Art Therapy
Art Therapy
E V I D E N C E R E V I E W
Acknowledgements 3
Executive summary 4
Background and Scope 4
Method 4
Key findings 4
Introduction 6
Review Questions and Scope 6
Question 1. What is the current evidence of the clinical effectiveness of art therapy? 7
Key findings 7
Method 7
Search Process 7
Findings 9
Question 2: What is the status of art therapy within the psychology profession in Australia? 15
Key Findings 15
Method 15
Findings 15
Implications 21
References 22
Appendix 23
Literature search process and study classification 23
LIST OF TABLES
LIST OF FIGURES
Fig 1. PRISMA diagram showing search process for identifying studies of the clinical effectiveness of
art therapy 8
This report has been prepared for the Transport Accident Commission (TAC). The Institute for Safety,
Compensation and Recovery Research (ISCRR) would like to acknowledge TAC for their assistance
and collaboration throughout the development of this evidence review. The authors also wish to
thank staff at ISCRR who supported the evidence review and production of the report.
Disclaimer
Please note: This Evidence Review has been produced by the Institute for Safety Compensation and
Recovery Research (ISCRR) Worldwide Evidence Scanning Team in response to a specific question
from the Transport Accident Commission. The content of this report may not involve an exhaustive
analysis of all existing evidence in the relevant field, nor does it provide definitive answers to the
issues it addresses. The review findings were current at the time of publication, February 2018.
Significant new research evidence may become available at any time.
ISCRR is a joint initiative of WorkSafe Victoria, the Transport Accident Commission and Monash
University. The opinions, findings and conclusions expressed in this publication are those of the
authors and not necessarily those of the Transport Accident Commission or ISCRR.
Art therapy is a psychological treatment involving creative visual art making as a form of non-verbal
expression. This therapeutic approach has been used to assist clients to explore, externalise, process
and resolve negative thoughts and feelings associated with trauma. Art therapy can also be
appropriate for individuals with difficulty verbally expressing themselves, including children or
individuals with acquired brain injury.
An evidence review on the clinical effectiveness of art therapy following trauma was conducted in
2012.1 The review included three randomised controlled trials (RCTs), and one systematic review
study that evaluated art therapy for children and adolescents delivered within inpatient settings. The
evidence review concluded there was insufficient evidence to determine whether art therapy was a
useful treatment for individuals who had experienced trauma.
The Transport Accident Commission commissioned this evidence review to provide an updated
review of the clinical effectiveness of art therapy.
The key review questions, developed in consultation with the TAC, were:
1. What is the evidence of effectiveness of art therapy?
2. What is the status of art therapy within the psychology profession in Australia? This included:
• The qualifications needed to become a registered art therapist in Victoria and the institutions
where those qualifications can be obtained; and
• The nature of art therapy currently being delivered within Victoria.
Method
Key findings
Question 1: What is the current evidence of the clinical effectiveness of art therapy?
• Nine primary studies and six systematic reviews that have evaluated the clinical effectives of
art therapy have been published since 2012.
• Art therapy has been used to treat physical and psychological trauma, thus these studies are
relevant for TAC clients.
• There is moderate evidence that art therapy can significantly reduce depression and anxiety
symptoms associated with psychological trauma based on four primary and one systematic
review study.
• There is very limited evidence that art therapy can significantly reduce depression symptoms
for individuals with physical trauma based on one study.
• The long-term efficacy of art therapy is unclear.
Question 2: What is the status of art therapy within the psychology profession in
Australia?
• Psychologists, counsellors and social workers can work with qualified art therapists to provide
interdisciplinary therapy.
Art therapy is a psychological treatment that involves creative visual art making as a form of non-
verbal expression. An art therapy session consists of the client using various art materials to express
their thoughts and emotions in the presence of an art therapist who helps to explore, build insight
and make meaning of the art work. This may take place individually or in a group.
Creative arts therapies can include various art modalities including visual art, music, dance, drama
and photography. For the purpose of this report, we focused on art therapies that use visual art-
making such as drawing, painting, and creating mosaic with clay, ceramics or any other material.
Traumatic events are often difficult to express in words alone and they can be stored in the brain
visually. Art therapy has been used to assist clients to explore these stored images, and to
externalise, process and resolve the negative thoughts and feelings associated with trauma.2 Art
therapy is also particularly helpful for people for whom expressing themselves verbally is
problematic, such as children or patients with acquired brain injury.
