In What Ways Can the Effectiveness of Art Therapy Be Evaluated?

• Loading metrics

Open Access

Peer-reviewed

Enquiry Commodity

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

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

ten

• Published: December 17, 2018
• https://doi.org/x.1371/journal.pone.0208716

Figures

Abstruse

Background

Anxiety disorders are 1 of the most diagnosed mental health disorders. Common handling consists of cerebral behavioral therapy and pharmacotherapy. In clinical practice, also art therapy is additionally provided to patients with feet (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.

Methods

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

Results

But three publications out of 776 hits from the search fulfilled the inclusion criteria: iii RCTs with 162 patients in total. All studies take a loftier 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 blueprint, collage making, complimentary painting, clay work, still life drawing and house-tree-person drawing. In that location is some evidence of effectiveness of AT for pre-test feet in undergraduate students. AT is peradventure 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 ameliorate emotion regulation.

Conclusions

Effectiveness of AT on anxiety has inappreciably been studied, then no strong conclusions tin can exist drawn. This emphasizes the need for high quality trials studying the effectiveness of AT on feet.

Commendation: Abbing A, Ponstein A, van Hooren S, de Sonneville Fifty, Swaab H, Baars E (2018) The effectiveness of fine art therapy for anxiety in adults: A systematic review of randomised and not-randomised controlled trials. PLoS I 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 commodity 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 be.

Introduction

Anxiety disorders are disorders with an 'abnormal' feel of fear, which gives ascent to sustained distress and/ or obstacles in social functioning [1]. Amidst these disorders are panic disorder, social phobia, agoraphobia, specific phobia, obsessive-compulsive disorder (OCD) and generalized anxiety disorder (GAD). The prevalence of feet disorders is high: 12.0% in European adults [2] and 10.1% in the Dutch population [iii]. Lifetime prevalence for women ranges from 16.3% [2, iv] to 23.4% [3] and for men from seven.8% to xv.ix% [2, three] in Europe. It is the most diagnosed mental health disorder in the United states [five] and incidence levels have increased over the last one-half of the twenty^th century [half-dozen].

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

The well-nigh mutual 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 announced to be only moderately effective. Pharmacological treatment causes side effects and a significant percentage of patients (between 20–l% [12–fifteen] is unresponsive or has a contra-indication. Combination with CBT is recommended [sixteen] but effectually fifty% of patients with anxiety disorders do not benefit from CBT [17].

To increase the effectiveness of treatment of feet disorders, additional therapies are used in clinical practice. An example is art therapy (AT), which is integrated in several mental wellness intendance programs for people with feet (e.yard. [18, 19]) and is also provided every bit a stand up-alone therapy. AT is considered an of import supportive intervention in mental illnesses [20–22], just 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 procedure of creating and (associated) experiencing, aiming for facilitating the expression of memories, feelings and emotions, improvement of self-reflection and the development and exercise of new coping skills [21, 23, 24].

AT is believed to support patients with feet in coping with their symptoms and to ameliorate their quality of life [20]. Based on long-term feel with treatment of feet in practice, AT experts describe that AT can better emotion regulation and self-structuring skills [25–27] and can increase cocky-awareness and cogitating abilities [28, 29]. According to Haeyen, van Hooren & Hutschemakers [30], patients experience a more than direct and easier admission 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 oft indicated in feet, 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 take a broader focus and include several (mental) health atmospheric condition [35–39]. Other reviews included AT in a broader definition of psychodynamic therapies [twoscore] or deal with several therapies (CBTs, expressive fine art therapies (e.g., guided imagery and music therapy), exposure therapies (e.g., systematic desensitization) and pharmacological treatments within ane treatment program) [41].

No review specifically aimed at the effectiveness of AT on anxiety or on specific feet disorders. For feet as the principal condition, thus non related to another primary disease or status (e.g. cancer or autism), there is no clarity on the testify nor of the employed therapeutic methods of AT for feet in adults. Furthermore, clearly scientifically substantiated working machinery(s), explaining the anticipated effectiveness of the therapy, are lacking.

Objectives

The principal 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 class of ATs employed and (3) reported and hypothesized working mechanisms.

Methods

Protocol and registration

The systematic review was performed co-ordinate to the recommendations of the Cochrane Collaboration for study identification, choice, 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 as well included because it was hypothesized that nRCTs are more executed than RCTs, for the research field of AT is still in its infancy.

Just publications in English, Dutch or German were included. These language restrictions were gear up because the reviewers were simply fluent in these 3 languages.

Types of participants.

Studies of adults (xviii–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 handling (no treatment, waiting list, sham treatment) and 2) active handling (standard care or any other treatment). Co-interventions were allowed, only only if the additional consequence of AT on anxiety symptom severity was measured.

Types of outcome measures.

Included were studies that had reduction of anxiety symptoms equally the primary outcome mensurate. 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 salubrious populations. Populations with PTSD were not excluded, since this used to exist an anxiety disorder until 2013 [46].

Searches

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 Cardinal 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 adjusted 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 ix, 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 procedure was independently carried out past 2 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 total text appraisal. These full texts were later on assessed according to the eligibility criteria. Any disagreement in written report selection between the 2 independent reviewers was resolved through discussion or by consultation of a 3rd reviewer (EB).

Information collection procedure

The information were extracted by using a data extraction spreadsheet, based on the Cochrane Collaboration Data Drove Form for intervention reviews (S1 Tabular array Data drove form).

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

Later separate extraction of the information, the results of the two independent assessors were compared and discussed to attain consensus.

Risk of bias in private studies

The run a 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 event assessments), attrition bias (incomplete outcome data), reporting bias (selective reporting). A sentence of 'low', 'loftier' or 'unclear' risk of bias was provided for each domain. Since the RoB tool was developed for utilise in pharmacological studies, nosotros followed the recommendations of Munder & Barth [48] that placed the RoB tool in the context of psychotherapy effect enquiry. Performance bias is defined here as "studies that did not use agile control groups or did not appraise patient expectancies or handling credibility", instead of just 'blinding of participants and personnel'.

