Developments in Art Therapy for Mental Health

What Words Can’t Express 

The process of making art, like literature, has long been shown to have mental and emotional health benefits. The APA describes art therapy as a type of psychotherapy that helps provide a way to express emotions and experiences not easily expressed in words.[1] The artist Georgia O’Keeffe said, “I found I could say things with color and shapes that I couldn’t say any other way – things I had no words for.” 

The American Art Therapy Association explains that art therapy includes active art-making, the creative process, and applied psychological theory - within a psychotherapeutic relationship - to enrich the lives of individuals, families, and communities.[2] Furthermore, art therapy is used to foster self-esteem and self-awareness, cultivate emotional resilience, promote insight, enhance social skills and reduce conflicts and distress. Although art therapy has been used to treat a range of mental health disorders including anxiety and depression, this type of therapy is particularly applicable to survivors of trauma because the nonverbal and experiential character of art therapy appears to be an appropriate approach to the often “wordless and visual nature of traumatic memories.”[3]

MechanismS of Art Therapy  

Art therapy engages the mind, body, and spirit in ways that are distinct from verbal communication. In an article published in the Journal of the American Art Therapy Association, Lusebrink 2010 differentiates art therapy from verbal therapies by the use of art media as a means of expression and communication, the multileveled meaning present in visual expressions, and the therapeutic effects of the creative process.[4] In a schematic framework known as the Expressive Therapies Continuum (ETC), three distinct levels (kinesthetic/sensory, perceptual/affective, and cognitive/symbolic) reflect different functions and structures in the brain that process visual and affective information.[5]  

This is particularly useful because the art therapist can first assess the client’s cognitive and emotional functioning through these different ETC levels in order to better address their strengths, challenges, and progress in art therapy. For example, Hendler et al. (2001) found that in individuals with post-traumatic stress disorder (PTSD), affectively-charged visual stimuli activate limbic regions and sensory areas of the cerebral cortex but not the prefrontal area. This is significant, as visual processing within non-PTSD individuals does include the prefrontal cortex which is critically involved in the emergence of conscious visual perception. On the other hand, client areas of strength would constitute a lack of difficulty in processing visual information on particular levels of the ETC. This framework is useful for helping art therapists determine where the “missing links'' are in terms of the sequence of visual information processing. 

These assessments can act as guidelines for starting points, pathways, and goals in art therapy.[6] The range of kinesthetic, sensory, perceptual, and symbolic opportunities also allow clients to practice and create alternative modes of expressive communication, which can help circumvent the limitations of language.[7] 

Art Therapy Sessions 

Though one can always choose to pursue the arts on their own time to calm and relax the mind, formal art therapy sessions are typically carried out by licensed clinicians, master's-level or higher degree holders trained in art and therapy work. Art therapists work with diverse populations in a variety of settings including hospitals, schools, veterans’ clinics, private practice and psychiatric and rehabilitation facilities.[8] One may choose to engage in a private art therapy session or a group setting with other individuals. 

Before beginning, it is important for the therapist to emphasize that the client does not need to be artistically or creatively inclined to benefit from this process. During a typical session, clients will engage in both art-making and meaningful conversation with the therapist.[9] The therapist's main goal is to describe the goal of art therapy, help the client choose an appropriate medium for expression (e.g., collage, painting, sculpture, drawing), and prompt the client with questions which will shape and guide the art making session. At the conclusion of the session, the therapist and client will debrief. To make sense of the process, they may collaboratively discuss any emotions and feelings that arose during the art making process, the work of art itself and its potential meanings, as well as plans for future sessions.[10] 

Applications for Addressing Trauma 

Art therapy has historically been used to address and treat trauma for a variety of reasons. Art is an effective means of expressing past trauma from a safe environment; it provides emotional distance from the actual event and provides an alternative outlet to confront unresolved trauma memories through the use of symbols and visual media. Additionally, PTSD UK notes how new research has found that art therapy fosters a mind-body connectedness and allows the brain to use mental and visual imagery.[11]

