Emotion regulation strategies and effects in art-making: A narrative synthesis

The effect of mandala coloring and free coloring on the happiness in veterans with post-traumatic stress disorder in the Covid-19 pandemic: a randomized clinical trial

BACKGROUND

Post-traumatic stress disorder (PTSD) can lead to complications such as depression and grief, which are more prevalent in veterans than in the general population. Recently, art-making, including mandala coloring, has gained attention as a potential treatment for PTSD patients.

METHODS

This randomized clinical trial was conducted on 84 male veterans diagnosed with PTSD and hospitalized at the Milad Psychiatric Center in Tehran, Iran. The patients were recruited using a convenience sampling method and were assigned to either the mandala coloring group or the free coloring group. The Post-Traumatic Stress Disorder Checklist DSM-5 and the Oxford Happiness Scale were used to collect data. The intervention group colored mandala designs, while the control group colored squares freely. Coloring was done twice a week for three weeks.

RESULTS

The mean baseline happiness scores did not differ significantly between mandala coloring group and free coloring group (p = 0.376). However, at the end of study, happiness scores were significantly higher in mandala coloring group than in free coloring group (p < 0.001). After the intervention, happiness score of both groups increased significantly (p < 0.001).

CONCLUSION

Both coloring methods increased veterans' happiness scores; however, mandala coloring was more effective than free coloring. It is recommended that art-making be added to conventional treatments for veterans with PTSD.

TRIAL REGISTRATION

This study was registered in Iranian Registry of clinical trials (No. IRCT20210604051491N1, 29/08/2021).

Functional near-infrared spectroscopy approach to the emotional regulation effect of drawing: Venting versus distraction

BACKGROUND

Drawing can regulate emotions through venting or distraction. Distraction is more helpful for short-term emotion recovery; however, the sustainability of this difference is yet to be clarified. This study used functional near-infrared spectroscopy (fNIRS) to explore potential differences between venting and distraction.

METHODS

A total of 44 college students participated in the experiment. After inducing fear by video, they were divided into two groups: The venting group drew their emotional experience, and the distraction group drew a house. Subsequently, the participants were instructed to relax by a brief video.

RESULTS

Although the distraction group had a higher valence than the venting group at the end of the drawing activity, there was no difference between the two groups after a relaxation period. Additionally, the activation pattern of the prefrontal cortex differed between the two groups. Compared to the distraction group, the venting group had fewer channels with elevated prefrontal activity during drawing, suggesting less cognitive control, and had more channels with reduced prefrontal activity during relaxation, suggesting a higher level of relaxation. Drawing coding and fNIRS data were both associated with variations in valence.

CONCLUSION

The less the cognitive control over emotion and the more free the expression of emotion during drawing, the higher the increase in valence; inversely, the more the cognitive control over emotion and the less free the expression of emotion, the lower the increase in valence.

Mind-body and art therapies impact on emotional regulation in patients with chronic diseases: a pragmatic mixed-methods randomized controlled trial

BACKGROUND

Effective emotional regulation is recognized as essential to a good mental health of people with chronic diseases, and Mind-body and Art Therapies (MBATs) could have a positive effect on emotional regulation skills in this population. Thus, we aimed to evaluate the effect of MBATs on emotional regulation as measured by the Difficulties in Emotion Regulation Scale (DERS) questionnaire.

METHODS

A convergent mixed approach nested in a pragmatic superiority two arms parallel randomized controlled trial was conducted. French speaking adults with one or more chronic somatic illnesses and not suffering from a chronic psychiatric disorder unrelated to one of their chronic somatic illness were included. At inclusion, non-directive interviews were conducted, followed by an initial DERS assessment. The same combination of evaluation was implemented after 6 months of activity (T1). After inclusion, each participant was randomized within either the intervention group (G1) or the control group (G2) following a controlled wait-list design by use of a pregenerated randomization list. Staff and patient were blinded to this list until the initial evaluation was completed, after which the trial was conducted in an open-label fashion. Participants chose 2 mediations: one creativity-focused (art-therapy, writing workshop, theatre of life, vocal workshop) and one mind-body-focused (mindfulness meditation, Pilates, shiatsu, ayurvedic massages). G1 started their mediations immediately after inclusion, while G2 started 6 months later. Primary outcome was the change in means at 6 months in the overall DERS score compared between each group. Non-directive interviews were carried out at the inclusion and after 6 months of MBATs. A continuous inductive analysis was carried out on gathered material in G1 to explore the participants' experiences regarding their disease and their perceived changes associated to the intervention.