A summary assessment of RoB for each report was based on the approach of Higgins & Light-green [47]: overall low RoB (depression adventure of bias in all domains), unclear RoB (unclear RoB in at to the lowest degree one domain) and high RoB (unclear RoB in more than one domain or loftier RoB in at to the lowest degree one domain).

Outcomes

The principal outcome measure out was anxiety symptoms reduction (pre-post handling). The outcomes are presented in terms of differences between intervention and control groups (e.m., risk ratios or odds ratios). Inside-group outcomes are as well presented, to identify promising outcomes and hypotheses for hereafter enquiry.

Data from studies were combined in a meta-analyses to estimate overall issue sizes, if at least ii studies with comparable study populations and handling were available that assessed the aforementioned specific outcomes. Heterogeneity was examined by computing the I² statistic and performing the Chi^two test. If heterogeneity was considered relevant, e.g. Iⁱⁱ statistic greater than 0.50 and p<0.x, sources of heterogeneity were investigated, subanalyses were performed equally deemed clinically relevant, and subtotals simply, or single trial results were reported. In case of a meta-analysis, publication bias was assessed by cartoon a funnel plot based on the principal outcome from all trials and statistical analysis of hazard ratios or odds ratios equally the measure of treatment upshot.

A content assay 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 testify of the studies with pregnant outcomes but was was assessed with the Grading of Recommendations Cess, Evolution and Evaluation (Grade) [49]. Evidence tin be scored equally loftier, moderate, low or very depression, co-ordinate to a set of criteria.

Results

Study selection

The search yielded 776 unique citations. Based on title and abstract, 760 citations were excluded considering the language was not English, Dutch or German (north = 23), were non about anxiety (n = 164), or it concerned anxiety related to another master disease or condition (n = 175), didn't business organisation adults (18–65 years) (n = 152), were non most AT (n = 94), were not a controlled trial (northward = 131), or were lacking a control group (n = 22) or feet symptoms were not used as event measure (north = 1).

Of the remaining 16 full text articles, 13 articles were excluded. Reasons were: lack of a control group [l–54], anxiety was related to another primary disease or status [55, 56], or the study population consisted of salubrious subjects [57, 58], did non concern subjects in the age between 18–65 years [59], or was not peer-reviewed [60] or did not accept pre-postal service 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, iii studies were included for the systematic review (Fig 1).

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 = i), not about feet (due north = 2), or were virtually feet related to cancer (n = 2), were not well-nigh AT (n = ii) or were not a controlled trial (n = 8). Nine full texts were screened for eligibility and were all excluded. Half dozen full texts were excluded because these concerned psychodynamic therapies and did not include AT [63–68]. Ii total texts were excluded because they concerned multidisciplinary handling and no carve up effects of AT were measured [18, xix]. The concluding 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 class, is presented in S2 Table Excluded studies with reasons for exclusion.

Report characteristics

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

In one report, AT is combined with some other treatment: a grouping interview [72]. The other two studies solely business AT (Table 2) [lxx, 71].

The provided AT varies considerably: mandala creation in which the trauma is represented [70] or colouring a pre-designed mandala, gratuitous clay work, free form painting, collage making, still life drawing [71], and house-tree-person drawings (HTP) [72]. Session elapsing differs from xx minutes to 75 minutes. The therapy catamenia ranges from but once to viii weeks, with one to x sessions in full (Table 2). In one study, the control group receives the co-intervention only: group interview in Yu et al. [72]. Henderson et al. [lxx] use 3 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 handling. Here, AT is compared to comfortably sitting. Study settings were outpatient: universities (Us) and prison (People's republic of 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.

Take a chance of bias within studies

Based on the Cochrane Collaboration's tool for assessing risk of bias, estimations of bias were made. Table three shows that the gamble of bias (RoB) is loftier in all studies.

Pick bias: overall, methods of randomization were not always described and selection bias tin can therefore non be ruled out, which leads to unclear RoB. Henderson et al. [seventy] 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 at that place was no baseline imbalance. Likewise Yu et al. [72] did not decribe the randomisation method, but two comparable groups were formed as concluded on baseline measures. Still it is unclear whether psychopathology of control and experimental groups are comparable.

Performance bias: Sandmire's RCT had inactive command, which gives a high risk on performance bias [48]. Like in psychotherapy outcome research, blinding of patients and therapists is not viable 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 handling expectancies or credibility prior to or early on in handling, so all studies were scored every bit 'high risk' on performance bias.

Detection bias: in all studies only cocky-written report questionnaires were used. The questionnaires used are all validated, which allows a low risk score of response bias. Nonetheless, the exact circumstances under which measures are used are non described [lxx, 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 (eastward.1000.[74]), which results in a 'unclear' adventure of detection bias.

Compunction bias: in the study of Henderson information technology is not clear whether the outcome dataset is complete.

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

Other issues: in Sandmire et al. [71] information technology was noted that the report 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 loftier.

Outcomes of individual studies

The measures used in the studies are shown in Table four. The outcome measures for anxiety differ and include the State-Trait Anxiety Inventory (STAI) (used in 2 studies), the Hamilton Anxiety Rating Scale (HAM-A) and the Zung Self-rating Anxiety Calibration (SAS) (used in 1 report). Quality of life was not measured in any of the included studies.

Anxiety–in study with inactive control.

Sandmire et al. [71] showed significant between-group effects of art making on state anxiety (tested with ANOVA: experimental group (hateful (SD)): 39.3 (9.iv) - 29.five (viii.6); control grouping (hateful (SD)): 36.two (viii.8) - 36.0 (ten.9)\; p = 0.001) and on trait feet (experimental group (hateful (SD)): 39.1 (5.8) - 33.3 (6.1); control group (hateful (SD)): 38.2 (10.2) - 37.3 (eleven.two); p = 0.004) In that location were no significant differences in effectiveness between the five types of art making activities.

Anxiety–in studies with active command.

