This chapter aims to provide an overview of the evidence for service user and service provider perspectives on the acceptability, relative benefits and potential harms of art therapy for people with non-psychotic mental health disorders.
Review methods
Bibliographic database searching
As the searches for the clinical effectiveness were comprehensive for art therapy literature, the same database was used for both the quantitative and qualitative reviews (see Chapter 2, Literature search methods).
Screening and eligibility
All abstracts, and then full papers, were read by two reviewers (AS and LU) who made independent decisions regarding inclusion or exclusion, and consensus, where possible, was obtained by meeting to compare decisions. In the event of disagreement, a third reviewer (EK) read the paper and made the decision. Study types included were:
qualitative research reporting the perspectives and attitudes of people with non-psychotic mental health disorders who have received art therapy in order to examine issues of acceptability
qualitative data embedded in trial reports or in accompanying process evaluations, to inform an understanding of how issues of acceptability are likely to affect the clinical effectiveness of art therapy
qualitative data either from separately conceived research or embedded within quantitative study reports, reporting the acceptability of art therapy to health care practitioners.
The inclusion and exclusion criteria for the qualitative review are reported in . Studies in all settings were included, although the community was the main setting of interest.
Eligibility criteria for the qualitative review.
Quality assessment strategy
Studies meeting the inclusion criteria were evaluated by two reviewers using the CerQual approach. CerQual (certainty of the qualitative evidence67) aims to assess how much certainty can be placed in the qualitative evidence for the review finding, or, in other words, how reliable the review finding is. This approach relies on assessing both the methodological quality of the individual included studies and the coherence of the review finding as defined by the extent to which a clear pattern across the individual study data is identifiable.
To assess methodological quality individual studies were appraised using an abbreviated version of the CASP quality assessment tool for qualitative studies.68
Two reviewers (AS and LU) independently applied the set of quality criteria to each included study. In the event of a disagreement, a third reviewer (EK) was consulted. Studies were included in the review regardless of study quality.
Whereas study quality applies to each individual included study, ‘coherence’ relates to the review finding which is subsequently developed through the synthesis of the individual studies. Therefore, the coherence of each review finding was then assessed by looking at the extent to which a clear pattern across the data was identified and was contributed by each individual study. This was assessed by looking to see if the review finding was consistent across multiple contexts and if the review finding incorporated explanations for any variation across individual studies. Coherence was further strengthened when the individual studies contributing to the finding were drawn from a wide range of settings. Using the assessment of methodological quality and assessment of coherence together, the certainty of each review finding was rated as high, moderate or low.
Data extraction strategy
Data extraction from included qualitative studies was undertaken independently by AS using a data extraction tool adapted and tailored for the precise purpose of the qualitative review. All data extractions were checked by LU, with any discrepancies being discussed by both data extractors. Where data for included studies were missing, reviewers attempted to contact the authors at their last known e-mail addresses.
For the purpose of data extraction, two principal approaches to decide what counts as qualitative evidence have been proposed.69 In the first, only data from primary studies which are illustrated by a direct quotation from the respondent are extracted, whereas in the second all qualitative data identified in the primary studies and relevant to the review question are extracted. Given the anticipated paucity of evidence, the latter, more inclusive, approach to data type was adopted, together with a selective approach to extract data relevant to the specific research question. A framework for extraction was developed which focused specifically on data relating to the review question, including how art therapy helped (relative benefits); how art therapy was unhelpful (potential harms); neutral effects (neither benefits or harms); barriers to participation [acceptability (a)]; and recommendations for service delivery [acceptability (b)] from patients and health practitioners. illustrates the data extraction elements.
Data extraction elements from the qualitative review
Data synthesis strategy
Qualitative meta-synthesis was undertaken to provide added value to the quantitative analysis by indicating patient issues around the acceptability of art therapy as a treatment for non-psychotic mental health disorders. Specifically, thematic synthesis was used to aggregate the findings.70 The framework developed for data extraction was used to shape the synthesis of the findings.