Exposure to trauma can lead to post-traumatic stress disorder (PTSD), a chronic condition with
symptoms including intrusive recollection (re-experiencing), avoidance/numbing and increased
arousal (hyper-vigilance). These symptoms can affect an individual’s life and serve as a barrier to
basic tasks. Art therapy has been used to treat PTSD and other psychological consequences related
to physical or psychological trauma.
An evidence review on the effectiveness of art therapy following trauma was conducted in 2012.1
The review included three randomised controlled trials (RCTs), and one systematic review study that
evaluated art therapy for children and adolescents delivered within inpatient settings. The evidence
review concluded there was insufficient evidence to determine whether art therapy was a useful
treatment for individuals who had experienced trauma.
This evidence review was conducted to identify the clinical effectiveness and current practice of art
therapy for trauma.
The key review questions, developed in consultation with the TAC, were:
1. What is the evidence of effectiveness of art therapy?
2. What is the status of art therapy within the psychology profession in Australia? This included:
• The qualifications needed to become a registered art therapist in Victoria and the institutions
where those qualifications can be obtained; and
• The nature of art therapy currently being delivered within Victoria.
This evidence review was undertaken in two parts to address each of the review questions:
1. An update of the previous evidence review by performing a systematic review of research studies
published since 2012 that examined the clinical effectiveness of art therapy; and
2. An environmental scan on the status of art therapy within the psychology profession in Australia.
This report was prepared by the ISCRR Worldwide Evidence Scanning Team and presents a review of
scientific and practice evidence.
Key findings
• Nine primary studies and six systematic reviews that have evaluated the clinical effectives
of art therapy have been published since 2012.
• Art therapy has been used to treat physical and psychological trauma, thus these studies
are relevant for TAC clients.
• There is moderate evidence that art therapy can significantly reduce depression and
anxiety symptoms associated with psychological trauma based on four primary and one
systematic review study.
• There is very limited evidence that art therapy can significantly reduce depression
symptoms for individuals with physical trauma based on one study.
Method
An updated systematic search of the scientific literature for evaluation studies of the clinical
effectiveness of art therapy published since 2012 was conducted in January 2018.
Literature search
The specific inclusion and exclusion criteria based on the original review are described below.
Population
The types of participants included individuals with an injury or condition due to motor vehicle
accident, or any other trauma, injury or condition. Trauma due to domestic violence, sexual or child
abuse was excluded.
Intervention
The search included evaluations of the effectiveness of art therapy delivered as a standalone
treatment or as part of a multidisciplinary treatment program. Interventions that included music
therapy, writing or dance therapy were excluded, as were creative art classes that were not
facilitated by an art therapist.
Outcomes
To be included primary evaluation and systematic review studies were required to report at least
one mental health measure as a primary outcome. Mental health outcomes could include
depression, anxiety, stress, or post-traumatic stress disorder symptomology. Eligible studies could
report physical health outcomes including quality of life, physical function or pain.
Search Process
The search process is summarised in Figure 1 below, and further described in the Appendix.
The quality of the included primary studies were assessed using the Effective Public Health Practice
Project (EPHPP) Quality Assessment tool for quantitative studies. The quality of the included
systematic reviews were assessed using A Measurement Tool to Assess systematic Reviews
(AMSTAR).
21 articles excluded
Eligibility
Fig 1. PRISMA diagram showing search process for identifying studies of the clinical effectiveness of art
therapy
Detailed findings
We identified for review 19 papers that included seven systematic review and 12 primary evaluation
studies. One systematic review2 and three primary studies3-5 from the 2012 ISCRR review6 (#0312-
002-R9) were included in this review. A summary of systematic review papers included for review is
shown in Table 1, and primary study characteristics in Table 2.
Of the 19 papers included for review, one systematic review7 and one primary study1 were
conducted in Australia. The remaining six systematic reviews were conducted in countries
comparable to the Australian context. The primary studies were conducted in a range of countries.
Of the twelve primary studies, eight were randomised controlled trials (RCTs), and three used a
cohort and one a controlled cohort study design.