In 2016, Campbell et al. (2016) conducted research to examine the impact of art therapy on those with combat-related PTSD. They administered a series of art therapy sessions in which participants engaged in creating a visual trauma narrative, mapping representations of their emotions, making images of the self before and after the trauma and creating final reflective art pieces. Results from a depression scale score showed that although not statistically significantly different, a trend toward greater reduction in depression symptoms for the test group compared to the control was noted.[12] Although these quantitative measures did not show statistical significance, a more recent study by Berberian et al. (2019) examined the qualitative outcomes of art therapy, or more specifically, montage painting, for active-duty military service members with traumatic brain injuries or PTSD. They found that group art therapy elicited improvement in interpersonal relatedness, as well as the expression of hopefulness and gratification. Art therapy allowed the individuals to work toward creating an individual trauma narrative which is a key component for recovery and healing.[13]

Aside from veterans and active-duty military service members, PTSD within children and early relational trauma has also been addressed through art therapy. Individuals who have experienced trauma at a young age show increased levels of suicide, alcohol addiction, and/or drug addiction later in life, thus art therapy is especially valuable as an early intervention for children who have been exposed to trauma in a variety of contexts and in different forms (e.g., witnessed or experienced gang violence, bullying, loss and grief, domestic abuse, suicide, homelessness, and drug abuse).[14] A study conducted by Woollett et al. (2020) invited school-aged children and their mothers in domestic violence shelters to participate in a pilot study aiming to integrate trauma-informed art and play therapy with traditional cognitive behavioral therapy (CBT). From baseline levels, children's depressive symptoms showed significant reduction and improvement in PTSD symptoms.[15] 

Another specific context which art therapy has been applied to is early relational trauma. This type of trauma is distinct from post-traumatic stress disorder in its emphasis on childhood abuse, various forms of neglect, and other neurological effects that occur during a specific time period when the developing brain was exposed to prolonged trauma.[16] Art therapy can be particularly helpful for early relational trauma clients who exhibit anger and frustration as they struggle to confront and articulate their emotions. The art they make is a non-verbal activity that reflects, mirrors and amplifies expression of the client's internal state of affects. A study by Chong (2015) presented a collection of clinical vignettes in which she notes that school-aged children with early relational trauma showed improvement in dimensions such as confidence, attention span, and the formation of positive relationships in school settings.[17]

Within communities of all ages and backgrounds, art therapy is a flexible, effective and low-intensity intervention for individuals dealing with trauma which can cultivate a greater sense of creativity, empowerment, and independence while fostering a healthy psychosocial relationship with themselves and others.[18] 

If you or someone you know would like to learn more about art therapy and how to incorporate it into your own life, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for additional guidance and support.  

Contributed by: Kaylin Ong

Editor: Jennifer (Ghahari) Smith, Ph.D.

References 

1 (2020, January 30). Healing Through Art - APA Blogs - Patients and Families. American Psychiatric Association. https://www.psychiatry.org/news-room/apa-blogs/healing-through-art#:~:text=Art%20therapy%2C%20a%20type%20of,the%20process%20of%20making%20art 

2 American Art Therapy Association. (2014). American Art Therapy Association. https://arttherapy.org/ 

3 Schouten, K. A., van Hooren, S., Knipscheer, J. W., Kleber, R. J., & Hutschemaekers, G. J. M. (2018). Trauma-Focused Art Therapy in the Treatment of Posttraumatic Stress Disorder: A Pilot Study. Journal of Trauma & Dissociation, 20(1), 114–130. https://doi.org/10.1080/15299732.2018.1502712 

4 Lusebrink, V. B. (2010). Assessment and Therapeutic Application of the Expressive Therapies Continuum: Implications for Brain Structures and Functions. Art Therapy, 27(4), 168–177. https://doi.org/10.1080/07421656.2010.10129380

