Cathy Malchiodi PhD, LPCC, LPAT, ATR-BC, REAT

Creative Arts Therapy and Expressive Arts Therapy

Here is a basic guide to creative, brain-wise approaches to therapy..

Posted June 30, 2014 | Reviewed by Ekua Hagan

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Creative interventions have been formalized through the disciplines of art therapy, music therapy, dance/movement therapy, drama therapy or psychodrama, poetry therapy, and play therapy, including sandtray therapy. Each discipline has been applied in psychotherapy and counseling with individuals of all ages, particularly children, for more than 70 years.

Art, music, dance, drama, and poetry therapies are referred to as “creative arts therapies” because of their roots in the arts and theories of creativity . These therapies and others that utilize self-expression in treatment are also called “expressive therapies” (Malchiodi, 2005; 2013; 2014).

Expressive arts therapies are defined as the use of art, music, drama, dance/movement, poetry/creative writing, bibliotherapy, play, and sandplay within the context of psychotherapy, counseling, rehabilitation, or medicine. Additionally, expressive therapies are sometimes referred to as “integrative” when various arts are purposively used in combination in treatment.

Individual approaches to creative arts therapy are defined as follows:

Art therapy is the purposeful use of visual arts materials and media in intervention, counseling, psychotherapy, and rehabilitation; it is used with individuals of all ages, families, and groups (Edwards, 2004; Malchiodi, 2012).

Music therapy is the prescribed use of music to effect positive changes in the psychological, physical, cognitive, or social functioning of individuals with health or educational problems (American Music Therapy Association, 2014; Wheeler, 2014).

Drama therapy is the systematic and intentional use of drama/theater processes, products, and associations to achieve the therapeutic goals of symptom relief, emotional and physical integration, and personal growth. It is an active approach that helps the client tell his or her story to solve a problem, achieve catharsis, extend the depth and breadth of his or her inner experience, understand the meaning of images, and strengthen his or her ability to observe personal roles while increasing flexibility between roles (National Association for Drama Therapy, 2014).

Dance/movement therapy is based on the assumption that body and mind are interrelated and is defined as the psychotherapeutic use of movement as a process that furthers the emotional, cognitive, and physical integration of the individual. Dance/movement therapy effects changes in feelings, cognition , physical functioning, and behavior (American Dance Therapy Association, 2014).

Poetry therapy and bibliotherapy are terms used synonymously to describe the intentional use of poetry and other forms of literature for healing and personal growth.

Play therapy is the systematic use of a theoretical model to establish an interpersonal process wherein trained play therapists use the therapeutic powers of play to help clients prevent or resolve psychosocial difficulties and achieve optimal growth and development (Crenshaw & Stewart, 2014; Webb, 2007).

Sandplay therapy is a creative form of psychotherapy that uses a sandbox and a large collection of miniatures to enable a client to explore the deeper layers of his or her psyche in a totally new format; by constructing a series of “sand pictures,” a client is helped to illustrate and integrate his or her psychological condition.

Integrative approaches involve two or more expressive therapies to foster awareness, encourage emotional growth, and enhance relationships with others. This approach distinguishes itself by combining modalities within a therapy session. Integrative approaches are based on a variety of orientations, including arts as therapy, arts psychotherapy, and the use of arts for traditional healing (Estrella, 2005; Knill, Levine, & Levine, 2005).

While some practitioners define art, dance/movement, music, or drama therapies as play therapies, creative arts therapies and expressive therapies are not merely subsets of play therapy and have a long history in mental health with distinct approaches. While the arts may sometimes be a form of play, encouraging individuals to express themselves through a painting, music, or dance involves an understanding of the media beyond the scope of play. In brief, the arts therapies are different from play therapy because they integrate knowledge of art with principles of psychotherapy and related fields.

The 1926 St. Louis Cardinals one their first of 11 World Series titles, defeating the New York Yankees. For most baseball fans, nostalgia tied to this event would be historical nostalgia - an appreciation for a distant-yet-self-referential past.

In addition to the disciplines and approaches mentioned above, many therapists integrate activities that enhance relaxation as part of trauma intervention. Relaxation techniques often include creative components such as music, movement, or art-making. For example, guided imagery or visualization , meditation , yoga, and other methods of stress reduction are also used with individuals who have experienced trauma or loss.

Finally, art, music, and dance/movement therapies and other creative interventions such as play have sometimes been incorrectly labeled as “nonverbal” therapies. They are both verbal and nonverbal because verbal communication of thoughts and feelings is a central part of therapy in most situations. In fact, most therapists who use these methods integrate them within a psychotherapy approach, including but not limited to psychodynamic, humanistic, cognitive, developmental, systems, narrative, solution-focused, and others.

There are also creative interventions that specifically focus on verbal communication and self-expression as part of treatment, such as drama therapy, creative writing, and poetry therapy, and bibliotherapy. In all cases, these approaches are "brain- wise " interventions that stimulate whole-brain responses to help individuals of all ages experience reparation, recovery and well-being.

