Effectiveness and mechanisms of the arts therapies in forensic care. A systematic review, narrative synthesis, and meta analysis.

Introduction: Mental health care provided to offenders with psychiatric problems in forensic settings mainly consists of verbal oriented treatments. In addition, experience-based therapies are used such as (creative) arts therapies: (visual) art therapy, music therapy, drama therapy and dance (movement) therapy. There are indications for effectiveness of arts therapies, but a systematic overview of effect studies of all arts therapies in forensic care is lacking. Methods: First, we performed a systematic review. Second, Thematic Analysis was used to synthesize the qualitative narrative results and define the hypothesized mechanisms of change. Third, we performed a meta-analysis to investigate the effects of arts therapies in reducing psychosocial problems of offenders. Twenty-three studies were included in the review. Quality and risk of bias was assessed using EPHPP (Effective Public Health Practice Project). Results: The included studies were heterogeneous in type of outcome measures and intervention characteristics. Synthesis of mechanisms of change involved in the methodical use of the arts in arts therapies resulted in a description of regulatory processes which are stimulated in arts therapies: perceptive awareness (interoceptive and exteroceptive), the regulation of emotions, stress, impulses, cognitions, social regulation, and self-expression. These processes play a role in developing prevention, coping and self-management skills. Eighteen studies were included in the meta-analyses (11 RCTs/CCTs; 7 pre-post studies). The meta-analyses indicated significant effects on both risk factors (psychiatric symptoms and addiction) and protective factors for criminal behavior (social functioning and psychological functioning). Effects on criminal and/or antisocial behavior were not significant, but this outcome measure was scarcely used among the studies. Discussion: The analyses in this study should be considered explorative. More research is needed to gain more solid conclusions about effectiveness and mechanisms of change of arts therapies in forensic institutions. However, the results of this first systematic review, synthesis of mechanisms and meta-analysis in this field are promising and show effects of arts therapies on risk and protective factors in individuals in forensic institutions. Systematic review registration: https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42020217884, identifier: CRD42020217884.

Anxiety reduction through art therapy in women. Exploring stress regulation and executive functioning as underlying neurocognitive mechanisms.

OBJECTIVES: To explore possible working mechanisms of anxiety reduction in women with anxiety disorders, treated with art therapy (AT). METHODS: A RCT comparing AT versus waiting list (WL) condition on aspects of self-regulation. Stress regulation (heart rate and heart rate variability) and executive functioning (daily behavioural and cognitive performance aspects of executive functioning (EF)) were evaluated in a pre-post design. Participants were women, aged 18-65 years with moderate to severe anxiety symptoms. RESULTS: Effectiveness of AT compared to WL was demonstrated in a higher resting HRV post treatment, improvements in aspects of self-reported daily EF (emotion control, working memory, plan/organize and task monitor), but not in cognitive performance of EF, stress responsiveness and down regulation of stress. The decrease in anxiety level was associated with improvements in self-reported daily EF. CONCLUSIONS: AT improves resting HRV and aspects of EF, the latter was associated with art therapy-related anxiety reduction.

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.