5 Expressive Therapies Continuum: Three-Part Healing Harmony | Psychology Today. (December 30, 2018). Www.psychologytoday.com. https://www.psychologytoday.com/us/blog/arts-and-health/201812/expressive-therapies-continuum-three-part-healing-harmony 

6 Lusebrink (2010) 

7 American Art Therapy Association 

8 Ibid. 

9 Homepage - The British Association Of Art Therapists. (2022, September 26). The British Association of Art Therapists; BAAT. https://baat.org/ 

10 What Is Art Therapy? | Psychology.org. (2022, February 15). Www.psychology.org. https://www.psychology.org/resources/what-is-art-therapy/#:~:text=During%20a%20session%2C%20an%20art 

11 How art therapy has helped those with PTSD – PTSD UK. (n.d.). https://www.ptsduk.org/how-art-therapy-has-helped-those-with-ptsd/ 

12 Campbell, M., Decker, K. P., Kruk, K., & Deaver, S. P. (2016). Art Therapy and Cognitive Processing Therapy for Combat-Related PTSD: A Randomized Controlled Trial. Art Therapy, 33(4), 169–177. https://doi.org/10.1080/07421656.2016.1226643 

13 Berberian, M., Walker, M. S., & Kaimal, G. (2018). “Master My Demons”: art therapy montage paintings by active-duty military service members with traumatic brain injury and post-traumatic stress. Medical Humanities, 45(4), 353–360. https://doi.org/10.1136/medhum-2018-011493 

14 Helping Kids Cope with Trauma. (October 20, 2017). Cedars-Sinai. https://www.cedars-sinai.org/blog/art-therapy-helps-children-cope-with-trauma.html#:~:text=Art%20therapy%20teaches%20kids%20how 

15 Woollett, N., Bandeira, M., & Hatcher, A. (2020). Trauma-informed art and play therapy: Pilot study outcomes for children and mothers in domestic violence shelters in the United States and South Africa. Child Abuse & Neglect, 107(1), 104564. https://doi.org/10.1016/j.chiabu.2020.104564 

16 Terradas, M. M., Poulin-Latulippe, D., Paradis, D., & Didier, O. (2020). Impact of early relational trauma on children’s mentalizing capacity and play: A clinical illustration. European Journal of Trauma & Dissociation, 100160. https://doi.org/10.1016/j.ejtd.2020.100160 

17 Chong, C. Y. J. (2015). Why art psychotherapy? Through the lens of interpersonal neurobiology: The distinctive role of art psychotherapy intervention for clients with early relational trauma. International Journal of Art Therapy, 20(3), 118–126. https://doi.org/10.1080/17454832.2015.1079727 

18 Boyadjis, A. (2019). Healing the Child Through Expressive Arts Therapy. https://minds.wisconsin.edu/bitstream/handle/1793/79197/Boyadjis%2C%20Andrea%20Thesis%202019%20compiled.pdf?sequence=1&isAllowed=y 

Stress Management for Students: Unveiling Coping Strategies & Creative Outlets

Adverse Effects of Stress

Stress is a feeling that most people experience at some point in their life. Students are especially prone to experiencing the negative effects of stress when they feel overworked, sleep deprived and overwhelmed. Symptoms of stress are demonstrated in our bodies, mental state, mood and behavior and have a prominent effect on our day-to-day lives. 

The Mayo Clinic notes that symptoms of stress can manifest in a variety of ways, such as:[1]

• Body - headache, fatigue, sleep problems

• Mood - anxiety, irritability, lack of focus/motivation, depression

• Behavior - over/undereating, angry outbursts, drug/alcohol misuse, social withdrawal 

It is important to be able to recognize the symptoms of stress in order to effectively manage the cause.[2] 