Combining the quantitative and qualitative data
Methodological work to date has been unable to establish the superiority of conducting the qualitative and quantitative synthesis in parallel or of conducting quantitative followed by qualitative, qualitative followed by quantitative or some more iterative approach. Our choice of method of combining data was determined by the needs of this particular review, in which the quantitative data were the main focus and the qualitative data were used for their explanatory potential. We, therefore, employ methods similar to those described by Noyes et al.71 to explore the effectiveness review in the light of supporting qualitative research data.
Results of the qualitative review
Included studies: qualitative review
From the 10,270 citations identified from the initial searches (see Chapter 2), 290 were considered following abstract sift and 42 papers were considered at full paper sift for the qualitative review. shows the flow chart of studies included in the qualitative review. The sifting process resulted in the inclusion of 12 studies (13 sources) at full paper sift. All included full papers were published between 2002 and 2013 (although one study was an unpublished manuscript linked to a published abstract within this time scale72). Two were theses,73,74 and one of these had an associated peer-reviewed paper75 which reported the same study.
Preferred reporting items for systematic reviews and meta-analyses (PRISMA) flow chart of studies included in the qualitative review.
Study respondents
Eleven studies assessed patients’ attitudes and two studies assessed health practitioner attitudes to the intervention [general practitioners (GPs) = 1; art therapists = 1]. The studies contained qualitative data from 188 patients and 16 health practitioners. The primary diagnoses of the patient populations studied included cancer (n = 6), depression/anxiety/stress (n = 3), PTSD (n = 1) and obesity (n = 1). The symptoms being treated by art therapy included depression, stress, anxiety, psychological distress, low self-esteem, fatigue and fear.
Six studies did not report the age of the participants. Where age range was reported,73,76–78 ages ranged from 26 to 82 years. Five studies77,81–84 did not report the gender of the participants. In four studies,72,73,76,78 all participants were female, while one study79 included 69 men and 88 women and a final study80 included four women and one man.
Study setting
Three studies80–82 were conducted in the UK. One of these studies82 provided data from patients and the other from GPs who referred patients to art therapy.81 Four studies73,74,78,83 were conducted in the USA, with one of these studies73 also including participants from Canada. Three of these studies73,78,83 provided data from patients and the final study74 provided data from art therapists. The remaining five studies were conducted in European countries, Sweden,76 Germany,77 France,72 Italy79 and Switzerland,84 and provided data from patients.
In seven studies,72,74,76,77,79,82,84 the art therapy took place in secondary care; one study81 took place in primary care and one study78 took place in a state correctional facility (USA). In another study73 participants had taken part in art therapy in varied settings including secondary care and private sessions. The setting was not reported in two studies.80,83
Intervention description
The reporting of the art therapy intervention was limited in a number of cases. One study81 did not report any details of the intervention, and two studies73,80 reported on perceptions of patients who had taken part in a variety of different interventions, although details of each were not reported. Of the remaining eight studies assessing patient views of art therapy, in four studies77,82,83,84 the art therapy had been conducted in a group, with group sizes ranging from four to nine participants, while three studies76,78,79 reported on individual sessions; in one study,72 the format was not reported. In six studies72,76,79,82–4 it was reported that the intervention had been delivered by an art therapist. This was reported to be a professional or qualified art therapist in three of these studies72,79,82 and an art therapy psychotherapist in a further study.84 The service provider was not reported in the remaining two studies.77,78 Sessions were 1 hour in length in three studies72,78,79 and 2 hours in length in two studies;82,84 duration was not reported in three studies.76,77,83 The number of sessions delivered ranged from 1 to 22. Sessions were reported as occurring weekly in four studies; the frequency was not reported in three studies. One study82 reported perceptions of patients who had taken part in art therapy as part of a rolling programme. shows the study characteristics of qualitative studies with data from patients.
Study characteristics of qualitative studies with data from patients
shows the study characteristics of qualitative studies with data from service providers.
Study characteristics of qualitative studies with data from service providers
Quality of the included studies
shows the methodological quality assessment of the included studies (adaptation of the critical appraisal skills programme checklist for qualitative studies.
