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Review: systematic review of effectiveness of art psychotherapy in children with mental health disorders

• Review Article
• Open access
• Published: 06 July 2021
• Volume 191 , pages 1369–1383, ( 2022 )

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• Irene Braito   ORCID: orcid.org/0000-0002-3695-6464 1 , 2 ,
• Tara Rudd 3 ,
• Dicle Buyuktaskin   ORCID: orcid.org/0000-0003-4679-3846 1 , 4 ,
• Mohammad Ahmed 1 ,
• Caoimhe Glancy 1 &
• Aisling Mulligan   ORCID: orcid.org/0000-0001-7708-1177 3 , 5  

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

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Introduction

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

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

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

Data extraction

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

Study inclusion and assessment

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

PRISMA 2009 flow diagram

Participant characteristics

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

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

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

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

Forms of art therapy intervention and assessment (Table 1 )

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

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

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

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

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

Outcome measures and statistical analysis (Table 1 )

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

Study design: children with psychiatric symptoms (Table 2 )

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

Forms of intervention and assessment (Table 2 )

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

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

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

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

Outcome measures and statistical analysis (Table 2 )

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

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

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

Assessment of bias

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

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

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

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

Strengths and limitations

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

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

Conclusions and future perspectives

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

Availability of data and material

Data can be made available to reviewers if required.

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Acknowledgements

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

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

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REVIEW article

Art therapy in the digital world: an integrative review of current practice and future directions.

• 1 Institute of Health Research and Innovation, University of the Highlands and Islands, Inverness, United Kingdom
• 2 Independent Researcher, Moray, United Kingdom
• 3 Population Health Science Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
• 4 Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, United Kingdom

Background: Psychotherapy interventions increasingly utilize digital technologies to improve access to therapy and its acceptability. Opportunities that digital technology potentially creates for art therapy reach beyond increased access to include new possibilities of adaptation and extension of therapy tool box. Given growing interest in practice and research in this area, it is important to investigate how art therapists engage with digital technology or how (and whether) practice might be safely adapted to include new potential modes of delivery and new arts media.

Methods: An integrative review of peer-reviewed literature on the use of digital technology in art therapy was conducted. The methodology used is particularly well suited for early stage exploratory inquiries, allowing for close examination of papers from a variety of methodological paradigms. Only studies that presented empirical outcomes were included in the formal analysis.

Findings: Over 400 records were screened and 12 studies were included in the synthesis, pertaining to both the use of digital technology for remote delivery and as a medium for art making. Included studies, adopting predominantly qualitative and mixed methods, are grouped according to their focus on: art therapists’ views and experiences, online/distance art therapy, and the use of digital arts media. Recurring themes are discussed, including potential benefits and risks of incorporating digital technology in sessions with clients, concerns relating to ethics, resistance toward digital arts media, technological limitations and implications for therapeutic relationship and therapy process. Propositions for best practice and technological innovations that could make some of the challenges redundant are also reviewed. Future directions in research are indicated and cautious openness is recommended in both research and practice.

Conclusion: The review documents growing research illustrating increased use of digital technology by art therapists for both online delivery and digital art making. Potentially immense opportunities that technology brings for art therapy should be considered alongside limitations and challenges of clinical, pragmatic and ethical nature. The review aims to invite conversations and further research to explore ways in which technology could increase relevance and reach of art therapy without compromising clients’ safety and key principles of the profession.

Introduction

Digital technology is increasingly present in psychotherapy practice worldwide, enabling clients and therapists to connect remotely. This way of improving access to therapy is important for those who might not otherwise be able to benefit from treatment due to living in more remote locations or having disabilities or mobility problems preventing them to attend therapy sessions in person. Despite this general trend of expansion in telehealth provision, to include also psychotherapy services, relatively little is known about its use within art therapy practice ( Choe, 2014 ; Levy et al., 2018 ). Research in the area focuses primarily on verbal therapies and more specifically on cognitive-behavioral therapy conducted online ( Hedman et al., 2012 ; Saddichha et al., 2014 ; Vigerland et al., 2016 ) with some notable examples of work highlighting issues key to psychodynamic psychotherapy ( De Bitencourt Machado et al., 2016 ; Feijó et al., 2018 ).

Art therapists support clients in engaging in creative processes to improve their psychological wellbeing. Due to incorporating art making within therapy process and the key role of triangular therapeutic relationship between the therapist, the client and the artwork ( Schaverien, 2000 ; Gussak and Rosal, 2016 ), art therapy practice is arguably more difficult to translate to online situations. However, suggestions have also been made that art therapy is particularly well suited to distance delivery, partially due to increasing ease of sharing images via online channels and non-reliance on verbal communication, and also due to dealing with symbols, metaphors and projections, which can manifest irrespective of medium used ( McNiff, 1999 ; Austin, 2009 ).

Art therapy profession has not entered the digital world only recently. In fact, it has been critically engaged in often difficult discussions on the risks and potential of digital technology for art therapy practice for over three decades ( Weinberg, 1985 ; Canter, 1987 , 1989 ; Johnson, 1987 ). Back in 1999 the Art Therapy Journal dedicated a special issue to the links between computer technology and art therapy and has repeated a similar issue a decade later. In 2019, the Journal asked therapists and researchers to consider ways in which professional assumptions can be updated, modernized or reframed to meet contemporary needs.

The use of digital technology in art therapy is not limited to online communication tools but extends to the application of digital media for the purpose of art making, equally relevant to face-to-face practice. While distance art therapy could potentially widen the reach of therapy to include new groups of clients, expanding the range of therapeutic tools to include digital arts media might extend art therapy toolbox to widen access for those clients who might not otherwise engage in traditional art materials for a variety of reasons.

However, it has been argued that the process of digital media adoption in art therapy is slow ( Carlton, 2014 ; Choe, 2014 ) and resistance to digital technology as well as concerns about the use of digital tools for art making in therapy have been reported in literature ( Kuleba, 2008 ; Klorer, 2009 ; Potash, 2009 ). It has been even implied that art therapists themselves may be more conservative and hesitant in their use of digital media than their clients ( McNiff, 1999 ; Peterson et al., 2005 ; Carlton, 2014 ). This cautiousness is stipulated to be informed by a heightened sense of responsibility for clients’ safety and wellbeing ( Orr, 2016 ). Art therapists’ own emotional factors and biases were cited to be important barriers to adoption of technology ( Asawa, 2009 ) while it has been suggested that therapists experience “conflict between the desire to promote art therapy and engage in technology and the desire to remain loyal to the field’s origins in traditional methods of communication and art media” ( Asawa, 2009 , p. 58).

The use of digital arts media is unique to art therapy practice and is perhaps not yet sufficiently researched for that reason, despite its potentially enormous implications for art therapy practice ( Kapitan, 2009 ). Lack of in-depth research on digital art making has been cited as a key barrier for practitioners to introduce digital arts media in therapy sessions ( Klorer, 2009 ; Potash, 2009 ). Similarly, limited guidelines from professional associations and importance of more specific technology-oriented ethical codes for practitioners are frequently highlighted ( Kuleba, 2008 ; Asawa, 2009 ; Alders et al., 2011 ; Evans, 2012 ).

A challenge identified in early stages of discussion on the use of technology in art therapy was the need for increased collaboration between art therapists, designers and developers in order to device technological solutions suitable to art therapy practice ( Gussak and Nyce, 1999 ). Limited attempts to develop art therapy-specific electronic devices to date lacked in-depth input from art therapists at the technical stage and, in consequence, appropriate integration of the established processes of art therapy with technology (e.g., Mihailidis et al., 2010 ; Mattson, 2015 ). In effect, art therapists who incorporate digital arts media in their practice elect to use painting apps not necessarily suitable for art therapy practice. There is also an ongoing debate on the tactile nature of art materials being lost if art is made using digital tools and potential impact on clients ( Kuleba, 2008 ; Garner, 2017 ). A similar discussion concerns the therapeutic relationship and specifically whether it could be recreated in distance therapy ( Klorer, 2009 ; Potash, 2009 ).

Despite these indicated debates on the usefulness of digital technology for art therapy practice and polarized opinions, some scholars and practitioners have advocated for increased efforts to incorporate digital art-making in the therapy process suggesting rising and permanent role of technology in art therapy ( McNiff, 2000 ; Kapitan, 2007 ; Thong, 2007 ). Given the rapidly growing interest in digital technology applications to art therapy practice, research has been developing relatively slowly and has not yet been systematized. Doing so would help paint an inevitably complex picture of how art therapy is currently engaging with digital technology and how it might make the best use of the opportunities it presents and critically address challenges early in the process.

In order to identify key topics important for practitioners and areas for further research, we aimed to capture and synthesize available research literature that explores the role of digital technology in the current and future art therapy practice (understood here as within-session work with clients). More specific research questions were:

- How do art therapists use digital technology in their practice?

- What benefits and challenges of using digital technology with clients do they identify?

- How do clients experience art therapy sessions with digital technology elements?

Methodology

Through our own experiences in research and practice and following some initial literature searches we were aware that the area we set to explore is complex and relatively novel. Thus, we anticipated that any published research accounts were likely to include a variety of study designs, appropriately to the overall exploratory character of research in the area and in line with research in arts therapies in general, which tends to draw upon diverse methodologies and beyond qualitative and quantitative paradigms, to include also arts-based approaches. We chose an integrative review framework as a guide to allow us to undertake a well-rounded but flexible evidence synthesis that would present a breadth of perspectives and combine methodologies without overvaluing specific hierarchies of evidence ( Whittemore and Knafl, 2005 ). Integrative review is an appropriate method at early stages of systematizing knowledge on a developing subject area ( Russell, 2005 ; Souza et al., 2010 ) and as such was deemed suitable for our exploratory work which aimed to identify central issues in the area, indicate the state of the scientific evidence across diverse methodological paradigms and identify gaps in current research ( Russell, 2005 ).