Cathy Malchiodi , PhD, LPCC, LPAT, ATR-BC, REAT

© 2014 Cathy Malchiodi, PhD

American Dance Therapy Association. (2007). What is dance therapy?

American Music Therapy Association. (2014). Music therapy makes a difference: What is music therapy?

Crenshaw, D., & Stewart, A. (eds.). (2014). A Comprehensive Guide to Play therapy. New York: Guilford Press.

Estrella, K. (2005). Expressive therapy: An integrated arts approach. In C. A. Malchiodi (Ed.), Expressive therapies (pp. 183–209). New York: Guilford Press.

Knill, P., Levine, E., & Levine, S. (2005). Principles and practice of expressive arts therapy: Towards a therapeutic aesthetics. London, UK: Jessica Kingsley.

Malchiodi, C. A. (2005). Expressive therapies. New York: Guilford Press.

Malchiodi, C.A. (Ed.). (2013). Art therapy and healthcare . New York: Guilford Press.

Malchiodi, C.A. (2014). Creative arts therapy approaches to attachment issues. In C. Malchiodi & D. Crenshaw (Eds.), Creative Arts and Play Therapy for Attachment Problems (pp. 3-18). New York: Guilford Press.

National Association for Drama Therapy. (2007). Frequently asked questions about drama therapy: What is drama therapy?

Webb, N. B. (Ed). (2007). Play therapy with children in crisis: Individual, group, and family treatment (3rd ed.). New York: Guilford Press.

Wheeler, B. (2015). Music therapy handbook . New York: Guilford Press.

Cathy Malchiodi PhD, LPCC, LPAT, ATR-BC, REAT

Cathy Malchiodi, Ph.D. , is a psychologist, expressive arts therapist, trauma specialist, and author of 20 books, including Trauma and Expressive Arts Therapy: Brain, Body, and Imagination in the Healing Process.

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Expressive Arts Therapy: 15 Creative Activities and Techniques

Expressive arts therapy

It is especially well suited to clients who lack the ability to articulate their inner world with words alone. These clients can use the many forms of creative arts to express themselves.

In this article, we will discuss expressive arts therapy by explaining the interventions used and the difference between expressive arts therapy and creative arts therapies. You will be introduced to expressive arts therapy techniques and ideas for your psychotherapy and counseling sessions, both with individual adults and groups.

The article will also introduce training programs and degrees in expressive arts therapy and present a brief review of some of the best books on the subject.

Before you continue, we thought you might like to download our three Positive CBT Exercises for free . These science-based exercises will provide you with detailed insight into Positive CBT and give you the tools to apply it in your therapy or coaching.

This Article Contains:

What is expressive arts therapy, expressive arts therapy vs creative arts therapy, 12 techniques and ideas for your sessions, 3 activities for adults and groups, training in expressive arts therapy, top 14 courses, programs, and degrees, 3 best books about expressive arts therapy, helpful positivepsychology.com resources, a take-home message.

Expressive arts therapy incorporates elements of all forms of creative expression into a multimodal expressive form of integrative psychotherapy (Knill et al., 2005).

Expressive arts therapists are proficient in interpreting creative expression, rather than arts practitioners who have trained in a specific form of therapy.

In expressive arts therapy, each client is encouraged to use multiple forms of creative expression to articulate their inner world, including drawing and painting, photography, sculptures using a range of materials from clay to paper mâché, music, drama and role-play , poetry, prose, and dance and movement.

Expressive arts therapy focuses on four major therapeutic modalities:

  • Imagination
  • Active participation
  • Mind–body connection

Human beings have used expressive arts as healing modalities since ancient times (Malchiodi, 2020). Expressive arts therapists facilitate multimodal creative expression, sometimes in one session, usually non-directively.

In other words, the therapist provides the materials, equipment, and media required to facilitate a client’s creative expression during the therapy session.

Dr. Cathy Malchiodi is a psychologist and expressive arts therapist who explains the four core healing practices when using expressive arts to work with trauma: movement, sound, storytelling through image, and silence through contemplative and self-regulatory practices.

Expressive arts therapy involves a multimodal integration of varied elements of the creative arts therapies into psychotherapy and counseling.

Creative arts therapies include art therapy, dance therapy , music therapy , drama therapy , and writing therapy . Creative arts therapists tend to be expert arts practitioners in one specific area who have gone on to train in a specific type of creative arts therapy (Stuckey & Nobel, 2010).

For example, a painter who has graduated with a fine art degree may then complete graduate training in art therapy to practice as an art therapist, or a professional performer may train as a dance or drama therapist.

However, expressive arts therapists are not expert arts practitioners. Rather, they are proficient in the skilled use of expressive arts as an integrative intervention in psychotherapy (Knill et al., 2005).

Drawing in art therapy

1. Drawing and painting

Intuitive drawing and painting with pastels, chalks, acrylics, and watercolors can be useful for expressing emotions, mood states, or relational dynamics that are difficult to express in words (Laws & Conway, 2019; Stuckey & Nobel, 2010; Trevisani et al., 2010).