Methodological quality assessment of the included studies (adaptation of the critical appraisal skills programme checklist for qualitative studies)
Our inclusion criteria specified that qualitative research or qualitative data within mixed methods studies were acceptable for inclusion; however, only three studies could be described as qualitative research.74–76 Researcher reflexivity can be described as awareness of the researcher’s contribution to the construction of meanings throughout the research process and an acknowledgement of the impossibility of remaining ‘outside of’ one’s subject matter while conducting research. Few studies made reference to researcher reflexivity, and in those that did these descriptions were often brief. Most studies provided descriptions of the context and aims of the study, recruitment methods and data collection methods, although these tended to be brief. The study methods used were interview methods in most studies (n = 10) [semistructured interviews (n = 7), in-depth interview (n = 1), interview (n = 2)]. One study used the focus group method, one used patient diaries, one used field notes, and one used the transcription of a video-recorded group discussion which had been used for a television programme. Only around half of the included studies provided an adequate description of data analysis methods, and in only a few studies were in-depth, detailed and rich data presented. It should be noted that this may have been, in part, a result of limitations imposed by journals. Furthermore, the level of evidence that was included was extended to include data identified in both the results section and the discussion and will include author comments and interpretation. If data were limited only to participants, it was feared that important data would be missed.
Certainty of the review findings
As described in the Quality assessment strategy section, the CerQual approach to assess the certainty of the review findings was applied. The CASP quality assessment finding, together with the number of studies contributing to the finding, and an assessment of the consistency of study setting and population, was assessed. Each finding could potentially be graded as being of high, moderate or low certainty. For the evidence from patients, there were a total of 38 findings: 20 were assessed to be of moderate certainty and 18 were assessed to be of low certainty. For the evidence from service providers, as only two studies contributed to the evidence, there were a total of 25 findings: 19 were assessed to be of moderate certainty and six were assessed to be of low certainty. Owing to the limited number of studies contributing to each finding, together with the fact that the majority of the individual studies included in the review were of low to moderate quality, no findings were assessed as being of high certainty.
Qualitative synthesis: evidence from patients
shows the patient views regarding how art therapy helped (relative benefits).
Patient views regarding how art therapy helped (relative benefits)
shows the patient views regarding how art therapy was unhelpful (relative harms).
Patient views regarding how art therapy was unhelpful (relative harms)
shows the patient views regarding the neutral effects of art therapy (neither nor benefits)/acceptability.
Patient views regarding the neutral effects of art therapy (neither harms nor benefits)/acceptability
shows the service delivery recommendations from patients.
Service delivery recommendations
Benefits of art therapy
Relationships
A number of respondents across several studies72,73,77,79–83 talked about relationships as important in art therapy. They suggested that art therapy was effective when a relationship with the art therapist was established.79,80,83 One patient commented ‘I felt she [the art therapist] really understood what I am going through’.79 A good relationship with the art therapist was seen as a requirement for an optimal art therapy programme,73,81 and that the art therapist should act as a guide.73 However, it was also noted that art therapy could be unhelpful if the art therapist was not skilled.73 One patient recounted, ‘I was getting very, sort of out there in terms of the anxiety and that kind of thing, and it seemed to become evident she couldn’t go there with me . . . She couldn’t deal with it, which was quite upsetting’.73
Respondents also discussed relationships with other group members and felt that art therapy was beneficial when these relationships could be established.73,77,80,82,83 These findings were observed in studies across a range of settings and in a range of populations.
Respondents also felt that art therapy had the effect of facilitating improved relationships with family members, friends and caregivers.72 This finding was observed in only one study, in which respondents had cancer, and therefore this finding may not be generalisable to other populations. In one study,81 respondents with anxiety, depression and stress suggested that art therapy could serve to reduce isolation.