Search Strategy

The following databases were searched for studies published until July 2020: MEDLINE, CINAHL Complete, APA PsycInfo, APA PsycArticles, Academic Search Complete and the Cochrane Library. Google Scholar search, backward and forward reference screening of included publications, and peer consultation were used to identify any other relevant articles. Search string ( Table 1 ) included the four key elements of this review: intervention (art therapy), intervention modification/adaptation (digital technology), methodology (empirical research) and population of interest (all client populations, any setting). These elements of a search strategy were conceptually guided by the PEO (Population-Exposure-Outcome) framework ( Khan et al., 2011 ; Bettany-Saltikov, 2016 ) instead of the more popular PICO (Population-Intervention-Comparison-Outcome), as the former was considered more suitable for capturing mixed method studies ( Methley et al., 2014 ).

Table 1. Search string development: concepts shaping this review and corresponding PEO elements.

Inclusion/Exclusion Criteria

We opted for broad inclusion criteria to report on all research studies pertaining to the use of digital technology in art therapy and therefore no specific definition of ‘digital’ was adopted other than how authors describe the focus of their paper(s). Time of publication was not initially considered a selection criterion but on reviewing the papers a decision was made to exclude those that focused on technology no longer relevant to modern practice, which, it was felt, related to articles published before 1999.

Articles were included in the review if they:

- concerned the use of modern (currently relevant) digital technology (DT) in within-session art therapy practice with clients;

- reported outcomes observed through empirical study, regardless of whether these were investigated using quantitative, qualitative, mixed or arts-based methods;

- were available online and in English.

Articles were excluded if they:

- focused exclusively on the use of digital technology for office work, assessment, supervision, training or research;

- were PhD theses, dissertations or books/book chapters;

- were theoretical/opinion papers with no empirical data reported.

Data Extraction

Data were extracted from included papers using a data collection form based on the Template for Intervention Description and Replication (TIDieR; Hoffmann et al., 2014 ) which helped to record the characteristics of the studies, interventions, outcomes and main findings reported.

Data Synthesis

We followed the recommended process for synthesizing data in an integrative review ( Whittemore and Knafl, 2005 ) by initially comparing the extracted data item by item, recognizing similarities and groupings, to eventually identifying meaningful categories for studies and interventions included in the review. Each of the papers was read multiple times to generate a mental map of ideas explored across the literature. Iterative process of examining the classified data enabled us to identify themes and relationships which constitute the essence of this synthesis process. Due to expectedly heterogenic character of included studies, attempts at establishing a meaningful classification were at all times guided by the above principles.

Of 474 records identified through database searching and consulting reference lists, 405 were excluded based on title and abstract screening. Full-texts for the remaining 69 records were consulted and 56 were excluded with reasons ( Figure 1 ). Many of the excluded papers were opinion pieces which did not present empirical outcomes, but were nevertheless helpful in gaining a fuller perspective of the topic and are frequently referred to in the discussion. Selection process resulted in 13 articles included in this review.

Figure 1. PRISMA flow diagram.

Study Characteristics

All of included research was undertaken either in the US (9 studies) or in Canada (4 studies). The studies were varied methodologically, with qualitative (6 studies), quantitative (1 study) and mixed methods (5 studies) paradigms all represented. The studies employed primarily surveys, focus groups, interviews, case studies and prototyping workshops, often following participatory and mixed-method designs, which seems appropriate for early explorations and for highly applied research with direct implications for clinical practice. Art therapists themselves were research participants in the majority of included papers with only three reporting specifically on client experiences ( Darewych et al., 2015 ; Levy et al., 2018 ; Spooner et al., 2019 ). Numbers of participants in qualitative, client-focused and/or workshop-based studies (8 studies) were generally low (ranging from single figures to 25 participants) and numbers of respondents in survey-based studies (4 studies) ranged from 45 to 195. Two papers ( Collie and Čubranić, 1999 , 2002 ) reported on the same research study and are referred to jointly throughout this review (including in tables).

The articles tended to discuss the use of digital technology in art therapy practice in a more general way or focus on one of the two uses of digital technology identified in our initial literature review: the use of online tools for distance art therapy and the use of digital media for art making within therapy sessions. Majority of the survey-based studies which examined directly arts therapists’ opinions on the use of digital technology in art therapy were interested in both uses of technology, while workshop-based studies typically focused on either distance delivery or exploration of digital media for art making. There were overlaps and we tried to capture the relationship between the digital technology interest and the categories we eventually decided to group the articles into in Figure 2 , which also provides an overview of methodologies and participant groups. The results are presented below in three seemingly separate groups of studies. However, the concepts explored in this research are inevitably intertwined, which is important to note to avoid over-simplifying the nature of opportunities and challenges brought into art therapy realm by the progressing developments in digital technology. Paragraphs below present key messages from the papers grouped in the three categories, except findings pertaining directly to the challenges and benefits of using digital technology within therapy, which will be discussed separately.

Figure 2. Selected characteristics of included studies: online/face-to-face delivery, digital/traditional arts media, methodology, participant group. *Indicates that a characteristic is present in a study.

General Views on Technology, Online Art Therapy, and Digital Arts Media

Art therapists’ views and opinions.

Four articles from two US-based research teams focused entirely on the views and opinions of art therapists on the use of digital technology in art therapy practice and utilized a survey design ( Table 2 : Peterson et al., 2005 ; Orr, 2006 , 2012 ; Peterson, 2010 ). They gathered both the therapists’ experience (based on practice) and expectations (based on personal attitudes). A total number of responses for the four included papers was 474, with majority coming from qualified art therapists and students in art therapy training (in one survey, only 61.5% of respondents were qualified art therapists with the other respondents being not practizing attendees of the AAT conference, Peterson et al., 2005 ). In one study, follow-up interviews were also undertaken with eight respondents selected according to their readiness for adopting new technologies ( Peterson, 2010 ).

Table 2. Characteristics of studies focusing on art therapists’ views and experiences.

Although all studies reported also on the general adoption of technology by art therapists in personal and professional practice including office work, research and training, this review extracted findings pertaining to in-session practice with clients as far as it was possible or to any aspects of digital technology use that directly affect work with clients. Therefore, information on other uses of technology by art therapists, although reported in the cited papers, is not presented here. The general message coming from all included surveys was that art therapists tended to use technology far more often for their own personal practice and for administrative professional tasks than within sessions with clients.

Across the studies, a trend emerged suggesting an increasing use of digital technology within art therapy sessions. A study comparing results from surveys undertaken 7 years apart, found that between 2004 and 2011 art therapists increased their use of digital media in their art therapy practice with clients: from 19 to 32% using technology as an artmaking tool during sessions and from 2.4 to 9.4% using web camera communication during sessions ( Orr, 2006 , 2012 ). In addition, in the 2011 survey, 11.8% respondents reported using online chat ( Orr, 2012 ). In an even earlier survey from 2002 ( Peterson et al., 2005 ), 12.3% respondents reported using technology with clients for creating digital artwork and 1.5% reported using web camera for communication in sessions, confirming the rise in in-session technology use over the years.

Two studies highlighted the need for specialist training in digital technology use for art therapists. Orr (2006) reported that in her 2004 survey only 28.5% respondents received some training in using technology to create art, 4.8% respondents felt that the training received met their needs well, while none felt that it met their needs very well. In 2011, the percentage of therapists who reported receiving training in the use of technology as therapeutic tool with clients increased slightly and stood at 36.5% and 11.5% of respondents felt that it has met their needs well ( Orr, 2012 ). Despite this rise in training opportunities, the author concluded that the training “has not kept up with the adoption rate of technology by art therapists” ( Orr, 2012 , p. 234) and that more and better education is indeed needed.

Another survey conducted almost a decade ago moved beyond establishing how art therapists use digital technology to determine their reasons for adopting or rejecting emerging digital tools for therapeutic use with their clients ( Peterson, 2010 ). A client’s response to a form of digital technology was found to be a key factor in art therapists’ decision as to whether the technology was an effective therapeutic medium. The respondents agreed that if a medium (including digital media) could safely contribute to a desirable change, then its inclusion in treatment is warranted. Cost was, again, cited as an adoption deterrent, while providing new capabilities for the therapist and the client was an additional adoption factor.

A theme consistent across the presented surveys seems to be the highly ethical and professional approach of art therapists in deciding on the use of technology with clients. The responses seemed consistent in indicating that a degree of familiarity with digital medium is necessary for therapists to implement it in therapy session with clients. Importantly, the clients’ response to any novel arts medium is the guiding factor in making decision about a specific technology adoption. Being certain of the benefits for clients seems to be a prerequisite for introducing a specific technology in art therapy sessions. The survey from 2011 revealed that art therapists were increasingly more concerned about ethical and confidentiality issues than 7 years before and that their main reservations about using digital media were linked with uncertainties around ethics ( Orr, 2006 , 2012 ).

Online Art Therapy: Digital Technology Used for Distance Art Therapy Sessions

We identified five research studies (of which one was reported in two articles) that were concerned primarily with application of digital technology solutions to remote art therapy delivery ( Table 3 : Collie and Čubranić, 1999 , 2002 ; Collie et al., 2006 , 2017 ; Levy et al., 2018 ; Spooner et al., 2019 ). Three of these studies, all from the same Canadian research team, similarly to research discussed above, examined art therapists’ opinions through focus groups ( Collie et al., 2006 ), interviews and participatory designs, including simulated online art therapy interventions ( Collie and Čubranić, 1999 , 2002 ; Collie et al., 2017 ). The studies were concerned with development of an online art therapy service for people with limited mobility, women with breast cancer and, most recently, young adult cancer patients. Two other studies from one US-based research team examined the experience of veterans participating in a blended (primarily online, with face-to-face initial assessment and re-evaluation) creative arts therapies program via semi-structured interviews and a single case study of an art therapy participant ( Levy et al., 2018 ; Spooner et al., 2019 ). Both studies were undertaken as part of a clinical program evaluation and therefore did not follow a fully experimental design. Although pre-post assessments were undertaken, these have not been reported yet.

Table 3. Characteristics of studies focusing on online / distance art therapy.