RESULTS

A total of 150 patients was randomized (75 per groups) at the end of the study. At T1, 133 patients filled out the final questionnaire (67 in G1 vs 66 in G2) and 112 interviews were analysed (54 in G1 vs 58 in G2). All 150 patients were analysed (intention to treat) using a multiple imputation approach. The mean DERS score at T0 was equal to 82.8 ± 21.1 and 85.0 ± 20.2 in G1 and G2 respectively. On average, at T1, the score decreased in the G1 (Δ = -4.8, SD = 21.3) and in G2 (Δ = -0.11, SD = 17.8). The difference in decrease, however, was not statistically significant (p = 0.13). Qualitative analysis underlined some MBATs benefits on emotional regulation, especially on regulation strategies. No harms related to the intervention has been observed.

CONCLUSIONS

This study only partially supports benefits on MBAT on emotional regulation skills enhancement in patients with chronic disease receiving MBATs, as measured by the DERS scale.

TRIAL REGISTRATION

The protocol was registered on Clinical Trials (NCT02911207).

Art-based interventions and art therapy to promote health of migrant populations - a systematic literature review of current research

BACKGROUND

This review aims to identify and analyse studies on art-based interventions and art therapy that are intended to promote better physical, mental and social health outcomes in culturally and linguistically diverse migrant populations.

METHOD

A systematic literature review was used to address the following questions: 1) What published studies over the past five years examined health outcomes? 2) What are the identifying characteristics of the studies? 3) What kinds of effect did these studies describe? 4) What implications do the findings have for future research in this field?

RESULTS

Art-based interventions and art therapy can significantly reduce traumatic stress symptoms and anxiety, enhance well-being by giving people greater life satisfaction and hope, and improve the social behaviour of children and adolescents.

CONCLUSION

In order to address humanitarian concerns in this field, researchers may apply innovative approaches to engage people from a refugee background in meaningful reflections on their lives.

The Ability to Integrate Beauty Scale (AIBS): Construction and Psychometric Properties on a Scale for Measuring Aesthetic Intelligence as a Resource for Personal Development

Background

Ferrucci, a philosopher and psychotherapist, presented an original three-factor aesthetic intelligence concept in his book "Beauty and Soul" (2009). The subject of this article is the presentation of work on the construction of a scale for measuring one of the three dimensions of aesthetic intelligence, the ability to integrate beauty (AIB). This is probably the first attempt to empirically operationalize this concept.

Methods

The three independent studies were carried out with a total of 604 participants. The aim of the first study was to develop the AIBS scale and to test its factor structure. During Study 2 and Study 3, we verified the AIBS structure through the confirmatory analysis and checked its convergent and discriminant validity.

Results

The outcomes indicate that a one-factor, and seven-item tool is characterized by very good psychometric properties. Moreover, the results suggest that the AIB is indeed positively related to the perception of artworks (6 dimensions of an aesthetic experience), regulation of emotions through artistic creative activities, as well as to aesthetic competencies in art. The AIB is indeed positively related to the greater intensity of light triad traits (humanism, kantianism, faith in humanity) and to the development of the individual in five areas of spirituality. AIB is also only slightly related to the search for meaning and to one dimension of well-being, which is satisfaction and the sense of power.

Exploring Change in Children’s and Art Therapists’ Behavior during ‘Images of Self’, an Art Therapy Program for Children Diagnosed with Autism Spectrum Disorders: A Repeated Case Study Design

(1) Background: ‘Images of Self’ (IOS) is a recently developed and evaluated art therapy program of 15 sessions to reduce difficulties in ‘sense of self’, ‘emotion regulation’, ‘flexibility’, and ‘social behavior’ of children diagnosed with Autism Spectrum Disorders (ASD). In this paper, it is explored whether change in the child’s behaviors corresponds to the therapist’s actions during IOS and 15 weeks later. (2) Method: In a repeated case study design, twelve children and seven therapists participated. Art therapists monitored their own and the children’s behavior by applying two observation instruments: the OAT (Observation of a child with autism in Art Therapy) and EAT (Evaluation of Art Therapist’s behavior when working with a child with autism). Child behaviors during art making were—individually and as a group—compared with therapist’s actions at three moments during the program. (3) Results: Ten of twelve children showed a substantial or moderate positive behavior change considering all OAT subscales at the end of the program and 15 weeks after treatment. Improvement of ‘social behavior’ stood out. Halfway treatment art therapists most prominently showed support of ‘emotion regulation’, ‘flexibility’, and ‘social behavior’. Clear one-on-one relationships between changes in children’s behavior and actions of therapists could not be identified. (4) Conclusion: The study provides new insights in the AT treatment process by monitoring children’s and therapists’ behavior. The art making itself and the art therapy triangle (child, art making, therapist) offer opportunities to improve verbal and nonverbal communication skills of the child.

