Art therapy’s research progress in depression: a literature review

Jiayun Zheng

Faculty of Science, University of Pécs, Pécs, Hungary

angeladanwan@ldy.edu.rs

Abstract. Depression seriously affects the overall well-being of patients, and it causes great suffering and pain. Around 5 to 10 percent of the population globally experience depression. Within this population, the prevalence of depression in women is approximately 1.5 to 2 times higher than men and about 50% of older adults above 65 years old suffer from depression than young adults. A creative form of psychotherapy — art therapy, specifically drawing and painting therapy, allows depressive patients to gain insights about their feelings, promoting healing in a harmless way. This article reviewed the benefits of art therapy in treating depressive patients based on past research. The review divides the patients into different age groups and sexes: elderly, children, adults, male, and female. It indicates that art therapy can be performed successfully across different age groups and sexes, bringing varieties of personalized benefits, especially for children, women, and elders. Some common benefits include increased self-esteem, change of perspective, and growth in mentalities.

Keywords: Art therapy, depression, drawing, painting.

1 Introduction

Depression is a mental illness that causes losing of interests in daily activities. Patients usually feel constant sadness, loneliness, and hopelessness. Indifference and inadequate treatment of depression may lead to increased incidence of suicide. More than 264 million people of all ages suffer from depression globally and the number continues to increase. Common treatment for depression includes consuming antidepressant and psychotherapy. While the actual value of antidepressant is still under debate, it is most likely that patients could experience withdrawal and addiction [1]. Psychotherapy may relatively be a better option, but 40% of patients in traditional psychotherapy break off in early stages consultation [2], the reason for that could be that different patients need different kinds of intervention [3]. A new form of psychotherapy, art therapy on the other hand, is highly responsive to patients’ needs, and it has no medical side effects like antidepressants.

Art therapy is a form of psychotherapy that uses art media as its primary mode of expression and communication. It is claimed to give better results than pharmacology or verbal psychotherapy [4]. About 84% of publications on art therapy refers to painting and drawing, while the remaining activities could be music, crafting etc. Thus, this review only focuses on painting and drawing, and aims to showcase benefits of art therapy in different age groups, sex differences, group therapy and individual therapy into the process of art therapy.

2 Art therapy in different age groups

2.1 Elderly

With the increase in age, elders tend to be more aware of the inexorability of death, they are more likely to ponder the meaning of their life excessively and this may lead to depression. Art therapy can help in expressing the thoughts that cannot be said verbally in artworks, addressing topics such as fear of death and sickness, loneliness, increasing self-esteem. With art therapy, patients gain insights of their problems and enable the change of perspectives viewing realities.

Positive effects and improves on elderly women’s depression were shown in a study of elderly women with major depressive disorder stable on pharmacotherapy [5]. In each session of the study, there were four parts, which are welcoming, guided imagery, artistic output, and verbal expression [5]. During artistic output, the topic “sense of loss” was worked through by having participants stop while their artworks were still unfinished and switching works with another participant. “Difficulty in dealing with difficult situations” was worked through by providing participants with rocks, which they were instructed to “place in a more beautiful context” within their artworks, thus helping them change their outlook on the situation [5]. The results support the claim that the changes in symptoms are similar to other psychotherapy, such as life review therapy, interpersonal therapy, depression management therapy [6]. This suggests that art therapy can have combinations of positive effects resembling that of other types of psychotherapy, which means art therapy could possibly be practised in treating the illness symptoms in all of the psychotherapy mentioned.

Depression in elderly usually comes with cognitive impairment, art therapy enables them to express non-verbal parts of themselves. Through the process of mandara drawing, drawing took turns, art therapy in elders reduces the resistance in revealing and helps formulate a positive self-image [7].

Ching-Teng, Y.et al [8], showed that art therapy increases self-esteem of elderly and therefore mitigates depression severity. It is also important to notice participants' improvement in interpersonal skills during group therapy. This reduces the elders' level of loneliness and acquiring this skill enables them to make new friends. Thus, maybe art therapy in groups may have a better result than individual therapy. With that being said, implementing art therapy in nursing homes as a long-term activity will increase the overall quality of life, especially psychologically, of the elders.

2.2 Children

Art therapy is beneficial to children. First, most children are not as expressive as adults, they can not convey what they feel inside most of the times, repressing those feelings can lead to mental illness such as depression; second, art is helpful tool in children’s development when it comes to resolving attachment issues, developing personality, and finding their places to fit in the society. Art therapy can increase communication skills, providing a safe creative space to express the unconscious, and also builds children’s self-esteem and socialisation skills, all of those elements mentioned improves overall well being of children and reduces risks of depression.

When kids drawing on paper, they can express their feelings such as anger, anxiety, sadness. Simple activity such as doodling with colour can help in creativity, anxiety releasing, and stimulate feelings [9]. The art work’s meaning is conveyed unrealised by the children, and their inner world can be interpreted by professionals. The experiential means of art therapy can also explore the relational state of the children which exists before words take over, allowing forming of new patterns in their brain [10]. This can be done because the relationship between the children and the art medium is similar to attachment theory, and this can offer a secure attachment to children, bridging a safe bond with the therapist [11]. However, more research on children with depression are needed, barely any of the research solely focused on depression but they focused on mental illness in general instead.

2.3 Adult

The benefit in elders and children can also be observed in the remaining adult populations. Drapeau, M.-C., & Kronish, N.[12] observed that a depressive patient’s artwork changed from a more splited line work into much refined art piece. Since artwork expression is linked to our subconscious, the change in art style may indicate that this patient’s inner world is integrated by art therapy sessions. It is through art that a patient can express the unspoken symbolic into some symbol, and the therapist may interpret it. This leads to self-acceptance and better awareness of problems.