Art therapy was delivered to target those with: injury from motor vehicle accident, trauma, spinal
cord injury, PTSD or other mental health disorders, stroke, breast cancer, dementia, schizophrenia
and personality disorders. One primary study evaluated the effectiveness of art therapy delivered to
healthy ageing adults.
Reference (year) Country Targeting those with Years searched N studies; N Outcomes Quality
participants rating1
Physical trauma Schouten et al (2015)8 The Netherlands Adult trauma - 2013 6; 223 Psychological trauma Medium
symptoms
Wethington et al United States Childhood trauma - 2007 1 of 72; nr Mental health symptoms High
(2008)22
Psychological Ramirez (2016) 9 United States Military-related nr 12; nr PTSD symptoms Low
trauma and mental PTSD
health disorders
Uttley et al (2015)10 United Kingdom Mental health - 2013 27; 965 Mental health symptoms High
disorders
Other conditions Reynolds (2012)11 United Kingdom Stroke nr nr Cognitive function, physical Low
function
Chancellor et al (2014)12 United States Dementia 1980-2013 16; 169 Cognitive function, wellbeing Low
Maujean et al (2014)7 Australia Range 2008-2013 8; 988 Mental health symptoms Low
Notes. 1Based on AMSTAR rating of systematic review quality, where high quality reviews achieved an AMSTAR rating of 9-11, medium quality reviews a rating of 5-8, and low quality reviews
a rating of 1-4; 2one primary study included for review evaluated art therapy; 2systematic review included in original review; nr = not reported; PTSD = post-traumatic stress disorder.
Reference (year) Country Study design Targeting those with Intensity Outcomes of interest Quality
N, % male rating1
(follow up)
Wang et al, 201513 China RCT (12m) Motor vehicle accident, 40m/w x 8 PTSD severity; post-traumatic growth; Strong
52, NR depression; anxiety
Physical trauma
Macri and Limoni (2017)14 Italy Cohort (post Spinal cord injury, 19, mean 15.5h Anxiety; depression; well-being; general Moderate
intervention) 74% health
Chapman et al (2001)32 United States Controlled cohort (nr) Childhood trauma, 85, 1 x 1h PTSD symptom severity Moderate
70%
Schreier et al (2005)52 United States RCT (18m) Childhood trauma 1 x 1h PTSD symptom severity Weak
Campbell et al (2016)15 United States RCT (post- Military related PTSD, 8 x 1.25h Depression; PTSD symptoms Weak
Psychological trauma and mental health disorders
Lyshak-Stelzer et al United States RCT (7d) Adolescent PTSD, 29, 1h/w x 16 PTSD symptom severity Moderate
(2007)42 55% male
Kopytin and Lebedev Russia RCT (post- Military related mood 1/w x 3 Mood disorder symptoms; quality of life Weak
(2013)16 intervention) disorder, 112, 91%
Caddy et al (2012)1 Australia Cohort (post- Mood disorders, 403, 6x 1.5h Mental health outcomes (depression, Weak
intervention) 18% anxiety, stress), quality of life, functioning
Crawford et al (2012)17 United Kingdom RCT (12m) Schizophrenia, 417, NR 1.5 h/w x 12m Global functioning; mental health Strong
symptoms; social functioning; satisfaction
with care
Haeyen et al (in press)18 The Cohort Personality disorders, 74, 1.5h/w x 10 Mental health symptoms Weak
Netherlands (post-intervention) 30%
Monti et al (2012)19 United States RCT (2w) Breast cancer, 18, 0% 2.5h/w x 8 Anxiety Moderate
conditions
Other
Kim (2013)20 Korea RCT (post- Healthy ageing, 50, 22% 3 x 1.25h/w x 4 Affect; anxiety; self-esteem Moderate
intervention)
Notes. 1Based on the Effective Public Health Practice Project (EPHPP) Quality assessment tool for quantitative studies;2 study from original review; nr = not reported; PTSD, post-traumatic stress disorder; RCT =
randomised controlled trial.
