expect . During the first few sessions, your art therapist will likely ask you about your health background as well as your current concerns and goals. They may also suggest a few themes to begin exploring via drawing, painting, sculpting, or another medium.
• Be prepared to answer questions about your art-making process . As the sessions progress, you'll likely be expected to answer questions about your art and how it makes you feel. For example: What were you thinking while doing the art? Did you notice a change of mood from when you started to when you finished? Did the artwork stir any memories?

Becoming an Art Therapist

If you are interested in becoming an art therapist, start by checking with your state to learn more about the education, training, and professional credentials you will need to practice. In most cases, you may need to first become a licensed clinical psychologist , professional counselor, or social worker in order to offer psychotherapy services.

In the United States, the Art Therapy Credentials Board, Inc. (ATCB) offers credentialing programs that allow art therapists to become registered, board-certified, or licensed depending upon the state in which they live and work.

According to the American Art Therapy Association, the minimum requirements:

• A master's degree in art therapy, or
• A master's degree in counseling or a related field with additional coursework in art therapy

Additional post-graduate supervised experience is also required. You can learn more about the training and educational requirements to become an art therapist on the AATA website .

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By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

SYSTEMATIC REVIEW article

Effectiveness of art therapy with adult clients in 2018—what progress has been made.

• School of Creative Arts Therapies, University of Haifa, Haifa, Israel

In the year 2000, an important art therapy literature review addressed an essential question—does art therapy work? It discussed 17 articles dealing with the issue of the effectiveness of art therapy. Two decades later, this research field has extended its scope and is flourishing. Several current reviews of research work have described the broad range of methods implemented today, which includes qualitative and quantitative studies; other reviews have focused on art therapy with specific populations, or by age group. The aim of this systematic literature review is to contribute to the ongoing discussion in the field by exploring the latest studies dealing with the effectiveness of art therapy with a broad scope of adult clients. We conducted a comprehensive search in four databases and review of every quantitative article that has addressed outcome measures in the art therapy field from 2000 to 2017. This paper presents the latest 27 studies in the field that examine the effectiveness of art therapy with adult clients and divides them into seven clinical categories: cancer patients, clients coping with a variety of medical conditions, mental health clients, clients coping with trauma, prison inmates, the elderly, and clients who have not been diagnosed with specific issues but face ongoing daily challenges. It underscores the potential effects of art therapy on these seven clinical populations, and recommends the necessary expansions for future research in the field, to enable art therapy research to take further strides forward.

In 1999, nearly two decades ago, the American Art Therapy Association (AATA) (1999) issued a mission statement that outlined the organization's commitment to research, defined the preferential topics for this research, and suggested future research directions in the field. One year later, Reynolds et al. (2000) published a review of studies that addressed the therapeutic effectiveness of art therapy. They included studies that differed in terms of research quality and standards. In eight studies by different authors, there was a single group with no control group; in four studies, there was a control group, but no randomization of the participants between the experimental group and the control group; and in only five studies was there randomization of the experimental group and the control group (RCT - Randomized Control Trial). They concluded that there was a substantial need to expand research in the field of art therapy to better determine the most appropriate interventions for different populations.

Two decades later, the field of research in art therapy has developed considerably. There are several reviews in the field that describe the expanding body of research work. Some of these reviews present studies that have examined the effectiveness of art therapy, without distinguishing between different populations. For example, as an extension of the work and review by Reynolds et al. (2000) , Slayton et al. (2010) reviewed articles published between 1999 and 2007 that measured the outcome of art therapy sessions with different populations. Their review included qualitative studies, studies based on a single client in therapy, studies with no control groups, studies with a control group but with no randomization, and a small number of studies with a control group and randomization. They concluded that there has been progress in the field, but further research is needed. Four years later, Maujean et al. (2014) summarized high-quality studies that implemented RCT that focused on art therapy with adults. They found eight such studies that were conducted between 2008 and 2013. Seven reported beneficial effects of art therapy for adult clients, but they also concluded that more reliable controlled studies were needed to draw conclusions.

Together with these comprehensive reviews, many literature reviews have appeared in recent years discussing specific populations and a range of research methods. For example, in the field of art therapy for adults, Holmqvist and Persson (2012) overviewed art therapy studies on clients with psychosomatic disorders, eating disorders, or facing crises, based on case studies and intervention techniques. They concluded that there were not enough studies to prove that art therapy is effective for these specific disorders. Similarly, Geue et al. (2010) and a year later, Wood et al. (2011) examined art therapy with cancer patients. They assessed quantitative and qualitative studies and found that most studies have dealt with women suffering from breast cancer. They also documented the intervention techniques that were specifically used with this population, and reported that overall, the quantitative studies reported an improvement in a number of emotional domains faced by these clients. Another article by Huet (2015) reviewed articles dealing with ways to reduce stress in the workplace through art therapy intervention techniques. In this article, a total of 11 articles were discussed that employed different research methods. The authors focused on describing different ways to use art therapy in this context and argued that there has been a gradual emergence of a vast body of knowledge that reinforces the benefits of art therapy for people working in stressful work environments.

In the past three years, a number of literature reviews of controlled quantitative studies have dealt more specifically with the issue of the effectiveness of art therapy in treating specific populations. Schouten et al. (2015) overviewed quantitative studies in art therapy with adult trauma victims. They found that only six studies included a control group (only one of which included randomization) in this field. Half reported a significant reduction in trauma symptoms and another study found a decrease in the levels of depression in clients treated with art therapy. They pointed out that it is difficult to produce quantitative meta-analyses in art therapy given the limited size of the groups and because the evaluation is often based on several therapeutic methods that are used simultaneously. Further Uttley et al. (2015a , b) reviewed all the studies dealing with art therapy for adult clients with non-psychotic psychiatric disorders (anxiety, depression, and phobias). They found 15 randomized controlled quantitative studies of which 10 indicated that the therapeutic process was effective (positive changes following therapy in comparison to the control group). They were unable to conduct a meta-analysis due to the clinical heterogeneity and lack of sufficient information in the studies. In addition, they reviewed 12 qualitative studies that provided data on 188 clients and 16 therapists.

This article deals with research that focuses on measuring the effectiveness of art therapy. It addresses two major challenges. The first is the definition of the term “effectiveness.” We adopted the definition suggested in Hill et al. (1979) ; namely, “the attribute of an intervention or maneuver that results in more good than harm to those to whom it is offered” (p. 1203). The current review takes a positivist perspective ( Holton, 1993 ) and relates to the measurement of effectiveness reported in quantitative studies that have been conducted in the field. Since the field of art therapy is still young, the scope of research is limited and the quality of research is diverse, which makes it difficult to create a comparative review that presents the knowledge in the field and draws thorough conclusions. Therefore, our review is based on the systematic review framework proposed in Case-Smith (2013) who divided the studies she reviewed into three levels of evidence. Level 1 refers to randomized controlled trials (RCT's), level 2 refers to nonrandomized two-group studies, and level 3 refers to nonrandomized one-group studies.

The second challenge has to do with the definition art therapy. We applied the standard definition provided by the American Art Therapy Association:

Art therapy, facilitated by a professional art therapist, effectively supports personal and relational treatment goals, as well as community concerns. Art therapy is used to improve cognitive and sensorimotor functions, foster self-esteem and self-awareness, cultivate emotional resilience, promote insight, enhance social skills, reduce and resolve conflicts and distress, and advance societal and ecological change ( American Art Therapy Association, 2018 ).

This definition makes it clear that art therapy is a process that takes place in the presence of a certified art therapist, and indicates different areas where an effect or outcome in therapy can be expected as a result of this form of treatment.

Thus, the research question was formulated according to “PICOS” components ( The PRISMA Group et al., 2009 ): Is art therapy effective for adult clients as measured in results published from 2000 to 2017, in various quantitative studies corresponding to Levels 1, 2, 3 ( Case-Smith, 2013 )? These studies assessed the effectiveness of art therapy on variety of indices including symptoms and physical measures, health or mental health assessments, quality of life assessment, or coping resources. These indices were typically evaluated through questionnaires and occasionally by projective drawings or physiological indices.

By posing this question, this systematic review joins the ongoing discussion in the field on the level of effectiveness of art therapy with adult clients. This forms part of the academization process in the field of art therapy, which involves attempting to relate intervention techniques in the field with their significance for theoretical research.

The search for relevant articles was carried out during the month of January 2017. Four major electronic databases were searched: Medline, PsycInfo, Scopus, and Web of Science. We searched for the term “art therapy” in the databases combined with the terms “Effectiveness,” “Efficacy,” “Outcome,” “Measurement,” “Treatment,” and “Intervention.” We restricted the search in the databases to articles published in English since the year 2000 for reasons of recency and the continued relevancy of the findings. In addition, all the literature reviews in the field (such as those reviewed above) were examined to locate additional articles that were pertinent to this study.

During the initial screening stage, the abstracts were read by both authors (who are certified art therapists) to exclude those that were irrelevant to the purposes of the study. At this point 151 articles remained (see Figure 1 ).

Figure 1. Search process.

In the next stage, the remaining articles were read and selected if they met the following inclusion criteria (see Figure 1 ):

- Reported a quantitative assessment of the effectiveness of art therapy on a sample of clients. Hence case studies, method descriptions, qualitative analyses, and literature reviews that did not meet these criteria were omitted. A total of 80 articles were removed at this stage.

- Enabled the assessment of the unique impact of art therapy. We thus omitted articles that described the use of a combination of therapeutic intervention techniques with a variety of art mediums simultaneously, not only visual art. A total of 14 articles were omitted at this stage.

- The art therapy was conducted in an ongoing manner in the presence of a certified art therapist. We thus omitted articles that described art intervention techniques that were not used in the context of therapy or were used in one-off art therapy interventions or therapy sessions with a non-certified art therapist. A total of 17 articles were removed at this stage.

Articles that met these inclusion criteria were defined as articles that examined the “effectiveness” of Art Therapy, and that quantified the impact of art therapy in a measurable way. A total of 37 studies were located in 40 articles (three studies were published in two different articles each). Of the 40 articles, 27 dealt with adult populations and are covered in this systematic review. This article categorizes mentioned articles in terms of the levels of evidence proposed by Case-Smith (2013) .

The findings derive from the 27 studies that we considered to have met the inclusion criteria. The choice to present the studies as a review rather than as a meta-analysis is due to the emergent nature of the field of art therapy. There is insufficient research in the field and the differences between studies and the indices measured are so great that it was impossible to produce a meta-analysis that would yield meaningful results (much like Uttley et al.'s conclusion, 2015a,b ). In addition, the authors discussed the issue of the clinical categorization until full agreement was reached, to enable the reader to access the knowledge in the field in a way that will allow and encourage researchers to continue to conduct research. For samples where there has been more research (for example, art therapy with cancer patients), this area could have been separate and examined in and of itself, and relevant conclusions specific to this population could have been drawn. However, for other populations there was often a scarcity of studies which led us to group and categorize populations with similar characteristics (for example, medical conditions).

The next section presents the findings categorized into seven clinical categories. Different research methods were used: 17 of the articles (15 studies) used a comparison group with randomization (Level 1), five articles (four studies) used a comparison group without randomization (Level 2), and five articles used a single group without a comparison group (Level 3). In addition, there was a notable gender trend in that nine of the articles only examined women whereas only two of the articles exclusively referred to men. Sixteen did not define the research population by gender.

Category 1: Cancer Patients

The first category consisted of art therapy with cancer patients (see Table 1 ). Six studies that examined effectiveness have been conducted with this specific population since 2006 and have been described in seven different articles ( Monti et al., 2006 , 2012 ; Oster et al., 2006 ; Öster et al., 2007 ; Bar-Sela et al., 2007 ; Svensk et al., 2009 ; Thyme et al., 2009 ). Five of the six studies were randomized (Level 1) and five dealt with women, most of whom had breast cancer. The total sample size ranged from 18 to 111 clients, most of whom were treated individually. Most of the therapeutic processes were short-term and ranged from five to eight sessions.

Table 1. Cancer patients.

Some of the studies utilized different streams of art therapy. For example, the largest study of 111 participants, ( Monti et al., 2006 ) included a mindfulness-based art therapy intervention—a combination of art therapy with mindfulness exercises. The measurement indices were very different for these studies and included questionnaires that examined physical symptoms, coping resources, quality of life, depression, anxiety, and fatigue. One specific study ( Monti et al., 2012 ) also dealt with fMRI measurements. The findings of this category suggest that through relatively short-term interventions in art therapy (primarily individual therapy), it is possible to significantly improve the emotional state and perceived symptoms of these clients.

Category 2: Medical Conditions

The second category consisted of art therapy with clients coping with a variety of medical conditions that were not cancer-related (see Table 2 ). Three studies examining the effectiveness of art therapy have been conducted since 2011, each of which deals with a completely different medical condition and employs a different research method. The earliest study dealt with art therapy with clients with advanced heart failure ( Sela et al., 2011 ). This study had a sample size of 20 clients who were randomly divided into two groups (level 1). The clients participated in group art therapy for 6 weeks. A 2013 study addressed art therapy with clients coping with obesity ( Sudres et al., 2013 ). This study examined 170 clients who were randomly divided into two groups (level 1). One group consisted of 96 clients who received art therapy for 2 weeks. A 2014 study addressed art therapy with 25 clients with HIV/AIDS ( Feldman et al., 2014 ), who received art therapy in individual or group settings and did not include control groups (level 3). The duration of the therapeutic process was one or more sessions. Despite the considerable differences between the populations and the indices measured, these preliminary studies present an introductory description that points to the potential of art therapy to assist these populations.

Table 2. Medical conditions.

Category 3: Mental Health

The third category covered art therapy with mental health clients (see Table 3 ). Four studies have been conducted since 2007 (two articles written on the same study— Crawford et al., 2012 ; Leurent et al., 2014 , see Table 3 ). Research in this category falls into two main diagnostic areas. The first covers two studies on individuals with schizophrenia ( Richardson et al., 2007 ; Crawford et al., 2012 ; Leurent et al., 2014 ) that involved randomization (level 1) with large samples (90-159 clients). The therapeutic process ranged from 12 sessions to a full year of therapy and included group therapy. The variety of indices that were used in these studies include measures of function, relationships and symptoms. Despite the attempt to use different types of research indices, in both studies, little or no effect was found to be associated with art therapy. Two studies were classified into the second diagnostic area: one addressing clients with psychiatric symptoms ( Chandraiah et al., 2012 ) (level 3) and the other addressing women coping with depression ( Thyme et al., 2007 ) (level 1). The therapeutic process ranged from 8 to 15 weeks. The findings reported in both studies suggested a change occurred in the duration of the therapeutic process. However, since neither study compared clients who received art therapy with those who received no therapy, it is difficult to evaluate the effectiveness of art therapy. Hence, the accumulated results of the studies in this category suggest that further research is needed to assess the effectiveness of interventions in art therapy for clients dealing with mental health issues.

