Is Art Therapy a Reliable Tool for Rehabilitating People Suffering From Brainmental Diseases

Introduction

Mental disorders establish a huge social and economic brunt for wellness care systems worldwide (Zschucke et al., 2013; Kenbubpha et al., 2018). In China, the lifetime prevalence of mental disorders was 24.20%, and 1-month prevalence of mental disorders was 14.27% (Xu et al., 2017). The situation is more severely in other countries, especially for developing ones. Given the large numbers of people in need and the humanitarian imperative to reduce suffering, in that location is an urgent need to implement scalable mental health interventions to address this burden. While pharmacological treatment is the starting time choice for mental disorders to convalesce the major symptoms, many antipsychotics contribute to poor quality of life and debilitating adverse effects. Therefore, clinicians have turned toward to complementary treatments, such as fine art therapy in addressing the wellness needs of patients more than half a century agone.

Art therapy, is defined by the British Clan of Fine art Therapists as: "a course of psychotherapy that uses art media as its master mode of expression and communication. Clients referred to art therapists are non required to have experience or skills in the arts. The art therapist's primary business organisation is not to make an esthetic or diagnostic assessment of the client'due south epitome. The overall goal of its practitioners is to enable clients to change and abound on a personal level through the use of artistic materials in a prophylactic and convenient environment" (British Clan of Art Therapists, 2015), whereas equally: "an integrative mental wellness and human services profession that enriches the lives of individuals, families, and communities through active art-making, creative procedure, applied psychological theory, and human experience within a psycho-therapeutic relationship" (American Art Therapy Clan, 2018) according to the American Art Clan. It has gradually go a well-known form of spiritual support and complementary therapy (Faller and Schmidt, 2004; Nainis et al., 2006). During the therapy, fine art therapists tin utilize many dissimilar art materials every bit media (i.eastward., visual art, painting, drawing, music, trip the light fantastic, drama, and writing) (Deshmukh et al., 2018; Chiang et al., 2019). Among them, drawings and paintings have been historically recognized as the about useful function of therapeutic processes inside psychiatric and psychological specialties (British Association of Art Therapists, 2015). Moreover, many other art forms gradually fall under the prevue of their own professions (eastward.yard., music therapy, dance/movement therapy, and drama therapy) (Deshmukh et al., 2018). Thus, we excluded these studies and only focused on studies of art therapy which mainly includes painting and drawing as media. Specifically, it focuses on capturing psychodynamic processes by means of "inner pictures," which become visible past the artistic procedure (Steinbauer et al., 1999). These pictures reflect the psychopathology of different psychiatric disorders and fifty-fifty their corresponding therapeutic process based on specific rules and criterion (Steinbauer and Taucher, 2001). Information technology has been gradually recognized and used as an alternative treatment for therapeutic processes inside psychiatric and psychological specialties, as well as medical and neurology-based scientific audiences (Burton, 2009).

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

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

Publications of Art Therapy

The literatures about "art therapy" published from January 2006 to December 2020 were searched in the PubMed database. The following topics were used: Title/Abstruse = "art therapy," Indexes Timespan = 2006–2020.

A full of 652 records were found. And so, we manually screened out the literatures that contained the word "art" but was not relevant with the subject field of this study, such equally country of the art therapy, antiretroviral therapy (Art), and assisted reproductive technology (Fine art). Finally, 479 records most art therapy were identified. Since we aimed to focus on fine art therapy included painting and cartoon as major media, we screened out literatures deeper, and identified 413 (84%) literatures involved in painting and drawing (Figure 1).

Figure i. Number of publications nigh fine art therapy.

Every bit we can see, the number of literature most fine art therapy is increasing slowly in the terminal xv years, reaching a acme in 2020. This indicates that more effort was made on this topic in recent years (Figure ane).