A Special Class of Experience: Positive Affect Evoked by Music and the Arts

A positive experience in response to a piece of music or a work of art (hence ‘music/art’) has been linked to health and wellbeing outcomes but can often be reported as indescribable (ineffable), creating challenges for research. What do these positive experiences feel like, beyond ‘positive’? How are loved works that evoke profoundly negative emotions explained? To address these questions, two simultaneously occurring classes of experience are proposed: the ‘emotion class’ of experience (ECE) and the positive ‘affect class’ of experience (PACE). ECE consists of conventional, discrete, and communicable emotions with a reasonably well-established lexicon. PACE relates to a more private world of prototypical aesthetic emotions and experiences investigated in positive psychology. After a review of the literature, this paper proposes that PACE consists of physical correlates (tears, racing heart…) and varied amounts of ‘hedonic tone’ (HT), which range from shallow, personal leanings (preference, liking, attraction, etc.) to deep ones that include awe, being-moved, thrills, and wonder. PACE is a separate, simultaneously activated class of experience to ECE. The approach resolves long-standing debates about powerful, positive experiences taking place during negative emotion evocation by music/art. A list of possible terms for describing PACE is proposed.

Emotional Creativity in Art Education: An Exploratory Analysis and Research Trends

The emotions that human beings experience have a key role in the environments in which they operate. In art education, creative processes are influenced by the emotions and experiences lived by the individual, enabling a more emotional and creative design to make life more pleasant. The aim was to examine the research during the period 1917–2020 on the development of emotional creativity in art education. Mathematical and statistical techniques were applied to 984 articles carried from Elsevier’s Scopus database. The findings yielded data on the scientific productivity of the journal, authors, research institutions, and countries/territories that promoted this field. The data showed an exponential trend, mostly in the last decade. Five lines of research stand out: emotion, higher education, education, art, and leadership. Moreover, five future research directions related to visual art education, affective paradigm, metacompetency, expressive arts therapy group, and cognitive empathy were detected. This study establishes the link between psychology, neuroscience, and artistic education to constitute the decision-making of the promoters of this topic of research. The analysis of international research allowed us to focus the future publications of academics and researchers, in addition to guaranteeing an adequate approach to the objectives of the institutions and funding centers.

Drawing on Dialogues in Arts-Based Dynamic Interpersonal Therapy (ADIT) for Complex Depression: A Complex Intervention Development Study Using the Medical Research Council (UK) Phased Guidance

Aim: The aim of this paper is to present the development and evaluation of an art psychotherapy brief treatment method for complex depression for patients referred to mental health services.

Background: Art Psychotherapy literature describes a range of processes of relational change through the use of arts focused and relationship focused interventions. Complex depression has a prevalence of 3% of the population in the West and it is recorded that in 2016 only 28% of that population were receiving psychological treatment. This study was developed to test the hypothesis of whether an accessible and acceptable approach to the treatment of complex depression could be developed in relation to existing evidence-based practice within mental health services.

Method: The United Kingdom Medical Research Council phased guidance for complex intervention development was used (Phases I and II) to develop the intervention. The process included producing a literature overview, systematic description of clinical practice, including a logic model and a clinical protocol. The art psychotherapy protocol described an arts-based dynamic interpersonal therapy approach (ADIT), offered 1:1 over 24 sessions. Further to this the intervention was tested for referrer acceptability. The intervention is in the early stages of evaluation, using changes to the patient's depression and anxiety measured pre- and post-treatment with a follow-up measure at 3 months following completion of treatment.

Results: Phase I of the study provided a good basis for developing a logic model and protocol. The authors found that there was good clinical consensus about the use of a structured clinical art psychotherapy method (ADIT) and the literature overview was used to support specific examples of good practice. The verification of clinical coherence was represented by a logic model and clinical protocol for delivering the intervention. The acceptability study demonstrated very high levels of acceptability for referrers reporting that (i) ADIT was acceptable for patients with complex/major depression, (ii) that they were likely to refer to ADIT in the future (iii) that the use of arts was likely to improve accessibility (iv) the use of arts was likely to improve outcomes and (v) that offering ADIT was an effective use of mental health resources.