Table 3. Mental health.

Category 4: Trauma Victims

The fourth category included art therapy with clients coping with trauma (see Table 4 ). In this category, two studies have been conducted since 2004, both with randomization (level 1). The first study ( Pizarro, 2004 ) was composed of a sample of 45 students who participated in two art therapy sessions. These students had dealt with a traumatic event, which could occur at different levels of intensity and at various stages in their lives. In addition, the comparison was made between an art-therapy group and two comparison groups where one underwent writing therapy and the other experimented with artwork, regardless of the traumatic event. Despite the attempt to use a wide range of indices, including symptom reporting and emotional and health assessments, and perhaps because of the short duration of therapy, this study failed to find significant results.

Table 4. Trauma victims.

The second study ( Kopytin and Lebedev, 2013 ) examined a sample of 112 war veterans who participated in 12–14 art therapy sessions. In this study, in which the definition of the traumatic event was more specific and defined by involvement in war, an attempt was also made to measure the level of improvement through a wide range of research indices, including reports of symptoms, emotional state, and quality of life. For some of the indices, there was a significant improvement compared to the control group.

These two articles thus present an inconsistent picture of the beneficial effects of this intervention, which may depend on the indices measured, the duration of therapy, and possibly the type of traumatic event.

Category 5: Prison Inmates

The fifth category deals exclusively with David Gussak's extensive research on art therapy with prison inmates ( Gussak, 2004 , 2006 , 2009a , b ) (see Table 5 ). In this area three effectiveness studies have been conducted since 2004 (two articles were written on the same study; see Table 5 ). The first examined an intervention group without a control group (level 3), in contrast to the other two studies which did include control groups (level 2); the sample sizes ranged from 48 to 247 participants in the 2009 study. The art therapy intervention was carried out in a group setting and lasted 4 weeks in the first study to 15 weeks in the most recent study. Initially, Gussak used measurements solely from drawings (FEATS), but in later and more comprehensive research, depression and locus of control were also assessed. In the three studies, there was a reported improvement attributed to the art therapy intervention, as seen in the emotional state of the prison inmates.

Table 5. Prison inmates.

Category 6: The Elderly

The sixth category covered art therapy with the elderly (see Table 6 ). Three effectiveness studies have been conducted since 2006: one study was conducted with healthy Korean American older individuals ( Kim, 2013 ), the second study involved older individuals coping with depression ( McCaffrey et al., 2011 ), and the third dealt with older individuals with moderate to severe dementia ( Rusted et al., 2006 ). In all three studies, the participants were randomly divided into groups (level 1), in a group therapy setting, with a sample size of 39–50 clients. The number of sessions ranged from 6 to 40. The authors of these studies were interested in a variety of indices. In both the study of elderly Koreans and the elderly coping with depression, various aspects of the emotional state of the clients were measured. Art therapy was considered to have led to an improvement on these measures. In a study of older people with dementia, many observational measures were used to assess emotional states, behavior, and abilities, but change was found only in some of them.

Table 6. The Elderly.

The findings suggest that art therapy seems to have a beneficial effect on older individuals who are coping with a variety of challenges in their lives, as reflected in the changes in the indices in these studies.

Category 7: Clients Who Face Ongoing Daily Challenges

The seventh category consisted of art therapy with clients who face ongoing daily challenges that do not fall into one diagnostic category (see Table 7 ). Three studies have been conducted since 2008, two of which address issues such as stress, distress, and burnout of individuals working in various health professions ( Italia et al., 2008 ; Visnola et al., 2010 ). These studies were carried out without randomization; in one study ( Visnola et al., 2010 ) there was a control group (level 2), whereas in the other ( Italia et al., 2008 ) there was not (level 3). The sample size ranged from 20 to 60 participants. The therapeutic process lasted 9–13 sessions in a group art therapy setting. These studies suggest that art therapy can help healthcare professionals reduce levels of stress, anxiety, and burnout connected to their work.

Table 7. Clients who face ongoing daily challenges.

The third article addresses art therapy for women undergoing fertility treatment ( Hughes and da Silva, 2011 ). The sample only included an intervention group (level 3) consisting of 21 women in a group art therapy setting. This study reported a reduction in anxiety and in feelings of hopelessness. The samples in the studies in this category were relatively small and usually did not include a control group. However, there is potential for further research in this area.

Discussion and Conclusion

The purpose of this review was to assess whether art therapy is effective for adult clients as measured in quantitative studies published from 2000 to 2017. Notably, since the Reynolds et al. (2000) review, the body of knowledge in this field has grown and established itself significantly, and a growing number of RCT studies (level 1) have been conducted with larger sample sizes. The advantage of such studies lies in the lesser likelihood of Type I errors as opposed to other studies with no control group or studies that have a control group but no randomization. Nevertheless, there are still only a small number of studies addressing each population, and these studies differ considerably in terms of the course of the therapeutic process, the proposed interventions and the indices that were examined, hence making a meaningful meta-analysis impossible. The findings however are largely encouraging and show a growing trend toward conducting more carefully designed studies that lend themselves to validation and replication; yet—there is a long road ahead. In the past, the effectiveness of art therapy was noticeable to those involved in the field, but less to other professionals. Today, by contrast, there are impressive published findings in a variety of areas. These studies can help expand the contribution of art therapists in other areas and with other populations.

During our search, we were struck by the large number of articles which appear to present interventions in the field of art therapy, but in fact were conducted by non-certified art therapists or were restricted to a therapeutic intervention of a single session in a manner that would not be considered therapy. The existence of such studies emphasizes the continued need to define, clarify and specify what art therapy is and what it is not, and specifically to clarify that this type of therapy must be composed of ongoing sessions and be conducted by a certified art therapist who meets the criteria defined for the profession ( American Art Therapy Association, 2018 ).

The first two clinical categories dealt with clients who are coping with a variety of medical conditions. In this section, we were surprised by the vast amount of research in the field of art therapy with cancer patients, most of which were categorized as level 1. Art therapy emerges strongly as a way to enhance their quality of life and their ability to cope with a variety of psychological symptoms. Our review supplements previous reviews in the field ( Geue et al., 2010 ; Wood et al., 2011 ) and shows that the findings on art therapy with cancer patients are primarily based on higher levels of evidence studies with randomization and relatively large samples.

The second category, which dealt with clients with a range of medical problems, was intended primarily to list the preliminary research in this field, due to the wide variability between the different populations. The differences in the populations treated suggests that, the measurement tools should be adapted to each type of medical issue. The only instrument that could possibly be applied to all these populations in future research is one that measures improvement in quality of life. It is surprising to note that unlike research on cancer patients, which has been considerable, there have been few studies on individuals with other medical conditions.

The third category dealt with clients with mental health issues. In this category we focused solely on adult clients (as opposed to children which will be reviewed in a separate article) and differentiated from the elderly (category 6). In addition, they were separated from clients coping with trauma (category 4). As a result, a relatively small number of studies met the strict criteria of this review regarding what could be defined as art therapy for clients with mental health issues, although some of the studies had large sample sizes and showed a higher level of evidence. For clients coping with schizophrenia, the reviewed findings are not optimistic. These data are congruent with the many articles on psychotherapy that have addressed this population and have emphasized the complexity of treating such individuals ( Pfammatter et al., 2006 ). Studies have shown that the most effective therapeutic approach for this population appears to be cognitive-behavioral ( Turner et al., 2014 ). Thus, future work should examine the effectiveness of the cognitive-behavioral approach in art therapy for this population. More research is also needed to better understand how art therapy can be effective with clients experiencing other mental health issues.

The fourth category addressed clients coping with trauma. While there have been few studies in this field, all of them are in a higher level of evidence. It is important to note that these studies did not assess post-traumatic stress disorder (PTSD), but rather individuals who have dealt with traumatic events. Even though the first study ( Pizarro, 2004 ) did not confirm the effectiveness of art therapy, the limited number of sessions with each client may have been a major factor. When dealing with trauma, there is a need for thorough processing of the experience, and it is quite possible that two sessions were insufficient. The second study ( Kopytin and Lebedev, 2013 ) reported that art therapy was beneficial when the intervention lasted longer. These data are consistent with the Schouten et al. (2015) review. Certain studies reviewed by Schouten et al. (2015) were not mentioned in our review because some were not published as articles, and others included single session interventions that were not led by a certified art therapist.

The fifth category addressed prison inmates. In this field, it is worth mentioning the work of Gussak, a researcher who has studied the field and conducted several studies with an increasing number of participants. His findings undoubtedly point to the potential of art therapy for inmates particularly in long term interventions.

The sixth category addressed the elderly. The field of geriatric art therapy has been gaining momentum in recent years ( Im and Lee, 2014 ; Wang and Li, 2016 ). It is clear from the articles that group therapy sessions are particularly suitable for these clients and that it is important to continue conducting research to target effective intervention methods for this population. The research findings certainly indicate the potential of this field.

The seventh and final category dealt with clients who are facing daily challenges in their lives. The findings suggest that art therapy can be a suitable form of treatment and a way to mitigate issues such as stress and burnout at work.

Overall, this review documents the extensive research conducted in recent years; although qualitative studies were not included in this article, there is no doubt that using a variety of research methods can help expand knowledge in the field. As concerns quantitative studies, the review examined the effectiveness of art therapy for adult clients from research in the field from recent years and with reference to seven clinical categories.

The current review has several limitations. First, due to the small number of studies in the field, it includes various levels of quantitative studies. Some lack comparison groups and others include comparison groups with other treatment methods (for example verbal therapy). This variability makes it difficult to generalize across findings, but not mentioning these studies would have led to the inclusion of an even smaller number of studies. Second, in many studies there are several indices of varying types (questionnaires, drawings, physiological indices). Occasionally, only some of these indices led to demonstrable indications of the effectiveness of art therapy. Due to the complexity of the findings, we were not always able to detail these subtleties and challenges in the current review, and future researchers interested in the field should examine these specific studies closely before conducting further research on the same population. In addition, due to the limited number of studies in this field, we needed to combine various subjects in certain cases, make decisions, and create artificial categories based on our professional knowledge and judgment. For example, the article on female infertility ( Hughes and da Silva, 2011 ) was placed in the seventh category of ongoing and daily challenges, and not in the second category of medical problems, due to the feasibility of this condition for various reasons, which are not necessarily medical.

Research in the field can be expanded in several ways. First, art therapy is a very broad domain that covers diverse populations, some of which have not yet been studied at all in the context of treatment effectiveness. Second, based on the conclusions derived from this review future studies should be planned so that they are performed by a certified art therapist, over a continuous period of time and on large enough samples. In so doing, within approximately a decade, it should be possible to produce a meaningful meta-analysis based on significant and comparable findings from the field, which could lead to more advanced and specific conclusions. Third, in order to raise the level of research in our field, it is important for researchers to devote time and thought to planning studies at the highest level (level 1). Large samples are not enough; one should also consider well-controlled studies (RCT), the blindness of the experiment, the blindness of the participants and the experimenters to the purpose of the research, the division of research groups and so on ( Liebherz et al., 2016 ; Munder and Barth, 2018 ). Finally, it is of great importance that researchers will select valid and reliable research tools that have been used extensively.

This documentation of the numerous studies on the effectiveness of art therapy was long and complex, but also filled us with hope. We are optimistic that this article will take the field one step further in this direction.

Author Contributions

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

Conflict of Interest Statement

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.

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Keywords: art therapy, effectiveness evaluation, adult, systematic review, clinical populations

Citation: Regev D and Cohen-Yatziv L (2018) Effectiveness of Art Therapy With Adult Clients in 2018—What Progress Has Been Made? Front. Psychol. 9:1531. doi: 10.3389/fpsyg.2018.01531

Received: 27 March 2018; Accepted: 02 August 2018; Published: 29 August 2018.

Reviewed by:

Copyright © 2018 Regev and Cohen-Yatziv. 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: Dafna Regev, [email protected]

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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Open Access

Peer-reviewed

Research Article

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

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

* E-mail: [email protected]

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

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

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

Roles Conceptualization, Writing – review & editing

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

Roles Writing – review & editing

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

Roles Conceptualization, Supervision, Writing – review & editing

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

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

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

• Published: December 17, 2018
• https://doi.org/10.1371/journal.pone.0208716
• Reader Comments

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

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

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

Conclusions

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

Citation: Abbing A, Ponstein A, van Hooren S, de Sonneville L, Swaab H, Baars E (2018) The effectiveness of art therapy for anxiety in adults: A systematic review of randomised and non-randomised controlled trials. PLoS ONE 13(12): e0208716. https://doi.org/10.1371/journal.pone.0208716

Editor: Vance W. Berger, NIH/NCI/DCP/BRG, UNITED STATES

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

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

Data Availability: All files are available from https://tinyurl.com/yamju5x5 .

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

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

Introduction

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

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

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

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

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

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

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

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

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

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

Protocol and registration

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

Eligibility criteria

Types of study designs..

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

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

Types of participants.

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

Types of interventions.

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

Types of comparisons.

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

Types of outcome measures.

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

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

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

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

Study selection

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

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

Data collection process

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

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

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

Risk of bias in individual studies

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

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

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

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

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

Quality of evicence

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

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

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

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https://doi.org/10.1371/journal.pone.0208716.g001

Screening of references from systematic reviews.

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

Study characteristics

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

https://doi.org/10.1371/journal.pone.0208716.t001

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

https://doi.org/10.1371/journal.pone.0208716.t002

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

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

Risk of bias within studies

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

https://doi.org/10.1371/journal.pone.0208716.t003

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

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

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

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

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

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

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

Outcomes of individual studies

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

https://doi.org/10.1371/journal.pone.0208716.t004

Anxiety–in study with inactive control.

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

Anxiety–in studies with active control.

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

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

Summary of outcomes and quality.

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

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

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

Meta-analysis.

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

Narrative synthesis

Benefiting populations..

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

Characteristics of AT for anxiety.