Understanding
Several studies included data concerning the importance of increased understanding as a beneficial result of art therapy.72,73,76,77,79,81–84 More specifically, respondents talked about an increased understanding of self73,77,79,81–84 and that art therapy promoted thinking about the future.72,73,76,77,81,83 These findings appeared to be consistent across different populations. In two studies, one in patients with obesity84 and the other in people with breast cancer,73 art therapy was felt to facilitate understanding of these illnesses; thus, this finding may be specific to people with a diagnosis of a physical illness.
Perspective
A further beneficial effect of art therapy was the provision of strength and perspective.76,83 This was illustrated by a participant in the McCaffrey et al. study:
These classes have put some perspective on my feelings and even though I am still sad and would give the whole world to have my husband back, I realize I can go on and I can have a good life.
McCaffrey et al.83 (p. 83)
However, it should be noted that this finding was judged to be of low certainty because it occurred in only two studies of overall low quality.
Distraction
Respondents highlighted distraction as a beneficial aspect of art therapy.72,73,84 More specifically, respondents pointed to distraction from pain72 and distraction from the illness, or escapism.72,73,84 As might be expected, these findings were restricted to cancer and obesity populations, and were, therefore, rated as low to moderate certainty.
Personal achievement
Several studies included data reflecting that the provision of art therapy gave participants a sense of personal achievement. In a number of studies,72,73,78,79,84 respondents commented that art therapy provided pleasure, satisfaction, accomplishment and a sense of pride. A patient reported, ‘I underestimate myself and didn’t think I was capable of doing what I did and of having any ideas. I am proud and I’ve rarely been that in my life’.84 In one study of women with cancer,72 it was reported that art therapy provided an opportunity to leave a legacy for loved ones.
Expression
Freedom of expression emerged as important across a range of studies.73,76,77,78,80–82 A patient commented, ‘It can touch the feelings that are buried . . . the art frees you up to touch deeper down that [sic] you would verbally’.81 Specifically, art therapy was thought of as a safe place to express emotions, such as fear73,76–78,81,82 and anger.73
Relaxation
A number of studies reported data suggesting art therapy provided a healing experience, comfort, encouragement, support and relaxation.73,77,78,80,81 One participant reported, ‘it was really relaxing and afterwards I felt good and encouraged’.77
Empowerment
Recipients of art therapy expressed that it gave them a sense of empowerment. This came in the form of control over emotions.73,76,80,81 In the Collie study,73 the author reports:
[The art therapist stated] ‘What art can do is it gives you . . . access to a larger part of who you are.’ She said art can take people away from their pain and show them that they are more than pain, and therefore can give a sense of control.
Collie73 (p. 77)
Art therapy also promoted control over real-life situations76 and it was also cited as raising self-esteem.78
Acceptability and potential harms of art therapy
Although recipients in most of the studies indicated a high level of acceptability of art therapy, some studies also described less positive attitudes.72,73,78,79,81 Some respondents made comments that indicated that, although they did not feel art therapy would be harmful, they did not feel it would be beneficial. In one study,79 a participant commented that art therapy was superficial; ‘I did not find anything particularly useful in it: afterwards I felt as before [she makes a gesture of opening her hands]. It is a little chat with a person who maybe can understand you, but in the end . . .’. Another patient felt it was childish. In another study,81 a participant felt it was self-indulgent, and, in a final study,78 a participant simply had a preference for other therapies. These findings were seen across only three studies of low to moderate quality.
More serious concerns included art therapy causing anxiety,72 increasing pain,72 and resulting in the activation of emotions that were not resolved.73 In one study,73 a participant was also concerned that art therapy may be harmful if the art therapist was not skilled. A final concern was that it may be harmful if art therapy is suddenly terminated.73 These findings were seen across only two studies, both in patients with cancer.
The provision of art therapy
Across several studies73,76,78,81 recommendations for art therapy were made. A participant in one study76 said that it was important that privacy be respected during art therapy. In addition, emotional support,73 a good relationship with the art therapist73,81 and that the art therapist should act as a guide73 were suggested to be important aspects of art therapy. Suggested improvements for art therapy were made in one study,78 including the need for further sessions of art therapy and for additional input from other therapies, such as individual counselling.