Take a look at the video under the next item for an example of an intuitive drawing session.

2. Sculpting

Clay sculpting during a session can be very therapeutic, as clay is moldable and remoldable. Clay can take a lot of impact, and sculpting can be used to represent abstract inner states, a self-image, and other people (Vaartio-Rajalin et al., 2020). It can then be stretched, pummeled, and flattened as a means of expressing emotions.

In the video below, expressive arts therapist Natalie Rogers uses the two techniques mentioned during a therapy session with the same client.

Mask making using a range of materials such as tissue paper, clay, or paper mâché can be a powerful tool for expressing the many different roles people play in different relationships and life situations (Jones, 1996).

It can also express personal strengths. In this article , art therapists Gioia Chilton and Rebecca Wilkinson describe how they use mask making while working with people in addiction recovery.

4. Movement

Movement can be a powerful form of self-expression to connect to the wisdom of the body and its innate healing capacity. This may include dance, but not necessarily.

Movement can relieve stress and can be a powerful tool for self-regulation (Jones, 1996). In the video below, somatic psychologist and dance/movement therapist Dr. Jennifer Tantia explains how she used movement to transform her client’s anxiety into a sense of agency.

Expressive journal writing can combine words, drawings, sketches, collages, or photos to represent emotions, thoughts, events, memories, aspirations, strengths, and other inner experiences.

The journal provides a safe place for a client to express their authentic voice and practice honest self-expression (Knill & Atkins, 2020).

It can help clients clarify thoughts and feelings and forge a deeper connection to their needs, aspirations, and goals. This activity can also be continued between sessions as an adjunct to therapy then discussed during sessions. In this article , expressive arts therapist Shelley Klammer explains the wider benefits of expressive journaling.

Poetry writing is a central technique in expressive arts therapy that aims to mobilize artistic language, symbolism, and poesy as the source of creative expression. Clients can be encouraged to write expressively but also share poems written by others that have moved them.

The video below is the trailer for the book Poetry in Expressive Arts: Supporting Resilience Through Poetic Writing  by Margo Fuchs Knill and Sally Atkins (2020) and presents examples of poetry written as therapy.

7. Role-play

We all play many roles in our lives – at work, in social situations, and in our relationships.

Drama therapy is a safe method for exploring these roles in a nonthreatening way (Jones, 1996). Masks and puppets can also be used to explore roles and express difficult feelings rather than participating in active role-play if a client is uncomfortable expressing themselves directly.

This drama therapy intervention enables clients to explore roles they dislike, roles they aspire to play in the future, and current roles they’d like to expand. Role-play may be used in interventions designed to enhance self-awareness, strengthen a sense of identity, and enhance relationships.

Collage can be used to make emotionally expressive images using cut-outs, photos, paints, and felt pens. The key to this exercise is working quickly and spontaneously, as free of internal verbal commentary as possible.

The expressive collage-making exercise by expressive arts therapist Shelley Klammer in the video below is designed to enhance self-acceptance.

9. Self-portraiture

Self-portraiture using a range of materials can be very cathartic, and a series of self-portraits can reflect how a client sees themselves changing over time. These can be made by drawing, painting, mask making, sculpture, photography, or mixed media using a combination of these materials.

10. Photography

Photography used in a therapeutic context is often called photo therapy or therapeutic photography (Gibson, 2018).

Photo therapy can enhance clients’ appreciation of their environment and what they love about their daily life. It can also be used to journal the healing process after trauma or loss.

In the TED Talk below, How Photography Saved My Life , Bryce Evans explains how therapeutic photography helped him recover from depression and anxiety.

11. Mandala making or coloring

Mandala making or coloring can be a wonderfully meditative exercise for emotional expression, centering, and self-soothing.

Mandala derives from the Sanskrit word for “circle,” and in Eastern religious traditions, mandalas are often used as an aid to contemplation and meditation.

To make a mandala from scratch, the client needs to draw a circle (perhaps tracing around a circular object or using a compass) and then fill the circle in with spontaneous patterns and colors.

Alternatively, mandala coloring books such as 150 Mandalas: An Adult Coloring Book With 150 Beautiful Mandalas in Various Styles for Stress Relief and Relaxation can be used to relieve stress and for self-soothing purposes (Koo et al., 2020).

12. Filmmaking

Filmmaking is another powerful expressive art form that is now available to most of us, given we can all make videos with our smartphones and edit them with various low-cost or free video-editing apps online.

This video trailer for the book Video and Filmmaking as Psychotherapy (Cohen et al., 2016) gives a taste of how filmmaking is being used in psychotherapy with veterans to treat post-traumatic stress disorder.

All the techniques above are used in expressive arts therapy in conjunction with person-centered, psychodynamic, cognitive-behavioral, and mindfulness-based approaches to maximize and integrate psychological healing.