Overview of Art Therapy

As divers by the British Association of Art Therapists, art therapy is a form of psychotherapy that uses art media as its primary style of communication. Based on above literature, several highlights need to exist summarized. (1) The main media of art therapy include painting, drawing, music, drama, trip the light fantastic toe, drama, and writing (Chiang et al., 2019). (ii) Master contents of painting and drawing include blind drawing, spiral cartoon, cartoon moods and cocky-portraits (Legrand et al., 2017; Abbing et al., 2018; Papangelo et al., 2020). (3) Art therapy is mainly used for cancer, depression and feet, autism, dementia and cognitive impairment, every bit these patients are reluctant to express themselves in words (Attard and Larkin, 2016; Deshmukh et al., 2018; Chiang et al., 2019). It plays an important role in facilitating engagement when direct verbal interaction becomes difficult, and provides a rubber and indirect style to connect oneself with others (Papangelo et al., 2020). Moreover, nosotros constitute that fine art therapy has been gradually and successfully used for patients with mental disorders with positive outcomes, mainly reducing suffering from mental symptoms. These findings suggest that art therapy tin not only be served as an useful therapeutic method to assist patients to open and share their feelings, views, and experiences, simply also as an auxiliary treatment for diagnosing diseases to help medical specialists obtain complementary data different from conventional tests.

Art Therapy for Mental Disorders

Based on the 413 searched literatures, we further limited them to mental disorders using the following primal words, respectively: Low OR anxiety OR Cerebral harm OR dementia OR Alzheimer's affliction OR Autism OR Schizophrenia OR mental disorder. Every bit a result, a total of 23 studies (five%) (Tabular array i) were included and classified afterwards reading the abstruse and the full text carefully. These studies include ix articles on low and anxiety, 4 articles on cognitive impairment and dementia, 3 articles on Alzheimer's affliction, 3 articles on autism, and 4 manufactures on schizophrenia. In addition to the English literature, in fact, some Chinese literatures also described the application of art therapy in mental diseases, which were non listed merely referred to in the following specific literatures.

Table one. Studies of art therapy in mental diseases.

Depression Disorders and Feet

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

In contempo years, many studies take shown that fine art therapy plays a significant role in alleviating depression symptoms and anxiety. Gussak (2007) performed an observational survey about populations in prison of northern Florida and identified that art therapy significantly reduces depressive symptoms. Similarly, a randomized, controlled, and unmarried-bullheaded study about fine art therapy for depression with the elderly showed that painting as an adjuvant treatment for low can reduce depressive and feet symptoms (Ciasca et al., 2018). In add-on, art therapy is besides widely used among students, and several studies (Runde, 2008; Zhenhai and Yunhua, 2011) have shown that art therapy also significantly reduces depressive symptoms in students. For example, Wang et al. (2011) conducted group painting therapy on thirty patients with depression for 3 months, and found that painting therapy could promote their social function recovery, improve their social adaptability and quality of life. Some other randomized clinical trial also showed that it could decrease hateful anxiety scores in the 3–12 year painting group (Forouzandeh et al., 2020).

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

Overall, art painting therapy permits patients to limited themselves in a manner adequate to the inside and outside culture, thereby diminishing depressed and anxiety symptoms.

Cerebral Impairment, and Dementia

Dementia, a progressive clinical syndrome, is characterized past widespread cognitive impairment in memory, thinking, behavior, emotion and functioning, leading to worse daily living (Deshmukh et al., 2018). Co-ordinate to the Alzheimer's Disease International 2015, in that location is 46.8 million people suffered from dementia, and numbers well-nigh doubling every 20 years, rising to 131.five meg by 2050. Although art therapy has been used as an alternative treatment for the dementia for long fourth dimension, the positive effects of painting therapy on cognitive function remain largely unknown. One intervention assigned older adults patients with dementia to a grouping-based art therapy (including painting) observed significant improvements in the clock drawing exam (Pike, 2013), whereas two other randomized controlled trials (Hattori et al., 2011; Rusted et al., 2016) on patients with dementia accept failed to obtain pregnant cerebral improvement in the painting grouping. Moreover, a cochrane systematic review (Deshmukh et al., 2018) included ii clinical studies of art therapy for dementia revealed that there is no sufficient bear witness about the efficacy of art therapy for dementia. This may be considering patients with severely cerebral impairment, who was unable to accurately remember or assess their ain behavior or mental state, might lose the power to savor the benefits of art therapy.