Barriers to participation
Barriers to participation in art therapy were reported in three studies.72,79,80 Respondents commented that they thought they were too ill to take part in the therapy,72 and in a further study respondents reported that art therapy was restricted to people with certain medical conditions.80 Other barriers included a fear of not being ‘good at art’80 and in two studies79,80 participants commented that a lack of understanding of art therapy could be a barrier to participation. shows the overall synthesis of patients’ views regarding the relative benefits, harm and acceptability of art therapy.
Overall synthesis of patients’ views regarding the relative benefits, harms and acceptability of art therapy.
Qualitative synthesis: evidence from service providers
shows the service providers’ views regarding how art therapy was helpful (relative benefits).
Service providers’ views regarding how art therapy was helpful (relative benefits)
shows the service providers’ views regarding how art therapy was unhelpful (relative harms).
Service providers’ views regarding how art therapy was unhelpful (relative harms)
shows the service providers’ views regarding the neutral effects of art therapy (neither harms nor benefits)/acceptability.
Service providers’ views regarding the neutral effects of art therapy (neither harms nor benefits)/acceptability
shows the service delivery recommendations from service providers.
Service delivery recommendations
Benefits of art therapy
In many ways the data from the two studies examining service provider views of art therapy mirrored those of the patients. Service providers felt that art therapy was beneficial when patients have time invested in them.81 One GP stated that ‘simply having the time to have somebody interested in them is therapeutic in itself’.81 Service providers also felt that a good indicator of the benefit of art therapy was when the patients say they like it or they felt they benefited.74,81 Art therapists felt that art therapy was most helpful when the therapist examines the effect of art-making process with clients.74 Furthermore, it was seen as beneficial when clients can communicate through artwork,74 when art therapists help clients improve their ability to manage anger,74 when it increases pride and self-esteem,74 and when thoughts and feelings are expressed more effectively.74 Finally, on a more practical level, art therapists felt that art therapy could be beneficial when it provides an opportunity for clients to do something better with their time.74
Acceptability and potential harms of art therapy
Service providers made a number of observations about the acceptability and potential harms of art therapy. According to the study that examined the perspectives of GPs referring patients to art therapy81 GPs, while not believing that art therapy could be harmful, do not regard it as beneficial either. In that study, GPs referring patients to art therapy commented on a lack of understanding of art therapy, reporting, ‘I don’t think I understood what the art bit was about’.81 They also suggested that the art part of the therapy was irrelevant, stating ‘[I] thought it was about offering people an opportunity to discuss things in therapy. If you or I went to a group we’d get something out of it’.81 They felt it was unlikely to help everyone,81 and on a more practical note they felt that art therapy gave them with an opportunity to take time back: ‘leaves me free for more medical care’.81 It should be noted that all of these neutral findings were generated from only one study of low quality, which looked at the opinions of GPs referring patients to art therapy and, therefore, cannot be generalised across other groups.
In terms of more serious detrimental effects of art therapy, Sharf74 reported findings from art therapists. These potential harms included when administrative decisions lead to poor treatment outcomes, for example when a client is not allowed to continue with art therapy; when the client lacks commitment or is non-compliant; and when the client is resistant to art therapy.
The provision of art therapy (service delivery)
Both types of service providers (GPs and art therapists), like patients, felt that a good relationship with the art therapist was important.74,81 GPs also reported that they felt the one-to-one contact was an important aspect of the therapy.81 Art therapists also felt that client commitment to recover, the client’s enjoyment of art therapy, providing a safe environment to express thoughts, feelings and experiences, matching techniques and materials to clients, displaying artwork, and creating art along with clients were important aspects of effective art therapy.74
Barriers to the provision of art therapy
Art therapists felt that their profession was not respected by members of other professional groups,74 and that this created a barrier to patients being referred to art therapy. Art therapists went on to suggest that, in situations where art therapists and other professionals were able to work together, improvements to the service, patient outcomes and accessibility of art therapy were made. shows the overall synthesis of service providers’ views regarding the relative benefits, harms and acceptability of art theraphy.