We share three activities with which to get started.

1. Mindful painting for stress relief

For this activity, you will need drawing pencils, ink pens, felt pens, colored pencils, pastels, chalks, crayons, acrylic and/or water paints, and brushes. This activity can be conducted with an individual or in a group.

The activity involves intuitively drawing or painting abstract representations of the things that stress your clients in response to the prompt ‘pressure.’ The idea is for clients to express how pressure makes them feel by making marks on the paper without judgment, rather than holding them in their bodies.

This exercise should begin with a brief mindful breathing exercise for each participant to relax and register their stress levels. Then, encourage them to make marks with colors that represent their feelings and draw and paint their problems away.

This video by Mindful Creative Muse for World Mental Health Day explains the process in more detail.

2. Guided imagery with music into a safe place

This activity can be conducted with individuals or in a group and was devised by music therapist Paula Higgins. For this activity, you will need space for clients to sit or lie down, yoga mats or cushions for them to lie on, and a device that can play music either using the video below or your own source.

The activity uses relaxation, guided imagery , music, and the mindfulness of breathing to create a sense of safety and stability. It could be particularly helpful for clients who are grieving, experiencing stress or anxiety, or in recovery from addiction.

You can download the transcript by clicking on the three dots on the right-hand side under the video and then clicking “open transcript.” You can copy and paste the transcript from the text box on the right. Adapt it for your session.

3. Mindful photography as phototherapy

This activity is again suitable for individuals or a group and involves slowing down through mindfully looking at photos to relieve stress through appreciation. Ruth Davey, the founder/director of Look Again has made a short video to give a taste of mindful photography and its benefits.

For this activity, each participant will need access to a digital camera of some sort. A mobile phone camera is more than adequate. Access to nature in either a garden or park is also preferable (Atkins & Snyder, 2017), as it’s much easier to slow down in nature than in a busy urban setting.

Participants benefit by relaxing, becoming more present, and through an enhanced sense of creativity and flow.

The International Expressive Arts Therapy Association has a searchable list of training programs. The following are some of the top courses available, from certificates to diplomas and degrees up to PhD.

components of creative arts therapy

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The best place to get started with expressive arts, is by learning more about it. Have a look at the following selection of courses, spread out over the globe.

1. Expressive Arts Florida Institute

Expressive Arts Florida Institute

The following courses range from an introductory online program to a series of campus-based master’s degrees in expressive arts therapy in conjunction with other approaches, such as coaching, conflict resolution, and peacebuilding.

  • Creative Wisdom – Introductory Online Training in Expressive Arts
  • Certificate Training Program in Intermodal Expressive Arts
  • Master of Arts Degrees in Expressive Arts Therapy; Expressive Arts Coaching and Consulting; and Conflict Transformation and Peacebuilding (offered in conjunction with the European Graduate School, Switzerland).

2. Lesley University, Cambridge, MA, United States

Lesley University has a range of on-campus courses available from undergraduate to graduate certifications and a doctoral program.

  • BA in Expressive Therapies
  • Certificate of Advanced Graduate Study in Expressive Therapies
  • Graduate Certificate in Expressive Therapies Studies for mental health professionals
  • PhD in Expressive Therapies – low residency

3. Appalachian State University, Boone, NC, United States

components of creative arts therapy

  • Degree in Clinical Mental Health Counseling with a Concentration in Expressive Arts Therapy
  • Graduate Certificate in Expressive Arts Therapy

4. The European Graduate School (EGS), Saas-Fee, Switzerland

The courses listed below and other programs at EGS are the only expressive arts therapies training options currently available in Europe.

They offer hybrid study options that comprise a residential component on campus in Switzerland with other studies conducted at a university in your home country. Programs include the following:

  • Continuing Education CAS Expressive Arts Practice
  • Certificate of Advanced Graduate Study in Expressive Arts
  • MA degrees in the fields of expressive arts therapy
  • Doctoral program

5. The University of Hong Kong, Centre of Behavioral Health, Hong Kong

The University of Hong Kong

This graduate degree program with a duration of two years full time or three years part time at Hong Kong University is the only one available in Asia.

  • Master of Expressive Arts Therapy

These books are highly recommended and created by experts in the field.

1. Principles and Practice of Expressive Arts Therapy: Toward a Therapeutic Aesthetics – Paolo J. Knill, Stephen K. Levine, and Ellen G. Levine

Principles and Practice of Expressive Arts Therapy

This book begins by describing the philosophical foundations of expressive arts therapies in poiesis (creating by making) as an antidote to mind–body dualism and modern alienation as the root cause of many mental health problems.

This book will really appeal to practicing psychotherapists who want to understand how to incorporate expressive arts techniques into their existing approach.

Find the book on Amazon .

2. Nature-Based Expressive Arts Therapy – Sally Atkins and Melia Snyder

Nature-Based Expressive Arts Therapy

This book is also aimed at practicing therapists and helping professionals with an interest in expressive arts and ecotherapy.