Discussion: Phase I of this intervention development study (following MRC guidance) demonstrated theoretical and practice coherence resulting in a clinical protocol and logic model. Whilst Phase II of this study showed promising results, Phase II would need to be sufficiently scaled up to a full trial to further test the intervention and protocol.

Cooperative and Individual Mandala Drawing Have Different Effects on Mindfulness, Spirituality, and Subjective Well-Being

Mandala drawing was first practiced by Tibetan buddhists and then developed by Carl Gustav Jung, who felt certain that mandala drawing has the function of integrating psychological division, enhancing psychological harmony, and preserving personality integrity. Previous studies on mandala drawing have mainly focused on alleviating people’s negative emotions, such as anxiety and depression. Therefore, this study explored the effect and mechanism of mandala drawing on the improvement of subjective well-being (SWB), mindfulness, and spirituality from positive psychology’s viewpoint and compared the different effects of cooperative mandala drawing (CMD) and individual mandala drawing (IMD) on mindfulness, spirituality, and SWB. A total of 76 students were recruited from Chang Gung University, and the aforementioned three main variables were measured before and after the coloring experiment. The results indicated that both CMD and IMD significantly enhanced the subjects’ spirituality. Compared with IMD, CMD has a more significant improvement and promotion effect on SWB of subjects by affecting PA, while IMD had no significant effect on PA, and the enhancement effect of SWB was weaker than that of CMD. Mindfulness, spirituality, and SWB all positively correlated with each other. This study highlights the mechanism of mandala drawing and the theoretical understanding of the relationship between mindfulness and SWB. Mandala drawing especially CMD has a positive effect on spirituality and SWB, which may provide individuals with a simple and easy method to improve their happiness.

Exploring the Effects of Guided vs. Unguided Art Therapy Methods

Art therapy has become known by its psychosocial and affective impact, but not so much by its effects on cognitive functioning. Based on a comparison between art therapy and music-making programs, we hypothesized that guided methods—dominant in music-making programs and characterized by an emphasis on execution (play the piece, produce the visual object) rather than ideation (conceive the visual object)—could boost the cognitive effects of art-making. We also hypothesized that removing ideation from the process with guided methods could decrease psychosocial/affective benefits. In order to test our hypotheses, we compared the effects of two art therapy methods on cognitive vs. psychosocial/affective domains. We implemented a short-term longitudinal study with patients with schizophrenia showing both psychosocial/affective and cognitive deficits. The sample was divided into two groups: unguided, instructed to ideate art pieces and execute them without external guidance, vs. guided, instructed to execute predefined art pieces following externally provided guidelines. There was no evidence that guided methods boost cognitive effects, since these were equivalent across groups. However, psychosocial/affective benefits were enhanced by unguided methods, suggesting that therapeutic methods can make a difference. Our study contributes to raising important new questions concerning the therapeutic mechanisms of art therapy.

The Effectiveness of Art Therapy for Anxiety in Adult Women: A Randomized Controlled Trial

OBJECTIVES

Art therapy (AT) as a treatment option for anxiety is regularly employed in clinical practice, but scientific evidence for its effectiveness is lacking, since this intervention has hardly been studied. The aim was to study the effectiveness of AT on anxiety in adult women. The specific type of AT studied was anthroposophic AT.

METHODS

A RCT comparing AT versus a waiting list (WL) condition on anxiety symptom severity, quality of life, and emotion regulation. Factors influencing treatment outcome were additionally explored. Participants were women, aged 18-65 years, diagnosed with generalized anxiety disorder, social anxiety disorder or panic disorder, with moderate to severe anxiety symptoms. The trial was registered in the Dutch Trial Registration (NTR28143).

RESULTS

Fifty-nine women were included, of which 47 completed the trial. Both per-protocol and intention-to treat analyses demonstrated effectiveness of AT compared to WL, showing a reduction in anxiety, an increase in subjective quality of life (both with large effects) and an improvement in accessibility of emotion regulation strategies (medium effect). Treatment effects remained after 3 months follow-up. Improved acceptance of emotions and improved goal-oriented action are aspects of emotion regulation that are associated with the decrease in anxiety level.

CONCLUSION

AT is effective in reducing anxiety symptoms, improving quality of life and aspects of emotion regulation. Future RCTs should use active controls (treatment as usual) and study cost-effectiveness.

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

Background

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

Methods

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

Results

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

Conclusions

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