In summary, we should intervene earlier in patients with balmy cerebral impairment, an intermediate stage between normal aging and dementia, in guild to forbid further transformation into dementia. To date, mild cognitive impairment is cartoon much attention to the importance of painting intervening at this stage in order to alter the course of subsequent cerebral turn down as before long as possible (Petersen et al., 2014). Recently, a randomized controlled trial (Yu et al., 2021) showed meaning relationship between improvement firsthand retentiveness/working retention span and increased cortical thickness in right heart frontal gyrus in the painting art group. With the long-term cerebral stimulation and engagement from multiple sessions of painting therapy, it is likely that painting therapy could atomic number 82 to enhanced cognitive functioning for these patients.

Alzheimer's Disease

Alzheimer'due south disease (AD) is a sub-blazon of dementia, which is ordinarily associated with chronic pain. Previous studies suggested that art therapy could exist used every bit a complementary treatment to relief pain for these patients since medication might induce severely side effects. In a multicenter randomized controlled trial, 28 mild Advertizement patients showed pregnant pain reduction, reduced anxiety, improved quality of life, improved digit span, and inhibitory processes, too equally reduced low symptoms later 12-week painting (Pongan et al., 2017; Alvarenga et al., 2018). Further study besides suggested that individual therapy rather than grouping therapy could be more than optimal since neuroticism can decrease efficacy of painting intervention on pain in patients with balmy Ad. In improver to release chronic hurting, art therapy has been reported to show positive effects on cognitive and psychological symptoms in patients with mild AD. For example, a controlled study revealed meaning improvement in the apathy scale and quality of life after 12 weeks of painting treatment mainly including color abstract patterns with pastel crayons or water-based paint (Hattori et al., 2011). Another study besides revealed that AD patients showed improvement in facial expression, soapbox content and mood later 3-weeks painting intervention (Narme et al., 2012).

Schizophrenia

Schizophrenia is a complex functional psychotic mental illness that affects about 1% of the population at some signal in their life (Kolliakou et al., 2011). Not only practice sufferers experience "positive" symptoms such every bit hallucinations, delusions, but likewise experience negative symptoms such every bit varying degrees of anhedonia and asociality, dumb working memory and attention, poverty of speech, and lack of motivation (Andreasen and Olsen, 1982). Many patients with schizophrenia remain symptomatic despite pharmacotherapy, and even attempts to suicide with a rate of x to fifty% (De Sousa et al., 2020). For these patients, art therapy is highly recommended to process emotional, cognitive and psychotic experiences to release symptoms. Indeed, many forms of art therapy have been successfully used in schizophrenia, whether and how painting may interfere with psychopathology to release symptoms remains largely unknown.

A recent review including twenty studies overall was performed to summary findings, however, concluded that information technology is not articulate whether art therapy leads to clinical comeback in schizophrenia with depression (Ruiz et al., 2017). Anyway, many randomized clinical trials reported positive outcomes. For instance, Richardson et al. (2007) conducted painting therapy for six months in patients with chronic schizophrenia and plant that art therapy had a positive effect on negative symptoms. Teglbjaerg (2011) examined experience of each patient using interviews and written evaluations before and later painting therapy and at a 1-yr follow-up and establish that group painting therapy in patients with schizophrenia could non only reduce psychotic symptoms, but likewise boost self-esteem and improve social function.

What'south more than, the characteristics of the painting tin can as well be used to gauge the health condition in patients with schizophrenia. For example, Hongxia et al. (2013) explored the correlation betwixt psychological wellness condition and characteristics of Business firm-Tree-Person tests for patients with schizophrenia, and showed that the detail feature of the test results can be used to guess the patient'south feet, depression, and obsessive-compulsive symptoms.

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

Autism

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

Art therapy is a form of expression that opens the door to communication without verbal interaction. It provides therapists with the opportunity to interact one-on-one with individuals with autism, and make wide connections in a more comfortable and effective manner (Babaei et al., 2020). Emery (2004) did a case study virtually a vi-yr-old boy diagnosed with autism and plant that art therapy is of great value to the development, growth and communication skills of the boy. Recently, i written report (Jalambadani, 2020) using 40 children with ASD participating in painting therapy showed that painting therapy had a meaning improvement in the social interactions, adaptive behaviors and emotions. Therefore, encouraging children with ASD to limited their feel by using nonverbal expressions is crucial to their development. Evans and Dubowski (2001) believed that creating images on paper could assist children limited their internal images, thereby enhance their imagination and abstract thinking. Painting tin also help autistic children express and vent negative emotions and thereby bring positive emotional experience and promote their cocky-consciousness (Martin, 2009). Co-ordinate to 2 studies (Wen and Zhaoming, 2009; Jianhua and Xiaolu, 2013) in Red china, Art therapy could besides improve the linguistic communication and advice skills, cerebral and behavioral performance of children with ASD.