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

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

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

Working mechanisms of AT.

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

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

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

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

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

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

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

Summary of evidence and limitations at study level

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

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

Strengths and limitations of this review

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

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

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

Comparison to the AT literature

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

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

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

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

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

Future perspectives

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

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

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

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

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

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

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

Supporting information

S1 checklist. prisma checklist..

https://doi.org/10.1371/journal.pone.0208716.s001

S1 File. Full list of search terms and databases.

https://doi.org/10.1371/journal.pone.0208716.s002

S1 Table. Data extraction form.

https://doi.org/10.1371/journal.pone.0208716.s003

S2 Table. Excluded studies with reasons for exclusion.

https://doi.org/10.1371/journal.pone.0208716.s004

S3 Table. Background characteristics of the included studies.

https://doi.org/10.1371/journal.pone.0208716.s005

Acknowledgments

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

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• Introduction
• Conclusions
• Article Information

The number of included studies and reports is not identical, because some articles published outcomes in separate reports, while others reported more than 1 study. AVAT indicates active visual art therapy; RCT, randomized clinical trial.

eAppendix. Data Extraction Form

eTable 1. Characteristics of the Included Studies, Including the Short ID, Title, a Brief Description of the Study Population, Intervention and Control Group

eTable 2. Ongoing or Recently Published Studies That Investigate the Effectiveness of AVAT

eFigure 1. Forest Plot of the Effects of AVAT for Studies Presenting Results as Change From Baseline

eFigure 2. Forest Plot of the Effects of AVAT for Studies Presenting Results as Post-test

eFigure 3. Funnel Plot for Change From Baseline Outcomes

eReferences

eTable. Detailed Description of Study Characteristics

Data Sharing Statement

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Joschko R , Klatte C , Grabowska WA , Roll S , Berghöfer A , Willich SN. Active Visual Art Therapy and Health Outcomes : A Systematic Review and Meta-Analysis . JAMA Netw Open. 2024;7(9):e2428709. doi:10.1001/jamanetworkopen.2024.28709

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Active Visual Art Therapy and Health Outcomes : A Systematic Review and Meta-Analysis

• 1 Institute of Social Medicine, Epidemiology and Health Economics, Charité – Universitätsmedizin Berlin, Berlin, Germany
• 2 Formerly Charité – Universitätsmedizin Berlin, Berlin, Germany

Question   Is active visual art therapy associated with patient health outcomes?

Findings   In this meta-analysis including 50 studies with 217 outcomes and 2766 individuals, evidence was markedly heterogeneous regarding outcomes, population, and study quality. Based on the available evidence, active visual art therapy was associated with an improvement in 18% of the patient outcomes.

Meaning   The findings of this study suggest that, given its association with patient outcomes, visual art therapy may be considered a valuable addition to standard medical care.

Importance   Art therapy has a long-standing tradition in patient treatment. As scientific interest in its use has recently grown, a comprehensive assessment of active visual art therapy is crucial to understanding its potential benefits.

Objective   To assess the association of active visual art therapy with health outcomes across patient groups and comparators.

Data Sources   The systematic literature search included the Cochrane Library, Embase, MEDLINE, CINAHL, ERIC, American Psychological Association PsycArticles, American Psychological Association PsycInfo, PSYNDEX, the German Clinical Trials Register, and ClinicalTrials.gov. No filters regarding language were applied. The search covered all dates before March 2021. Data analysis was conducted from April 24 to September 8, 2023.

Study Selection   Randomized clinical trials with any type of patient population comparing the intervention with any control not using active visual art therapy were included. Two researchers independently screened the abstracts and full texts.

Data Extraction and Synthesis   Data extraction followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, and study quality was evaluated using the Cochrane Risk of Bias tool. Data were synthesized using narrative summaries, forest plots, and random effects meta-analyses.

Main Outcome and Measures   In line with the protocol, all outcome measures of the included studies were extracted.

Results   The search identified 3104 records, of which 356 outcomes of 69 studies were included, with a total of approximately 4200 participants, aged 4 to 96 years, in the review. The meta-analyses included 50 studies and 217 outcomes of 2766 participants. Treatment indications included mental, neurological, and other somatic disorders, and prevention. Most outcome measures focused on depression, anxiety, self-esteem, social adjustment, and quality of life. Art therapy was associated with an improvement in 18% of the 217 outcomes compared with the controls (1%), while 81% showed no improvement. The standardized mean difference in the change from baseline of the meta-analyses of 0.38 (95% CI, 0.26-0.51) and posttest analysis of 0.19 (95% CI, 0.12-0.26) also indicated an improvement of outcomes associated with art therapy. Overall study quality was low.

Conclusions and Relevance   In this systematic review and meta-analysis of randomized clinical trials, visual art therapy was associated with therapeutic benefits for some outcomes, although most studies were of low quality. Further good-quality studies are needed to provide additional insights for its best possible integration into routine care.

The use of art therapy is widespread across many countries and disciplines, 1 especially in the areas of mental health, 2 rehabilitation, pain management, holistic cancer treatment, and care of older individuals. Various versions of art therapy are used in a wide variety of settings, including hospitals, 3 schools, 4 prisons, 5 or nursing homes. 6 Despite its popularity, to our knowledge, the use of art therapy was never systematically documented, which impedes the estimation of the number of global recipients. The lack of documentation and scarcity of large studies might be the reason why art therapy is not always routinely funded and integrated into standard care. Our study contributes to closing this gap.

A report from the World Health Organization has summarized the existing evidence on art and health in a scoping review, triangulating different study designs, patient groups, and indications. 7 After including more than 900 publications in the review, the authors concluded that the arts have a great potential to enhance and maintain good health. While this extensive report has provided many useful insights into the benefits of art therapy and has further established the role art can play in gaining and maintaining health, the review has been criticized for the absence of a systematic literature search and a quality screening of the individual studies. 8

We set out to conduct what is, to our knowledge, the first systematic review and meta-analysis of all existing randomized and controlled art therapy evidence in a single report that also takes quality of the included studies into account. We therefore believe that it may be a helpful addition to the World Health Organization report and other existing literature. To provide an overview of the complex evidence base, we aimed to gather all currently available studies on the effectiveness of art therapy. Since the overall study quality and methods are very diverse, we decided to focus on randomized clinical trials (RCTs), which are considered the standard for evaluating interventions and limit some of the bias associated with other study designs. 9

With this systematic review and meta-analysis, we aimed to gather all available evidence regarding the effectiveness of active visual art therapy (AVAT). Since we are particularly interested in enhancing the well-being of patients, we decided to focus on the application of AVAT both to alleviate current symptoms and as a preventive measure.

The protocol for this systematic review and meta-analysis has been registered with PROSPERO ( CRD42021233272 ), and details of the methods have been published. 10 We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses ( PRISMA ) reporting guideline, 11 and the Cochrane handbook. 12 The literature search flow diagram is shown in Figure 1 .

We defined AVAT as any type of artistic activity in which patients would actively manipulate materials with their hands, such as drawing, painting, ceramic sculpting, any form of arts and crafts, and sand painting. Not included were all forms of music therapy, dance therapy, literature-based therapy, and therapy based on performing arts. To keep the diverse range of art therapies as comparable as possible, we also excluded all digital interventions.

As per our predefined search criteria, we only included RCTs in which one group used AVAT and the other group used anything other than AVAT (including no intervention, treatment as usual, attention control, or a non-AVAT intervention). Studies that used art as a diagnostic tool but not as an intervention were excluded.

We included all patient groups and groups receiving targeted preventive art therapy. Reasons for exclusion were induced moods (eg, artificial anxiety induction in healthy intervention groups), studies on healthy college students, or educational classroom settings with no clear preventive or curative target.

We included all RCT outcomes in our review. To identify the range of conditions and issues addressed by art therapy, we extracted all scales and measures from the studies included in our review and assigned them to broader categories.

If a study had more than 1 method of measuring the same end point, we only included 1 measure for this end point, selected either based on popularity of the measure or interpretability of the score. Studies with an attrition of more than 50% were excluded from the analysis.

To create a conclusive overview, we did not apply any language filters or date of publication limits. The search consisted of 3 elements, which were combined. 10 The first element referred to the art, the second element referred to the therapeutic use of the art, and the third consisted of an adapted RCT filter. 13 , 14 The search strategy was adapted according to the functionality of the individual databases, and the literature search syntax was peer reviewed by 2 of us (R.J. and A.B.) according to the Peer Review of Electronic Search Strategies guideline. 15

Following the Cochrane recommendations, we searched the Cochrane library, MEDLINE, and Embase (through Ovid). In addition, we searched CINAHL, ERIC, American Psychological Association PsycArticles, American Psychological Association PsycInfo, PSYNDEX (all through EBSCOHost), the German Clinical Trials Register, and ClinicalTrials.gov. At the time of our search, the World Health Organization International Clinical Trials Registry Platform was not accessible. We also conducted a hand search of the Journal of Creative Arts Therapies . All systematic searches were conducted March 8 and 9, 2021.

The study selection followed a 2-step process, aided by Covidence software 16 ; first, all titles and abstracts were screened, and second, relevant studies were identified through thorough review of the full text. Both steps were done independently: the title and abstract screening (R.J., W.A.G., and A.B.) and the full text screening (R.J. and W.A.G.). All disagreements were resolved by a subsequent discussion.

The references of identified reviews were screened for studies that we might have missed. Any protocols for planned studies we found were matched to the published study for later bias evaluation and added to the list of ongoing studies.

Information on the intervention (materials used, frequency, duration, and therapist training), control group, participants (age, sex, and indication), study characteristics (country of study and study arms), outcome (group size, scale description, and preintervention and postintervention data), data regarding possible bias, and other information were extracted by 1 of us (R.J. or C.K.) using a data extraction form (eAppendix in Supplement 1 ).

For better comparability, we tagged the outcomes across all studies with outcome tags, which we aggregated in a second step into 6 broader categories. A similar approach was used for the recorded treatment indications. Furthermore, we categorized the included study populations into 3 age groups according to the patients’ median, mean, or range of age, depending on how the data were reported. If participants spanned more than 1 age category, we labeled that study in accordance with the greatest numbers of its members. We defined children and adolescents as a study population younger than 18 years, adults as individuals aged between 18 and 65 years, and older adults as those older than 65 years.

If there were multiple control groups that could not be combined due to missing data (eg, combined SDs), we extracted the less-specific control group (eg, treatment as usual) to ensure greater compatibility across studies. If there were multiple follow-up measures of an outcome, we only considered the first measurement after the intervention had stopped to ensure comparability.

Bias evaluation was performed by 1 of us (R.J. or C.K.) using an adapted version of the Cochrane risk-of-bias tool for randomized trials. 17 , 18 The evaluated domains of bias were the randomization process, deviations from intended interventions, missing outcome data, measurement tool used, measurement of the outcome, selection of the reported result, and other factors.

We performed random-effects meta-analyses, with standardized mean difference (SMD) as pooled-effect size and 2-sided 95% CIs. Outcomes with sufficient data are displayed in forest plots. To be displayed, each study outcome had to report at least the number of participants in the study and the mean (SD) of the outcome for the control and intervention groups separately, measured after the intervention. Likert scales with 5 or more levels, as well as scales with counts, were treated as continuous data for the analysis.

We summarized outcomes reported as either change from baseline or posttest separately, following standard practice. If both were reported, we used change from baseline. Change from baseline represents the change of variables after the AVAT treatment compared with a baseline level determined before the intervention, whereas posttest measures are observations after the intervention. Given the heterogeneity of the outcomes, we applied a random-effects model for the meta-analyses. We planned to perform a meta-regression including patient age, publication date, intervention duration, therapist qualification, treatment setting, type of AVAT, and country.

The analysis was conducted from April 24 to September 8, 2023, using RStudio, version 4.3.0 (R Foundation for Statistical Computing). 19 Specifically, we used the package meta to calculate the meta-analysis and create the forest plots for all outcomes with sufficient and adequate outcome data. 19 , 20 We chose Hedges g as the effect size and used the package’s default random-effects model DerSimonian-Laird. For the creation of the risk-of-bias plot ( Figure 2 ), we used the packages robvis 21 and ggplot2. 22

Our search yielded 1368 results in the Cochrane library: 1223 through Ovid, 407 through EBSCOhost, 78 from Clinicaltrials.gov, and 10 from the German Clinical Trials Register. A further 18 studies were added after reference screening during the literature-screening stage. Of the resulting 3104 reports, 855 were duplicates and were removed using EndNote. 23 The full study selection process can be seen in Figure 1 . 11 We translated all non-English and non-German records (including French, Chinese, Korean, and Turkish articles) during the screening process using Google Translate 24 and DeepL Translator. 25 There were 5 reports that could not be translated due to their format and resulting technical limitations (2 Persian, 2 Hebrew, and 1 Korean), and were thus excluded.

We identified 75 reports of 69 studies that were eligible for this review 3 , 26 - 98 (eTable 1 in Supplement 1 ). Some publications reported the results of 2 studies in 1 article (eg, Gussak et al 46 ), whereas the results of other studies were reported in several publications (eg, Öster et al, 70 - 72 Svensk et al, 75 and Thyme et al 76 ). When there were multiple reports of the same study, we included all outcome measures that were not duplicates. The article title and a brief description of the study population, intervention, and control group are presented in the eTable 1 in Supplement 1 , while a more-detailed description of the characteristics of the included studies, including age of participants, country of publication, scale of the outcome, total hours of intervention, level of bias, and characteristics of intervention and control groups, are displayed in the eTable in Supplement 2 .

Overall, most studies included an adult population (n = 31), followed by children and adolescents (n = 17) and older adults (n = 17); approximately 4200 participants were included. The age range was 4 to 96 years. Four studies examined the effect of AVAT on children together with their parents.

We included studies from 21 known countries; 1 study did not specify its location. Most studies were conducted in the US (23), followed by the UK (5), Iran (5), and Sweden (4). Japan, Israel, Germany, and China each contributed 3 trials. Furthermore, 2 studies were conducted in each of the following countries: the Netherlands, Turkey, Taiwan, South Korea, India, and France, and 1 study each was carried out in Iraq, Italy, Brazil, Russia, Tanzania, Australia, and Indonesia.

The included control groups were very diverse and subsequently classified into 6 categories. These control categories were treatment as usual (25), other (17), attention control (10), no intervention (10), waiting list control (5), and not specified (2).