Henderson et al. [70] reported no pregnant effect of creating mandalas (trauma-related art making) versus random art making on anxiety symptoms (tested with ANCOVA: experimental grouping (mean (SD)): 45.05 (ten.75) - 41.xvi (11.xxx); control group (mean (SD): 49.05 (12.29) - 44.05 (10.12), p-value: not reported) immediately after treatment. At follow-upwardly after i month at that place was likewise no pregnant issue of creating mandalas on anxiety symptoms: experimental grouping (mean (SD): forty.95 (11.54); command grouping (mean (SD): 42.0 (xiii.26)), simply there was significant comeback of PTSD symptom severity at 1-calendar month follow-upwards (p = 0.015).

Yu et al. (2016) did not written report analyses of betwixt-group effects. Only the experimental group, who made HTP drawings followed by group interview, showed a significant pre- versus post-handling reduction of anxiety symptoms (2-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 (nine.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-handling (HAM-A (mean (SD): 24.75 (6.14) - 25.22 (vii.37), non significant; SAS (mean (SD): 62.57 (7.36) - 66.eleven (10.41), p = 0.33).

Summary of outcomes and quality.

Of 3 included RCTs studying the effects of AT on reducing feet symptoms, 1 RCT [71] showed a pregnant anxiety reduction, ane RCT [72] was inconclusive because no between-group outcomes were provided, and one RCT [70] plant no significant anxiety reduction, only did observe signifcant reduction of PTSD symptoms at follow-upwardly.

Regarding within-group differences, two studies [71, 72] showed significant pre-posttreatment reduction of anxiety levels in the AT groups and 1 did non [70].

The quality of the evidence in Sandmire [71] as assessed with the GRADE classification is depression 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 minor sample size (imprecision [75]) led to downgrading of at to the lowest degree two levels.

Meta-analysis.

Because data were comparatively comparable betwixt the included studies due to variation in study populations, control treatments, the type of AT employed and the employ 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 depression due to loftier RoB. Based on pre-posttreatment anxiety reduction (inside-group analysis) AT may be effective for adult prisoners with pre-release anxiety [72].

Characteristics of AT for feet.

Sandmire et al. [71] gave students with pre-exam stress ane selection out of five art-making activities: mandala design, free painting, collage making, gratuitous clay work or still life drawing. The activeness was express to ane session of 30 minutes. This was washed in a setting simulating an art center where students could use art materials to save stress. The mandala design activity consisted of a pre-designed mandala which could exist completed by using pencils, tempera paints, watercolors, crayons or markers. The free form painting activeness 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 apply fine-tip permanent makers, crayons, colored pencils and pastels to add detailed blueprint 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 cut out the images and additonal images from provided magazins and gluing them on a white slice of paper. Participants could also choose for a clay activity to make a 'pleasing form'. Examples were a pinch pot, gyre pot and small animate being figures. The terminal option for fine art-making was a still life drawing, by arranging objects into a pleasing associates 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 cartoon a house, a tree and a person also as another objects on a sheet of paper. Yu follows the following interpretation: the firm is regarded every bit the projection of family, the tree represents the environment and the person represents self-identification [76]. The HTP drawing is ordinarily used as a diagnostic tool, but is used in this report as an intervention to enable prisoners to get more enlightened of their emotional issues and cognitions in relation to their upcoming release. A counselor gives helpful guidance based on the drawing and reflects on breezy or missing content, so that the drawings tin 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 up 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 full 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 unmarried assistants of art making to treat the treatment of stressful situations (final exams) of undergraduate liberal art students. The art intervention did non explicitly expose students to the source of stress, hence a general working machinery of AT is expected. The authors merits that art making offers a bottom-upwardly arroyo to reduce feet. Art making, in a non-verbal, tactile and visual manner, helps entering a flow-like-state of listen that tin reduce anxiety [77], comparable to mindfulness.

Yu reports that nonverbal symbolic methods, like HTP-drawing, are thought to reverberate subconscious cocky-relevant information. The process of art making and reflection upon the art may lead to insights in emotions and (incorrect) cognitions that tin be addressed during counseling. The authors state that "HTP-drawing is a natural, easy mental intervention technique through which counselors tin guide prisoners to course helpful cognitions and behaviors within a relative relaxing and well-protected psychological surround". In this instance the artwork is seen as a grade of unconscious self-expression that opens up possibilities for verbal reflections and counseling. In the process of drawing, the advisor gives guidance so the drawing becomes more consummate 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 likewise. The AT intervention focussed on the creative expression of traumatic memories, which tin can been seen as an indirect approach to exposure, with active engagement. The authors point that mandala creation (related to trauma) leads to changes in noesis, facilitating increasing gains. Exposure, recall and emotional distancing may exist important attributes to recovery.

Summarizing, iii different types of AT can be distinguised: one) using art-making as a pleasant and relaxing activity; ii) using fine art-making for expression of (unconsious) cerebral 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, nosotros tin hypothesize that AT may contribute to reducing anxiety symptom severity, considering AT may:

• induce relaxation, past stimulating a flow-like state of mind, presumably leading to a reduction of cortisol levels and hence stress and feet 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 safety environment for the conscious expression of (hard) emotions and memories, what is similar to exposure, call back and emotional distancing, possibly leading to improve emotion regulation [70].

Discussion

Currently there is no overview of evidence of effectiveness of AT on the reduction of feet symptoms and no overview of the intervention characteristics, the populations that might do good 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

3 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. Because the pocket-sized corporeality of studies, nosotros can conclude that effectiveness research on AT for anxiety in adults is in a beginning land and is developing.

The included studies accept a high risk of bias, small to moderate sample sizes and in total a very small number of patients (due north = 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 testify is shown for AT for pre-test anxiety in undergraduate students [71]. I RCT on prelease anxiety in prisoners [72] was inconclusive considering no betwixt-group event analyses were provided, and one RCT on PTSD and anxiety symptoms in students [70] found pregnant reduction of PTSD symtoms at follow-up, but no pregnant feet reduction. Regarding within-grouping differences, two studies [71, 72] showed significant pre-posttreatment reduction of anxiety levels in the AT groups and one did not [lxx]. Intervention characteristics, populations that might benefit from this treatment and working mechanisms were described. In decision, these findings pb us to await that art therapy may be constructive in the treatment of anxiety in adults as it may improve stress regulation, cerebral regulation and emotion regulation.