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

In a discussion, art therapy plays a significant part in children with ASD, non just equally a method of treatment, but also in understanding and investigating patients' problems.

Other Applications

In improver to the above mentioned diseases, art therapy has also been adopted in other applications. Dysarthia is a mutual sequela of cerebral palsy (CP), which directly affects children's language intelligibility and psycho-social adjustment. Speech therapy does not always assistance CP children to speak more than intelligibly. Interestingly, the fine art therapy can significantly improve the language intelligibility and their social skills for children with CP (Wilk et al., 2010).

In brief, these studies propose that art therapy is meaningful and accepted by both patients and therapists. Most often, art therapy could strengthen patient's emotional expression, cocky-esteem, and self-sensation. Notwithstanding, our findings are based on relatively small samples and few good-quality qualitative studies, and crave cautious interpretation.

The Application Prospects of Fine art Therapy

With the development of modern medical technology, life expectancy is as well increasing. At the same time, information technology also brings some side effects and psychological issues during the treatment process, especially for patients with mental disease. Therefore, there is an increasing demand for finding appropriate complementary therapies to ameliorate life quality of patients and psychological health. Art therapy is primarily offered as private art therapy, in this review, nosotros found that fine art therapy was about commonly used for depression and anxiety.

Based on the above findings, art therapy, every bit a non-verbal psychotherapy method, not only serves as an auxiliary tool for diagnosing diseases, which helps medical specialists obtain much information that is difficult to gain from conventional tests, judge the severity and progression of diseases, and understand patients' psychological land from painting characteristics, but also is an useful therapeutic method, which helps patients open upwardly and share their feelings, views, and experiences. Additionally, the implementation of fine art therapy is not limited by historic period, linguistic communication, diseases or environment, and is easy to exist accepted past patients.

Art therapy in hospitals and clinical settings could be very helpful to aid treatment and therapy, and to enhance communications betwixt patients and on-site medical staffs in a not-verbal way. Moreover, art therapy could be more effective when combined with other forms of therapy such as music, dance and other sensory stimuli.

The medical mechanism underlying art therapy using painting as the medium for intervention remains largely unclear in the literature (Salmon, 1993; Broadbent et al., 2004; Guillemin, 2004), and the evidence for effectiveness is insufficient (Mirabella, 2015). Although a number of studies take shown that art therapy could improve the quality of life and mental health of patients, standard and rigorous clinical trials with large samples are all the same lacking. Moreover, the long-term outcome is nonetheless to exist assessed due to the lack of follow-up assessment of art therapy.

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

In the future, fine art therapy may be more thoroughly investigated in the following directions. First, more loftier-quality clinical trials should be carried out to gain more reliable and rigorous prove. Second, the evaluation methods for the effectiveness of art therapy need to be as diverse as possible. It is necessary for the investigation to include not only subjective scale evaluations, just also objective means such as brain imaging and hematological examinations to be more disarming. Third, information technology will be helpful to specify the details of the art therapy and patients for objective comparisons, including types of diseases, painting methods, required qualifications of the therapist to perform the art therapy, and the theoretical basis and machinery of the therapy. This practice should be continuously promoted in both hospitals and communities. Fourth, guidelines nigh fine art therapy should exist gradually formed on the basis of accumulated evidence. Finally, mechanism of art therapy should be further investigated in a variety of ways, such equally at the neurological, cellular, and molecular levels.

Author Contributions

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

Funding

This study was financially supported by the National Key R&D Program of China (2019YFC1712200), International standards research on clinical enquiry and service of Acupuncture-Moxibustion (2019YFC1712205), the National Natural Scientific discipline Foundation of Communist china (62006220), and Shenzhen Science and Engineering science Research Plan (No. JCYJ20200109114816594).

Conflict of Involvement

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

Publisher's Note

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

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