Common Stressors

Students encounter a number of ongoing stressors, which involve the typical day-to-day challenges they face. Both high school and college students commonly report experiencing continuous stress related to their education, specifically academic-related stress. Pascoe and Parker (2020) found that this stress stems from factors such as the pressure to achieve high grades and concerns about receiving poor marks.[3] A 2017 survey conducted by the Organisation for Economic Co-operation and Development (OECD) across 72 countries involving 540,000 student respondents aged 15-16 revealed that, on average, 66% of students feel stressed about receiving low grades and 59% worry that tests will be difficult. Additionally, the survey found that 55% of students experience high levels of anxiety regarding school testing, even when adequately prepared. Furthermore, 37% of students reported feeling “highly tense” while studying.[4] 

With the prominence of social media in the lives of today’s students, news and world events are more readily available, thus providing additional stress in the lives of students. Information about politics, school shootings, and war are readily available, adding additional stress in their lives as they perceive the world they live in as “unsafe.”[5] Additionally, media can push unhealthy and unrealistic body images as well as idealistic lifestyle expectations on young minds, warping their sense of reality and leaving them feeling inadequate in comparison. While it is important for students to be informed, today’s teens have much more information at their fingertips than ever before, thereby exacerbating their stress. Since the many pressures and events that incite feelings of stress often cannot be avoided, people engage in utilizing coping mechanisms; however, not all coping mechanisms are healthy.[6] 

Unhealthy Coping Methods

As stress levels continue to rise in student populations, a number of unhealthy coping mechanisms have become increasingly popular. Harvard Health (2012) notes that some common methods of dealing with stress involve doing activities that help one put aside their worries for some time (e.g., constantly sleeping, binge-watching television, alcohol consumption and taking illegal drugs.[7] New York University (2015) found that alcohol and marijuana were common relaxers utilized by students for temporary relief from the daily pressures in their lives.[8] Additionally, temporary relief tends to be found through over- or under-eating, smoking, and engaging in a whirlwind of social activities in an attempt to avoid facing their problems. Unfortunately, a buildup of stress can lead to a person lashing out at others and increased violent behavior. On the surface, these coping mechanisms may seem to offer relief; however, many of these actions are not effective at relieving pressure and can actually exacerbate the stress one already feels to a higher degree. Fortunately, there are a number of creative methods of coping with stress that have a positive effect on students.[9]

Effective and Creative Outlets

Art

Art can be used to mitigate feelings of stress and anxiety. Specifically, art therapy is a type of psychological intervention that utilizes various artistic mediums and the individual's creative expression to facilitate the therapeutic exploration and comprehension of emotions – ultimately resulting in the creation of artwork. It is both a natural and enjoyable way for students to manage their stress.[10] Research conducted by Zaidel (2014) on the influence of art and active creativity on the brain indicates that patients who engage in newly discovered creative outlets often experience elevated dopamine levels. Dopamine, a neurotransmitter frequently depleted in individuals suffering from anxiety, depression, and excessive stress, tends to increase through the practice of art therapy. As a result, art therapy emerges as a beneficial option for individuals dealing with high stress levels, as it can effectively raise dopamine levels and promote a sense of happiness and well-being in patients.[11]

Music

Another effective outlet for stress is music. Listening to music offers a stress-reducing effect by influencing both the hypothalamic-pituitary-adrenal axis and the autonomic nervous system. A study published by the Cambridge University Press (2021) indicates that music demonstrated a decrease in cortisol levels (a well-known biomarker of stress) and a reduction in sympathetic activity (reflected in lower heart rate and blood pressure).[12] 

Different compositional elements of music (e.g., melody, rhythm, tonality and frequency) seem to influence individual relaxation responses. While most studies have used classical music, these effects have been observed across various music genres. High-frequency music, particularly at 528 Hz, appears to play a significant role in stress relief. Lata and Kourtesis (2021) note that music with this frequency can lower cortisol levels and increase oxytocin levels, regulating stress response and social bonding.[13] 