The included studies used a wide variety of art therapy interventions, which we clustered into the 7 following categories according to the materials used: drawing/sketching (48), painting (43), arts and crafts (23), sculpting (17), not specified (12), coloring-in/mandala (7), and other (7). Most interventions fell into 2 or more of the categories. Most AVAT interventions (49) included a therapeutic element, 17 did not, and for the remaining 3 it was unclear.

We identified 23 study descriptions of ongoing research projects that fulfilled our criteria of AVAT. An overview of these studies can be found in eTable 2 in Supplement 1 .

Most studies investigated AVAT received by patients with mental health problems (37 studies), followed by patients with neurologic symptoms (13 studies), art therapy as prevention (10 studies), or for patients with other somatic challenges (9 studies).

We identified 356 end point measures of 48 different outcome categories in the studies. Most outcome measures focused on depression, anxiety, self-esteem, social adjustment, and quality of life. Most frequently, AVAT was used to alleviate psychiatric symptoms (86 measures), improve psychological well-being (77), reduce social and behavioral problems (63), and improve cognitive function (16) or other somatic symptoms (eg, pain, asthma exacerbations, and hand function) (17). Seven measures (eg, treatment satisfaction or intervention costs) fit in none of those categories.

Of the identified 69 studies with 356 end point measures, we included 50 studies with 217 end point measures in the meta-analysis. Reasons for omitting end points included missing posttest means or SDs (96), a participant dropout rate of more than 50% (9), an ordinal (2) or dichotomous (2) outcome, and other reasons, such as measures of subscales when there was a total score of the instrument provided (30).

A total of 217 outcomes of 50 studies from 53 publications, including data from 2766 patients were included in 2 meta-analyses 4 , 26 - 28 , 30 , 31 , 33 , 35 - 39 , 41 , 42 , 44 - 48 , 50 - 53 , 55 - 57 , 59 - 64 , 66 , 67 , 69 , 71 , 73 , 75 , 76 , 79 - 84 , 86 , 90 - 92 , 96 - 99 (eTable 1 in Supplement 1 ). Of the total 217 outcomes, 18% favored AVAT, 1% favored the control group, and 81% showed no effect.

We created forest plots as a visual representation of the results (eFigure 1 and eFigure 2 in Supplement 1 ). These meta-analyses are explorative and thus nonconfirmatory. In the change from baseline random-effects meta-analysis, AVAT was associated with more positive health outcomes than the control groups (SMD, 0.38; 95% CI, 0.26-0.51). Results should be interpreted with caution due to substantial heterogeneity ( I 2  = 71%; τ 2  = 0.23; P  < .001).

The posttest random-effects meta-analysis also favored outcomes of disorders treated with AVAT over the control groups (SMD, 0.19; 95% CI, 0.12-0.26). Heterogeneity was substantial ( I 2  = 53%; τ 2  = 0.08; P  < .001).

We conducted some explorative subgroup analyses. We divided the data by age groups and found, based on visual inspection of the forest plot, the outcomes of children improved slightly more on average than the other 2 age groups. When looking at the control groups, we could see that this seemed to be especially true when comparing AVAT with no intervention or treatment as usual (posttest) and waiting list (change from baseline) comparison groups, and that interventions with a therapeutic element might lead to a slightly more favorable total result.

We calculated a meta-regression with the 9 moderators we predefined in the protocol. The meta-regression yielded inconclusive results due to the large number and variety of included factors.

Bias in the measurement of the outcome, selective reporting bias, and other sources of bias were the most common causes for bias in the measurement of the outcomes. While many studies displayed low bias in multiple categories, all studies had at least 1 source of unclear or high bias. The eTable in Supplement 2 provides a detailed list of all assessed bias, including for missing outcome data. The funnel plots indicate a slight publishing bias (eFigure 3 and eFigure 4 in Supplement 1 ).

Overall, AVAT was associated with an improvement of health outcomes, especially in the area of mental health or when treating somatic conditions that may be associated with impaired mental health. This aligns with our practical observations made in clinical settings, where AVAT seems to be frequently associated with the management of mental health issues.

Multiple factors are of special relevance when discussing the results of this review. One of these factors involves the properties of the AVAT interventions. While it was exceeding the scope of this review to separate the effects of the different art types from each other to estimate outcomes, the presence or absence of a therapeutic element seems to be of particular relevance to the intervention. This observation aligns with the principles of patient-centered care, emphasizing the critical role of therapeutic engagement in the healing process.

A notable observation is the regional difference in AVAT research, with more studies conducted in the US and UK, possibly indicating differences in AVAT use. This may hint at the possible influence of structural and political factors shaping research priorities. With the benefits of AVAT, these findings underscore the need to promote equitable health care access by extending the benefits of AVAT to diverse populations, regardless of regional boundaries.

To further the quality of art therapy research and thereby lay the foundation for a future integration into standard care, it might be beneficial to establish guidelines that enhance research consistency and comparability. These guidelines should include standards for reporting AVAT and control interventions, thereby facilitating the future synthesis of treatment effects. Furthermore, the guidelines should incorporate a framework on suitable control interventions to avoid methodologic flaws. Such improvements would not only increase the research quality of the field but also provide a better foundation for evidence-based clinical decision-making.

This study has limitations. While this meta-analysis exclusively focused on RCTs, a triangulation of different methods is valuable when studying a complex and multifaceted intervention such as art therapy. Furthermore, the heterogeneity of the control groups posed unique challenges when examining AVAT. Several studies had to be excluded because the control group’s engagement included AVAT and therefore could not serve as a valid comparator. But even the remaining control interventions often contained therapy elements, such as psychotherapy, pharmaceuticals, and therapy dog encounters. Some complex treatment-as-usual interventions may have contained elements of AVAT. These potentially very effective control interventions might dilute the true effects of AVAT interventions in our data and have probably contributed to the observed heterogeneity. The observed association of AVAT and improved health outcomes in our data, despite these strong comparators, attests to the potential of AVAT.

In this systematic review and meta-analysis, we found an overall benefit associated with AVAT interventions with the potential to improve various patient outcomes, particularly in the area of mental health. Those positive tendencies might even increase in magnitude with improving study quality. To reach that goal, international collaboration and harmonization of research methods are important.

Accepted for Publication: June 14, 2024.

Published: September 12, 2024. doi:10.1001/jamanetworkopen.2024.28709

Open Access: This is an open access article distributed under the terms of the CC-BY License . © 2024 Joschko R et al. JAMA Network Open .

Corresponding Author: Ronja Joschko, MSc, Institute of Social Medicine, Epidemiology and Health Economics, Charité – Universitätsmedizin Berlin, Luisenstr. 57, 10117 Berlin, Germany ( [email protected] ).

Author Contributions: Ms Joschko had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: Joschko, Roll, Berghöfer, Willich.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: Joschko, Klatte.

Critical review of the manuscript for important intellectual content: Grabowska, Roll, Berghöfer, Willich.

Statistical analysis: Joschko, Klatte, Roll, Willich.

Administrative, technical, or material support: Joschko, Klatte, Grabowska, Berghöfer, Willich.

Supervision: Joschko, Roll, Berghöfer.

Conflict of Interest Disclosures: Ms Joschko, Dr Berghöfer, and Dr Willich reported being members of the International Society of Arts and Medicine. No other disclosures were reported.

Data Sharing Statement: See Supplement 3 .

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What is Art Therapy? Fact Sheet

Share this fact sheet as a hand-out to help raise awareness about art therapy and the work art therapists do with their clients and communities they serve.

 What is Art Therapy?

Art therapy is a mental health profession that enriches the lives of individuals, families, and communities through active art-making, creative process, applied psychological theory, and human experience within a psychotherapeutic relationship.

Especially when people are struggling, facing a challenge, or even a health crisis — their own words or language fails them. During these times, an art therapist can help clients express themselves in ways beyond words or language. Art therapists are trained in art and psychological theory and can help clients integrate nonverbal cues and metaphors that are often expressed through the creative process.

Art therapists work with individuals of all ages, including children who are experiencing behavioral challenges or those with Autism Spectrum Disorder. They assist people and caregivers in health crises; victims of violence or other trauma — including our military service members and student survivors of mass shootings; older adults with dementia; and anyone that needs help coping with life’s challenges.

Who are Art Therapists?

Art therapists are credentialed mental health professionals. They are trained in a broad range of psychological theory and ways to use art media and creative processes to help people cope with mental health challenges. Art therapists hold Masters – level or higher degrees. Look for a therapist with the credentials ATR ( art therapist registered ) or ATR – BC ( board – certified art therapist registered ) .

Where do Art Therapists Work?

Art therapists serve diverse communities in di ff erent settings — from medical institutions like hospitals, cancer treatment centers and psychiatric facilities, to wellness centers and schools. Many art therapists have independent practices. They also help support individuals and communities after a crisis or traumatic event.

Why is Art Therapy Effective?

Art therapy is particularly e ff ective during times of crisis, changes in circumstance, trauma, and grief.

According to research, art therapy helps people feel more in control of their own lives , and helps relieve anxiety and depression, including among cancer patients , tuberculosis patients in isolation , and military veterans with PTSD . In addition, art therapy assists in managing pain by moving mental focus away from the painful stimulus.

Do You Have to be Good at Art?

You don’t have to be an artist or even “artsy” to make art. Everyone is creative – and we all remember making art as children.

In art therapy sessions, your art therapist may encourage you to try di ff erent art media such as color pencils, paints, clay, and collage. Sometimes non – traditional art materials ( e.g. tree branches and leaves ) are intentionally introduced to you in order to expand your creative expression. You may also explore di ff erent styles of expression, using doodling, abstract designs, and contour drawing. Art therapists are trained to facilitate a type of art making for your specific needs.

To experience the process of art therapy, it’s important to work with a trained and credentialed art therapist . Find an art therapist near you on AATA’s Art Therapist Locator . 

“This collage represents the healing space I am intentional in creating for each of my clients.” — Natasha Green, MA, ATR

“Visual art helps give choices back to the patients who have lost the ability to make many of the choices in their care and empowering the patient to make decisions in art, to do things in art, to observe things in art, is important to their ability to cope with their circumstances.”

— Valerie Hanks, ATR-P, art therapist at UAB Hospital and Children’s Hospital of Alabama

“Especially among my children and teen clients, I am always inspired by their willingness to use art materials to discover novel and meaningful ways to create their own emotional language… experimenting with mediums that help them resonate with their feelings more clearly, and connect verbal and non- verbal language together.”

— Matthew Chernaskey, MA, ATR, art therapist at an outpatient clinic with children, teens, and families

“Art-making encourages self-exploration and expression. It encourages more vulnerability simply through art being an expression of oneself. By externalizing their emotions, thoughts, and behaviors through art, they may feel less judgment and/or shame toward themselves. Art making may give clients an increased sense of control over what they disclose.”

— Natasha Green, MA, ATR, art therapist in private practice at Green Amethyst Art Therapy

“Visual arts offer veterans suffering from PTSD a nonthreatening alternative to compose in images what is inexpressible to them with words. It is a way in and often the first step to organize and express overwhelming feelings and sensations they experience. Most importantly, their own artwork becomes the narrative to tell their story and is the foundation that we use to begin therapy.”

— Rosemarie Rogers, ATR-BC, LCAT, art therapist with Veterans Affairs

• Open access
• Published: 11 September 2024

The effect of mindfulness-based art therapy (MBAT) on the body image of women with polycystic ovary syndrome (PCOS): a randomized controlled trial

• Zahra Ramazanian Bafghi 1 ,
• Atefeh Ahmadi 2 ,
• Firoozeh Mirzaee 2 &
• Masumeh Ghazanfarpour 1  

BMC Psychiatry volume  24 , Article number:  611 ( 2024 ) Cite this article

Metrics details

The prevalence of polycystic ovary syndrome (PCOS) has increased in the last decade, resulting in enduring psychological effects, including negative body image. This study explored the effect of mindfulness-based art therapy (MBAT) on body image in women with PCOS.

In a randomized, single-blind, controlled trial conducted in Kerman, Iran, women of reproductive age (18–45) who were diagnosed with PCOS and met specific inclusion criteria were randomly allocated to either the MBAT intervention group or a control group placed on a therapy waiting list. The main focus of the study involved evaluating alterations in body image scores as the primary measure. Additionally, the study assessed secondary outcomes, which encompassed various domains of the Multidimensional Body-Self Relations Questionnaire (MBSRQ) before, immediately after, and one month after the intervention. The trial is registered with www.irct.ir (Registration code (25/01/2020): IRCT20170611034452N9).

Between August 2020 and January 2021, 66 participants were randomly assigned to the MBAT or waiting list group, and the study was completed by 60 women. At the end of the intervention, body image (adjusted mean difference from baseline (AMD) of 29.22 [95% CI 19.54, 38.90], P  < 0.05) and at the one-month follow-up (AMD of 34.77 [95% CI 24.75, 44.80], P  < 0.05) were greater in the MBAT group than in the waiting list group. At certain time points, some MBSRQ domains, including body area satisfaction (BASS) ( p  < 0.05), appearance evaluation ( p  < 0.05), fitness orientation ( p  > 0.05), health orientation ( p  < 0.05), and self-classified weight ( p  > 0.05), had higher scores than did the control group. However, only BASS had a conclusive effect size (large). Additionally, appearance orientation ( p  > 0.05), illness orientation ( p  > 0.05), health evaluation ( p  < 0.05), fitness evaluation ( p  > 0.05), and overweight preoccupation ( p  < 0.05) had lower scores with variable and inconclusive effect sizes.

Conclusions

The MBAT has potential as an effective approach for enhancing body image in women with PCOS. However, some MBSRQ domain results were inconclusive, likely due to the small sample size. Therefore, further research with a larger sample size is recommended.

Peer Review reports

Introduction

Polycystic ovary syndrome (PCOS) is a complex and multisystem endocrine disorder that affects reproductive, metabolic, and psychological health in individuals from adolescence to menopause [ 1 , 2 ]. PCOS is a growing global public health concern, with increasing prevalence rates, greater disability burdens, and variations among countries [ 3 ]. In Iran, 13.6%, 19.4%, and 17.8% of the population had PCOS according to the diagnostic standards of the NIH, Rotterdam, and AE-PCOS Society, respectively [ 4 ].