Wethington et al Paediatric trauma PTSD symptom severity: 0/1 studies reported significant
(2008) decrease
Conclusion: insufficient evidence to determine effectiveness
Ramirez (2016) PTSD PTSD symptom severity: 4/6 studies reported significant
Psychological trauma
and mental health
decrease
Additional reported impacts: increased ability to verbalise
di d
Uttley et al (2015) Non-psychotic mental Mental health symptoms: 10/15 studies reported significant
health disorders improvement
Caddy et al Mood disorders Depression: ↓ baseline to post intervention mean dif 17.3, p < 0.001
(2012) Anxiety: ↓ baseline to post intervention mean dif 13.0, p < 0.001
Stress: ↓ baseline to post-intervention mean dif 16.4, p<0.001
Crawford et Schizophrenia Global functioning: ns
al (2012) Mental health symptoms: ns
Social functioning: ns
Haeyen et Personality Mental health: ↑ baseline to post-intervention mean dif 9.6, p<0.01
al (2017) disorders
Kim (2013) Healthy ageing Mood: ↑post-intervention intervention vs control mean dif 14.2, p <
0.001
Anxiety: ↓ post-intervention intervention vs control mean dif -16.2, p <
0.001
Self-esteem: ↑ post-intervention intervention vs control mean dif 3.8, p <
0.001
Note. #Mean difference not reported. M=Mean; ns= not significant, PTSD= post-traumatic stress disorder
Key Findings
• Psychologists, counsellors and social workers can work with qualified art therapists to
provide interdisciplinary therapy.
• The peak art therapy professional organisations in Australia are the Professional
Association for Arts Therapy in Australia, New Zealand and Singapore (ANZATA) and the
Australian Creative Arts Therapies Association (ACATA).
• To be eligible for membership of ANZATA, art therapists must have completed an
approved Masters level course in art therapy.
• Two accredited training institutions in Victoria offered Master of Art Therapy courses.
• In February 2018 there were 56 art therapists in the Melbourne area who were members
of a professional organisation.
• Public and private health institutions in Victoria offer art therapy for mental health and
medical conditions.
Method
A desktop scan of publicly available grey literature was conducted in January and February 2018 to
examine the current practice of art therapy in Australia.
We searched the electronic search engine Google using combinations of the following terms: art
therapy, art therapists, Victoria, accident, injury and trauma. Additionally we conducted targeted
searches of the webpages of: the Australian Institute of Health and Welfare (AIHW), the Australian
Psychological Society (APS), the Australian Health Practitioner Regulation Agency (AHPRA), the
Psychotherapy and Counselling Federation of Australia (PACFA), and the International Institute for
Complementary Therapists (IICT).
Findings
Art therapists work within mental health, allied health and human services. Art therapy is a tool used
by mental health professionals to help clients, especially those who have suffered some kind of
trauma in their lives, to open up and unlock their inner feelings, which may be known, unknown or
unable to speak about.
Psychologists, counsellors and social workers can work with qualified art therapists to provide
interdisciplinary therapy. Additionally allied health professionals are trained in art therapy and offer
art therapy as a component of their core therapy services.
A website search to identify relevant evidence-based guidelines in Australia yielded very limited
results (see Appendix). The Australian Counselling Association (ACA) offers art therapy workshops
and events for practising health professionals. ∗
∗
https://www.theaca.net.au/
∗
https://arttherapycourses.com.au/art-therapy-course-details/accreditation-and-recognition/
Institution Course name Prerequisite Intensity; mode Practical training Professional recognition
Master of Art Therapy Undergraduate degree in a relevant field 2y FT; F2F 750h placement ANZATA
University
La Trobe
Art Therapy Short Course Program None 1-2d; F2F None None
Masters in Therapeutic Arts Practice No information available 3y PT; nr 1.5d/w x 12m ANZATA
The Miecat
Institute
Professional Doctorate in Therapeutic Arts MIECAT Masters or equivalent 5y PT; nr Group and individual ANZATA
Practice supervision
Certificate in Educational and Clinical Art Therapy CECAT introductory course 6-12m PT; F2F, online None ANZATA
Diploma in Educational and Clinical Art Therapy CECAT Certificate Course 3-6m PT; F2F, online None No information available
Master Class for Certified and Graduate Art Aged 21 years; training or experience in No information No information No information available
Therapists psychological theory or practice available available
Advanced Diploma of Art Therapy None 12 or 24m; F2F, online 100h supervised Eligibility for membership
placement with ACATA
Bachelor of Arts Psychotherapy At least 18 years, Certificate IV, Diploma, 3y FT; F2F 480h placement Eligibility for membership
Advanced Diploma or Associate Degree with PACFA, ACATA,
ANZATA and the ACA.