In two studies ( Collie and Čubranić, 2002 ; Collie et al., 2017 ) the participants were also co-researchers, described as art therapists, counselors, educators and people with experience of life-threatening illness (total n = 17), who were invited to take part in simulated online art therapy group sessions. The interventions experienced in the two studies were quite different, one being a group art therapy session in which participants communicated and shared digital images created in real time ( Collie and Čubranić, 2002 ), while the other included both synchronous and asynchronous elements, allowing participants to take part in live chat-based session and also upload images to a discussion board outside of scheduled session times ( Collie et al., 2017 ). In both studies participants shared their experience via discussions and follow-up interviews. Another study ( Collie et al., 2006 ) used focus groups and interviews with similarly diverse participants ( n = 25) to generate clinical and technological guidelines for distance art therapy.

One of the key conclusions coming from the studies was that online group art therapy, being a relatively novel intervention, would require certain adaptations in relation to face-to-face practice ( Spooner et al., 2019 ), for example development of suitable “social protocols” ( Collie and Čubranić, 1999 ), refining of communication procedures ( Collie and Čubranić, 2002 ) and development of “new therapeutic models” ( Collie et al., 2006 ). These adaptations would need to comply with the legal and ethical guidelines, with new telehealth-related guidance eventually required for art therapy profession and initially adapted from related disciplines such as counseling or psychology ( Spooner et al., 2019 ).

Among participating health professionals (including a large proportion of art therapists), there seemed to be quite polarized opinions about the use of computers in therapy, with majority in favor of distance art therapy, but some participants also expressing concerns about “antitherapeutic” character of technology ( Collie et al., 2006 ). Distance delivery was not generally viewed as allowing anonymous participation – in fact, high value was put on close personal interaction regardless of communication technology used ( Collie et al., 2006 ). A sense of connection and “togetherness” was observed in a study of an online group art therapy ( Collie et al., 2017 ), suggesting that the usual therapeutic group factors may be transferable in a distance therapy setup.

In their evaluation of a US-based creative arts therapy program for veterans living in rural areas, Levy et al. (2018) reported primarily positive experiences of using an online art therapy service. Participants appreciated the delivery mode and not having to travel long distances to sessions and described the normally expected positive effects of therapy like increased confidence, improved communication and making sense of emotions through self-expression. A case study of a female veteran participating in the program ( Spooner et al., 2019 ) initially revealed a decrease in perceived quality of life and satisfaction with health, which was attributed by her and her therapist to the actual progress in therapy being made: becoming more aware of emotions and ready to explore more difficult topics to eventually rediscover aspects of herself that were previously lost. These accounts seem to confirm that the therapeutic process can manifest within distance art therapy sessions and therapeutic outcomes can be achieved.

Two papers, published almost two decades apart ( Collie and Čubranić, 1999 ; Levy et al., 2018 ), proposed that distance art therapy creates subtle shifts within the usual triangular relationship between the client, the therapist and the artwork ( Schaverien, 2000 ). It was suggested that the client/artwork relationship is emphasized, while the client and the therapist are geographically separated and the client remains particularly connected and “co-present” with the art. This could create new opportunities for therapy and mean that the physical separation between the client and the therapist might affect art therapy less than verbal forms of therapy.

Digital Arts Media: Digital Technology Used for Making Artwork in Art Therapy Sessions

Three articles focused primarily on the use of digital media within face-to-face therapy settings ( Table 4 : Choe, 2014 ; Darewych et al., 2015 ; Kaimal et al., 2016 ), but it needs to be noted that the technologies discussed can potentially be successfully applied in distance therapy situations. Two papers examined applicability of iPads and/or other touchscreen devices to art therapy. One study reported on the experiences of adults with developmental disabilities through phenomenological approach ( Darewych et al., 2015 ), while the other set to explore some unique potentially therapeutic features of art applications for iPads from art therapists’ perspective, utilizing the methods of a survey and focus groups ( Choe, 2014 ). The third and most recent study focused on the relevance of virtual reality art-making tools ( Kaimal et al., 2016 ). This small selection of papers nevertheless provides a good overview of the current application of digital media to making art in art therapy sessions and introduces a client perspective.

Table 4. Characteristics of studies focusing on digital arts media use in art therapy.

In her investigation on iPads’ applicability to art therapy, Choe (2014) defined three qualities of art apps most valued by art therapists: ease of use or intuitiveness, simplicity, and responsiveness. The therapists who took part in the study believed that it was essential that any art apps were matched with the needs of individual clients and that no single app examined in this project could satisfy the needs of all clients and art therapists. The study found that the therapists had higher expectations of digital than of traditional art materials and were not prepared to compromise on the app’s speed, control or immediacy of working with images. It was suggested that certain client populations may in particular benefit from digital art making in therapy, including, among others, clients with developmental disorders, clients with suppressed immune systems (due to iPads being easier to clean), and clients who have experienced tactile trauma. It was also proposed that digital art making posed risks to some client groups, including those with internet addiction, psychosis or obsessive-compulsive disorder ( Choe, 2014 ). Another study similarly recommended caution about using immersive VR-based tools for art making with clients managing acute psychiatric symptoms ( Kaimal et al., 2020 ).

A study examining the experiences of eight adults with developmental disabilities who used digital art making in art therapy sessions ( Darewych et al., 2015 ), concluded that the participants appreciated the ease of use of the apps tested, which allowed them to create images independently. Those with olfactory and tactile sensitivity preferred the texture-free touchscreen devices to traditional art materials.

Making art in virtual reality, as “a new medium that challenges the traditional laws of the physical world and materials” ( Kaimal et al., 2020 , p. 17), was also tried and tested for use in art therapy in a small experiential study. The authors propose that therapeutic change can occur in VR environments and that it relates primarily to the unique qualities of the medium and to the fact that the participant is exposed to new environments of choice and creative opportunities not available in the material world ( Kaimal et al., 2020 ).

Challenges and Opportunities of Using Digital Technology in Art Therapy Practice

The following section presents findings across the three sets of studies that pertain more specifically to the challenges and opportunities of the use of digital technology in art therapy practice. Although these are grouped into three categories, not dissimilar to the categories of studies presented above, findings are based on contributions from across all papers examined in this review. We found frequent overlaps in aspects of technology discussed within papers, for example it was common for studies generally focusing on digital media to provide insights on remote delivery and vice versa. Not wanting to lose those, we decided to thematically analyze the content of all 13 included articles to identify themes relating to the advantages and disadvantages of technology use in art therapy, pertaining in particular to digital media and technologies and processes enabling remote delivery.

General Concerns About Including Digital Technology in Art Therapy Practice

Cost of equipment.

High cost of equipment was cited as the main reason for not including technology in art therapy sessions in a survey from 2004 ( Orr, 2006 ) and from 2002 ( Peterson et al., 2005 ), particularly the cost of electronic art tools advanced enough to allow for true emotional expression ( Orr, 2006 ). However, this issue was not as prominent in a survey from 2011, when it seemed that ethical concerns of art therapists were predominant barriers to introducing technology in therapy sessions ( Orr, 2012 ).

The importance of a specialist training for art therapists in the use of digital technology is highlighted across studies ( Collie et al., 2006 ; Orr, 2006 , 2012 ; Kaimal et al., 2020 ). It is recognized that skilful and active facilitation, essential for providing appropriate container (safe environment) and ensuring client safety ( Collie et al., 2017 ; Kaimal et al., 2020 ), requires extra time for learning ( Orr, 2006 ). Similarly, more effort and time investment in training might be needed on the client’s side, either to adjust to an online mode of therapy ( Spooner et al., 2019 ) or to a new type of digital arts media ( Kaimal et al., 2020 ). A concern has been raised about this additional learning potentially impeding the therapeutic process and that extra time might be needed for establishing a therapeutic relationship ( Collie et al., 2006 ).

Technical issues

Unfamiliarity and not being comfortable with the devices were cited as key barriers to engaging technology in art therapy sessions ( Peterson et al., 2005 ; Orr, 2006 ), which could present a challenge for both the therapist and the client ( Spooner et al., 2019 ). Problems with connectivity, including not having sufficient strength of signal and reliability, were cited as common issues in studies that examined online art therapy ( Levy et al., 2018 ; Spooner et al., 2019 ). Both inexperience and technical breakdowns could cause distress to clients ( Collie et al., 2006 , 2017 ).

Concerns Related to Online Art Therapy

Confidentiality and safety.

Concerns about maintaining confidentiality and privacy in art therapy sessions in which online technology is introduced were raised across the studies ( Orr, 2012 ; Collie et al., 2017 ; Levy et al., 2018 ). It was suggested that conducting a session online does not allow for the same assurance of privacy as in a suitable therapy room, due to potential for interruptions from family or housemates ( Levy et al., 2018 ), and that creating a safe emotional container in a cyberspace is harder than in face-to-face therapy ( Collie et al., 2017 ). In addition to confidentiality and safety issues, other ethical concerns have been raised, for example that technology can be used by clients for inappropriate online interactions ( Orr, 2012 ), that the comfort of home environment in case of online sessions might lead clients to behave in ways that they would not in a therapist’s office or that the therapist might potentially observe something concerning or illegal in clients’ private home space ( Levy et al., 2018 ).

Technological limitations

A study on online art therapy for veterans highlighted some limitations encountered in how artwork was shared between the client and the therapist, including therapists being unable to view the client’s drawing process as well as their facial expression ( Levy et al., 2018 ). When artworks were made using traditional art media and shown to the webcam, the quality of the image was at times compromised, leading to blur or loss in subtle detail ( Levy et al., 2018 ). Observing art making process directly seemed desirable while not easily achievable in online therapy setting. Levy et al. (2018) also highlighted the importance of the chronological order in which elements are added to the drawing and expressed concern about the therapist not knowing the content of the image until it is completed. In a survey from 2004 a doubt was raised as to whether it would at all be possible for an art therapist to conduct a session without being able to observe art making process in real time ( Collie et al., 2006 ).