Strengths and limitations of this review

The strength of this review is firstly that it is the starting time systematic review on AT for principal 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 two checklist was used to appraise and improve the quality of the review and the results were reported according to the PRISMA guidelines. A tertiary strength is that the search strategy covers a long period of 20 years and a large number of databases (13) and two journals.

A outset limitation, according to cess with the AMSTAR 2 checklist, is that only peer reviewed publications were included, which entails that many only not all information sources were included in the searches. Not included were searches in trial/study registries and in gray literature, since peer reviewed publication was an inclusion benchmark. Content experts in the field were likewise non consulted. Secondly, only three RCTs met the inclusion criteria, each with a different target population: students with moderate PTSD, students with pre-examination anxiety and prisoners with pre-release feet. This ways that simply a small part of the populations of adults with feet (disorders) could be studied in this review. A tertiary (possible) limitation concerns the restrictions regarding the included languages and search menses applied (1997- Oct 2017). With respect to the latter it tin can be said that all included studies are published after 2006, making it likely that the restriction in search period has not influenced the event 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. At that place are many definitions for AT and discussions about the nature of AT (e.g. [78]). We considered an intervention to be art therapy in instance the visual arts were used to promote wellness/wellbeing and/or the author called it art therapy. Thus, only art making equally 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 fine art therapy studies. This tool is adult 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 arroyo is not fully tailored for these type of studies, it was difficult to decide whether the the exact classification of the available testify was low or very low.

Comparing 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 mitt promising results of AT and on the other hand showing many methodological weaknesses of AT trials. For instance, other systematic reviews on AT also written 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 prove is likely to exist depression to very low as well. These reviews likewise conclude on methodological shortcomings of fine 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 every bit a consious pathway to difficult emotions and (traumatic) memories; leading to better emotion regulation; and iii) using art-making for expression, to gain insight in (unconscious) cerebral patterns; leading to ameliorate cognitive regulation.

These 3 approaches tin be linked to ii major directions in art therapy, identified by Holmqvist & Persson [74]: "art-equally-therapy" and "art-in-psychotherapy". Art-every bit-therapy focuses on the healing ability and relaxing qualities of the art process itself and was first described past Kramer in 1971 [79]. This can be linked to the findings in the written report of Sandmire [71], where information technology is suggested that art making led to lower stress levels. Art making is already associated with lower cortisol levels [fourscore]. 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 feel likewise every bit the repetitive muscular activity inherent to art making.

Art-in-psychotherapy, first described past 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], then what the patient experienced during the process of creating the art work, can exist deepened in conversation. In practice, these approaches frequently overlap and interweave with one another [83], which is probably why it is combined in ane direction 'art-in-psychotherapy'. It might exist beneficial to consider these ways of conscious and unconscious expression separately, because it is a key different view on the importance of art making.

The overall film of the described and hypothesized working mechanisms that emerged in this review atomic number 82 to the hypotheses that feet symptoms may decrease because AT may support stress regulation (by inducing relaxation, presumably comparable to mindfulness [64,84], emotion regulation (by creating the prophylactic condition for expression and examination of emotions) and cognitive regulation (as fine art work opens up possibilities to investigate (unconscious) cognitions). These types of regulation all contribute to better cocky-regulation [85]. The hypothesis with respect to stress regulation is further supported past results from other studies. The process of creating art tin can promote a country of mindfulness [57]. Mindfulness can increase self-regulation [84] which is a moderator betwixt coping strength and mental symptomatology [86]. Improving patient'southward self-regulation leads, amongst others, to improvement of coping with affliction weather condition like anxiety [85, 86]. Our findings are in accordance with the findings of Haeyen [xxx], stating that patients learn to limited emotions more than effectively, considering AT enables them to "examine feelings without words, pre-verbally and sometimes less consciously", (p.2). The connection between fine art therapy and emotion regulation is also supported by the recently published narrative review of Gruber & Oepen [87], who found meaning constructive 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 non hateful that AT does not work. Art therapists and other care professionals practice feel 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 feet disorders in general and specifically, and for people with feet in specific situations are still defective. To get loftier quality prove of effectiveness of AT on feet (disorders), more than robust studies are needed.

As well feet symptoms, the effectiveness of AT on aspects of self-regulation similar emotion regulation, cerebral regulation and stress regulation should exist further studied too. By evaluating the changes that may occur in the different areas of self-regulation, better hypotheses tin can be generated with respect to the working mechanisms of AT in the treatment of anxiety.

A key indicate for AT researchers in developing, executing and reporting on RCTs, is the outcome of risk of bias. It is recommended to address more specifically how RoB was minimalized in the pattern and execution of the study. This tin 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 operation 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 loftier. This implies that loftier or even medium quality of evidence can never exist reached for this intervention, even when all other aspects of the report are of loftier quality. Behavioral interventions, similar psychotherapy and other complex interventions, face the same challenge. In 2017, Munder & Barth [48] published considerations on how to use the Cochrane'due south risk of bias tool in psychotherapy issue 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 fine art therapy and (other) complex interventions where blinding is not possible.

Conclusions

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 prove of effectiveness of AT for pre-test anxiety in undergraduate students. AT may likewise exist effective in reducing pre-release anxiety in prisoners.

The included RCTs demonstrate a wide variety in AT characteristics (AT types, numbers and elapsing of sessions). The described or hypothesized working mechanisms of art making are: consecration 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 cerebral regulation by using the art process to open up possibilities to investigate and (positively) modify (unconscious) cognitions, beliefs and thoughts.