This book explains how environmentally aware creative expression can be used to heal the relationship between human beings and nature that can exacerbate and even cause mental health problems from an ecotherapy perspective.

3. Trauma and Expressive Arts Therapy: Brain, Body, and Imagination in the Healing Process – Cathy A. Malchiodi

Trauma and Expressive Arts Therapy

This book is specifically aimed at therapists and helping professionals who work with trauma.

Malchiodi explains the neuroscience of trauma and how expressive arts can reprogram the nervous system through holistic acts of creative expression, by helping to process traumatic experiences that often evade language.

PositivePsychology.com has free resources that can help you introduce expressive arts interventions into your practice.

Try our Self-Love Journal worksheet, which provides 10 journal prompts for those clients needing to cultivate self-compassion.

Alternatively, try our Mapping Emotions worksheet, which uses visualization and color to enhance emotional awareness.

Our Positive Psychology Toolkit© also contains numerous expressive arts therapy tools, including Rewriting the Narrative With Humor, a tool for promoting emotional wellbeing and resilience using writing therapy to reframe a narrative about an embarrassing event with humor.

Also in the Toolkit is Drawing Grief,  an expressive arts tool that aims to help bereaved clients explore their thoughts and feelings about their loss through drawing.

If you’re looking for more science-based ways to help others enhance their wellbeing, check out this signature collection of 17 validated positive psychology tools for practitioners . Use them to help others flourish and thrive.

Some pre-linguistic symptoms from trauma, grief, addiction, and anxiety may be inaccessible to conventional language processing. New neural pathways can be built through creative expression, which is a much more potent approach than talking.

Expressive arts therapy is an intervention that can help heal the body and mind, with ancient roots in ritual, music, song, art, poetry, dance, and drama across all cultures.

And although this approach is relatively new to Western psychotherapy, it is growing in relevance as our understanding of the functioning of the brain and nervous system explains why expressive arts therapy can be so effective.

We hope you enjoyed reading this article. For more information, don’t forget to download our three Positive CBT Exercises for free .

  • Atkins, S., & Snyder, M. (2017). Nature-based expressive arts therapy: Integrating the expressive arts and ecotherapy . Jessica Kingsley.
  • Cohen, J. L., Johnson, J. L., & Orr, P. (2016). Video and filmmaking as psychotherapy: Research and practice . Routledge.
  • Gibson, N. (2018). Therapeutic photography: Enhancing self-esteem, self-efficacy and resilience . Jessica Kingsley.
  • Jones, P. (1996). Drama as therapy: Theatre as living . Routledge.
  • Knill, M. F. & Atkins, S. (2020). Poetry in expressive arts: Supporting resilience through poetic writing . Jessica Kingsley.
  • Knill, P. J., Levine, E. G., & Levine, S. K. (2005). Principles and practice of expressive arts therapy: Toward a therapeutic aesthetics . Jessica Kingsley.
  • Koo, M., Chen, H. P., & Yeh, Y. C. (2020). Coloring activities for anxiety reduction and mood improvement in Taiwanese community-dwelling older adults: A randomized controlled study. Evidence-Based Complementary and Alternative Medicine, 2020 , 6964737.
  • Laws, K. R., & Conway, W. (2019). Do adjunctive art therapies reduce symptomatology in schizophrenia? A meta-analysis. World Journal of Psychiatry , 9 (8),107–120.
  • Malchiodi, C. A. (2020). Trauma and expressive arts therapy: Brain, body, and imagination in the healing process . Guilford Press.
  • Stuckey, H. L. & Nobel, J. (2010). The connection between art, healing and public health: A review of current literature. American Journal of Public Health , 100 (2), 254–263.
  • Trevisani, F., Casadio, R., Romagnoli, F., Zamagni, M. P., Francesconi, C., Tromellini, A., Di Micoli, A., Frigerio, M., Farinelli, G., & Bernardi, M. (2010). Art in the hospital: Its impact on the feelings and emotional state of patients admitted to an internal medicine unit. The Journal of Alternative and Complementary Medicine , 16 (8), 853–859.
  • Vaartio-Rajalin, H., Santamäki-Fischer, R., Jokisalo, P., & Fagerström, L. (2020). Art making and expressive art therapy in adult health and nursing care: A scoping review. International Journal of Nursing Science , 8 (1),102–119.

components of creative arts therapy

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What Is Expressive Arts Therapy?

Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

components of creative arts therapy

Rachel Goldman, PhD FTOS, is a licensed psychologist, clinical assistant professor, speaker, wellness expert specializing in eating behaviors, stress management, and health behavior change.

components of creative arts therapy

Master1305 / Getty Images

What Expressive Arts Therapy Can Help With

Effectiveness, things to consider, how to get started.

Expressive arts therapy is an integrative, multimodal approach that utilizes a variety of methods including writing, music, visual arts, drama, and dance to help people achieve personal growth. In this type of treatment, people work with a trained therapist who helps them explore and understand their reactions to their experience with different forms of expressive art.