Overall synthesis of service providers’ views regarding the relative benefits, harms and acceptability of art therapy.
Combining the quantitative and qualitative findings
Qualitative meta-synthesis was undertaken to provide added value to the quantitative analysis by indicating patient issues around the acceptability of art therapy as a treatment for non-psychotic mental health disorders. This section aims to synthesise the findings from the two reviews.
The findings from the quantitative review demonstrated that depression, anxiety, low mood, distress and self-esteem were significantly reduced, and QoL and coping were significantly increased, relative to the control group in one to six studies.48,52,58,59,61,62 Trauma was not significantly improved relative to the control group despite an improvement from baseline in three studies.47–49 Cognition was not significantly improved in the one study it was reported in.51 The findings of the qualitative review demonstrated that, overall, art therapy was viewed as an acceptable treatment by patients and service providers, with relatively few reports describing art therapy as unhelpful or unacceptable.
Some of the outcomes reported in the quantitative studies appear to map on to the qualitative findings around the beneficial and, in a smaller number of cases, the harmful outcomes of taking part in art therapy. illustrates this mapping of outcomes from each review.
Mapping of qualitative findings against quantitative outcome measures
Findings from the qualitative review that appear to map on to the quantitative coping outcome include both helpful and unhelpful qualitative findings. Self-esteem also mapped on to qualitative findings. Quantitative outcome domains that mapped to a lesser extent to the qualitative findings were QoL, distress, mood and anxiety (although in opposite directions). There was no qualitative evidence that mapped specifically to the quantitative outcome domains of depression, trauma or cognition.
More in-depth synthesis of the findings of the two reviews was particularly challenging given that, despite art therapy being defined as a complex intervention, the quantitative primary studies did not explore the mechanisms of art therapy that may modify its effectiveness, such as therapist skill. However, the qualitative review findings can help to elucidate the potential treatment effect modifiers identified in the quantitative review, despite the fact that in most cases it was not possible to assess their effect on outcomes. The potential treatment effect modifiers identified in the studies included, in the quantitative review included, experience/qualification of the art therapist, individual versus group art therapy, age, gender and pre-existing physical conditions.
Experience/qualification of the art therapist
The review of the quantitative evidence demonstrated that there was considerable variability in the reporting of the accreditation of the therapist, although most studies were conducted by a person who was seen be qualified as an art therapist. The findings of the qualitative review demonstrated that a good relationship with the art therapist was reported as an important for art therapy to be helpful. Therefore, it appears that the experience and skill of the art therapist may be an important mechanism of art therapy.
Individual versus group art therapy
The quantitative review reported that the majority of RCTs are of group art therapy, with only four of the 15 RCTs examining individual art therapy.49,55,56,62 Of the studies of individual art therapy, two49,62 did not demonstrate an improvement on quantitative measures compared with the control group. Given that the qualitative findings also pointed to the importance of relationships with other group members as a particularly beneficial aspect of art therapy, with this finding seen in across several studies, an important mechanism in art therapy may be the group setting.
Pre-existing physical condition
The quantitative review highlighted that in nine studies patients had pre-existing physical conditions.50,51,54–58,61,62 The remaining six studies were in people who were depressed,47,59 people with PTSD,48,49 or older people.52,53 Neither the qualitative review nor the quantitative review found evidence that the effectiveness or helpfulness of art therapy differed across patients with or without pre-existing physical conditions. However, the qualitative review showed that a small number of themes appeared to apply mainly to people with pre-existing physical conditions. These themes included the facilitation of an improved relationship with family, friends and caregivers; facilitation of an understanding of the illness in two studies,72,84 one of obesity and one of palliative care impatients; distraction from pain; distraction from the illness/escapism; and providing the opportunity for legacy. These findings may have implications for how art therapy is delivered to different populations to maximise beneficial effects.
Although age and gender were identified as potential treatment modifiers in the quantitative review, neither review was able to demonstrate any evidence that these variables had an effect on quantitative outcomes or patients’ perspectives and attitudes towards art therapy.