Benefits of Online Art Therapy

Bridging divides/connecting.

Research on online art therapy seems to confirm that online mode of delivery has the potential to bridge geographical distances ( Collie and Čubranić, 1999 ; Collie et al., 2017 ) and expand access to services otherwise unavailable to clients living in rural and more remote areas ( Collie and Čubranić, 2002 ; Levy et al., 2018 ). It also helps make art therapy more accessible to clients regardless of barriers such as stigma or disability ( Spooner et al., 2019 ), and especially mobility disabilities ( Peterson, 2010 ). It was also observed that technology might have an equalizing effect in a group therapy setting if it is new to everyone ( Collie et al., 2017 ) and that the semi-anonymity of an online group might in fact increase a sense of privacy, particularly for those who are worried about being judged by appearance ( Collie and Čubranić, 1999 ; Collie et al., 2017 ). Technologies that enable collaborating on a single artwork from different locations or even looking at each other’s art on the screen were reported to bring a sense of connection and emotional closeness, as if being in the same place ( Collie et al., 2006 , 2017 ). It was also felt by some that distance delivery promotes community involvement, integration and social engagement by, for example, allowing incorporation of family members into the treatment plan ( Levy et al., 2018 ; Spooner et al., 2019 ).

Therapeutic rapport

Some studies found a positive impact of online mode of art therapy on developing therapeutic rapport ( Orr, 2012 ; Levy et al., 2018 ; Spooner et al., 2019 ). The use of technology in therapy was seen by some as comforting and actually helpful in reducing client’s resistance to therapy and/or art making ( Orr, 2012 ). Considering the client’s home environment by the therapist was referred to as an opportunity to establish deeper trust ( Levy et al., 2018 ) and a case study of a female veteran confirmed that her progress was greatly facilitated by the opportunity to invite the art therapist into her home ( Spooner et al., 2019 ).

Some papers suggested that using technology for distance therapy can be empowering ( Orr, 2012 ), allowing the client to take a more active role in their own treatment process and to have a greater autonomy within and outside therapy sessions ( Levy et al., 2018 ; Spooner et al., 2019 ). There were also indications that creating art in a home setting might lead to increased engagement in arts processes on a more regular basis and between therapy sessions ( Levy et al., 2018 ; Spooner et al., 2019 ).

Best Practice Recommendations for Online Art Therapy

Two papers in particular ( Collie et al., 2006 ; Levy et al., 2018 ) attempted to suggest solutions to some of the challenges mentioned above and ways of working which might increase safety and efficacy of online AT practice.

Among the recommendations developed by Collie and her team for distance art groups for women with cancer some seemed potentially applicable to all online art therapy situations ( Collie et al., 2006 ). These included: using a mix of technologies and accommodating clients’ individual preferences, clearly explaining limits to confidentiality imposed by Internet communication, providing guidance to participants for creating suitable private spaces, ensuring that participants have access to immediate local support as an alternative method of addressing emotional safety, and ensuring the safety and confidentiality of art sent from one place to another. The need for training for practitioners in offering art therapy from a distance was also highlighted ( Collie et al., 2006 ). Similar message was repeated in a more recent study, which concluded that the importance of skilful and typically more active than face-to-face facilitation of an online art therapy group calls for specialized training ( Collie et al., 2017 ).

Levy et al. (2018) proposed that in order to address potential technical issues with connectivity, therapists might offer their clients more than one way to connect and agree alternative ways of contact (e.g., by telephone) in case the connection breaks mid-session, to be able to continue any unfinished discussions and/or obtain closure before the end of the session. It was also suggested that interruptions from family could be minimized if the therapist and the client agree in advance how these would be handled, e.g., client could alert therapist when others are present. Instructing clients to be prepared for the session and to call exactly at appointed times was also proposed best practice. To address issues with blurred or unclear image while showing artwork to the webcam, it was recommended that, in case of digital artwork, client might share their screen, and in case of art made with traditional arts media, a digital photograph might be taken and shared with the therapist. Establishing a common vocabulary for describing artwork was another suggestion for improving communication.

Concerns Related to Digital Arts Media

Lack of tactile qualities.

An opinion that technology is cold, isolating, and even “dehumanizing” is repeated particularly in the literature published in the previous decade ( Collie et al., 2006 ; Orr, 2006 ). These seem to refer primarily to the nonsensory character of digital arts media ( Orr, 2006 ), the lack of tactile and sensual qualities ( Collie et al., 2006 ; Orr, 2012 ; Choe, 2014 ) or even lack of tangible physical engagement with the medium as in case of making art in virtual reality ( Kaimal et al., 2020 ). It was suggested that this lack of sensory input might lead to clients disconnecting not only from art materials, but also from their own bodies and social interactions ( Orr, 2012 ) and that the therapeutic value of working with “traditional” tactile art materials should not be underestimated ( Collie et al., 2006 ; Orr, 2006 ). Technology was also cited as potentially overwhelming and distracting from the creative process ( Orr, 2012 ).

Limited room for expression

An observation was made in a paper published over two decades ago that the small size of a computer screen and small mouse movements, used at that time to create images on-screen, could “tame emotions” ( Collie and Čubranić, 1999 ). Similar concern that the standardization of digital tools for art making could impede emotional or creative expression was voiced in forthcoming publications ( Collie et al., 2006 ; Orr, 2012 ). It was also speculated that a computer image, that exists as multiple copies of itself, might not be an adequate container for emotional material ( Collie and Čubranić, 1999 ) and that using computers for art making might put more emphasis on the product than on the artistic process ( Collie et al., 2006 ). The VR software used for art making was also described as “somewhat crude and clunky” ( Kaimal et al., 2020 , p. 22), potentially disorienting and incomparable with traditional arts materials in terms of the range of visual effects possible.

Benefits of Digital Arts Media

Freedom of expression.

It was suggested across a number of papers that digital arts media can be empowering by possessing expressive qualities not necessarily achievable with traditional physical art materials ( Collie et al., 2006 ; Orr, 2012 ). Digital art making, including in virtual reality, was proposed to reduce inhibitions, promote freedom ( Collie and Čubranić, 1999 ; Darewych et al., 2015 ; Kaimal et al., 2020 ), and facilitate multimodal expression not limited to images ( Collie et al., 2006 ). It was observed that inhibitions were diminished in creating artwork using digital media since there were no expectations of how a digital artwork should look like and it was also speculated if the elusiveness of a computer image might in fact strengthen the therapeutic process ( Collie and Čubranić, 1999 ). VR environments were found to enhance the freedom of expression without the constraints of the physical world, empower clients with restrictions in their movements and “explore creative opportunities otherwise unavailable in the material world” ( Kaimal et al., 2020 ). Playfulness of the artmaking process and creative exploration was another positive aspect of engaging with digital arts media noted in the literature ( Collie and Čubranić, 1999 ; Kaimal et al., 2020 ).

Digital environment

Some unique technological features of digital environments were cited as presenting key advantages for therapy, including portability, “an all-in-one art studio” ( Darewych et al., 2015 ). Several studies reported therapeutic benefits of a mess-free digital environment for art making, particularly for clients resistant to touching materials ( Orr, 2012 ), those who did not want to get messy during art therapy sessions ( Peterson, 2010 ) and particularly for clients with developmental disabilities combined with tactile or olfactory sensitivities ( Darewych et al., 2015 ). Another potentially therapeutic feature of digital arts media was identified as being able to record and preserve the stages of development of an artwork ( Collie et al., 2006 ), or document work in progress to enhance client’s understanding of how their work has developed over time ( Orr, 2012 ).

This review set out to provide some understanding of how digital technology is applied with therapeutic intent within art therapy sessions. We were able to answer two of our research questions, describing how art therapists work with digital technology in their practice and discussing the benefits and challenges of both online provision and the use of digital arts media. The perspective we were able to provide is the one of art therapists’ primarily and still little is known about clients’ experiences, attitudes and outcomes ( Kapitan, 2009 ; Edmunds, 2012 ; Carlton, 2014 ).

Research to date, although some survey-based, is largely qualitative and heterogeneous, presenting difficulties to any inter-studies comparisons. However, these seeming limitations demonstrate, in fact, the seriousness with which the subject has been approached by art therapy practitioners and researchers. Creative use of diverse methodologies to examine art therapists’ views is an essential first step, appropriate for the early stage exploration of how (and indeed, whether) digital technology might be used in art therapy practice. It is appropriate that early investigations are cautious and focused on practitioner’s perspective before any new strategies may be implemented in the actual practice with clients. Such approach seems highly ethical and client-focused, as indeed confirmed in this review in the reasons given by art therapists for their reluctance and cautiousness with which they decide on whether to introduce digital technology in art therapy sessions. Impacts on clients are of primary importance and therapists, understandably, are not willing to compromise on client safety in adopting technological solutions not thoroughly tested ( Peterson, 2010 ; Orr, 2016 ).

Nevertheless, it is important to highlight that the findings in this review are largely based on art therapists’ opinions and attitudes, not necessarily rooted in experience of using technology in practice. Given the common human error of judgment in terms of imagining theoretical concepts in practice, one can only wonder if some of the opinions expressed might have changed following an actual engagement in digital media-based or online practice, particularly if, as suggested ( Asawa, 2009 ), emotions such as fear and anger might guide art therapist’ initial impressions on technology, and, as suggested elsewhere ( Collie et al., 2017 ), art therapists might be surprised at how quickly they start to feel comfortable with technology that they have had a chance to try out.

As suggested previously, the review confirmed that the perception of digital technology in art therapy realm is dominated by ambivalence and tendencies to pull toward and against, which seems an appropriate attitude on encountering something which we do not yet fully understand. Both an increasing interest in the opportunities that digital technology potentially brings, as well as cautiousness around implementation have been apparent in the literature examined. Nevertheless, a common recognition seems to prevail that, given the likely permanency of digital technology in all aspects of our lives, understanding its benefits and potential harm in therapy situations is indeed essential to reduce risks and increase the therapeutic relevance of digital tools ( Kapitan, 2007 ; Asawa, 2009 ; Orr, 2012 ; Kaimal et al., 2016 ).