Notes. #Does not represent an exhaustive list of all available courses; ACA = Australian Counselling Association; ACATA = The Australian Creative Arts Therapies Association; ANZATA = Professional Association for
Arts Therapy in Australia, New Zealand and Singapore; FT = full time; F2F = face to face; nr = not reported; PACFA = Psychotherapy and Counselling Federation of Australia; PT = part time
Note. # Not an exhaustive list of all institutions and organisations that offered art therapy programs and treatments.
The RTSSV is a not-for-profit organisation that offers free face-to-face and telephone counselling
services across Victoria to individuals affected by road trauma. The RTSSV established the Art
Therapy Group in 2012 as part of their peer support program.
Initially targeting mothers bereaved through road trauma, the Art Therapy Group has since
expanded to include any individual directly or indirectly affected by road trauma.
Monthly facilitated sessions are offered at the Surrey Hills Community Centre in Melbourne.
Clients are encouraged to express their thoughts and feelings related to grief and loss through
the art medium. The group occasionally produce shared pieces of art. For example, in 2016 the
group created a mural made from felt for the annual Time for Remembering ceremony. The
work of pulling apart the soft fibres and bringing them together again in the felting process was
seen to be symbolic of the internal healing process after trauma.
This evidence review identified the best available current evidence of the clinical effectiveness of art
therapy, as well as the current practice of art therapy in Victoria. A summary of key findings
according to the two guiding review questions is presented below.
Question 1: What is the current evidence of the clinical effectiveness of art therapy?
• Nine primary studies and six systematic reviews that have evaluated the clinical effectives of
art therapy have been published since 2012.
• At therapy has been used to treat physical and psychological trauma, thus these studies are
relevant for TAC clients.
• There is moderate evidence that art therapy can significantly reduce depression and anxiety
symptoms associated with psychological trauma based on four primary and one systematic
review study.
• There is very limited evidence that art therapy can significantly reduce depression symptoms
for individuals with physical trauma based on one study.
• The long-term efficacy of art therapy is unclear.
Question 2: What is the status of art therapy within the psychology profession in
Australia?
• Psychologists, counsellors and social workers can work with qualified art therapists to provide
interdisciplinary therapy.
• The peak art therapy professional organisations in Australia are the Professional Association
for Arts Therapy in Australia, New Zealand and Singapore (ANZATA) and the Australian
Creative Arts Therapies Association (ACATA).
• To be eligible for membership of ANZATA, art therapists must have completed an approved
Masters level course in art therapy.
• Two accredited training institutions in Victoria offered Master of Art Therapy courses.
• In February 2018 there were 56 art therapists in the Melbourne area who were members of a
professional organisation.
• Public and private health institutions in Victoria offer art therapy for mental health and
medical conditions.
1. Caddy L, Crawford F, Page AC. 'Painting a path to wellness': correlations between participating in a
creative activity group and improved measured mental health outcome. Journal of Psychiatric & Mental Health
Nursing. 2012;19(4):327-33.
2. Wethington HR, Hahn RA, Fuqua-Whitley DS, Sipe TA, Crosby AE, Johnson RL, et al. The effectiveness of
interventions to reduce psychological harm from traumatic events among children and adolescents: a systematic
review. American journal of preventive medicine. 2008;35(3):287-313.
3. Chapman L, Morabito D, Ladakakos C, Schreier H, Knudson MM. The Effectiveness of Art Therapy
Interventions in Reducing Post Traumatic Stress Disorder (PTSD) Symptoms in Pediatric Trauma Patients. Art
Therapy. 2001;18(2):100-4.
4. Lyshak-Stelzer F, Singer P, St. John P, Chemtob C. Art Therapy for Adolescents with Posttraumatic Stress
Disorder Symptoms: A Pilot Study. Art Therapy. 2007;24(4):163-9.
5. Schreier H, Ladakakos C, Morabito D, Chapman L, Knudson MM. Posttraumatic stress symptoms in
children after mild to moderate pediatric trauma: a longitudinal examination of symptom prevalence, correlates,
and parent-child symptom reporting. The Journal of trauma. 2005;58(2):353-63.
6. Donoghue E, Piccenna L. Art Therapy. Institute for Safety, Compensation and Recovery Research,;
February 2012.