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

Supporting information

Acknowledgments

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

References

1. 1. Hassink-Franke LT, B., van Heest F., Hekman J,. van Marwijk H., & van Avendonk Thou. Dutch chief care standard anxiety [NHG-Standaard Malaise (tweede herziening)]. 2012.
   • View Article
   • Google Scholar
2. ii. Wittchen HU, Jacobi F, Rehm J, Gustavsson A, Svensson M, Jönsson B, et al. The size and brunt of mental disorders and other disorders of the brain in Europe 2010. European Neuropsychopharmacology. 2011;21(9):655–79. pmid:21896369
   • View Article
   • PubMed/NCBI
   • Google Scholar
3. 3. de Graaf R, ten Have M, van Gool C, van Dorsselaer S. Prevalence of mental disorders and trends from 1996 to 2009. Results from the Netherlands Mental Health Survey and Incidence Report-2. Social Psychiatry and Psychiatric Epidemiology. 2011;47(2):203–xiii. pmid:21197531
   • View Commodity
   • PubMed/NCBI
   • Google Scholar
4. 4. Kessler RC, Dupont RL, Berglund P, Wittchen H-U. Impairment in Pure and Comorbid Generalized Anxiety Disorder and Major Low at 12 Months in Two National Surveys. American Periodical of Psychiatry. 1999;156(12):1915–23. pmid:10588405
   • View Article
   • PubMed/NCBI
   • Google Scholar
5. 5. Kessler RC, Chiu WT, Demler O, Walters EE. Prevalence, Severity, and Comorbidity of 12-Month DSM-Iv Disorders in the National Comorbidity Survey Replication. Archives of General Psychiatry. 2005;62(half-dozen):617. pmid:15939839
   • View Article
   • PubMed/NCBI
   • Google Scholar
6. six. Twenge JM. The historic period of anxiety? The nativity cohort alter in feet and neuroticism, 1952–1993. Periodical of Personality and Social Psychology. 2000;79(6):1007–21. pmid:11138751
   • View Article
   • PubMed/NCBI
   • Google Scholar
7. 7. Baxter AJ, Vos T, Scott KM, Ferrari AJ, Whiteford HA. The global burden of anxiety disorders in 2010. Psychological Medicine. 2014;44(xi):2363–74. pmid:24451993
   • View Article
   • PubMed/NCBI
   • Google Scholar
8. eight. Mendlowicz MV. Quality of Life in Individuals With Anxiety Disorders. American Journal of Psychiatry. 2000;157(5):669–82. pmid:10784456
   • View Article
   • PubMed/NCBI
   • Google Scholar
9. nine. Aderka IM, Hofmann SG, Nickerson A, Hermesh H, Gilboa-Schechtman E, Marom South. Functional harm in social anxiety disorder. Journal of Anxiety Disorders. 2012;26(three):393–400. pmid:22306132
   • View Article
   • PubMed/NCBI
   • Google Scholar
10. 10. Naragon-Gainey G, Gallagher MW, Chocolate-brown TA. A longitudinal test of psychosocial impairment across the anxiety disorders. Psychological Medicine. 2013;44(08):1691–700.
    • View Article
    • Google Scholar
11. 11. Konnopka A, Leichsenring F, Leibing Eastward, König H-H. Price-of-affliction studies and cost-effectiveness analyses in anxiety disorders: A systematic review. Journal of Affective Disorders. 2009;114(1–3):xiv–31. pmid:18768222
    • View Article
    • PubMed/NCBI
    • Google Scholar
12. 12. Blanco C, Heimberg RG, Schneier FR, Fresco DM, Chen H, Turk CL, et al. A Placebo-Controlled Trial of Phenelzine, Cerebral Behavioral Group Therapy, and Their Combination for Social Anxiety Disorder. Archives of General Psychiatry. 2010;67(three):286. pmid:20194829
    • View Article
    • PubMed/NCBI
    • Google Scholar
13. 13. Davidson JRT, Foa EB, Huppert JD, Keefe FJ, Franklin ME, Compton JS, et al. Fluoxetine, Comprehensive Cerebral Behavioral Therapy, and Placeboin Generalized Social Phobia. Archives of General Psychiatry. 2004;61(10):1005. pmid:15466674
    • View Article
    • PubMed/NCBI
    • Google Scholar
14. 14. Hyman SE. The Diagnosis of Mental Disorders: The Trouble of Reification. Annual Review of Clinical Psychology. 2010;6(1):155–79.
    • View Commodity
    • Google Scholar
15. 15. Lydiard RB, Brawman-Mintzer O, Ballenger JC. Recent developments in the psychopharmacology of anxiety disorders. Journal of Consulting and Clinical Psychology. 1996;64(four):660–viii. pmid:8803355
    • View Article
    • PubMed/NCBI
    • Google Scholar
16. xvi. Bandelow B, Sher L, Bunevicius R, Hollander E, Kasper Due south, Zohar J, et al. Guidelines for the pharmacological handling of anxiety disorders, obsessive–compulsive disorder and posttraumatic stress disorder in principal care. International Periodical of Psychiatry in Clinical Practice. 2012;16(2):77–84. pmid:22540422
    • View Article
    • PubMed/NCBI
    • Google Scholar
17. 17. Nielsen SKK, Hageman I, Petersen A, Daniel SIF, Lau 1000, Winding C, et al. Do emotion regulation, attentional control, and attachment mode predict response to cognitive behavioral therapy for anxiety disorders?–an investigation in clinical settings. Psychotherapy Enquiry. 2018:i–11.
    • View Article
    • Google Scholar
18. xviii. Drožđek B, Bolwerk N. Evaluation of grouping therapy with traumatized asylum seekers and refugees—The Den Bosch Model. Traumatology. 2010;16(iv):117–27.
    • View Commodity
    • Google Scholar
19. nineteen. Drožđek B, Kamperman AM, Bolwerk N, Tol WA, Kleber RJ. Group Therapy With Male Asylum Seekers and Refugees With Posttraumatic Stress Disorder. The Journal of Nervous and Mental Disease. 2012;200(ix):758–65. pmid:22922235
    • View Article
    • PubMed/NCBI
    • Google Scholar
20. 20. Öster I, Svensk A-C, Magnusson EVA, Thyme KE, Sjodin M, Åstrom S, et al. Art therapy improves coping resources: A randomized, controlled study among women with breast cancer. Palliative & Supportive Intendance. 2006;four(01).