In addition to the increased research need, the importance of specialist training for art therapists has been commonly advocated ( Orr, 2006 , 2012 ; Kapitan, 2007 ; Kuleba, 2008 ; Carlton, 2014 ; Kaimal et al., 2016 ). A call has also been made for development of new ethical guidelines for art therapists, which would provide an appropriate framework, aligned with practice needs and with practical considerations ( Alders et al., 2011 ; Evans, 2012 ). This need for robust guidance, which would help ensure client safety and increase therapists’ confidence in working with technology, has been highlighted more recently by the changing global health situation (COVID-19 pandemic), in which art therapists found themselves transitioning to online practice with unprecedented speed and often against own preference. It is a striking realization that in a survey conducted only 15 years ago none of the respondents reported that they had conducted online art therapy ( Peterson, 2006 ). McNiff’s prediction from over two decades ago that distance art therapy would grow ( McNiff, 1999 ) has, however, become reality, if only too suddenly for some.

This review has synthesized the challenges and benefits of working with clients online, as reported in literature, and any solutions proposed by the authors. It is clear that distance art therapy differs from the usual face-to-face situation on many levels and requires adaptations on both art therapists’ and clients’ side. The relatively novel way of working therapeutically demands more effort and time initially (e.g., for learning of procedures and devices), but has the potential to become less burdensome practically in the long term (e.g., saving the need to travel to sessions). More importantly, it demands skilful and perhaps more active facilitation from art therapists in order to create a safe enough container for clients in virtual space ( Collie et al., 2017 ). It is recognized that this might be harder to achieve in online therapy and compensations might need to be made for the lack of physical presence and limited non-verbal expressions ( Chilton et al., 2009 ). It has been suggested that semi-anonymity that online contact allows might be both restricting and facilitating for the development of therapeutic relationship and emotional connection ( Collie et al., 2017 ; Levy et al., 2018 ). The responsibility for successful outcomes does not lie entirely with art therapists, and clients might similarly be expected to take on a more active role in their own treatment for a distant art therapy to be beneficial. There is a potential for this increased engagement to promote community integration and to feel empowering for the client ( Orr, 2012 ; Levy et al., 2018 ; Spooner et al., 2019 ). The pace of technological advancements also means that certain technical limitations mentioned in the literature may already be overcome, for example observations by some that a computer is not conducive to group therapy ( Kuleba, 2008 ).

As indicated at the beginning of our work, opportunities and limitations of digital technology in art therapy extend beyond telehealth and remote connectivity. The use of digital arts media presents entirely new challenges for the profession and, arguably, entirely new possibilities with potentially profound impacts on practice. There are polarized opinions and ideas around the therapeutic value and risks of incorporating digital arts media in art therapy sessions.

It has been indicated that digital media provide more security to experiment and offer more freedom of expression due to endless modifications and manipulation of artwork being possible, as well as an option to not leave a trace of one’s creative experimentation if one wish ( Canter, 1987 ; Collie and Čubranić, 1999 ; McLeod, 1999 ; Parker-Bell, 1999 ; Peterson et al., 2005 ; Edmunds, 2012 ; Orr, 2016 ). A notion that making digital art may be less intimidating than working with traditional art materials has been widely discussed in literature ( Weinberg, 1985 ; Hartwich and Brandecker, 1997 ; Collie and Čubranić, 1999 ; McLeod, 1999 ; Thong, 2007 ; Evans, 2012 ; Orr, 2012 ; Kaimal et al., 2016 ). However, it is worth noting that the potentially freeing and playful novelty of digital arts media might not have the same effect nowadays and an observation made in 1999 that people feel less self-conscious due to not having expectations about how a digital image should look like ( Collie and Čubranić, 1999 ) is already likely to be redundant. Similarly, propositions that interaction with digital art making tools gives a sense of mastery and independence ( Canter, 1989 ; Edmunds, 2012 ; Orr, 2012 ) might naturally become less relevant with increased use and familiarity.

Nevertheless, the therapeutic potential of making changes to artwork, recording, sharing and revisiting the process of creation, and allowing both the artwork and the process evolve over time, cannot be underestimated ( Hartwich and Brandecker, 1997 ; McLeod, 1999 ; McNiff, 1999 ; Evans, 2012 ; Orr, 2016 ). Interaction between the person and the electronic device used for art making is potentially therapeutically powerful. It has been suggested that artmaking process becomes a mirror of this relationship ( Hartwich and Brandecker, 1997 ) but also that a computer is simply a mediator in the relationship developing between the client and the therapist ( Orr, 2010 ) or that it can support and provide a transactional space between them ( Gussak and Nyce, 1999 ). The role of the machine in the development of the therapeutic process remains unclear and it will be important to investigate how it affects (or fits within?) the triangular relationship between the client, the therapist and the art.

Probably the most prominent accusation against digital art making tools is their “synthetic” nature, lacking sensual and tactile qualities of traditional arts media, often considered therapeutic in themselves ( Kuleba, 2008 ; Klorer, 2009 ; Potash, 2009 ; Carlton, 2014 ; Orr, 2016 ; Garner, 2017 ). Suggestions have been made that this seemingly distant and nontactile nature of digital arts media might result in clients disconnecting not only from sensory experience but also from relationships and the “real world” in the present moment ( Klorer, 2009 ; Potash, 2009 ). This perception of the isolating, impersonal and even dehumanizing character of digital technology, as well as coldness associated with computers, have been widely discussed by art therapy researchers and practitioners ( Gussak and Nyce, 1999 ; McLeod, 1999 ; Collie and Čubranić, 2002 ; Collie et al., 2006 ; Orr, 2006 ; Kuleba, 2008 ). However, some have observed that constant technological advances gradually lead to the cold digital media becoming more integrated with human interactions, senses and emotions, in increasingly intuitive and responsive way ( Orr, 2012 ). Touchscreen sensitivity, for example, allows for pressure to be incorporated in digital art making, mimicking physical art materials, an important quality which was not previously available for art created with a computer mouse, as noted by McNiff two decades ago ( McNiff, 1999 ). Despite some issues which are unlikely to be resolved, it is probably safe to say that with technology generally becoming more human-oriented we may expect an increasing relevance of digital art making tools for art therapy.

An entirely new art medium which is now available within virtual reality environments presents its own unique concerns and prospects ( Kaimal et al., 2020 ), including creative opportunities reaching beyond material world, but also risks of further disconnection from the real tactile experience. Here also some of the previously expresses preconceptions might be challenged, for example another observation made by McNiff that “computer art will never replace the three-dimensional presence of the actual thing being made” ( McNiff, 2000 , p. 97). It remains debatable of course whether virtual presence is at all comparable to physical experience, but it might be that an opportunity to print out a virtually created artwork using a 3D printer makes the distinction less obvious.

A substantial attention is dedicated in literature to speculation on groups of clients who might benefit most from working with digital arts media. It has been suggested that although this is primarily an individual matter and not necessarily defined by age, contradictory to stereotype ( Asawa, 2009 ), children and young people might be particularly responsive to digital artmaking ( Alders et al., 2011 ; Carlton, 2014 ). Reports on successful practice with hospitalized children highlight the benefit of adaptations enabled by technology to compensate for physical and emotional challenges ( Thong, 2007 ; Malchiodi and Johnson, 2013 ). Digital arts media offer a sterile art making environment ( Malchiodi and Johnson, 2013 ; Orr, 2016 ) and can be used by patients who might not be able to hold art materials but might be able to interact with space or make art on a tablet device using tiny gestures ( McNiff, 1999 ; Hallas and Cleaves, 2017 ). It has been also demonstrated that the previously mentioned lack of sensory input might be therapeutically beneficial for clients with developmental disabilities and those with olfactory and tactile sensitivities ( Darewych et al., 2015 ). It has been proposed that digital art making tools might be in fact an ideal medium for clients easily overwhelmed by tactile sensations ( Alders et al., 2011 ), allowing them to sustain a safer and longer art making experience ( Edmunds, 2012 ).

Some art therapy practitioners and researchers have long made a proposition that technology-enhanced therapy, whether in form of online delivery or adoption of digital arts media for art making, may actually be the best form of therapy for certain clients and not a mere substitute for more traditional ways of working ( Collie and Čubranić, 1999 ; McNiff, 1999 ; Parker-Bell, 1999 ; Evans, 2012 ). Others have pointed out to contradictory beliefs of some art therapy practitioners, focusing more on potential risks and worrying that technology would “remove what art therapy holds sacred, which is the art.” ( Asawa, 2009 , p. 64). Between the two polarizing perspectives might be most commonly advocated one, that digital technology is not a replacement for traditional arts media or long established ways of working, but rather an added value, a new quality, expanding and not limiting the profession ( McLeod, 1999 ; McNiff, 1999 ; Orr, 2006 ; Choe, 2014 ).

While flexibility and adaptability have been cited as qualities shared by art therapists that could support them in the predicted continued integration of technology in therapy ( Spooner et al., 2019 ), a question remains whether art therapy profession would accept technology as a true creative and therapeutic medium ( McNiff, 1999 ; Peterson, 2006 ; Austin, 2009 ). Over three decades ago, it was suggested that the answer might depend on art therapists’ innate curiosity as artists to investigate the new medium ( Canter, 1989 ) and, more recently, that the potential of technology in art therapy is only limited by practitioners’ creativity and imagination ( McLeod, 1999 ; McNiff, 1999 ; Peterson, 2010 ). It has been already proposed that art therapy profession, to remain relevant, might need to “move beyond historically validated media” and also to new contexts ( Kapitan, 2007 , p. 51).

Future Research

Given the growing interest in digital technology within art therapy world and the current global health crisis (COVID-19 pandemic) which forced therapists to move their practice online, we expect and would welcome a rise in research in the area. While we already have some understanding of art therapists’ perspective, more research to explore clients’ experiences is clearly needed. This research need must not, however, compromise on clients’ safety and ethical ways of working with technology in art therapy sessions and should observe (and help develop) guidelines from professional associations for the discipline ( Zubala and Hackett, 2020 ). Once new ways of working are established, these need to be reflected in art therapists’ education and research could contribute to identifying the needs for training.