7. Maujean A, Pepping CA, Kendall E. A systematic review of randomized controlled studies of art therapy.
Art Therapy. 2014;31(1):37-44.
8. Schouten KA, de Niet GJ, Knipscheer JW, Kleber RJ, Hutschemaekers GJ. The effectiveness of art therapy
in the treatment of traumatized adults: a systematic review on art therapy and trauma. Trauma Violence &
Abuse. 2015;16(2):220-8.
9. Ramirez J, Erlyana E, Guilliaum M. A Review of Art Therapy Among Military Service Members and
Veterans with Post-Traumatic Stress Disorder. Journal of Military and Veterans Health. 2016;24(2):40-51.
10. Uttley L, Scope A, Stevenson M, Rawdin A, Buck ET, Sutton A, et al. Systematic review and economic
modelling of the clinical effectiveness and cost-effectiveness of art therapy among people with non-psychotic
mental health disorders. Health Technology Assessment. 2015;19(18):1-+.
11. Reynolds F. Art therapy after stroke: Evidence and a need for further research. Arts in Psychotherapy.
2012;39(4):239-44.
12. Chancellor B, Duncan A, Chatterjee A. Art Therapy for Alzheimer's Disease and Other Dementias.
Journal of Alzheimers Disease. 2014;39(1):1-11.
13. Wang XL, Lan C, Chen JW, Wang WY, Zhang H, Li L. Creative arts program as an intervention for PTSD:
a randomized clinical trial with motor vehicle accident survivors. International Journal of Clinical and
Experimental Medicine. 2015;8(8):13585-91.
14. Macri E, Limoni C. Artistic activities and psychological well-being perceived by patients with spinal cord
injury. Arts in Psychotherapy. 2017;54:1-6.
15. Campbell M, Decker KP, Kruk K, Deaver SP. Art Therapy and Cognitive Processing Therapy for Combat-
Related PTSD: A Randomized Controlled Trial. Art Therapy: Journal of the American Art Therapy Association.
2016;33(4):169-77.
16. Kopytin A, Lebedev A. Humor, self-attitude, emotions, and cognitions in group art therapy with war
veterans. Art Therapy. 2013;30(1):20-9.
17. Crawford MJ, Killaspy H, Barnes TR, Barrett B, Byford S, Clayton K, et al. Group art therapy as an
adjunctive treatment for people with schizophrenia: a randomised controlled trial (MATISSE). Health Technology
Assessment. 2012;16(50):iii-76.
18. Haeyen S, van Hooren S, Van der Veld WM, Hutschemaekers GJ. Promoting mental health versus
reducing mental illness in art therapy with patients with personality disorders: a quantitative study. The Arts in
Psychotherapy.In press.
19. Monti DA, Kash KM, Kunkel EJ, Brainard G, Wintering N, Moss AS, et al. Changes in cerebral blood flow
and anxiety associated with an 8-week mindfulness programme in women with breast cancer. Stress and health
: journal of the International Society for the Investigation of Stress. 2012;28(5):397-407.
20. Kim MK, Kang SD. Effects of art therapy using color on purpose in life in patients with stroke and their
caregivers. Yonsei Medical Journal. 2013;54(1):15-20.
Search process
Search words
“art therapy” AND (rehabilitation OR trauma OR accident OR condition)
English language only, humans, and year 2012 to current
The databases searched were Ovid Medline, Embase, Web of Science, PsychINFO, CINAHL, and
Cochrane database of systematic reviews.
Identified titles were retained if they evaluated an art therapy intervention delivered as a stand-
alone treatment or as part of a multidisciplinary approach. Following the initial screening process,
full text articles were obtained and assessed for eligibility based on specific criteria developed a
priori by the ISCRR project team in collaboration with the TAC project sponsor.
Study classification
The electronic database searches yielded 755 potentially relevant references. A further three were
identified through other sources and the four studies in the 2012 ISCRR Art Therapy Evidence Review
were included. After removal of duplicates 571 records remained. Screening of the titles and
abstracts resulted in 531 records excluded and 40 full text articles were assessed for eligibility. Seven
systematic reviews and 12 primary studies that fit the inclusion criteria were retained for data
extraction and synthesis. Information on study design, population, art therapy intervention
characteristics and study results were extracted for each included intervention study.