    • View Commodity
    • Google Scholar
21. 21. Nederland FeG. GZ Vaktherapeut. Beroepscompetentieprofiel. 2012.
22. 22. Balkom ALJM van VIv, Emmelkamp PMG, Bockting CLH, Spijker J, Hermens MLM, Meeuwissen JAC. Multidisciplinary Guideline Anxiety Disorders (Third revision). Guideline for diagnostics and treatement of adult patients with an feet disorder. [Multidisciplinaire richtlijn Angststoornissen (Derde revisie). Richtlijn voor de diagnostiek, behandeling en begeleiding van volwassen patiënten met een angststoornis]. Utrecht: Trimbos Institute; 2013.
23. 23. Malchiodi CA. Handbook of art therapy. Malchiodi CA, editor: New York, NY etc.: The Guilford Printing; 2003.
24. 24. Schweizer C, de Bruyn J, Haeyen South, Henskens B, Visser H, Rutten-Saris Yard. Fine art Therapy. Handbook Fine art therapy. [Beeldende therapie. Handboek beeldende therapie]. Bohn Stafleu van Loghum; 2009. p. 25–77.
25. 25. Eren N, Öğünç NE, Keser 5, B1kmaz Due south, Şahin D, Saydam B. Psychosocial, symptomatic and diagnostic changes with long-term psychodynamic art psychotherapy for personality disorders. The Arts in Psychotherapy. 2014;41(4):375–85.
    • View Commodity
    • Google Scholar
26. 26. Haeyen South. Panel discussion for experienced arts therapist about arts therapies in the handling of personality disorders. Internal document on behalf of the evolution of the National multi-disciplinary guideline for the treatment of personalities disorders. Utrecht: Trimbos Institute; 2005.
27. 27. Morgan L, Knight C, Bagwash J, Thompson F. Borderline personality disorder and the role of art therapy: A discussion of its utility from the perspective of those with a lived experience. International Journal of Art Therapy. 2012;17(3):91–seven.
    • View Commodity
    • Google Scholar
28. 28. Bateman A, Fonagy P. Psychotherapy for Deadline Personality Disorder: Oxford University Press; 2004 2004/04.
29. 29. Ouwens 1000, Vroling M., Haeyen S., Faassen 50., Kranendonk H., Metzemaekers R. et al. Peeking at the neighbors. Inventory research on the intervention forms by art therapists [Gluren bij de buren. Inventariserend onderzoek naar de interventievormen door vaktherapeuten]. Tijdschrift voor Vaktherapie. 2007;2007(4):17–22.
    • View Article
    • Google Scholar
30. thirty. Haeyen Due south, van Hooren S, Hutschemaekers Chiliad. Perceived effects of art therapy in the treatment of personality disorders, cluster B/C: A qualitative report. The Arts in Psychotherapy. 2015;45:i–10.
    • View Commodity
    • Google Scholar
31. 31. Nanda U, Barbato Gaydos HL, Hathorn K, Watkins Northward. Art and Posttraumatic Stress: A Review of the Empirical Literature on the Therapeutic Implications of Artwork for War Veterans With Posttraumatic Stress Disorder. Environment and Behavior. 2010;42(three):376–90.
    • View Article
    • Google Scholar
32. 32. Schouten KA, de Niet GJ, Knipscheer JW, Kleber RJ, Hutschemaekers GJM. The Effectiveness of Art Therapy in the Treatment of Traumatized Adults. Trauma, Violence, & Abuse. 2014;sixteen(2):220–8.
    • View Article
    • Google Scholar
33. 33. Ramirez J. A Review of Art Therapy Among Military Service Members and Veterans with Post-Traumatic Stress Disorder. Journal of Military machine and Veterans' Wellness 2016;24(ii).
    • View Article
    • Google Scholar
34. 34. Williams ME, Thompson SC. The Use of Community-Based Interventions in Reducing Morbidity from the Psychological Impact of Conflict-Related Trauma Among Refugee Populations: A Systematic Review of the Literature. Journal of Immigrant and Minority Health. 2010;13(4):780–94.
    • View Article
    • Google Scholar
35. 35. Uttley 50, Stevenson M, Scope A, Rawdin A, Sutton A. The clinical and cost effectiveness of group art therapy for people with not-psychotic mental wellness disorders: a systematic review and cost-effectiveness analysis. BMC Psychiatry. 2015;15(1).
    • View Article
    • Google Scholar
36. 36. Slayton SC, D'Archer J, Kaplan F. Outcome Studies on the Efficacy of Art Therapy: A Review of Findings. Fine art Therapy. 2010;27(3):108–18.
    • View Article
    • Google Scholar
37. 37. Van Lith T. Fine art therapy in mental health: A systematic review of approaches and practices. The Arts in Psychotherapy. 2016;47:nine–22.
    • View Article
    • Google Scholar
38. 38. Lankston L, Cusack P, Fremantle C, Isles C. Visual art in hospitals: case studies and review of the show. Periodical of the Royal Society of Medicine. 2010;103(12):490–nine. pmid:21127332
    • View Article
    • PubMed/NCBI
    • Google Scholar
39. 39. Fenner P, Abdelazim RS, Bräuninger I, Strehlow 1000, Seifert Yard. Provision of arts therapies for people with severe mental illness. Current Opinion in Psychiatry. 2017;xxx(4):306–11. pmid:28441170
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
40. xl. Fonagy P. The effectiveness of psychodynamic psychotherapies: An update. World Psychiatry. 2015;14(2):137–50. pmid:26043322
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
41. 41. McGrath C. Music performance anxiety therapies: A review of the literature. In: Taylor Southward, editor.: ProQuest Dissertations Publishing; 2012.
42. 42. Higgins JPT GSe. Cochrane Handbook for Systematic Reviews of Interventions Version 5.1.0 [updated March 2011].: The Cochrane Collaboration, 2011; 2011 [Available from: http://handbook-five-1.cochrane.org/.
43. 43. Moher D. Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The PRISMA Statement. Annals of Internal Medicine. 2009;151(4):264. pmid:19622511