It has been defined as a process of self-discovery that relies on artistic self-expression as a way to achieve emotional release.

This type of therapy is characterized by a focus on the creative process itself, utilizing a wide range of materials, and exploring a number of different techniques as part of a therapeutic intervention.

People who are experiencing mental health problems may have a difficult time interpreting or describing how they are feeling. The use of expressive arts can help people learn more about themselves and share what they are feeling in a therapeutic context.

Types of Expressive Arts Therapy

As a multimodal therapy, expressive arts therapy draws on a few different types of single-modal approaches. Four of the main types of creative arts that are often used in expressive arts therapy include:

  • Art therapy : This approach involves utilizing the visual arts—such as drawing, painting, and sculpting—to work through emotions, thoughts, or experiences. 
  • Dance therapy : This type of therapy involves utilizing physical movement and dance to help people cope with mental health symptoms such as anxiety, stress, and depression.
  • Music therapy : This approach utilizes listening to or creating music to help improve mood and ease anxiety. 
  • Writing therapy: This approach involves exploring thoughts and emotions through writing. For example, people may write in a journal about their life or create expressive works such as poems or fictional stories. 

It is important to note that the types of expressive arts used above are examples of single therapeutic modalities when used on their own. Expressive arts therapy is different because it integrates many of these techniques and incorporates a variety of tools instead of being limited to a single approach.

According to the Expressive Arts Therapy program at Appalachian State University, it is the healing actions of the artistic experiences themselves that set expressive arts therapy apart from more traditional, uni-modal approaches.

By drawing on different modalities and integrating them in ways that are beneficial to each individual’s needs, this approach to treatment can create unique experiences that allow people to better understand their emotions, thoughts, memories, and experiences.

Therapists who practice expressive arts therapy may draw on a wide variety of techniques in order to create a treatment that is best suited to the individual's needs. Such techniques can include:

  • Painting or finger painting with acrylics or watercolor
  • Clay sculpting
  • Mask making
  • Journal writing
  • Poem writing
  • Psychodrama
  • Songwriting
  • Listening to music
  • Role-playing
  • Improvisation
  • Printmaking
  • Mosaic painting
  • Self-portraiture
  • Photography
  • Mandala coloring

In addition to utilizing the healing properties of self-expression through expressive art, professionals also incorporate psychotherapeutic modalities including psychodynamic , cognitive-behavioral , and mindfulness-based approaches.

Expressive arts therapy may be beneficial for a number of different mental health conditions. It can be used with both adults and children. Some conditions or concerns it may help include:

  • Attention-deficit hyperactivity disorder (ADHD)
  • Bereavement
  • Brain injuries
  • Chronic medical conditions
  • Developmental disorders
  • Eating disorders
  • Emotional problems
  • Interpersonal issues
  • Poor self-esteem
  • Post-traumatic stress disorder (PTSD)

This approach may also be useful when treating children who may not yet have the ability to describe what they are thinking or feeling.

Benefits of Expressive Arts Therapy

The use of the expressive arts can augment the benefits of talk therapy by allowing people to use the strategies that work best for them. For some people, talking about their experiences may be their preferred form of self-exploration. Other people, however, may benefit more from activities such as drawing a picture or writing in a journal. 

According to the International Expressive Arts Therapy Association (IEATA), this involves integrating arts processes with psychology and community education to help people improve creativity, gain clarity, and achieve deep healing.

While the use of some types of expressive art may be limited for various reasons including physical disability, many art activities are suitable for a wide variety of individuals and in different settings. Such activities can often be employed in any setting with only minimal supplies. 

One review found that expressive arts therapy has been used in a wide range of contexts including community centers, with the homeless, with immigrants, with cancer patients, with patients in dementia care, and with patients in hospice care.  

Research suggests that the use of the expressive arts for therapeutic purposes offers several benefits. A few of these include developing strengths and skills, personal growth, symptom reduction, improved communication, and making meaning of personal experiences.

  • A 2021 review of the research on the use of expressive art therapy in adult health and nursing care concluded that this approach helped improve collaboration between patients, their families, and health care professionals.
  • A 2019 study found that art therapy was linked to improvement in cognitive functioning in elderly adults who had a mild neurocognitive disorder.
  • A 2016 review of a pilot study using expressive arts therapy with hospitalized children reported that the program was embraced by hospital staff and family members due to subjective reports that children were calmer and seemed less stressed after therapy sessions. Other measures also suggested that the children experienced improvements in mood.

More generally, art-making has been found to have several positive mental health effects.

  • One 2020 study found that a coloring activity helped reduce anxiety and improve mood in older adults.
  • Another study found that painting pictures and playing musical instruments helped improve the emotional well-being of older women.

If you are thinking about trying art therapy, there are some important things you should consider. You don't have to have training or experience in any of these activities. You also don't have to be good at the art form you are focusing on during your sessions. The goal of this process is not what you are creating; it is the process of creating it that matters.