Rise in online art therapy practice could be observed on a large scale in the previous months (second trimester of 2020) and new interventions have been developed with impacts already captured in research which was in press at the time of writing of this review (e.g., Gomez Carlier et al., 2020 ; Newland et al., 2020 ). It is important that these accounts of sudden changes in practice are recorded and examined for any lessons to be learned for a longer-term approach to how art therapy might contribute to mitigating the psychological impacts of the pandemic, which are likely yet to emerge ( Miller and McDonald, 2020 ; Titov et al., 2020 ; Wind et al., 2020 ; Zubala and Hackett, 2020 ). The research to follow must acknowledge the extraordinary circumstances under which art therapy has adopted online mode of working, often not by choice but due to demands of the situation and clients’ or employers’ expectations. This fact alone and combined with other factors may have huge implications for practice and we hope that these are captured sensitively in forthcoming research.

Regardless of the mode of delivery, there remains a lot to learn in terms of the emotional and interpersonal implications of digital artmaking for the development of the therapeutic relationship. Previous research encouragingly indicates that therapeutic alliance in verbal psychotherapies can be successfully recreated in an online setting ( Sucala et al., 2012 ). In art therapy case, however, potential impact of technology is not limited to client-therapist relationship but extends to the essence of the triangular relationship including also the artwork. Understanding the impacts of digital tools on the dynamics of this triangular relationship and their place within it seems fundamental to increasing art therapists’ confidence in introducing digital arts media in sessions.

Limitations

This review attempted to capture research findings from diverse literature for a holistic understanding of the topic ( Whittemore and Knafl, 2005 ) and we recognize that such approach brings some inevitable challenges which we were able to address partially.

Firstly, the heterogeneous character of included studies and breadth of perspectives adopted by the authors meant that the synthesis relied vastly on our own interpretation of the findings due to no specific guidance on such syntheses available. Neither meta-analysis nor meta-synthesis could be performed and instead a method not dissimilar to thematic analysis was employed for identifying key themes often present across the literature examined. It might be that such approach could have missed some of the findings potentially best captured via another methodology. Additionally, inclusion of papers focusing on art therapists’ views and opinions mean that findings are based on both the anticipated and the actual practice-based experiences.

Secondly, we acknowledge that PhD theses, dissertations and book chapters were deliberately excluded from the review due to limited resources and also due to expected further complexities arising from an attempt to synthesize insights from these data sources. The searches have, however, identified substantial volume of material on the subject published in books and available as unpublished doctoral theses and masters dissertations and it would have been valuable to examine these also, perhaps in a more narrative type of review or as part of more specific sub-topic explorations. Similarly, only articles presenting empirical findings were included which means that a number of important opinion papers have not been formally a part of this review. Instead, recognizing the contribution of these authors to the overall conversation, we refer to their work in the extended discussion section. We are also aware that strict inclusion criteria meant that some contemporary uses of digital technology in art therapy such as digital photography, computer animation or digital storytelling, are not discussed here. Peer-reviewed papers in these areas seem sparse despite comprehensive practice-based literature available (e.g., Loewenthal, 2013 ; Malchiodi, 2018 ). Therefore, while it was not our intention to exclude these widely used techniques, we acknowledge that this review might not be a complete representation of practice, now commonly adopting many other imaginative uses of digital technology.

Thirdly, we chose not to undertake a formal quality assessment of the studies included, which might have enabled a fairer weight to be allocated to findings, currently considered and presented as being of equal value. An informal quality assessment has been, however, included and we decided that a more formal analysis would not match the complexity of the topic and the nature of the very early exploratory studies, meaning that useful insights might be lost with a standardized form of assessment applied. With progress in research in the area and more methodologically coherent groupings of studies possible, we expect that future syntheses would be able to perform more formalized quality assessments, particularly on studies that report on client experiences.

This review offers an integrative synthesis of research undertaken to date on the use of digital technology in art therapy, including both online connectivity allowing distance delivery as well as digital artmaking within therapy sessions. The complex characteristics and methodologies of included papers resulted in diverse findings which were integrated to identify key themes in the growing debate on the role of digital technology in art therapy. Potential benefits and challenges were identified, including impacts on the therapy process and the therapeutic relationship. It may be safely concluded that the use of technology in art therapy presents both immense opportunities and serious risks that need to be considered by practitioners, professional associations, and the clients themselves. It is important that early research in the area strives to examine both in order to help art therapists make an informed choice when deciding on whether to incorporate digital technologies in their practice.

We would like to invite the art therapy community worldwide to expand this conversation and to explore together, safely but with curiosity and openness, the expanse of the digital world which, if nothing else, deserves our consideration of its relationship to art therapy. We propose that we approach this exploration with acknowledgment of its importance for the continued relevance of art therapy ( Kapitan, 2007 ) but also reflecting that “art therapy is eclectic and not reducible to a single set of algorithms” ( Gussak and Nyce, 1999 , p. 194). It might be a demanding but a fascinating journey.

Author Contributions

AZ conceptualized, planned, and undertook the review, analyzed the data, and wrote the first draft of the manuscript. NK and SH revised the work critically and contributed to edits. All authors contributed to and approved the final version of the manuscript.

Conflict of Interest

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

Acknowledgments

AZ would like to thank co-authors, Catriona MacInnes, Simon Reekie, Gill Houlsby, and other art therapists, conversations with whom helped shape the thinking about this research.

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Keywords : art therapy, digital technology, remote delivery, digital arts media, telehealth, online therapy, integrative review

Citation: Zubala A, Kennell N and Hackett S (2021) Art Therapy in the Digital World: An Integrative Review of Current Practice and Future Directions. Front. Psychol. 12:595536. doi: 10.3389/fpsyg.2021.600070

Received: 01 September 2020; Accepted: 12 March 2021; Published: 08 April 2021.

Reviewed by:

Copyright © 2021 Zubala, Kennell and Hackett. 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: Ania Zubala, [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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Art Therapy Research Topics

Art Therapy Research Topics : Art therapy is a fascinating field that combines art and psychology to promote emotional healing, self-expression, and personal growth. Here are some art therapy research topics that you could consider:

• Effectiveness of Art Therapy in Treating Trauma Survivors: Investigate how art therapy can help individuals cope with and heal from traumatic experiences.
• Art Therapy as a Tool for Managing Anxiety and Stress: Examine the role of art therapy in reducing anxiety and stress levels and improving overall well-being.
• Art Therapy and Depression: Efficacy and Mechanisms: Explore how art therapy can be used to alleviate symptoms of depression and the underlying mechanisms at play.
• Expressive Arts Therapies for Children with Autism Spectrum Disorder: Study the benefits of art therapy and other expressive arts therapies in enhancing communication and social skills in children with autism.
• Art Therapy in Addiction Recovery: A Holistic Approach: Investigate how art therapy can complement traditional addiction treatment methods and support individuals in their recovery journey.
• Cultural Sensitivity in Art Therapy: Addressing Diversity and Inclusion: Examine how art therapists can effectively work with clients from diverse cultural backgrounds while respecting their unique perspectives.
• Art Therapy and Body Image: Nurturing Self-acceptance and Positive Body Image: Explore how art therapy can be used to promote a healthy and positive relationship with one’s body.
• Art Therapy for Grief and Loss: Exploring Expressive Outlets for Healing: Study the use of art therapy to help individuals process and cope with grief and loss.
• The Role of Art Therapy in Enhancing Self-Esteem and Self-Identity: Investigate how art therapy can empower individuals to develop a stronger sense of self and self-worth.
• Art Therapy in Hospitals: Improving Patient Well-being and Recovery: Examine the benefits of incorporating art therapy into medical settings to enhance patient outcomes and overall well-being.
• Creative Art Therapies for Children with ADHD: Study how creative art therapies, including art therapy, can help children with ADHD improve focus, self-regulation, and emotional expression.
• Art Therapy and Older Adults: Promoting Cognitive Health and Emotional Resilience: Explore the use of art therapy to support cognitive function and emotional well-being in the elderly population.
• Art Therapy and Veterans: Healing from Post-Traumatic Stress Disorder (PTSD): Investigate the potential of art therapy to assist veterans in coping with and recovering from PTSD.
• Art Therapy in School Settings: Fostering Emotional Intelligence and Social Skills: Examine the integration of art therapy programs in schools to enhance students’ emotional intelligence, empathy, and social interactions.
• Art Therapy and Mindfulness: A Synergistic Approach to Mental Health: Study how combining art therapy with mindfulness techniques can enhance self-awareness, stress reduction, and emotional regulation.

These art therapy research topics offer a range of opportunities to explore the therapeutic benefits of art and creativity in various contexts, contributing to a deeper understanding of how art can be used as a powerful tool for healing and personal growth.

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Essays on Art Therapy

Brief description of art therapy.

Art therapy is a form of expressive therapy that uses the creative process of making art to improve a person's physical, mental, and emotional well-being. It is based on the belief that the creative process involved in artistic self-expression helps people to resolve conflicts and problems, develop interpersonal skills, manage behavior, reduce stress, increase self-esteem and self-awareness, and achieve insight.

Importance of Writing Essays on This Topic

Essays on art therapy are essential for both academic and personal exploration. They provide an opportunity to delve deep into the theory and practice of art therapy, allowing students and individuals to gain a comprehensive understanding of its principles, benefits, and applications. Writing essays on this topic also encourages critical thinking and analysis, fostering a deeper appreciation for the power of art as a therapeutic tool.

Tips on Choosing a Good Topic

• Consider personal experiences: Reflect on personal experiences with art and how it has impacted your emotional well-being.
• Explore current research: Look into recent studies and developments in the field of art therapy to find relevant and impactful topics.
• Discuss practical applications: Consider the practical applications of art therapy in various settings, such as hospitals, schools, and community centers, to identify compelling essay topics.