Benefits such as improved interpersonal communication, increased assertiveness, greater appreciation of loss and hope repetitively occur in studies of art therapy in depressive adults. A heterogeneous sample of adult depressive patients participated in group therapy [13]. Their results indicate that symptoms significantly improved after 4 to 8 weeks of art therapy, using standardised depression scale. The procedure involves 60 mins of art-making and 30 mins of group discussion. However, Drapeau, M.-C. and Kronish, N. [12] assessed the patients over a period of 12 weeks compared to this experiment which assessed for only 4 to 8 sessions. The duration is shorter because the sample in this study consisted of only non-chronic patients, that is, they experience quicker improvement with art therapy and the benefit may be more pronounced. Therefore, we need to consider the chronic level of the patient while practising art therapy in depression.

In another study of a small sample of 5 depressive adults, positive results such as acceptance of depression, increasing awareness of self and others, and readiness to build new relationships were observed through interviewing the patients [14]. The patients completed the questionnaires on 3 topics, the intensity of the depression, levels of anxiety, and general wellbeing. The assessment showed immediate improvement, this may be the sample patients included mild to moderate depression. Therefore, we may observe that the less severe the depression, the quicker the improvement of depressive symptoms in adults.

3 Art therapy in different sexes

Women with depression are more sensitive to external factors such as interpersonal relations and family issues, they are more likely to express their feelings than men, because men are socially conditioned to stay more stoic. Differences in emotion expression based on sex was studied in children’s drawings. Girls scored higher on emotional expression tasks and were likely to combine literal and metaphorical expression than boys[15]. Because women are sensitive to external relations, and on top of that more expressive when drawing, they have wider range for change than male in art therapy.

Art therapy prison shows that depressive male focus more on the end result of the art piece due to their competitive nature, whilst depressive women get satisfaction simply from socialisation with other group members, empathising with them, and catalysing the discussion further [16]. In the initial sessions, women tend to say self-deprecating things, while men express anger towards each other. Negative depressive symptoms in women are more internalised such as worthlessness, sadness, and externalised in men, such as irritability, aggression. As the therapy progressed, both genders improved in communication, understanding individual responsibility and contribution relative to the group. However, women showed an increase in internal locus of control, that is they no longer seek validation and pity from other group members externally, but rather develop them internally. This means that art therapy may be more beneficial and suited for women compared to men, since their drawings are more emotionally expressive, and they are more sensitive to external environments.

When comparing color usage and sex differences, older males use color less frequently than younger males, both older and younger females use color equally, suggesting that as male approach puberty they tend to inhibit their emotional response [17]. Art therapy can help in emotion regulation immediately in the first 15 minutes of a session [18]. More research is needed on selecting emotional unresponsive male and apply the ‘15 minutes method’ mentioned to gain more insights.

4 Group and Individual art therapy

Though none of the articles has done any experiment comparing, we can still conclude some challenges and benefits. In the interview with depressive patients, they have mentioned stress in sharing and discussing their drawings with fellow group members, it was distressing sharing deep, painful part of self to strangers in group, however, it was the most valued and memorable part of the therapy and indeed increased their willingness to open up, realising others could be helpful. Patients may be afraid of others' judgement of their artwork. Group therapy also increases socialization and communication skills, as art therapy involves speaking and listening with the therapist and group members. Bonding with other people could also make depressed patients feel less alone whilst individual therapy may be prefered by patients expecting a safe space with one to one interactions. The most commonly beneficial art therapy settings may be giving each patient individual focus in group settings.

5 Neurological insight

Bridging the gap between art therapy and the brain may bring more effective and beneficial results. Combinational use of MoBI and Expressive Therapies Continuum (ETC) can complement each other in the process of art therapy. MoBI, a technology which shows real time interaction between the brain and body. It is useful in examining the brain dynamics and motor behaviours that are associated with the higher complex processes involved in artistic expression [19]. The ETC model explains how the brain processes information when different art media is used [20]. More research is needed examining them working together, which will possibly provide more measurable data and framework on personalising the art therapy.

6 Limitations and difficulty

Firstly, the interpretation of artwork by the art therapist is subjective, there is no standard dictionary sort of thing for understanding the metaphor and symbolism, it solely depends on the experience level of the therapist and explanation from the patient. Secondly, more research is needed across different populations. The studies of male and female articles were mostly subjects in prison, future research on different groups of people would provide more insights. Thirdly, it is unclear in some research whether the benefit was caused by only drawing and painting or art therapy in general.

Difficulty patients face may be doubting the meaning of therapy during the initial stage, so if initially patients do not connect and show no interest in this artistic approach, it is hard to maintain consistency. Patients may stress over spontaneous drawing or be unconfident in their artistic ability, therefore it is important to let them feel unhinged and realise the goal is not producing the best art but the process of creating.

7 Conclusion

Art therapy encourages self-exploration, self-expression, communication, understanding and explanation, integration, and symbolic thinking [21]. All of those elements can target the IFC score tests of depression [20]. This means it can meet patients ' needs better, compared to other traditional psychotherapy. Personalization of treatment further may require use of MoBI and ETC. On top of that, its creative and interesting approach is suitable to patients across all age and gender populations. Producing similar positive effects, such as increasing self-esteem, changes of perspective, growth in mentality, and regulation of emotion.

In conclusion, art therapy is a beneficial treatment option for depression. It is safer than medication and more engaging than traditional therapy. In future studies, we can dive deep into correlating specific depressive symptoms with specific art procedures. More research is needed studying different types of people struggling with depression that are caused by diseases, war, trauma. Multidisciplinary studies with neuroaesthetic may provide more scientific insight in the process.