"One does not need to be an artist or have any special skills to express oneself through art-making; the most important thing is an open attitude to creativity in everyday life. This allows one to give oneself and others a chance to interact with and be touched by art and to vary the pattern of everyday life," suggested the authors of one review of research on the use of the expressive arts in therapy.

Expressive arts therapy isn’t right for everyone. For example, it might not be right for you if you are skeptical or unwilling to participate in the creative experience. It may also not be appropriate for some psychiatric conditions such as schizophrenia.

It’s also important to be receptive and open to the creative experience. It isn’t the same thing as taking an art class. Your focus isn’t on learning artistic techniques, but on the inner emotional experience as you engage in the artistic process, either in a receptive (such as listening to music) or creative (such as making art) manner.

If you are interested in trying expressive arts therapy:

  • First, find a therapist : Your first step is to find a professional with training and experience in the expressive arts. For example, you might ask your doctor to refer you to a professional in your area who practices this type of therapy or look for a therapist in your area using an online therapist directory.
  • Check with your insurance : You should also ask about payment options and check with your insurance provider to see if your policy will cover the treatment. This treatment is more likely to be covered by insurance if a licensed psychologist or psychiatrist provides it.
  • Know what to expect : During an expressive arts therapy session, your therapist may guide you through a process of exploring what you are feeling using some expressive art activity. For example, your therapist may have you work through various activities, or you might focus on specific forms of expression such as writing or dance. 

Knill PJ, Levine EG, Levine SK. Principles and Practice of Expressive Arts Therapy: Toward a Therapeutic Aesthetics . Jessica Kingsley Publishers; 2005.

Appalachia State University / Expressive Arts Therapy. Questions about expressive arts therapy . 2021.

Cleveland Clinic. Creative arts therapies .

International Expressive Arts Therapy Association. Who are we? 2017.

Vaartio-Rajalin H, Santamäki-Fischer R, Jokisalo P, Fagerström L. Art making and expressive art therapy in adult health and nursing care: A scoping review .  Int J Nurs Sci . 2020;8(1):102-119. doi:10.1016/j.ijnss.2020.09.011

Mahendran R, Gandhi M, Moorakonda RB, Wong J, Kanchi MM, Fam J, Rawtaer I, Kumar AP, Feng L, Kua EH. Art therapy is associated with sustained improvement in cognitive function in the elderly with mild neurocognitive disorder: findings from a pilot randomized controlled trial for art therapy and music reminiscence activity versus usual care . Trials . 2018;19(1):615. doi:10.1186/s13063-018-2988-6

Siegel J, Iida H, Rachlin K, Yount G. Expressive arts therapy with hospitalized children: a pilot study of co-creating Healing Sock Creatures© . J Pediatr Nurs . 2016;31(1):92-8. doi:10.1016/j.pedn.2015.08.006

Koo M, Chen HP, Yeh YC. Coloring activities for anxiety reduction and mood improvement in Taiwanese community-dwelling older adults: a randomized controlled study . Evid Based Complement Alternat Med . 2020 Jan 21;2020:6964737. doi:10.1155/2020/6964737

Liddle JL, Parkinson L, Sibbritt DW. Painting pictures and playing musical instruments: change in participation and relationship to health in older women . Australas J Ageing . 2012;31(4):218-21. doi:10.1111/j.1741-6612.2011.00574.x

Laws KR, Conway W. Do adjunctive art therapies reduce symptomatology in schizophrenia? A meta-analysis . WJP. 2019;9(8):107-120. doi:10.5498/wjp.v9.i8.107

Farokhi M. Art therapy in humanistic psychiatry . Procedia - Social and Behavioral Sciences . 2011;30:2088-2092. doi:10.1016/j.sbspro.2011.10.406

By Kendra Cherry, MSEd Kendra Cherry, MS, is a psychosocial rehabilitation specialist, psychology educator, and author of the "Everything Psychology Book."

  • Research article
  • Open access
  • Published: 22 July 2021

Effectiveness of arts interventions to reduce mental-health-related stigma among youth: a systematic review and meta-analysis

  • Shivani Mathur Gaiha   ORCID: orcid.org/0000-0002-0636-8936 1 , 2 , 3 ,
  • Tatiana Taylor Salisbury   ORCID: orcid.org/0000-0002-8249-3886 4 ,
  • Shamaila Usmani 5 ,
  • Mirja Koschorke 4 ,
  • Usha Raman   ORCID: orcid.org/0000-0002-9023-9853 6 &
  • Mark Petticrew 2  

BMC Psychiatry volume  21 , Article number:  364 ( 2021 ) Cite this article

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Educational interventions engage youth using visual, literary and performing arts to combat stigma associated with mental health problems. However, it remains unknown whether arts interventions are effective in reducing mental-health-related stigma among youth and if so, then which specific art forms, duration and stigma-related components in content are successful.