Meditation

Meditative practices can also relieve stress experienced by students. The Mayo Clinic describes meditation as a simple and inexpensive method of relaxation that doesn’t involve any materials or equipment to participate. Meditation is classified as a form of complementary medicine that involves the connection between the mind and body. By engaging in meditation, individuals can achieve a profound sense of relaxation and cultivate a calm state of mind.[14] During meditation, one directs their attention to clearing away the influx of chaotic thoughts that often clutter the mind and contribute to stress. This practice has the potential to improve both physical and emotional well-being, fostering a sense of overall balance and tranquility. Meditation can serve as a tool for relaxation and stress management by redirecting one’s focus towards calming elements. Through meditation, one can develop the ability to maintain inner peace and a centered state of mind.[15] 

Furthermore, the benefits of meditation extend beyond the duration of the practice, itself. It can help individuals navigate their daily lives with a greater sense of composure. Yoga is a well known form of meditation utilized to cultivate both physical flexibility and mental tranquility through a sequence of poses and controlled breathing exercises. By engaging in specific postures that demand balance and concentration, attention is redirected away from the demands of a stressful day and towards the present moment.[16]

Exercise

Medical professionals consistently encourage maintaining an active lifestyle as the positive effects of physical exercise have been widely recognized (e.g., improving physical health and combating illness). Exercise is also regarded as essential for preserving mental well-being and can alleviate stress. The Anxiety and Depression Association of America (2022) notes that exercise has significant efficacy in reducing fatigue, enhancing alertness and focus, and improving overall cognitive function.[17] This research is supported by a 2015 study conducted van der Zwan et al., which compared a number of stress intervention methods and indicated physical activity was effective in reducing stress in the sample group.[18] This can be particularly beneficial when stress has depleted one's energy or ability to concentrate. When stress impacts the brain, affecting its numerous neural connections, the rest of the body experiences the repercussions as well. Exercise and other forms of physical activity stimulate the production of endorphins(a natural pain-relieving chemical in the brain) and also contribute to improved sleep, subsequently reducing stress levels.[19]

Psychotherapy

If creative outlets for stress reduction are not enough to mitigate the extreme levels of stress one is experiencing, psychotherapy can be used alongside or in place of creative outlets for stress reduction. Psychotherapy, also known as talk therapy, encompasses a range of therapeutic approaches designed to assist individuals in recognizing and modifying distressing emotions, thoughts and behaviors.[20] People often turn to psychotherapy when coping with intense or prolonged stress caused by work or family circumstances, the bereavement of a loved one, or challenges within relationships or family dynamics. Various forms of psychotherapy and interventions have demonstrated efficacy in addressing mental health disorders. Frequently, the treatment approach is customized to suit the particular case someone is experiencing. This involves identifying techniques for managing stress and formulating targeted problem-solving strategies.[21] 

There are a number of evidence-based approaches in psychotherapy that aid in dealing with stress:

• Cognitive Behavioral Therapy (CBT)

• Acceptance and Commitment Therapy (ACT)

• Mindfulness-Based Stress Reduction (MBSR) 

Both CBT and ACT are evidence-based psychotherapies utilized to help people manage symptoms of stress. CBT places greater emphasis on modifying or rectifying one's negative thoughts in order to relieve distress while ACT focuses more on transforming the way our personal experiences (e.g. thoughts, emotions, memories, and physical reactions) function and increasing our psychological flexibility, so that they no longer have a hold on us.[22,23] MBSR utilizes meditation principles to assist individuals in developing a heightened awareness of the influence negative thoughts have on their physical sensations.[24]

While beneficial for students, any of the afore-mentioned creative outlets and therapies can be useful for the general population experiencing stress, as well.

If you or someone you know is experiencing extreme stress and/or anxiety, please reach out to a licensed mental health professional (e.g., a psychotherapist, psychologist or psychiatrist) for guidance and support.

Contributed by: Ananya Kumar

Editor: Jennifer (Ghahari) Smith, Ph.D.