Studies have shown that patients with PCOS report more negative body image (BI) results than healthy people do [ 5 , 6 , 7 ]. BI is defined as the mental image of the body and the attitude toward oneself, appearance, health, integrity, normal functioning, and gender of the individual. BI is a multidimensional structure that refers to people’s perceptions and attitudes, including feelings, thoughts, and behaviors related to their body and appearance [ 8 ]. Many clinical features of PCOS, such as hirsutism, obesity, irregular menstruation, and infertility, are associated with body dissatisfaction [ 9 ]. Individuals with PCOS who have a negative perception of BI often experience consequences such as dissatisfaction with their appearance; loss of femininity and sexual attractiveness; anxiety; depression; reduced healthy behaviors; and negative impacts on their lives [ 10 , 11 , 12 ].

Numerous studies have suggested that the use of mindfulness-based stress reduction (MBSR) or art therapies can improve BI in various populations [ 13 , 14 , 15 ]. Integrating these approaches into mindfulness-based art therapy (MBAT) could have a substantial impact. Although MBSR is technique-based, combining it with art therapy enhances its appeal, as it can enhance present-moment engagement and foster attention regulation, body awareness, and emotional regulation [ 16 , 17 , 18 ]. MBAT can be particularly engaging and therapeutic for individuals who might not respond as well to traditional talk therapies, and it can help in accessing and processing emotions that are not easily articulated [ 19 ]. This engagement can be crucial for women with PCOS, who might experience fatigue [ 20 ] or lack motivation [ 21 ] due to their condition.

The rationale for selecting MBAT as an intervention method in the present study over other evidence-based behavioral therapies, such as cognitive behavioral therapy (CBT) and acceptance and commitment therapy (ACT), is based on the following considerations: While CBT and ACT have been shown to be effective at addressing body image issues [ 22 ], they might not be as engaging or holistic as MBAT for improving BI in women with PCOS. Notably, women with PCOS often experience alexithymia [ 7 ], anxiety, and depression [ 5 ], which can affect their body image [ 23 , 24 ]. In this context, CBT focuses primarily on cognitive restructuring, which might not fully address the emotional and sensory experiences [ 25 ] related to body image and related factors. On the other hand, ACT emphasizes acceptance and mindfulness [ 26 ] but lacks the creative, expressive component of art therapy. MBAT has the potential to enhance mental and physical well-being by simultaneously engaging and reorganizing various biological and behavioral processes, offering a promising biobehavioral approach for reducing anxiety, depression, and other psychological symptoms and disorders while mitigating daily stress and improving quality of life, especially in chronic medical conditions [ 17 , 27 , 28 , 29 , 30 ]. Therefore, incorporating stress-focused methods with art therapy could provide a comprehensive approach to addressing BI issues, considering their links to psychological distress.

This study aimed to evaluate the effect of the MBAT on the BI in adult women of reproductive age with PCOS. It was hypothesized that participants in the MBAT would demonstrate improvement in BI and that their scores in the Multidimensional Body-Self Relations Questionnaire (MBSRQ) domains would increase after the intervention and at the one-month follow-up compared with those in the waiting-list control group.

Study design and participants

The present study employed a single-blind, two parallel-armed randomized controlled trial to investigate the effect of the MBAT on the BI of women of reproductive age with PCOS in Kerman, Iran. The trial received approval from the Research Ethics Committees of Kerman University of Medical Sciences (Approval code: IR.KMU.REC.1398.485), and registration was completed on the Iranian clinical trial website (Registration code (25/01/2020): IRCT20170611034452N9).

Following approval from the Ethics Committee of Kerman University of Medical Sciences, eligible participants who met the inclusion criteria were selected through convenience sampling involving referrals from healthcare centers affiliated with Kerman Medical Sciences and established women’s and midwifery clinics in Kerman. After providing informed consent, a baseline assessment with two instruments (the demographic checklist and MBSRQ) was started. Ultimately, eligible individuals were randomly assigned to two groups: the control group and the intervention group.

The presence of PCOS was confirmed through a review of medical records and by obtaining a diagnosis verification from the respective gynecologist. This confirmation adhered to the Rotterdam criteria [ 31 ], which state that a patient can be diagnosed with PCOS if they meet at least two of the following three criteria: (1) Irregular or infrequent ovulation (oligo-anovulation), (2) Clinical and/or biochemical signs of excess androgen; (3) The specific ovarian morphology was characterized by multiple small cysts (polycystic ovarian morphology). Any uncertainties were resolved through consultation with project colleagues, including the supervisor and advisor professors. Recruitment commenced in November 2020, and the study, along with follow-up assessments, concluded in April 2021.

The inclusion criteria for the study participants were as follows: (1) diagnosis of polycystic ovary syndrome based on the Rotterdam criteria by a gynecologist; (2) women (single or married) aged between 18 and 45 years; (3) nonpregnant and not breastfeeding; (4) no use of psychiatric or psychoactive medications or any medication with psychological side effects within the 60 days preceding the intervention; (5) absence of other physical or mental illnesses recorded in the participant’s medical records; (6) no alcohol, drug, or psychoactive substance use by the participant; (7) willingness to participate in counseling sessions; and (8) nonparticipation in concurrent or prior counseling sessions for body image other than this study.

The exclusion criteria for the study included individuals who met the following conditions: (1) became pregnant during the course of the research, (2) did not participate in two or more counseling sessions, (3) lacked the willingness to continue participating in the study during its execution, and (4) had any acute stress-inducing events during the intervention.

Estimation of sample size and sampling process

The sample size for each group was determined via the following formula for comparing two means:

In this formula, S1 represents the standard deviation (SD) of the intervention group after treatment, and S2 represents the SD of the control group after treatment, with values of 0.90 and 0.75, respectively, based on Jalilian et al.‘s study [ 32 ]. Similarly, X1 denoted the mean of the intervention group after treatment (0.94), and X2 was the mean of the control group after treatment (0.11). \(Z_{1-\frac{\alpha}{2}}\) equaled 1.96, and \(Z_{1-\beta}\) equaled 0.84.

By using the provided equation, the calculated sample size for each group was approximately 17 participants. To bolster the study’s statistical power to 80% and accommodate possible attrition, a group of 30 individuals was selected. As the research entailed two distinct groups, the overall projected sample size was 60 individuals.

Randomization and masking

After providing informed consent and conducting the baseline assessment, the participants were randomly assigned to two groups at a 1:1 ratio. The randomization process was executed via the random number table method. Each participant was assigned a unique code by an individual external to the research team. Following this, one of the researchers, with closed eyes, randomly chose participants from the table by initiating the selection process with the tip of a pen and proceeding in the direction of either rows or columns.

The intervention group underwent MBAT for counseling, whereas the control group was placed on a waiting list without intervention. To ensure minimal interaction and information exchange between the two groups, there were no scheduled meetings or communications between the intervention and control groups throughout the research duration. After completing their follow-up assessment, participants in the wait-listed condition were offered the chance to engage in complimentary MBAT sessions.

The randomization process aimed to reduce potential biases, and efforts were made to uphold ethical considerations related to participant allocation. The specific procedures for managing the control group during the waiting period were provided, ensuring consistency and transparency in the study design. The assessors and the statistical analysis team were kept unaware of the treatment allocation. Due to limitations in terms of the intervention methods, participants and researchers could not be blinded. Nevertheless, we ensured that the outcome assessors and the statistical analysis team were blinded to the conditions to minimize bias. To achieve this, we labeled the MBAT group as ‘Code 1’ and the control group as ‘Code 2.’

The intervention group underwent eight online MBAT sessions, each lasting 90–120 min, which were delivered twice a week over a period of four weeks. To ensure that the sessions were effective and manageable, the participants were divided into smaller groups [ 33 ]. Each MBAT session was organized with a maximum of 8 participants per group. Conversely, the control group remained on a waiting list and received no intervention. After completing their follow-up assessment, participants in the wait-listed condition offered the chance to engage in free MBAT sessions.

The development of the MBAT sessions drew inspiration from studies conducted by Monti et al. [ 29 ] and Jang et al. [ 30 ] (Table  1 ). A Master’s student in counseling in midwifery who was trained in the MBAT conducted the sessions online. The accuracy of the implementation of the MBAT intervention was ensured under the supervision of an experienced psychological therapist. The participants received audio exercise instructions via WhatsApp for daily home practice, complemented by specialized music during the sessions. The questionnaire was completed through online links. To ensure effective technique execution, daily practice instructions (minimum of 45 min) were shared via WhatsApp. Sessions fostered group discussions, emotional expression, and the incorporation of prior assignments. Unfinished tasks resulted in double assignments in the following session.

The primary efficacy outcome measure was the change in the BI score from baseline to the endpoint between the two groups.

The secondary outcomes were changes in the MBSRQ domains (appearance evaluation (AE), appearance orientation (AO), fitness evaluation (FE), fitness orientation (FO), health evaluation (HE), health orientation (HO), illness orientation (IO), body area satisfaction (BASS), overweight preoccupation (OP), and self-classified weight (SW)).

Measurements

In this study, two questionnaires were employed to fulfill the research objectives:

Demographic and health information Checklist: This checklist collects demographic information encompassing variables such as education, marital status, type and duration of infertility (infertility, defined as the inability to conceive after one year of regular, unprotected intercourse [ 34 ]), acne, occupation, and menstrual status (irregular menstruation was defined as having menstrual cycles that are less than 21 days or more than 45 days between 1 and 3 years post menarche, less than 21 days or more than 35 days, or fewer than 8 cycles per year more than 3 years post menarche up to perimenopause, any cycle lasting more than 90 days more than 1 year post menarche, or primary amenorrhea by age 15 or more than 3 years post thelarche (breast development [ 35 ]), exercise history (regular exercise in the past three months), family history of PCOS, scars (history of conditions or illnesses affecting physical appearance, e.g., breast surgeries, etc.), age, height (cm), weight (kg), age at menarche, marriage duration (years), number of pregnancies, number of children, illness duration (months), infertility duration (years), and hirsutism (assessed using the Ferriman–Gallwey score [ 34 ] with the aid of a visual guide).

MBSRQ: The MBSRQ is designed to assess individuals’ attitudes toward various dimensions of their BI. This questionnaire, developed by Cash, comprises 69 items and 10 subscales evaluating the following domains [ 36 ]: AE (7 items) assesses satisfaction with overall physical appearance; AO (12 items) measures the importance placed on appearance and grooming; FE (3 items) evaluates perceptions of physical fitness and activity levels; FO (13 items) assesses the importance of physical fitness in one’s lifestyle; HE (6 items) measures perceptions of physical health and freedom from illness; HO (8 items) evaluates commitment to a healthy lifestyle; IO (5 items) assesses responsiveness to and concern about physical symptoms; BASS (9 items) measures satisfaction with specific body areas; OP (4 items) addresses concerns related to weight, dieting, and eating behavior; and SW (2 items) reflects self-perception and classification of one’s weight.

The questionnaire employs a 5-point Likert scale ranging from “Very Dissatisfied” to “Very Satisfied,” with corresponding scores ranging from 1 to 5. The scoring system was designed to assign higher scores to individuals with more positive BI. In a study conducted in Iran by Zarshenas et al., the internal consistency of the MBSRQ subscales was found to be acceptable, with Cronbach’s alpha values ranging from 0.70 to 0.87 [ 37 ].

Statistical analysis

The data were analyzed via Stata version 14.0, which was developed by Stata Corp. LLC in Texas, USA. Categorical data are described using absolute and relative frequencies, whereas quantitative data are characterized using means and standard deviations (SDs). When comparing baseline characteristics between groups, we followed the Imbens and Rubin approach and considered a standardized mean difference of less than 0.25 for continuous quantitative variables and a risk difference index of less than 10% for qualitative variables [ 38 ].

In this study, we used a complete case analysis approach, including only participants who completed all the study sessions. Since none of the auxiliary variables were significant according to Little’s test [ 39 ] ( p  < 0.05), we considered our missing data pattern to be missing completely at random (MCAR). Additionally, we had a 9.9% rate of missing data, and we accounted for up to this percentage of attrition when the sample size was calculated.

To examine the primary outcome, an analysis of variance and covariance (ANOVA/ANCOVA) was used to identify discrepancies in all the data, with the baseline score considered a covariate (one factor, one covariate). To gauge the impact of the pretest on the results and compare the two analysis models, we calculated the partial eta2 effect size. A change of more than 10% in the partial eta2 between the two analysis models was regarded as important.

Before conducting ANOVA/ANCOVA, we assessed the assumptions. While most variables displayed a normal distribution, certain variables did not adhere to this assumption, as anticipated. Given that the sample size exceeds 30, this nonnormality does not introduce bias into the analyses because of the central limit theorem. Various effect size measures, including the partial eta square, mean difference (MD), and Cohen’s d-based standardized mean difference (SMD), were employed. Cohen’s d values in the range of 0.2–0.5 indicate a “small” effect, 0.5–0.8 signify a “medium” effect, and values surpassing 0.8 denote a “large” effect. Interpretation of partial eta-square effect sizes falls into categories: 0.010–0.059 for a “small” effect, 0.060–0.139 for a “medium” effect, and greater than 0.140 for a “large” effect [ 40 ]. Effect sizes were reported with 95% confidence intervals (CIs), and statistical significance was determined at levels less than 0.05.

Protocol amendment

The original registration for this randomized controlled trial study titled “Comparison between the Effect of Counseling Based on Rational-Emotional-Behavior Theory (REBT) and the MBAT on the BI of Women with PCOS” underwent a protocol amendment because of the unforeseen impact of the COVID-19 pandemic. When the research team was preparing to start enrolling participants, the COVID-19 pandemic began. Consequently, the research team addressed the challenges encountered during participant recruitment and intervention delivery. To ensure successful study sampling, the team adjusted the study’s aim, removing REBT as a method. The study focused solely on the impact of the MBAT intervention on the body image of women with PCOS.

In response to pandemic restrictions and to ensure participant safety, the intervention was adapted for online delivery. Video conferencing platforms were utilized for remote MBAT sessions. The participants received detailed guidelines, and their progress was closely monitored during online sessions to maintain intervention integrity and consistency. To accommodate these modifications, a revised sample size calculation was conducted to ensure statistical power and account for the updated study design.

As an administrative error in the initial section of our protocol, we incorrectly stated the study type as “quasiexperimental”. This was an error, and we want to emphasize that we are not misleading. Additionally, in subsequent sections of the protocol, we have clarified that the study is indeed randomized. We acknowledge that the trial registry entry does not mention secondary outcome measures—the domains of the Multidimensional Body-Self Relations Questionnaire—while we mentioned this in our research proposal, and we agree that we should have added more details to the entry.