Essay Topics

• The Role of Art Therapy in Mental Health Treatment
• The Impact of Art Therapy on Children with Autism
• Art Therapy as a Tool for Stress Relief and Anxiety Management
• The Use of Art Therapy in Trauma Recovery
• Exploring the Intersection of Art and Healing in Art Therapy
• Art Therapy Techniques for Self-Exploration and Personal Growth
• The Ethical Considerations in Art Therapy Practice
• Art Therapy and Expressive Arts for Mindfulness and Well-being
• The Integration of Art Therapy in Counseling and Psychotherapy
• The Effectiveness of Art Therapy for Veterans with PTSD

Concluding Thought

Engaging with art therapy through essay writing provides an opportunity to deepen understanding and appreciation of the profound impact of art on mental and emotional well-being. Through exploration and critical analysis, individuals can gain insight into the transformative power of art therapy and its potential to improve lives.

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Art Therapy for Psychosocial Problems in Children and Adolescents: A Systematic Narrative Review on Art Therapeutic Means and Forms of Expression, Therapist Behavior, and Supposed Mechanisms of Change

Liesbeth bosgraaf.

1 Faculty of Healthcare and Social Work, NHL Stenden University of Applied Sciences, Leeuwarden, Netherlands

2 Alliade, Care Group, Heerenveen, Netherlands

3 KenVaK, Research Center for Arts Therapies, Heerlen, Netherlands

4 Faculty of Psychology, Open University, Heerlen, Netherlands

Marinus Spreen

Kim pattiselanno, susan van hooren.

5 Faculty of Healthcare, Zuyd University of Applied Sciences, Heerlen, Netherlands

Associated Data

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

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

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

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

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

Introduction

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

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

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

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

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

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

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

Study Design

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

Eligibility Criteria

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

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

Study Selection

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

Quality of the Studies

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

Data Collection and Analysis

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

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

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

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

Study characteristics/outcome.

ASD, Autism Spectrum Disorder; CATIS, Childhood Attitude Toward Illness Scale; CBCL, Child Behavior Checklist; CCT, Clinical Controlled Trial; DAS, Draw a Story; DSM, Diagnostic Statistic Manuel of Mental Disorders; ID, Intellectual Disability; RCT, Randomized Controlled Trial; LOC, Locus of Control; PTSD, Post Traumatic Stress Disorder; SCIT, Synallactic Collective Image Therapy; SF-AT, Solution Focused Art Therapy; SSRS, Social Skills Rating System; TF-ART, Trauma Focused Expressive Art Therapy; TRS, Teacher Rating Scales; UCLA, University of California at Los Angeles Post-traumatic Stress Disorder Reaction Index .

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

Study Population

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

Number of Participants

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

Type of Intervention, Frequency, and Treatment Duration

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

Control Interventions

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

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

Applied Means and Forms of Expression

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

Characteristics AT interventions.

ATI, Art Therapy Institute; CBT, Cognitive Behavioral Therapy; DBT, Dialectic Behavioral Therapy; ETC, Expressive Therapies Continuum; LOC, Locus of Control; PTSD, Post Traumatic Stress Disorder; SF-AT, Solution Focused Art Therapy .

Materials/Techniques

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

Topics/Assignments

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

The Role of Language

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

Therapist Behavior

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

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

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

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

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

Supposed Mechanisms of Change

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

Specific Mechanisms of Change

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

General Mechanisms of Change

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

Synthesized Findings

Means and forms of expression and therapist behavior.

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

The Therapist Behavior Was Non-directive

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

The Therapist Behavior Was Directive

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

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

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

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

Therapist Behaviors in Relation to Psychosocial Outcomes

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

Non-directive Therapist Behavior

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

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

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

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

Directive Therapist Behavior

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

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

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

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

Eclectic Therapist Behavior

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

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

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

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

Overall Results

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

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

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

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

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

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

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

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

Strengths and Limitations of This Review

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

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

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

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

Recommendations

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

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

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

Conclusions

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

Data Availability Statement

Author contributions.

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

Conflict of Interest

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

Acknowledgments

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

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

Supplementary Material

The Supplementary Material for this article can be found online at: https://www.frontiersin.org/articles/10.3389/fpsyg.2020.584685/full#supplementary-material

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What Creative Arts Therapies Teach Us About DBT Skills Training

Bridging dbt with the arts for deeper understanding..

Posted April 15, 2024 | Reviewed by Jessica Schrader

• What Is Therapy?
• Find a therapist near me
• Research supports the effectiveness of combining DBT with creative arts to improve outcomes.
• Facilitators can teach wise-mind skills through drama therapy techniques.
• Action-based DBT utilizes storytelling and role-play to make skill learning more accessible and impactful.

In the ever-evolving realm of mental health, therapists are always exploring new and innovative methods to enhance traditional treatments. Creative arts therapists have led the way in utilizing art-based interventions to teach DBT skills.

Creative arts therapy combines visual arts, movement, drama, music, writing, and other creative processes to support clients in their healing process. Many mental health clinicians have embraced creative arts therapy interventions to improve their clients' health and wellness.

There is a growing body of research that indicates that therapists can utilize creative interventions to help clients learn and generalize DBT skills. In this post, I will provide a brief literature review of therapists who have been doing this integrative work and provide an example of how drama therapy can be utilized to teach the DBT skill of wise mind.

DBT and Art Therapy

Research indicates that integrating art therapy into established psychotherapy forms, such as cognitive-behavioral therapies, can have significant positive effects on client well-being. For example, a study by Monti et al. (2012) demonstrated the potential of mindfulness -based art therapy (MBAT) in alleviating emotional distress, highlighting the power of combining art therapy with the core feature of mindfulness in DBT. Though this study did not specifically discuss DBT, it demonstrated that implementing mindfulness, a core component of DBT, can assist individuals who are facing significant physical and emotional stressors.

Building on research that examined mindfulness and art therapy, several practitioners have contributed articles that specifically address the integration of DBT and art therapy within clinical populations. For example, researchers Huckvale and Learmonth (2009) led the charge by developing a new and innovative art therapy approach grounded in DBT for patients facing mental health challenges. Furthermore, Heckwolf, Bergland, and Mouratidis (2014) demonstrated how visual art and integrative treatments could help clients access DBT, resulting in stronger generalization and implementation of these skills outside of the session. The clinicians concluded that this integrative approach to treatment could reinforce skills, contribute to interdisciplinary team synergy, and enact bilateral integration.

Other notable examples from art therapists include Susan Clark’s (2017) DBT-informed art therapy, a strategic approach to treatment that incorporates creative visual exercises to explore, practice, and generalize DBT concepts and skills.

Expanding Beyond Visual Art Therapy

DBT has now been integrated with other expressive art therapies, including drama and music. Art therapists Karin von Daler and Lori Schwanbeck (2014) were instrumental in this expansion when they developed Creative Mindfulness, an approach to therapy integrating various expressive arts therapies with DBT. Creative Mindfulness “suggests a way of working therapeutically that is as containing and structured as DBT and as creative, embodied, and multi-sensory as expressive arts” (p. 235). These clinicians incorporated improvisation into their work, a tool that can be simultaneously playful, experiential, and grounding, ultimately producing substantial new insights for clients.

Moreover, music and drama therapists have recognized the benefits of multisensory skill teaching, expanding the creative techniques used to teach DBT skills ( Deborah Spiegel, 2020 ; Nicky Morris, 2018 , and Roohan and Trottier, 2021 ).

My Own Experience Integrating Drama Therapy and DBT

Personally, I am a big advocate of both dialectical behavior therapy (DBT) and drama therapy. In fact, I love these modalities so much that I dedicated not only my master's thesis but also my dissertation to better understanding how to reinforce DBT skills through dramatic techniques. In the process, I developed a new approach called Action-Based DBT that uses dramatic interventions like storytelling, embodiment, and role-playing to create a supportive environment for participants to learn skills in a more personalized and embodied way. An expert panel review demonstrated that this format can effectively support skill learning, especially for clients who struggle with the standard format of DBT skills training. Additionally, mental health clinicians found the program easily adaptable across populations in both individual and group settings.

Embodying the Mind States

To illustrate this approach and its effectiveness, the following is an example of how drama therapy methods can teach the DBT skill of wise mind within the context of an action-based DBT group.

The facilitator begins the group session by reviewing general guidelines and introducing the targeted DBT skill for the day: wise mind. The group then participates in improvisational warm-up activities to promote creativity , positive social interaction, and group connectivity. Following the warm-up, the facilitator distributes the DBT mind states handout (Linehan, 2015) and provides brief psychoeducation on this skill. Three chairs are placed in the front of the group room, facing the semi-circle of clients. Each chair had a piece of colored construction paper taped to the front, reading as Reasonable, Wise and Emotion . The facilitator explains that each chair represents one of the three mind states: reasonable mind, emotion mind and wise mind. To encourage exploration of the mind states, the facilitator can assign a more specific role to each state of mind. For example, the reasonable mind is The Computer, the emotion mind is The Tornado, and the wise mind is The Sage. Group members are invited to think of a scenario in which they felt they had difficulty accessing their wise mind. Clients then take turns embodying each mind state by sitting in the chair and speaking from the respective role. When a client first sits in a chair, the facilitator aids in enrolling the individual by asking questions about the role (i.e. The Computer, The Tornado, The Sage). For example, the facilitator may ask about the posture, tone of voice, or a “catchphrase” for this role. The client then embodies the role and responds to questions from the group as the specific mind state. After the embodiment, clients engage in verbal processing. The wise mind directive supports clients in developing kinaesthetic awareness of the three mind states. Embodying these mind states within the context of a supportive group and engaging in verbal processing around the experience can increase awareness of the mind states, which is helpful for clients who are trying to understand their emotional response to lived events outside of the group setting.

The creative arts therapies offer a dynamic pathway to teaching and reinforcing DBT skills. Incorporating visual art, drama, or music in the process of learning DBT skills allows clients to engage with these concepts in a multisensory and embodied way.