    • View Article
    • PubMed/NCBI
    • Google Scholar
44. 44. Abbing A, Ponstein A, Baars E, van Hooren S, de Sonneville L, & Swaab H. Effectiveness and working mechanisms of visual art therapies in the treatment of anxiety in adults. A systematic review of RCTs and nRCTs. PROSPERO 2017 CRD42017080733 2017
    • View Article
    • Google Scholar
45. 45. Shea BJ RB, Wells G, Thuku Yard, Hamel C, Moran J, Moher D, Tugwell P, Welch V KE, Henry DA. AMSTAR 2: a critical appraisement tool for systematic reviews that include randomised or non-randomised studies of healthcare interventions, or both. BMJ. 2017(358:j4008). pmid:28935701
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
46. 46. Frances A, American Psychiatric Association. Task Force on D-I. Diagnostic and statistical manual of mental disorders, DSM-Four-TR. 4th ed., text revision. ed. Frances A, American Psychiatric Association. Job Force on D-I, editors: Washington, DC: American Psychiatric Association; 2000.
47. 47. Higgins JPT, Altman DG, Gotzsche PC, Juni P, Moher D, Oxman AD, et al. The Cochrane Collaboration'south tool for assessing risk of bias in randomised trials. BMJ. 2011;343.
    • View Article
    • Google Scholar
48. 48. Munder T, Barth J. Cochrane's take a chance of bias tool in the context of psychotherapy outcome research. Psychotherapy Research. 2017;28(3):347–55. pmid:29224503
    • View Article
    • PubMed/NCBI
    • Google Scholar
49. 49. Ryan R HS. How to GRADE the quality of the evidence. Cochrane Consumers and Communication Group. 2016 (Version 3.0 December 2016).
    • View Commodity
    • Google Scholar
50. 50. Allen KN, Wozniak DF. The Linguistic communication of Healing: Women'south Voices in Healing and Recovering From Domestic Violence. Social Work in Mental Wellness. 2010;nine(1):37–55.
    • View Article
    • Google Scholar
51. 51. Asawa P. Reducing feet to applied science: Utilizing expressive experiential interventions. In: Adams JD, editor.: ProQuest Dissertations Publishing; 2003.
52. 52. Heynen E, Roest J, Willemars 1000, van Hooren South. Therapeutic alliance is a factor of change in arts therapies and psychomotor therapy with adults who have mental health problems. The Arts in Psychotherapy. 2017;55:111–5.
    • View Article
    • Google Scholar
53. 53. Kimport ER, Hartzell Due east. Clay and Anxiety Reduction: A Ane-Group, Pretest/Posttest Design With Patients on a Psychiatric Unit of measurement. Art Therapy. 2015;32(4):184–ix.
    • View Article
    • Google Scholar
54. 54. Lande RG, Banks Williams 50, Francis JL, Gragnani C, Morin ML. Characteristics and Effectiveness of an Intensive Armed forces Outpatient Treatment Program for PTSD. Journal of Assailment, Maltreatment & Trauma. 2011;20(5):530–viii.
    • View Article
    • Google Scholar
55. 55. Swami V. Sketching people: Prospective investigations of the bear on of life drawing on torso image. Body Epitome. 2017;xx:65–73. pmid:27987417
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
56. 56. Selders Yard, Visser R, van Rooij Westward, Delfstra G, Koelen JA. The evolution of a brief group intervention (Dynamic Interpersonal Therapy) for patients with medically unexplained somatic symptoms: a airplane pilot report. Psychoanalytic Psychotherapy. 2015;29(two):182–98.
    • View Article
    • Google Scholar
57. 57. Eaton J, Tieber C. The Furnishings of Coloring on Anxiety, Mood, and Perseverance. Art Therapy. 2017;34(1):42–half-dozen.
    • View Article
    • Google Scholar
58. 58. Back-scratch NA, Kasser T. Tin Coloring Mandalas Reduce Anxiety? Art Therapy. 2005;22(2):81–5.
    • View Commodity
    • Google Scholar
59. 59. Kim SK. A randomized, controlled study of the furnishings of art therapy on older Korean-Americans' good for you aging. The Arts in Psychotherapy. 2013;40(one):158–64.
    • View Article
    • Google Scholar
60. sixty. Toroghi LM. The Effectiveness of Art Therapy On Housewives General Health, Anxiety and Self-efficacy in Tehran. European Psychiatry. 2015;xxx:852.
    • View Commodity
    • Google Scholar
61. 61. de Morais AH, Dalécio Human, Vizmann S, Bueno VLRdC, Roecker S, Salvagioni DAJ, et al. Result on scores of depression and anxiety in psychiatric patients after clay work in a day hospital. The Arts in Psychotherapy. 2014;41(ii):205–ten.
    • View Article
    • Google Scholar
62. 62. Campbell One thousand, Decker KP, Kruk Chiliad, Deaver SP. Art Therapy and Cognitive Processing Therapy for Gainsay-Related PTSD: A Randomized Controlled Trial. Fine art Therapy. 2016;33(4):169–77. pmid:29332989
    • View Article
    • PubMed/NCBI
    • Google Scholar
63. 63. Andersson 1000, Paxling B, Roch-Norlund P, Östman Grand, Norgren A, Almlöv J, et al. Net-Based Psychodynamic versus Cognitive Behavioral Guided Self-Help for Generalized Anxiety Disorder: A Randomized Controlled Trial. Psychotherapy and Psychosomatics. 2012;81(6):344–55. pmid:22964540
    • View Article
    • PubMed/NCBI
    • Google Scholar
64. 64. Egger N, Konnopka A, Beutel ME, Herpertz S, Hiller W, Hoyer J, et al. Brusque-term price-effectiveness of psychodynamic therapy and cognitive-behavioral therapy in social anxiety disorder: Results from the SOPHO-NET trial. Journal of Affective Disorders. 2015;180:21–eight. pmid:25879721
    • View Article
    • PubMed/NCBI
    • Google Scholar
65. 65. Knijnik DZ, Salum GA, Blanco C, Moraes C, Hauck S, Mombach CK, et al. Defense Mode Changes With the Addition of Psychodynamic Grouping Therapy to Clonazepam in Social Anxiety Disorder. The Journal of Nervous and Mental Disease. 2009;197(7):547–51. pmid:19597364