Sample characteristics

Between August 2020 and January 2021, of the 101 patients screened for the trial, 66 were eligible, provided informed consent and were randomly assigned to two groups (32 to the control group and 34 to the intervention group). Six patients withdrew their data from the study after group allocation, and 30 patients in each group completed the study (Fig.  1 ). Two people from the intervention group and 4 people from the control group dropped out: 1 person from the intervention group due to severe COVID-19, 1 person due to an unfortunate accident, and 4 people from the control group due to an unwillingness to complete the questionnaire. The test was excluded from the study.

Flow chart of the study

The participants’ demographic and health characteristics are presented in Table  2 . The differences between the two groups in terms of clinical and demographic characteristics based on the proposed method of Imbens and Rubin [ 38 ] were inconsiderable.

Primary outcome

According to the crude model analysis, the average BI values at postintervention and at the one-month follow-up were significantly different between the groups ( P  < 0.05, as indicated in Table  3 ). In the context of ANCOVA, after adjusting each measurement to its corresponding baseline, the partial eta2 values improved by > 10%.

Secondary outcomes

Tables  4 , 5 and 6 show the MBSRQ domains and summary scores after the intervention and at the one-month follow-up. ANCOVA was used to adjust for baseline differences in each measurement. Across both time points, all scores were greater within the MBAT group than in the control group, with exceptions noted for AO and IO postintervention, FE score after follow-up, and HE and OP at both measurements. Notably, only the differences in HE postintervention; OP after follow-up; and AE, HO, and BASS at both time points reached statistical significance.

The present study aimed to evaluate the efficacy of MBAT compared with a waiting-list control group for women with PCOS in Iran. Compared with those in the control group, women who received MBAT improved their overall BI scores, and these effects were sustained at the one-month follow-up, with a conclusive result. Some MBSRQ domains demonstrated improvements with different effect sizes, with some suggesting enduring changes in BI domains through the MBAT, particularly in the BASS, whereas others remained inconclusive. To the best of our knowledge, this is the first experimental study to assess the impact of the MBAT on the BI in PCOS patients.

In general, the results indicate that participants in the MBAT group experienced greater BI than did those in the waiting list group did, even after adjusting for baseline measurements. The standardized mean differences revealed improvements in the BI with a large effect size, providing conclusive evidence at both time points.

Some MBSRQ domains, such as the SW and FO domains, showed improvements with small effect sizes. However, at the follow-up assessment, HO and FE displayed more substantial improvements with medium effect sizes, albeit the results were inconclusive. This finding suggested that the benefits of MBAT may extend beyond immediate effects, potentially leading to more enduring changes in MBSRQ domains. Notably, HO at follow-up, along with AE and BASS at both time points, exhibited considerable improvements with large effect sizes. Notably, the BASS results were conclusive, indicating the potential of the MBAT as a meaningful intervention for enhancing satisfaction with specific body areas. Conversely, OP postintervention and HE at both time points showed lower score with small to medium effect sizes, and even OP at follow-up exhibited a large effect size; however, all the effects remained inconclusive.

The MBSRQ domains demonstrating improvement indicate that MBAT was effective in enhancing participants’ satisfaction with their body areas, overall appearance evaluation, and health orientation. These positive changes underscore the potential cognitive (e.g., improved perceptions of body areas and health), behavioral (e.g., increased focus on healthful behaviors), and emotional (e.g., reduced concern about weight) benefits associated with the MBAT. Conversely, the domains with inconclusive or nonsignificant results indicate variability in the effects of the MBAT on different aspects of BI. For example, the lack of significant changes in fitness-related domains may indicate that although MBAT positively influences body satisfaction and health orientation, it may not directly impact fitness behaviors or perceptions. Similarly, the decrease in health evaluation scores warrants further investigation to determine whether this reflects a temporary heightened awareness of health issues that participants aimed to address following the intervention.

According to the literature, few comprehensive studies have examined the impact of the MBAT on BI, encompassing various sample groups, including those with PCOS and other populations, especially those with quantitative designs. Nevertheless, in 2017, Buck conducted a qualitative study [ 41 ] that combined mindfulness and art therapy to enhance students’ understanding of BI factors and promote self-compassion. The study’s key findings included heightened awareness and acceptance through mindfulness and features related to art therapy, such as normalization, vulnerability, and the distinct concept of tangibility. Focus-oriented art therapy involves using art to enhance somatic awareness and connect with inner bodily sensations, promoting a deeper mind-body connection for resolving distressing experiences [ 42 ].

The integration of MBSR principles into MBAT highlights the importance of mindfulness in shaping individuals’ perceptions of their bodies. Mindfulness is associated with self-regulation, enabling individuals to confront uncomfortable experiences without impulsive reactions [ 43 ]. Engaging in mindfulness practices fosters mental stability; appreciation for each moment; and the cultivation of inner strength, patience, nonjudgmental awareness, self-acceptance, compassion, and flexibility [ 18 ]. In this context, mindfulness serves to counteract biased information processing related to BI dissatisfaction.

Chang et al. [ 44 ] reported a positive impact of online-delivered MBSR on BI in women with breast cancer [ 44 ]. In another study, Pintado and Andrade [ 14 ] found that, compared with a personal image advice program, a mindfulness-based intervention based on MBSR effectively enhanced emotional and psychological aspects related to BI in breast cancer patients [ 14 ].

Additionally, the inclusion of art therapy components within the MBAT provides a unique avenue for participants to express their thoughts and feelings related to BI through creative expression. Art therapy can help improve BI by helping individuals address both conscious and unconscious self-narratives and promoting mental and physical well-being through creative expression [ 45 , 46 ]. It offers a means to resolve conflicts, enhance social skills, manage behavior, reduce stress, boost self-esteem, and gain valuable insights [ 46 ]. Engaging in artistic activities enables individuals to explore mind-body relationships and reshape their self-perceptions, fostering self-care and self-management [ 47 ], which contributes to more positive BI. Higenbottam’s study [ 15 ] demonstrated the effectiveness of art therapy in addressing BI concerns among adolescent girls facing various challenges, including negative BI eating disorders and eating disorders.

The present study had several limitations, as follows. First, the intensity level of MBAT sessions may not be generalizable to other settings where patients with PCOS typically seek care (e.g., with their primary care or gynecologic providers). To address this concern, we propose conducting feasibility studies in more varied clinical settings. Second, the results of some MBSRQ domains, due to wide confidence intervals, remained inconclusive, possibly because of an inadequate sample size. Thus, further research with a larger sample size is highly recommended. Considering various potential factors beyond our control, such as social media [ 48 ], sociocultural factors [ 49 , 50 ], family members’ influences [ 51 ], COVID-19 and quarantine [ 52 , 53 , 54 ], and even noncomprehensive intervention session content, our intervention may not adequately address certain dimensions of the MBSRQ. Third, the control group did not receive any kind of intervention. In future studies, it might be helpful to provide them with general education classes to determine whether group support could influence the main results. Fourth, we had to move the intervention online because of COVID-19 restrictions. Although this is different from what is usually done, it actually has some benefits, such as making the program more accessible and reaching a wider audience.

In summary, our research contributes to the increasing body of evidence affirming the effectiveness of the MBAT in enhancing perceptions of BI, revealing a substantial and conclusive effect. The findings from this investigation endorse the potential of the MBAT as a viable intervention deserving further scrutiny in PCOS populations where individuals contend with BI dissatisfaction and aspire to enhance their positive BI. By synergizing mindfulness and art therapy, the MBAT provides a comprehensive approach to address the multifaceted nature of BI concerns. We recommend that future researchers and clinicians consider a more targeted use of our MBAT session content to address the dimensions of the MBSRQ domains that exhibited deterioration or remained unchanged.

Data availability

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

Abbreviations

Mindfulness-Based Art Therapy

• Polycystic ovary syndrome

Mindfulness-based stress reduction

Multidimensional Body-Self Relations Questionnaire

Rational-Emotional-Behavior Theory

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Acknowledgements

The authors would like to thank the Kerman University of Medical Sciences, for financial support of this research under Institutional Grant (Grant Number: 98000704). Thanks to all women for participating in this study.

Funding was received from the Research Institute of Kerman University of Medical Sciences (Grant Number: 98000704), Kerman, Iran.

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All authors contributed to the study conception and design. ZR: Investigation, Writing - Original Draft, Formal analysis, Visualization. AA: Conceptualization, Methodology, Supervision, Project administration, Visualization. FM: Conceptualization, Methodology, Project administration, Review & Editing, Visualization. MG: Formal analysis, Visualization. All the authors have approved the final version of the manuscript for submission.

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This manuscript was derived from a master’s thesis. The trial received approval from the Research Ethics Committees of Kerman University of Medical Sciences (Approval code: IR.KMU.REC.1398.485), and registration was completed on the Iranian clinical trial website (Registration code (25/01/2020): IRCT20170611034452N9). Written informed consent was obtained from all the subjects to enter the study, and the participants could easily withdraw from the study whenever they were willing. The study was conducted following the Declaration of Helsinki and Ethics Publication on Committee (COPE). Unique codes were used for each of the participants to ensure information confidentiality.

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Bafghi, Z.R., Ahmadi, A., Mirzaee, F. et al. The effect of mindfulness-based art therapy (MBAT) on the body image of women with polycystic ovary syndrome (PCOS): a randomized controlled trial. BMC Psychiatry 24 , 611 (2024). https://doi.org/10.1186/s12888-024-06057-8

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• Published: 13 September 2024

A qualitative study on reasons for women’s loss and resumption of Option B plus care in Ethiopia

• Wolde Facha   ORCID: orcid.org/0000-0002-7463-524X 1 ,
• Takele Tadesse 1 ,
• Eskinder Wolka 1 &
• Ayalew Astatkie 2  

Scientific Reports volume  14 , Article number:  21440 ( 2024 ) Cite this article

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• Health care
• Medical research

Loss to follow-up (LTFU) from Option B plus, a lifelong antiretroviral therapy (ART) for pregnant women living with human immunodeficiency virus (HIV), irrespective of their clinical stage and CD4 count, threatens the elimination of vertical transmission of the virus from mothers to their infants. However, evidence on reasons for LTFU and resumption after LTFU to Option B plus care among women has been limited in Ethiopia. Therefore, this study explored why women were LTFU from the service and what made them resume or refuse resumption after LTFU in Ethiopia. An exploratory, descriptive qualitative study using 46 in-depth interviews was employed among purposely selected women who were lost from Option B plus care or resumed care after LTFU, health care providers, and mother support group (MSG) members working in the prevention of mother-to-child transmission unit. A thematic analysis using an inductive approach was used to analyze the data and build subthemes and themes. Open Code Version 4.03 software assists in data management, from open coding to developing themes and sub-themes. We found that low socioeconomic status, poor relationship with husband and/or family, lack of support from partners, family members, or government, HIV-related stigma, and discrimination, lack of awareness on HIV treatment and perceived drug side effects, religious belief, shortage of drug supply, inadequate service access, and fear of confidentiality breach by healthcare workers were major reasons for LTFU. Healthcare workers' dedication to tracing lost women, partner encouragement, and feeling sick prompted women to resume care after LTFU. This study highlighted financial burdens, partner violence, and societal and health service-related factors discouraged compliance to retention among women in Option B plus care in Ethiopia. Women's empowerment and partner engagement were of vital importance to retain them in care and eliminate vertical transmission of the virus among infants born to HIV-positive women.

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Introduction.

Lost to follow-up is a major challenge in the prevention of mother-to-child transmission (PMTCT) of HIV among HIV-exposed infants (HEI). Globally, about 1.5 million children under 15 years old were living with HIV, and 130,000 acquired the virus in 2022 1 . In the African region, an estimated 1.3 million children aged 0–14 were living with HIV at the end of 2022, and 109,000 children were newly infected 2 . Five out of six paediatric HIV infections occurred in sub-Saharan Africa in 2022 3 . Most of these infections are due to mother-to-child transmission (MTCT), accounting for around 90% of all new infections 4 , 5 . Without any intervention, between 15 and 45 percent of infants born to HIV-positive mothers are likely to acquire the virus from their mothers, with half dying before their second birthday without treatment 3 . Almost 70% of new HIV infections were due to mothers not receiving ART or dropping off during pregnancy or breastfeeding 3 .

In Ethiopia, the burden of MTCT of HIV is high, with a pooled prevalence ranging from 5.6% to 11.4% 6 , 7 , 8 , 9 , 10 . Ethiopia adopted the 2013 World Health Organization’s Option B plus recommendations as the preferred strategy for the PMTCT of HIV in 2013 11 , 12 , 13 , 14 . Accordingly, a combination of triple antiretroviral (ARV) drugs was provided for all HIV-infected pregnant and/or breastfeeding women, irrespective of their CD4 count and World Health Organization (WHO) clinical staging 11 , 13 . Besides, the drug type was switched from an EFV-based to a DTG-based regimen to enhance maternal life quality and decrease LTFU from Option B plus care 11 , 15 . The Efavirenz-based regimen consists of Tenofovir (TDF), Lamivudine (3TC), and Efavirenz (EFV), while the DTG-based regimen consists of TDF, 3TC, and DTG 13 , 15 , 16 . The change in regimen was due to better tolerability and rapid viral suppression, thereby retaining women in care and achieving MTCT of HIV targets 17 , 18 .

The trend of women accessing ART for PMTCT services increases, and new HIV infections decrease over time 3 , 19 , 20 . However, the effectiveness of Option B plus depends not only on service coverage but also on drug adherence and retention in care 4 , 15 , 21 . In this regard, quantitative studies conducted in Ethiopia showed that the prevalence of LTFU from Option B plus ranged from 4.2% to 18.2% 22 , 23 , 24 . Besides, the overall incidence of LTFU ranged from 9 to 9.4 per 1000 person-months of observation 25 , 26 , which is a challenge for the success of the program.

Qualitative studies also revealed that the main reasons for LTFU among women were maternal educational status, drug side effects, lack of partner and family support, lack of HIV status disclosure, poverty, discordant HIV test results, religious belief, stigma, and discrimination, long distance to the health facility, and history of poor adherence to ART 27 , 28 , 29 , 30 , 31 , 32 . Reasons for resumption to care were a decline in health status, a desire to have an uninfected child, and support from others 30 , 33 . Unless the above risk factors for LTFU are managed, the national plan to eliminate the MTCT of HIV by 2025 will not be achieved 34 .