In my personal experience, weaving drama therapy techniques into DBT skills training has proven to be profoundly impactful. The Action-Based DBT approach, with its emphasis on storytelling and embodiment, offers an immersive and experiential learning environment that can be especially beneficial for those who find traditional methods challenging.

Looking ahead, my next post will delve into how storytelling can be harnessed to teach DBT skills in a way that is both engaging and memorable.

To find a therapist, please visit the Psychology Today Therapy Directory .

Clark, S. M. (2017). DBT-informed art therapy: Mindfulness, cognitive behavior therapy, and the creative process. Jessica Kingsley Publishers.

Heckwolf, J. I., Bergland, M. C., & Mouratidis, M. (2014). Coordinating principles of art therapy and DBT. The Arts in Psychotherapy, 41(4), 329-335.

Huckvale, K., & Learmonth, M. (2009). A case example of art therapy in relation to dialectical behaviour therapy. International Journal of Art Therapy, 14(2), 52-63.

Monti, D. A., Kash, K. M., Kunkel, E. J., Brainard, G., Wintering, N., Moss, A. S., Rao, H., Zhu, S., & Newberg, A. B. (2012). Changes in cerebral blood flow and anxiety associated with an 8-week mindfulness programme in women with breast cancer. Stress and Health, 28(5), 397-407.

Morris, N. (2018). Dramatherapy for borderline personality disorder: Empowering and nurturing people through creativity. Routledge.

Roohan Mary Kate, Trottier Dana George. (2021) Action-based DBT: Integrating drama therapy to access wise mind. Drama Therapy Review, 7 (2), 193 https://doi.org/10.1386/dtr_00073_1

Spiegel, D., Makary, S., & Bonavitacola, L. (2020). Creative DBT activities using music: Interventions for enhancing engagement and effectiveness in therapy. Jessica Kingsley Publishers.

Von Daler, K., and Schwanbeck, L. (2014). Creative mindfulness: Dialectical behavior therapy and expressive arts therapy. In L. Rappaport (Ed.), Mindfulness and the arts therapies: Theory and practice (pp. 107-116). Jessica Kingsley Publishers.

Mary Kate Roohan, Psy.D., is a licensed psychologist and drama therapist and the founder of Thrive and Feel, a therapy practice that supports clients in managing emotional sensitivity.

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125 of the best art research paper topics of 2023.

When you need original art research paper topics that you know will impress your professor, you just need to visit this page. Our experienced academic writers are striving to update the list of topics as frequently as possible. This means that you should always be able to find a unique topic to write about in your next art research paper. And keep in mind that our list of topics is entirely free. You can use any topic you see here for free – and even reword it to suit your needs. Don’t hesitate to get in touch with our experts if you need more ideas or a list of topics tailored to your specific needs.

Don’t Know Which Art Topics to Write About?

Don’t worry too much if you don’t know which art topics to write about. We have organized our list of topics into several categories so you should have no problem finding the perfect topic in just a couple of minutes. So, why would you want to waste your time searching for topics when we have so many ideas that you can use right now? Check out our list and pick the best one for your academic paper.

Easy Art Research Topics

The best way to save some time is to simply choose some easy art research topics. Check out our ideas and pick the one you like the most:

• Ancient Roman art
• Talk about carnival masks in Venice
• Talk about human sacrifices in art
• The history of art in Ancient Greece
• Talk about Ancient Greece sculptures
• Talk about early musical instruments
• Primeval art forms
• Mesoamerican pyramid art

Art History Research Paper Topics

Are you interested in writing about the history of art? There are plenty of things to talk about, that’s for sure. Check out these unique art history research paper topics:

• The history of art in Eastern Europe
• Russian art: the beginning
• An in-depth look at Mayan art
• The first works of art in the world
• Discuss art in the Greek theater
• The inception of Renaissance art
• Compare and contrast Art Nouveau and Art Deco
• The effects of art on the world

Difficult Art Research Paper Topics

If you want to impress your classmates and your professor, you should definitely choose one of our difficult art research paper topics:

• The concept of fashion in ancient Asian tribes
• Egyptian art inside the pyramids
• Analyze stained glass in Western Europe
• Art in ancient Babylon
• Discuss movement and rhythm in art

Art Topics Ideas for College Students

College students should, of course, try to look for more complex topics to write their papers about. Here are some great art topics ideas for college students:

• Who was Frida Kahlo?
• Talk about the life and works of Francisco Goya
• The importance of Georgia O’Keeffe’s art
• Balance as a main principle of art
• Discuss the history of printmaking
• Talk about Medieval art

Most Interesting Art Topics to Write About

In this list, we will add our most recent and most interesting art topics to write about. Select the topic you like and start writing your paper right away:

• The woman and child theme in African art
• Spirituality and art
• An in-depth analysis of Kuba art
• How can we decode abstract art?

Art Debate Paper Topics

Did your teacher ask you to write an art debate paper? You will certainly find this list of art debate paper topics very useful in this case:

• Leonardo Da Vinci and religious art
• Renaissance art peculiarities
• Differences between Persian and Asian art
• What makes Claude Monet stand out?
• Unity and variety in modern art

Controversial Art Topics

Don’t be afraid to write a research paper on a controversial topic. You can get some very nice bonus points. Check out these awesome controversial art topics:

• Discuss Chris Ofili’s “The Holy Virgin Mary”
• The controversial “Origin of the World” by Gustave Courbet
• Talk about Marcel Duchamp as a controversial artist
• What makes Yoko Ono a controversial artist?
• The savage art of Gauguin

Modern Art Research Paper Topics

We know, discussing modern art in a research paper is not easy. However, the topic can make a huge difference. Here are some easy modern art research paper topics for you:

• Artistic performances in modern art
• The peculiarities of the Cubism movement
• What is surrealism?
• What is still life art?
• What is Fantasy art?
• Technology in modern art
• Analyze a political cartoon
• Discuss Cubism

Artist Biography Ideas

Writing an artist biography can get you a top grade very quickly. Researching a lesser known artist will also get you bonus points. Here are our best artist biography ideas:

• Talk about the life and works of Frank Lloyd Wright
• An in-depth look at the work of Andy Warhol
• Talk about the life and works of Marcel Duchamp
• Discuss the works of Jackson Pollock
• The contribution of Salvador Dalí to art
• Talk about the life and works of Wolfgang Amadeus Mozart
• Talk about the life and works of Grandma Moses
• Talk about the life and works of Henri-Émile-Benoît Matisse

Art Therapy Research Paper Topics

Why not write your next paper on the subject or art therapy? This will certainly get the attention of your professor. Here are some of our best art therapy research paper topics ever:

• Benefits of art therapy for autistic children
• Best techniques for art therapy
• Art therapy in UK hospitals
• Discuss the effects of this type of therapy
• How does art therapy work?
• Interesting activities that can be used as art therapy
• Art therapy in modern United States hospitals
• Latest advancements in art therapy
• Effects of art therapy on abused children
• How effective is art therapy?

African Art Ideas

We can guarantee that your professor will award you some bonus points if you manage to find a great topic. Here are the most interesting African art ideas possible:

• Discuss art in the Yaka and Suku tribes
• Discuss art in Burkina Faso
• Couples in African art
• Analyze the Nubian Pyramids at Meroe
• The importance of art for ritual life in Africa
• Analyze modern art in Zimbabwe
• Art and socio-politics in Africa
• Strangers in African art
• Discuss Islamic arts in ancient Africa
• Analyze art in Tanzania

Writing a paper about art epochs shouldn’t be too difficult. Also, you can find plenty of information about any epoch online. Here are some ideas for an essay about art epochs:

• Talk about art in the Prehistoric epoch
• Discuss ancient art
• Art during the Hellenistic period
• Talk about art in the Baroque epoch
• Talk about prehistoric art in Europe
• Art during the Mannerism period
• Talk about art in the Renaissance epoch
• Art during the Rococo epoch
• Talk about art in the Neoclassicism epoch
• Art during the Mesopotamian age
• Talk about art in the Medieval epoch
• Discuss art during the Byzantine period

Renaissance Art Research Paper Topics

Yes, Renaissance art is not an easy subject. However, if you are a college or university student, you should give our renaissance art research paper topics a try:

• Talk about peculiar altarpieces in the Renaissance period
• What are Fresco cycles?
• Talk about the secularism theme
• The anatomy of the human being in art
• An in-depth analysis of the linear perspective
• Discuss realism in the Renaissance period
• Uses of light in art
• Landscape in Renaissance-era art works
• Discuss the humanism theme
• And in-depth look at rationalism in the Renaissance era

Contemporary Art Research Paper Topics

We’ve discovered that professors really appreciate contemporary art (and papers written about it). So don’t hesitate to pick one of our exceptional contemporary art research paper topics:

• Talk about pop art
• Modern sculptures
• Talk about an important work of modern art
• Talk about architecture as a form of art
• Discuss film as a form of art
• Figurative art vs. geometric art
• Discuss the concept of minimalist art

High School Art Research Paper Topics

Did you know that your teacher will be more likely to give you a top grade if you manage to find an interesting topic? Check out these awesome high school art research paper topics and pick the best one for you:

• Discuss the Surrealist movement
• What makes a work of art abstract?
• Signs of globalization in art
• Compare and contrast the Gothic and Neo-Gothic movements
• What is Abstract Expressionism?
• Talk about the Bauhaus movement
• Compare Russian art and American art during the Cold War

Photography As Art Ideas

Yes, photography is art. Also, you will almost definitely be the only one writing about this subject in your class. Here are our best photography as art ideas:

• Using lighting effectively for photography
• Artistic expressions of renowned photographers
• Discuss 3 of the most famous photographs
• Capturing the vision of the artist on film
• The effects of lenses on the image
• How photography changed the face of art
• Framing and timing techniques
• Are photographs a form of art?
• The many sues of lighting in a photography studio
• Is war photography a form of art?
• Expressing feelings with photos
• The life and work of Alfred Stieglitz

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