Discussion
Discussion of the qualitative review
The aim of the qualitative systematic review was to provide a detailed user perspective on the acceptability and relative benefits and potential harms of art therapy. Overall, art therapy was viewed as an acceptable treatment across the populations of participants studied.
A number of beneficial aspects of art therapy emerged, together with a relatively smaller number of harmful aspects of art therapy, with relative harms being reported in only two studies.72,73 An important theme emerging from the data was the relationship with the art therapist. This was raised as a positive and beneficial aspect of art therapy but also as potentially harmful, and further as a recommendation for service provision. A good relationship between the patient and art therapist was viewed as essential for successful, effective art therapy. However, harm could be caused in situations in which a positive relationship was not achieved, the therapist was viewed as unskilled, when emotions activated through therapy could not be resolved or the therapist was suddenly unavailable through sudden termination of the service. This finding was seen in evidence reported by patients and by service providers,74,81 who also stressed the importance of a good therapeutic relationship.
Some themes, such as the importance of expression, the relationship with the art therapist and with other group members and the facilitation of an increased understanding of self, were consistent across populations, while a small number of themes appeared to apply to populations in which a diagnosis of a pre-existing physical condition was present. These themes included the facilitation of an improved relationship with family, friends and caregivers, identified in one study of a cancer population,72 facilitation of an understanding of the illness in two studies (one of obesity84 and one of cancer73), distraction from pain in one study of cancer,72 distraction from the illness/escapism in two studies of cancer populations72,73 and one of an obesity population84 and providing the opportunity for legacy in a study of a cancer population.72
Understanding and personal achievement were other important themes emerging from the evidence. In addition, some barriers to participation were reported. A small number of participants also reported that they did not want to take part in art therapy, which reiterates the importance of considering patient preference in choice of treatment.14,15
The combination of the findings from the quantitative and qualitative reviews examined how outcomes from the quantitative review mapped on to themes emerging from the qualitative review. This demonstrated that a number of themes from the qualitative review appear to map on to the quantitative coping outcome. This included both helpful and unhelpful qualitative themes. Self-esteem also mapped on to qualitative findings. Furthermore, the combining of the two reviews identified a number of mechanisms within art therapy that may modify the effectiveness and acceptability of the treatment and should be considered in further research and in the implementation of art therapy.
Limitations
Overall the evidence base was small (n = 12), with only two studies examining service provider views74,81 and, furthermore, only one of these74 examined art therapists’ views. The majority of the included studies were of low or moderate quality. Limitations on word limits imposed by journals may have contributed to this, as theses and grey literature provided better-quality evidence. Lack of rich data was the main limiting factor relating to the qualitative evidence base.
Other significant limitations in the evidence base include the fact that the vast majority of studies reported only positive findings. This may have been because of researcher bias, in that most of the authors of the reports were art therapists,85 and the method of investigation in a number of studies appears to be biased towards the reporting of positive findings.
There was a lack of evidence comparing art therapy with other treatment options; therefore, we are unable to make comparisons regarding the acceptability of art therapy compared with other potential treatments participants might be offered.
Combining the qualitative and quantitative data proved difficult because of the paucity of the evidence base as a whole and the fact that meta-analysis was not possible. However, coping emerged as an important factor across both reviews, and this is an outcome domain that is likely to be pertinent to people with long-term health conditions. The small evidence base means it is not currently possible to make any generalisations around age, gender or setting.
Conclusions
From the small number of qualitative studies identified, art therapy was reported to be an acceptable treatment. The benefits associated with art therapy included the development of relationships with the therapist and other group members, understanding the self/own illness/the future, gaining perspective, distraction, personal achievement, expression, relaxation and empowerment. Small numbers of patients reported varying reasons for not wanting to take part and therefore art therapy may not be a preferred treatment option for everyone. A small number of cases highlighted potentially negative effects of art therapy, which included the evoking of feelings that could not be resolved. Overall, there was low to moderate certainty in the review findings.