Currently, because of its fewer side effects and better tolerability, a Dolutegravir (DTG)-based regimen is given as a preferred first-line regimen to pregnant and/or breastfeeding women to reduce the risk of LTFU 13 , 16 . The goal is to reduce new HIV transmissions and achieve Sustainable Development Goal (SDG) 3.3 of ending Acquired Immunodeficiency Syndrome (AIDS) as a public health threat by 2030 35 , 36 , 37 . As mentioned above, there is rich information on the prevalence and risk factors of LTFU among women on Option B plus care before the DTG-based regimen was implemented. Besides, the previous qualitative studies addressed the reasons for LTFU from providers’ and/or women’s perspectives rather than including mother support group (MSG) members. However, there was a lack of evidence that explored the reasons for LTFU and resumption of care after LTFU from the perspectives of MSG members, lost women, and healthcare workers (HCWs) providing care to women. Therefore, this study aimed to explore the reasons why women LTFU and resumed Option B plus care after the implementation of a DTG-based regimen in Ethiopia.

Materials and methods

Study design and setting.

An exploratory, descriptive qualitative study 38 was conducted between June and October 2023. This study was conducted in two regions of Ethiopia: Central Ethiopia and South Ethiopia. These neighbouring regions were formed on August 19, 2023, after the disintegration of the Southern Nations, Nationalities, and Peoples' Region after a successful referendum 39 . The authors included these nearby regions to get an adequate sample size and cover a wider geographic area. In these regions, 140 health facilities (49 hospitals and 91 health centers) provided PMTCT and ART services to 28,885 patients at the time of the study, of whom 1,236 were pregnant or breastfeeding women (675 in South Ethiopia and 561 in Central Ethiopia).

Participants and data collection

Study participants were women who were lost from PMTCT care or resumed PMTCT care after LTFU, MSG members, and HCWs provided PMTCT care. Mother support group members were HIV-positive women working in the PMTCT unit to share experiences and provide counselling services on breastfeeding, retention, and adherence, and to trace women when they lost Option B plus care 11 , 40 . Healthcare workers were nurses or midwives working in the PMTCT unit to deliver services to women enrolled in Option B plus care.

Purposive criterion sampling was employed to select study participants from twenty-one facilities (nine health centers and twelve hospitals) providing PMTCT service. A total of 46 participants were included in the study. The interview included 15 women (eleven lost and four resumed care after LTFU), 14 providers, and 17 MSG members. Healthcare workers and MSG members were chosen based on the length of time they spent engaging with women on Option B plus care; the higher the work experience, the more they were selected to get adequate information about the study participants. Including the study participants in each group continued until data saturation.

The principal investigator, with the help of HCWs and MSG members, identified lost women from the PMTCT registration books and appointment cards. A woman's status was recorded as LTFU if she missed the last clinic appointment for at least 28 days without documented death or transfer out to another facility 15 . Providers contacted women based on their addresses recorded during enrolment in Option B plus care, either via phone (if functional) or by conducting home visits for those unable to be reached. Informed written consent was obtained, and the research assistants conducted in-depth interviews at women’s homes or health facilities based on their preferences. After an interview, eleven women who lost care were counselled to resume PMTCT care, but nine returned to care and two refused to resume care. Besides, the principal investigator, HCWs, and MSG members identified women who resumed care after LTFU, called them via phone to visit the health facility at their convenience, and conducted the interview after obtaining consent. The research team covered transportation costs and provided adherence counselling to women post-interview. A woman resumed care if she came back to PMTCT care on her own or healthcare workers’ efforts after LTFU.

One-on-one, in-depth interviews were conducted with eligible MSG members and HCWs at respective health facilities. A semi-structured interview guide translated into the local language (Amharic) was used to collect data. The guide comprises the following constructs: why women are lost to follow-up from PMTCT care, what made them resume caring after LTFU, and why they did not resume Option B plus care after LTFU with probing questions (Supplementary File 1 ). The interview was conducted for 18 to 37 min with each participant, and the duration was communicated to study participants before the interview. The interview was audio-taped, and field notes were taken during the interviews.

Data management and analysis

Thematic analysis was used to analyze the data. The research assistants transcribed the interviews verbatim within 48 h of data collection and translated them from the local language (Amharic) to English for analysis. The principal investigator read the translated document several times to get a general sense of the content. An inductive approach was applied to allow the conceptual clustering of ideas and patterns to emerge. The authors preferred an inductive approach to analyze data since there were no pre-determined categories. The core meaning of the phrases and sentences relevant to the research aim was searched. Codes were assigned to the phrases and sentences in the transcript, which were later used to develop themes and subthemes. The subthemes were substantiated by quotes from the interviews. The interviews developed two themes: reasons for LTFU and the reasons for resumption after LTFU. The findings were triangulated from healthcare workers, MSG members, and client responses. Open code software version 4.03 was used to assist in data management, from open coding to the development themes and sub-themes.

Background characteristics of the study participants

We successfully interviewed 46 participants (14 providers, 15 women, and 17 MSG members) until data saturation. The mean (± standard deviation [SD]) of age was 25.53 (± 0.99) years for women, 32.5 (± 1.05) years for MSG members, and 32.2 (± 1.05) years for care providers. Three out of fifteen women did not disclose their HIV status to their partner, and 5/15 women’s partners were discordant. The mean (± SD) service years in the PMTCT unit were 10.3 (± 1.3) for MSG members and 3.29 (± 0.42) for care providers (Supplementary File 2 ).

Reasons for LTFU

Women who started ART to prevent MTCT of HIV were lost from care due to different reasons. Societal and individual-related factors and health facility-related factors were the two main dimensions that made women LTFU. The societal and individual-related factors were socioeconomic status, relations with husbands or families, lack of support, HIV-related stigma and discrimination, lack of awareness and perceived antiretroviral (ARV) side effects, and religious belief. Health facility-related factors such as lack of confidentiality, drug supply shortages, and inadequate service access led to women's loss from Option B plus care (Supplementary File 3 ).

Societal and individual-related factors

Socioeconomic status.

Lack of money to buy food was a major identified problem for women’s LTFU. Women who did not have adequate food to eat became undernourished, which significantly increased the risk of LTFU. Besides, they did not want to swallow ARV drugs with an empty stomach and thus did not visit health facilities to collect their drugs.

“My life is miserable. I have nothing to eat at my home. How would I take the drug on an empty stomach? Let the disease kill me rather than die due to hunger. This is why I stopped to take the medicine and LTFU.” (W-02, 30-year-old woman, divorced, daily labourer)

Women also disappeared from PMTCT care due to a lack of money to cover transportation costs to reach health facilities.

I need a lot of money to pay for transportation that I can’t afford. Sometimes I came to the hospital borrowing money for transportation. It is challenging to attend a follow-up schedule regularly to collect ART medications.” (W-11, 26-year-old woman, married, housewife)

Relationships with husbands and/or families

Fear of violence and divorce by sexual partners were identified as major reasons for the LTFU of women from PMTCT care. Due to fear of partner violence and divorce, women did not want to be seen by their partners while visiting health facilities for Option B plus care and swallowing ARV drugs. As a result, they missed clinic appointments, did not swallow the drugs, and consequently lost care.

“Due to discordant test results, my husband divorced me. Then I went to my mother's home with my child. I haven’t returned to take the drug since then and have lost PMTCT care.” (W-03, 25-year-old woman, divorced, commercial sex worker)

Women did not disclose their HIV status to their discordant sexual partners and family members due to fear of stigma and discrimination. As a result, they did not swallow drugs in front of others and were unable to collect the drugs from health facilities.

“I know a mother who picked up her drugs on market day as if she came to the market to buy goods. No one knows her status. She hides the drug and swallows it when her husband sleeps.” (P-05, 29-year-old provider, female, 3 years of experience in the PMTCT unit) “I don't want to be seen at the ART unit. I have no reason to convince the discordant husband to visit a health facility after delivery. My husband kills me if he knows that I am living with HIV. This is why I discontinued the care.” (W-12, 18-year-old woman, married, housewife)

Women who lack partner support in caring for children at home during visits to health facilities find it difficult to adhere to clinic visits. Besides, women who did not get financial and psychological support from their partners faced difficulties in retaining care.

“Taking care of children is not business for my husband. How could I leave my two children alone at home? Or can I bring them biting with my teeth?” (W-05, 24-year-old woman, divorced, daily labourer) “ I didn't get any financial or psychological support from my husband. This made me drop PMTCT care.” (W-15, 34-year-old woman, married, daily labourer) Lack of support

Women living with HIV also had complaints of lack of support from the government, non-governmental organizations (NGOs), and HIV-related associations in cash and in kind. As a result, they were disappointed to remain in care.

"Previously, we got financial and material support from NGOs. Besides, the government arranged places for material production and goods sale to improve our economic status. However, now we didn't get any support from anywhere. This made our lives hectic to retain PMTCT care.” (W-06, 29-year-old woman, married, daily labourer)

HIV-related stigma and discrimination

Fear of stigma and discrimination by sexual partners, family members, and the community were mentioned as reasons for LTFU. Gossip, isolation, and rejection from societal activities were the dominant stigma experiences the women encountered. As a result, they did not want to be seen by others who knew them while collecting ARV drugs from health facilities, and consequently, they were lost from care and treatment.

“Despite getting PMTCT service at the nearby facility, some women come to our hospital traveling long distances. They don't want to be seen by others while taking ARV drugs there due to fear of stigma and discrimination by the community.” (P-10, 34-year-old provider, female, 2 years of experience in the PMTCT unit) “I am a daily labourer and bake ‘injera’ (a favourite food in Ethiopia) at someone's house to run my life. If the owner knew my status, I am sure she would not allow me to continue the job. In that case, what would I give my child to eat?” (W-12, 18-year-old woman, married, housewife) “My family did not know that I was living with the virus. If they knew it, I am sure they would not allow me to contact them during any events. Thus, I am afraid of telling them that I had the virus in my blood.” (W-05, 24-year-old woman, divorced, daily labourer)

Lack of awareness and perceived ARV side effects

Sometimes women went to another area for different reasons without taking ARV drugs with them. As per the Ethiopian national treatment guidelines 13 , they could get the drugs temporarily from any nearby facility that delivers PMTCT service. However, those who did not know that they could get the drugs from other nearby PMTCT facilities lost their care until their return. Others were lost, considering that ARV drugs harm the health status of their babies.

“One mother refused to retain in care after the delivery of a congenitally malformed baby (no hands at birth). She said, 'This abnormal child was born due to the drug I was taking for HIV. I delivered two healthy children before taking this medication. I don't want to re-use the drug that made me give birth to a malformed baby." (P-14, 32-year-old provider, female, 4 years of experience in the PMTCT unit)

When they did not encounter any health problems, women were lost from care, considering that they had become healthy and not in need of ART. Some of them also believe that having HIV is a result of sin, not a disease. Besides, some women believed that it was not possible to have a discordant test result with their partner.

“I didn't commit any sexual practice other than with my husband. His test result is negative. So, from where did I get the virus? I don't want to take the drug again.” (W-02, 30-year-old woman, divorced, daily labourer)

Religious belief

Some study participants mentioned religious belief as a reason for LTFU and a barrier to resumption after LTFU. Women discontinued Option B plus care due to their religious faith and refused to resume care as they were cured by the Holy Water and prayer by religious leaders.

“I went to Holy Water and was there for two months. My health status resumed due to prayer by monks and priests there. Despite not taking the drugs during my stay, God cured me of this evil disease with Holy Water. Now I am healthy, and there is no need to take the medicine again.” (W-09, 25-year-old woman, married, daily labourer)

Some women believed that God cured them and made their children free of the virus despite not taking ART for themselves and not giving ARV prophylaxis for their infants.

“Don't raise this issue again (when MSG asked to resume PMTCT care). I don't want to use the medicine. I am cured of the disease by the word of God, and my child is too. My God did not lie in His word.” (MSG-16, 32-year-old MSG, married, 16 years of service experience “Don't come to my home again. I don't have the virus now. I have been praying for it, and God cured me.” (W-03, 25-year-old woman, divorced, commercial sex worker)

Health facility-related factors

Shortage of drug supply.

Women were not provided with all HIV-related services free of charge and were required to pay for therapeutic and prophylactic drugs for themselves and their infants. Most facilities face a shortage of prophylactic drugs, primarily cotrimoxazole and nevirapine syrups, for infants and women, and other drugs used to treat opportunistic infections. As a result, women lost their PMTCT care when told to buy prophylactic syrups for infants and therapeutic drugs to treat opportunistic infections for themselves.

“Lack of cotrimoxazole syrup is one of the major reasons for women to miss PMTCT clinic visits. In our facility, it was out of stock for the last three months. Women can't afford its cost due to their economic problems.” (MSG-03, 34-year-old provider, married, 12 years of service experience)

Inadequate service access

Most women travelled long distances to reach health facilities to get PMTCT service due to the absence of a PMTCT site in their area. Due to a lack of transportation access and/or cost, they were forced to miss clinic visits for PMTCT care.

“In this district, there were only two PMTCT sites. Women travelled long distances to get the service. To reach our facility, they must travel half a day or pay more than three hundred Ethiopian birr for a motorbike that some cannot afford. Thus, women lost the service due to inadequate service access.” (P-06, 30-year-old provider, male, 2 years of experience in the PMTCT unit)

In almost all facilities, PMTCT service was not given on weekends and holidays, despite women's interest in being served at these times. When ARV drugs were stocked out at their homes, they did not get the drugs if facilities were not providing services on weekends and holidays. When appointment date was passed, they lost care due to fear of health workers’ reactions.

Lack of confidentiality

Despite maintaining ethical principles to retain women in care, breaches of confidentiality by HCWs were one of the reasons for LTFU by women. Women were afraid of meeting someone they knew or that their privacy would not be respected. As a result, they lost from PMTCT care.

“I don’t want to visit the facility. All my information was distributed to the community by a HCW who counselled me at the antenatal clinic.” (W-09, 25-year-old woman, married, daily labourer)

Reasons for resumption after LTFU

Healthcare workers' commitment to searching for lost women, partners’ encouragement, and women’s health status were key reasons for resuming women's Option B plus services after LTFU.