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
66. 66. Leichsenring F, Salzer Due south, Beutel ME, Herpertz S, Hiller W, Hoyer J, et al. Psychodynamic Therapy and Cognitive-Behavioral Therapy in Social Anxiety Disorder: A Multicenter Randomized Controlled Trial. American Journal of Psychiatry. 2013;170(7):759–67. pmid:23680854
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
67. 67. Leichsenring F, Salzer S, Beutel ME, Herpertz South, Hiller W, Hoyer J, et al. Long-Term Outcome of Psychodynamic Therapy and Cognitive-Behavioral Therapy in Social Anxiety Disorder. American Journal of Psychiatry. 2014;171(10):1074–82. pmid:25016974
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
68. 68. Leichsenring F, Salzer South, Jaeger U, Kachele H, Kreische R, Leweke F, et al. Short-Term Psychodynamic Psychotherapy and Cognitive-Behavioral Therapy in Generalized Anxiety Disorder: A Randomized, Controlled Trial. American Journal of Psychiatry. 2009;166(8):875–81. pmid:19570931
    • View Article
    • PubMed/NCBI
    • Google Scholar
69. 69. Bell CE, Robbins SJ. Consequence of Fine art Production on Negative Mood: A Randomized, Controlled Trial. Art Therapy. 2007;24(2):71–5.
    • View Article
    • Google Scholar
70. 70. Henderson P, Rosen D, Mascaro Northward. Empirical report on the healing nature of mandalas. Psychology of Aesthetics, Inventiveness, and the Arts. 2007;1(3):148–54.
    • View Article
    • Google Scholar
71. 71. Sandmire DA, Gorham SR, Rankin NE, Grimm DR. The Influence of Fine art Making on Feet: A Pilot Study. Art Therapy. 2012;29(ii):68–73.
    • View Article
    • Google Scholar
72. 72. Yu YZ, Yu Ming C, Yue Thou, Hai Li J, Ling L. House–Tree–Person drawing therapy as an intervention for prisoners' prerelease anxiety. Social Beliefs and Personality: an international journal. 2016;44(6):987–1004.
    • View Article
    • Google Scholar
73. 73. Grant Southward, Pedersen E, Osilla K, Kulesza M, D'Amico E. Information technology is time to develop advisable tools for assessing minimal clinically important differences, performance bias and quality of evidence in reviews of behavioral interventions. Addiction. 2016;111(nine):1533–5. pmid:27095296
    • View Article
    • PubMed/NCBI
    • Google Scholar
74. 74. Holmqvist Grand, Persson CL. Is there evidence for the use of art therapy in treatment of psychosomatic disorders, eating disorders and crunch? A comparative written report of two different systems for evaluation. Scandinavian Periodical of Psychology. 2011;53(1):47–53. pmid:22023072
    • View Article
    • PubMed/NCBI
    • Google Scholar
75. 75. Guyatt GH, Oxman AD, Kunz R, Brozek J, Alonso-Coello P, Rind D, et al. Grade guidelines vi. Rating the quality of testify—imprecision. Journal of Clinical Epidemiology. 2011;64(12):1283–93. pmid:21839614
    • View Article
    • PubMed/NCBI
    • Google Scholar
76. 76. Yan H, & Chen J. The broad prospects of the clinical applications of drawing art therapy [In Chinese]. Medicine and Philosophy. 2011;ten:56–7.
    • View Article
    • Google Scholar
77. 77. Sarid O, Huss E. Trauma and acute stress disorder: A comparison between cognitive behavioral intervention and art therapy. The Arts in Psychotherapy. 2010;37(1):8–12.
    • View Commodity
    • Google Scholar
78. 78. Cascone Southward. Experts Warn Adult Coloring Books are non Art Therapy https://news.artnet.com/art-globe/experts-warn-developed-coloring-books-not-art-therapy-3235062015 [Available from: https://news.artnet.com/art-globe/experts-warn-adult-coloring-books-not-art-therapy-323506.
79. 79. Kramer E. Art as therapy with children. Studies in Fine art Education. 1975;sixteen(2):68.
    • View Article
    • Google Scholar
80. eighty. Kaimal G, Ray K, Muniz J. Reduction of Cortisol Levels and Participants' Responses Following Art Making. Art Therapy. 2016;33(two):74–fourscore. pmid:27695158
    • View Commodity
    • PubMed/NCBI
    • Google Scholar
81. 81. Csikszentimihalyi Yard. Creativity: Catamenia and the psychology of discovery and invention. New York: HarperCollins; 1997.
82. 82. Naumburg G. Dynamically oriented art therapy: its principles and practices. Illustrated with iii instance studies. New York: Grune & Stratton; 1966.
83. 83. McNeilly G, Instance C, Killick 1000, Schaverien J, Gilroy A. Changing Shape of Fine art Therapy: New Developments in Theory and Practice: London: Jessica Kingsley Publishers; 2011.
84. 84. Brown KW, Ryan RM. The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology. 2003;84(4):822–48. pmid:12703651
    • View Article
    • PubMed/NCBI
    • Google Scholar
85. 85. Huijbregts SCJ. The role of stress in self-regulation and psychopathology [De rol van stress bij zelfregulatie en psychopathologie]. In: Swaab H, Bouma A., Hendrinksen J. & König C. (red) editor. Klinische kinderneuropsychologie. Amsterdam: Boom; 2015.
86. 86. Baumeister RF, Gailliot Yard, DeWall CN, Oaten M. Self-Regulation and Personality: How Interventions Increase Regulatory Success, and How Depletion Moderates the Effects of Traits on Behavior. Journal of Personality. 2006;74(6):1773–802. pmid:17083666
    • View Article
    • PubMed/NCBI
    • Google Scholar
87. 87. Gruber H, Oepen R. Emotion regulation strategies and furnishings in fine art-making: A narrative synthesis. The Arts in Psychotherapy. 2018;59:65–74.
    • View Article
    • Google Scholar

strongthoughte.blogspot.com

Source: https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0208716