References

1 Mayo Foundation for Medical Education and Research. (2021). How Stress Affects Your Body and Behavior. Mayo Clinic. https://www.mayoclinic.org/healthy-lifestyle/stress-management/in-depth/stress-symptoms/art-20050987  

2 Ibid.

3 Michaela C. Pascoe, Sarah E. Hetrick & Alexandra G. Parker (2020) The impact of stress on students in secondary school and higher education, International Journal of Adolescence and Youth, 25:1, 104-112, DOI: 10.1080/02673843.2019.1596823

4 Ibid.

5 Simmons, A. (2019). As Teen Stress Increases, Teachers Look for Answers. Edutopia. https://www.edutopia.org/article/teen-stress-increases-teachers-look-answers/ 

6 Columbia University. (2021). Is social media threatening teens’ mental health and well-being? Columbia University Irving Medical Center. https://www.cuimc.columbia.edu/news/social-media-threatening-teens-mental-health-and-well-being 

7 The President and Fellows of Harvard College. (2012, August 4). Watch Out for Unhealthy Responses to Stress. Harvard Health. https://www.health.harvard.edu/healthbeat/watch-out-for-unhealthy-responses-to-stress 

8 New York University. (2015). NYU study examines top high school students’ stress and coping mechanisms. NYU. https://www.nyu.edu/about/news-publications/news/2015/august/nyu-study-examines-top-high-school-students-stress-and-coping-mechanisms.html

9 Harvard Health

10 Sage Neuroscience Center. (2021, July 27). How Art Can Help Relieve Stress. Sage Neuroscience Center. https://sageclinic.org/blog/art-relieve-stress/#:~:text=How%20Can%20Drawing%20and%20Painting,%2C%20depression%2C%20and%20excessive%20stress  

11 Zaidel DW. Creativity, brain, and art: biological and neurological considerations. Front Hum Neurosci. 2014 Jun 2;8:389. doi: 10.3389/fnhum.2014.00389. PMID: 24917807; PMCID: PMC4041074.

12 Lata, F., & Kourtesis, I. (2021). Listening to music as a stress management tool. European Psychiatry, 64(S1), S609-S609. doi:10.1192/j.eurpsy.2021.1621

13 Ibid.

14 Mayo Clinic. (2022). Meditation: A simple, fast way to reduce stress. Mayo Foundation for Medical Education and Research (MFMER). 

https://www.mayoclinic.org/tests-procedures/meditation/in-depth/meditation/art-20045858

15 Ibid.

16 Ibid.

17 Anxiety and Depression Association of America. (2022). Physical Activity Reduces Stress. ADAA. https://adaa.org/understanding-anxiety/related-illnesses/other-related-conditions/stress/physical-activity-reduces-st#:~:text=Exercise%20and%20other%20physical%20activity,your%20body%20to%20produce%20endorphins.

18 van der Zwan, J.E., de Vente, W., Huizink, A.C. et al. Physical Activity, Mindfulness Meditation, or Heart Rate Variability Biofeedback for Stress Reduction: A Randomized Controlled Trial. Appl Psychophysiol Biofeedback 40, 257–268 (2015). https://doi.org/10.1007/s10484-015-9293-x

19 Anxiety and Depression Association of America

20 U.S. Department of Health and Human Services. (2023). Psychotherapies. National Institute of Mental Health. https://www.nimh.nih.gov/health/topics/psychotherapies  

21 Ibid.

22 Guarna, J. (n.d.). Comparing ACT and CBT. Association for Contextual Behavioral Science. https://contextualscience.org/comparing_act_and_cbt#

23 Wersebe H, Lieb R, Meyer AH, Hofer P, Gloster AT. The link between stress, well-being, and psychological flexibility during an Acceptance and Commitment Therapy self-help intervention. Int J Clin Health Psychol. 2018 Jan-Apr;18(1):60-68. doi: 10.1016/j.ijchp.2017.09.002. Epub 2017 Oct 17. PMID: 30487911; PMCID: PMC6220909.

24 Johns Hopkins Medicine. (2023) Stress Busters: 4 Integrative Treatments. The Johns Hopkins University. https://www.hopkinsmedicine.org/health/wellness-and-prevention/stress-busters-4-integrative-treatments