Healthcare workers’ commitment

The majority of lost women resumed Option B plus care after LTFU when healthcare workers called them via phone or conducted home visits for those who could not be reached by phone call.

“We went to a woman’s home, who started ART during delivery and lost for four months, travelling about 90 kilometers. She just cried when she saw us. She said, 'As long as you sacrificed your time traveling such a long distance to return me and save my life, I will never disappear from care today onward.' Then, she returned immediately and was linked to the ART unit after completing her PMTCT program.” (P-13, 32-year-old provider, male, 5 years of experience in the PMTCT unit) “We have an appointment date registry for every woman. We waited for them for seven days after they failed to arrive on the scheduled appointment date. From the 8th day onward, we called them via phone if it was available and functional. If we didn't find them via phone, we conducted home visits and returned them to care.” (P-02, 24-year-old provider, female, 3 years of experience in the PMTCT unit)

Partner encouragement

Women who got their partners' encouragement did not drop out of PMTCT care. Besides, most women returned to care and restarted their ARV drugs due to partner encouragement.

“I did not disclose my HIV status to my husband, which was diagnosed during the antenatal period. I lost my care after the delivery of a male baby. When my husband knew my status, rather than disagreeing, he encouraged me to resume the care to live healthily and to prevent the transmission of HIV to our baby. This was why I resumed care after LTFU.” (W-14, 28-year-old woman, divorced, daily labourer)

Women’s health status

Some women returned to Option B plus care on their own when they felt sick and wanted to stay healthy.

“When I felt healthy, I was away from care for about eight months. Later on, when I sought medical care for the illness, doctors gave me medicine and linked me to this unit (the PMTCT unit). I returned because of sickness.” (W-06, 29-year-old woman, married, daily labourer)

This qualitative study assessed the reasons why women left the service and why they resumed care after LTFU. The study aimed to enhance program implementation by providing insights into reasons for LTFU and facilitators for resumption from women's, health professionals', and MSG members' perspectives. We found that financial problems, partner violence, lack of support, HIV-related stigma and discrimination, lack of awareness, religious belief, shortage of drug supply, poor access to health services, and fear of confidentiality breaches by healthcare providers were major reasons for LTFU from PMTCT care. Healthcare workers’ commitment, partner encouragement, and feeling sick made women resume PMTCT care after LTFU.

In this study, fear of partner violence and divorce were identified as major reasons that made women discontinue the PMTCT service. Men are the primary decision-makers regarding healthcare service utilization, and the lack of male involvement in the continuity of PMTCT care decreases maternal health service utilization, including PMTCT services 41 , 42 . In addition, economic dependence on men threatened women not to adhere to clinic appointments without their partner’s willingness due to fear of violence and divorce 28 . Thus, strengthening couple counselling and testing 13 , male involvement in maternal health services, and women empowerment strategies like promoting education, property ownership, and authority sharing to reach decisions on health service utilization were crucial to retaining women in PMTCT care. Besides, legal authorities and community and religious leaders should be involved in preventing domestic violence and raising awareness about the negative effects of divorce on child health.

Financial constraints to cover daily expenses were major reasons expressed by women for LTFU from PMTCT care. Consistent with other studies, this study revealed that a lack of money to cover transportation costs resulted in poor adherence to ART and subsequent loss of PMTCT care 27 , 29 , 43 . As evidenced by other studies, lack of food resulting from financial problems was a major reason for LTFU in the study area 30 . As a result, women prefer death to living with hunger due to food scarcity, which led them to LTFU. Besides, women of poor economic status spent more time on jobs to get money to cover day-to-day expenses than thinking of appointment dates. Thus, governments and organizations working on HIV prevention programs should strengthen economic empowerment programs like arranging loans to start businesses and creating job opportunities for women living with HIV.

Despite continuous information dissemination via different media, fear of stigma and discrimination was a frequently reported reason for LTFU among women in PMTCT care. Consistent with other studies conducted in Ethiopia and other African countries, our study identified that fear of stigma and discrimination by partners, family, and community members are significant risk factors for LTFU 27 , 28 , 29 , 31 . As a result, women did not usually disclose their HIV status to their partners 28 , 32 so that they could not get financial and psychological support. This highlights the need to intensify interventions by different stakeholders to reduce HIV-related stigma and discrimination in the study area. Women's associations, community-based organizations, and religious, community, and political leaders should continuously work on advocacy and awareness creation to combat HIV-related stigma and discrimination.

Our study revealed that a lack of support for women made them discontinue life-saving ARV drugs. In developing countries like Ethiopia, most women living with HIV have low socio-economic status to run their lives, and thus they need support. However, as claimed by the majority of study participants, the government and organizations working on HIV programs were decreasing support from time to time. This was in line with qualitative studies such that lack of support by family members or partners 27 was identified as a barrier to adherence to and retention in PMTCT care 27 , 28 , 29 , 30 , 32 . Organizations working on HIV programs need to design strategies so that poor women get support from partners, family members, the community, religious leaders, and the government to stay in PMTCT care. Moreover, some women thought incentives and support must be given to retain them in Option B plus care. Thus, HCWs should inform women during counselling sessions that they should not link getting PMTCT care to incentives or support.

Women infected with HIV want to be healthy and have HIV-free infants, which could be achieved by proper utilization of recommended therapy as per the protocol 27 , 43 . However, women’s religious beliefs were found to interfere with adherence to the recommended treatment protocol, made them LTFU, and refused resumption after LTFU. Although religious belief did not oppose the use of ARV drugs at any time, women did not take the medicine when they went to Holy Water and prayer. As evidenced by previous studies, lost women perceived that they were cured of the disease with the help of God and refused to resume PMTCT care 27 , 30 . This finding suggests the need for sustained community sensitization about HIV and its treatment, engaging religious leaders. They need to inform women on ART that taking ARV drugs does not contradict religious preaching, and they should not discontinue the drug at any religious engagement.

Once on ART, women should not regress from care and treatment due to problems related to the facility. Unlike the study conducted in Malawi, which reported a shortage of drugs as not a cause of LTFU 29 , in the study area there was a shortage of drugs and supplies to give appropriate care to women and their infants and to retain them in care. They did not get all services related to HIV free of charge and were requested to pay for them, including the cotrimoxazole syrup given to their infants. The finding was consistent with the study conducted in Malawi, where the irregular availability of cotrimoxazole syrup was mentioned as a risk factor for LTFU 32 .

On some occasions, there may also be a shortage of ARV prophylaxis (Nevirapine and Zidovudine syrups) at some facilities for their infants that they couldn’t get from private pharmacies. Services related to PMTCT care were expected to be free of charge for mothers and their infants throughout the care. Ensuring an adequate supply of prophylactic and therapeutic drugs should be considered to prevent the MTCT of HIV and control the spread of the disease among communities via appropriate resource allocation. Facilities should have an adequate supply of ARV prophylaxis and should not request that women pay for diagnostic services. Besides, they always need to provide cotrimoxazole syrup free of charge for HIV-exposed infants.

Lack of awareness of a continuum of PMTCT care among women is a major challenge to retaining them in care. Women who experienced malpractice against standard care practice and had misconceptions about the disease were at higher risk for LTFU. Those women who forgot to take ARV drugs due to different reasons (maybe due to poor counselling) did not get the benefits of ART. Improved counselling and appropriate patient-provider interaction increase women’s engagement in care and reduce the risk of LTFU 28 , 44 . Thus, proper counselling on adherence, malpractice, and misconceptions should be strengthened by healthcare providers in PMTCT units to create optimal awareness for retention.

Maintaining clients’ confidentiality is the backbone of achieving HIV-related treatment goals. However, some women disappear from PMTCT care due to a lack of confidentiality by HCWs delivering the service. Although not large, women claimed a lack of privacy during counselling, and disclosing their HIV status in the community was practiced by some healthcare professionals. The finding was consistent with the study conducted in developing countries, including Ethiopia, where lack of privacy and fear regarding breaches of confidentiality by healthcare workers were identified as risk factors for LTFU 31 , 32 , 44 . Thus, HCWs should deliver appropriate counselling services and maintain clients’ confidentiality to develop trust among women.

The validity of the findings of this study was strengthened by the triangulating data collected from women, MSG members, and HCWs delivering PMTCT service. Besides, the study included women from the community who had already been lost from care during the study, which minimized the risk of recall bias. However, we recognized the following limitations. First, the study did not explore the husband’s perspective to validate the findings from women and HCWs. Second, the study may have different reasons for LTFU for women who were unreached or unwilling to participate compared to those who agreed to be interviewed. Thus, further studies are advised to include the husband’s perception to validate their concern and to address all women who have lost care.

Conclusions

Financial constraints to cover transportation costs, fear of partner divorce and violence, HIV-related stigma and discrimination, lack of psychological support, religious belief, shortage of drug supply, inadequate service access, and breach of confidentiality by HCWs were major reasons for women’s lost. Healthcare workers’ commitment to searching for lost women, partners’ encouragement to resume care, and women’s desire to live healthily were explored as reasons for resumption after LTFU. Women empowerment, partner engagement, involving community and religious leaders, awareness creation on the effect of HIV-related stigma and discrimination for the community, and service delivery as per the protocol were of vital importance to retain women on care and resume care after LTFU. Besides, HCWs should address false beliefs related to the disease during counseling sessions to retain women in care.

Data availability

All data generated or analysed during this study are included in this article and its Supplementary Information files.

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Acknowledgements

The authors acknowledge the staff of the South Ethiopia and Central Ethiopia Regional Health Bureaus for their technical and logistic support. Moreover, the authors sincerely thank the research assistants who translated and transcribed the interview. The authors would also like to thank the study participants who were involved in the study.

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Department of Epidemiology and Biostatistics, School of Public Health, College of Health Sciences and Medicine, Wolaita Sodo University, Wolaita Sodo, Ethiopia

Wolde Facha, Takele Tadesse & Eskinder Wolka

School of Public Health, College of Medicine and Health Sciences, Hawassa University, Hawassa, Ethiopia

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W.F. was involved in the study's conception, design, execution, data acquisition, analysis, interpretation, and manuscript drafting. T.T., E.W., and A.A. were involved in the project concept, guidance, and critical review of the article. All the authors have reviewed and approved the final manuscript and agreed to publish it in scientific reports.

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Correspondence to Wolde Facha .

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The study protocol was reviewed and approved by the Institutional Review Board (IRB) of Wolaita Sodo University (ethical approval number WSU41/32/223). The study was carried out following relevant legislation and ethics guidelines. Written informed consent was obtained from all participants before an interview, and interviewee anonymity was guaranteed.

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Facha, W., Tadesse, T., Wolka, E. et al. A qualitative study on reasons for women’s loss and resumption of Option B plus care in Ethiopia. Sci Rep 14 , 21440 (2024). https://doi.org/10.1038/s41598-024-71252-2

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DOI : https://doi.org/10.1038/s41598-024-71252-2

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Where art meets neuroscience: a new horizon of art therapy

Advances in human brain imaging help us evaluate brain functions from many perspectives. We can define structural brain differences between individuals with various disorders, such as adult schizophrenia ( 1 ) and childhood, autistic-spectrum disorders ( 2 ). From these studies, we can posit hypotheses regarding structure, and how structure relates to symptoms. However, often we find it difficult to assign causality to such findings. For example, we can ask whether structural anomalies cause the symptoms or whether symptoms drive the abnormal brain structures. Nevertheless, we can confidently say that the brain’s structure changes as a consequence of illness and activity, eg, imaging data show that with proper rehabilitation, the injured brain rewires and recovers its function ( 3 ). We label this process “brain plasticity.” Various fields use the concept of brain plasticity. One such very exciting, emerging field involves the study of art and the brain, or art therapy ( 4 ). Originally, art therapy used pure art concepts, void of scientific inquiry. Now, slowly, it is embracing scientific thinking by using abundant neuroscientific data and the objective tools of scientific investigation. For years, we recognized that art-making allowed one to reframe experiences, reorganize thoughts, and gain personal insights that often enhanced one’s quality of life. Art therapy has gained popularity because it combines free artistic expression with the potential for significant therapeutic intervention. Although based on subjective data and testimonies, various artistic disciplines have helped patients with diverse disorders that include developmental or acquired, medical, and/or psychiatric conditions ( 5 , 6 ).

To utilize nonstandard, medical therapies within the well-established medical model, we must demonstrate the utility and efficacy of novel tools and approaches. The scientific method is one way we can demonstrate that art and art therapy modify the brain’s physiology and structure and lead to a more flexible, adaptable individual. Moreover, if we want to validate non-standard approaches, such as art therapy, we need more studies to assess their effects on brain function. As we might imagine, it is very difficult to define art and its optimal therapeutic uses. Naturally, as a new field, art therapy is trying to define its territory and claim its domain within brain science. To gain acceptance and credibility from the medical establishment, art therapy is, seemingly, hoping to assign unique artistic processes to specific brain structures, but the specific brain effects of the artistic process are difficult to study. Nevertheless, through neuroscience, art therapy is attempting to locate particular brain areas or activity patterns that may be devoted exclusively to art-making ( 7 , 8 ). Yet, this specificity presents a problem – the brain does not distinguish between the processes used to create a scientific invention and a work of art – the brain undergoes identical activity sequences and manipulations ( 9 , 10 ).

At the outset, an artist may wish to express an idea and a scientist may hope to develop a new treatment or novel molecule. Next, both artist and scientist choose their tools. Then, both experiment, and, eventually, create a final product. At the system level, the brain is unaware of the anticipated outcome, ie, a new pharmaceutical agent or a sculpture. If we accept that scientific and artistic processes use congruent networks, we can assume that artists and scientists use very similar brain processes to deploy their conceptualizations ( 11 ). As such, in terms of therapy, there is no difference between using scientifically validated novel art therapy and other current standard therapeutic interventions. Treating human pathology using art gives us a tremendous alternative unique and novel option for engaging brain networks that enhance the way the brain processes information, incorporates external and internal data, and develops new efficient brain connections. Ultimately, our goal is for humans to become better adapted to their defined environments. It is quite evident that scientists, clinicians, and artists must come together to share and discuss their experiences. Their interaction can lead to novel communication and cooperation. Clearly, at the brain level, any intervention’s goal is the dynamic enhancement of emotion, cognition, and executive flexibility so that one fully participates in life and avails oneself of the experiential and hereditary gifts in his or her environment ( 12 ). Ultimately, we hope to integrate all disciplines without prejudice and develop novel therapies that optimize the treatment of mental illness.