We searched 13 databases, including PubMed, Medline, Global Health, EMBASE, ADOLEC, Social Policy and Practice, Database of Promoting Health Effectiveness Reviews (DoPHER), Trials Register of Promoting Health Interventions (TRoPHI), EPPI-Centre database of health promotion research (Bibliomap), Web of Science, PsycINFO, Cochrane and Scopus for studies involving arts interventions aimed at reducing any or all components of mental-health-related stigma among youth (10–24-year-olds). Risk of bias was assessed using the Effective Public Health Practice Project (EPHPP) Quality Assessment Tool for Quantitative Studies. Data were extracted into tables and analysed using RevMan 5.3.5.

Fifty-seven studies met our inclusion criteria ( n  = 41,621). Interventions using multiple art forms are effective in improving behaviour towards people with mental health problems to a small effect (effect size = 0.28, 95%CI 0.08–0.48; p  = 0.007) No studies reported negative outcomes or unintended harms. Among studies using specific art forms, we observed high heterogeneity among intervention studies using theatre, multiple art forms, film and role play. Data in this review are inconclusive about the use of single versus multiple sessions and whether including all stigma components of knowledge, attitude and behaviour as intervention content are more effective relative to studies focused on these stigma components, individually. Common challenges faced by school-based arts interventions included lack of buy-in from school administrators and low engagement. No studies were reported from low- and middle-income countries.

Arts interventions are effective in reducing mental-health-related stigma to a small effect. Interventions that employ multiple art forms together compared to studies employing film, theatre or role play are likely more effective in reducing mental-health-related stigma.

Peer Review reports

Stigma or a negative disposition towards mental ill-health and people with mental health problems is a widely recognized barrier in help-seeking for mental health problems [ 1 ]. Public stigma, consists of ‘problems of knowledge (ignorance), problems of attitude (prejudice), and problems of behaviour (discrimination).’ [ 2 ] Such stigma especially inhibits help-seeking by youth due to their inability to recognize mental health problems, difficulty in talking about their problems for fear of peer pressure and a negative perception of people with mental health problems as dependent, which clashes with their desire to be self-reliant [ 3 ]. Thus, although an estimated 10–20% of youth aged 10–24 years suffer from mental health problems, [ 4 ] 63–86% of all mental health problems that require a diagnosis generally go undetected [ 5 ]. Therefore, interventions targeting non-clinical youth groups to reduce mental-health-related stigma may promote youth help-seeking behaviour and ultimately address unattended mental health needs.

Most anti-stigma interventions and/or campaigns have been conceptualized using knowledge-attitude-behavior paradigm [ 6 ]. Knowledge is defined as information an individual perceives about mental health as a function of memory and stereotyping (related to, for e.g., treatment efficacy, symptom recognition, help-seeking, and employment), attitude is defined as perceptions or views towards people with mental disorders or about mental disorders (related to negative attitudes, for e.g., desiring social control and social distance), and behavior as intended or actual discriminatory actions towards people with mental health problems (related to, for e.g. social exclusion, which may contribute to status loss or human rights violations of someone living with a mental health problem) [ 2 , 7 , 8 , 9 ]. Further, effective strategies in anti-stigma interventions include education, social contact (interaction with a person who suffers from a mental health problem) and protest [ 10 ]. In addition, effective interventions are often locally tailored, perceived as credible and of a longer duration [ 11 ]. In school-based settings, experiential learning (learning through reflection on doing), empathy building, interactive and prolonged exposure to anti-stigma content is likely effective [ 12 , 13 ]. Overall, systematic reviews of anti-stigma intervention studies report that in the long term and among youth, educational interventions are likely more effective than social contact interventions in reducing stigma with moderate effect [ 14 , 15 , 16 ]. Among the approaches used, educational interventions have employed a variety of visual, literary and performing arts to improve relatability, interactivity and engagement.

Art is broadly defined as any means for expression of individual and social values, through concrete and artistic activities and processes [ 17 ]. Further per Dewey’s conceptualisation of art, arts interventions may communicate moral purpose or education [ 18 ] or explain experiences of one’s daily emotional and rational world [ 19 ]. The evidence for arts-based educational interventions is generally limited, despite its documented emotional and visceral effects [ 20 ]. Despite multiple, relevant systematic reviews, uncertainties remain regarding the overall effectiveness of arts-based interventions in reducing mental-health-related stigma and relative effectiveness of interventions employing different art forms, varying durations and conceptualizations of stigma. A review of 22 studies evaluating the impact of mass media interventions including film, photographs, radio and comics attributed reduced prejudice (attitude) for mental health problems to creative and artistic content [ 21 ]. The majority (86%) of studies in this review focused on student populations. Other reviews of studies among 11–18 year olds using creative activities such as music, dance, singing, drama and visual arts [ 22 ] and performing arts, [ 23 ] indicate that arts-based interventions improve knowledge, another component of mental-health-related stigma. As some reviews are focused on educational versus social contact-based interventions, [ 14 , 15 , 16 ] they do not focus on the distinguishing role of arts-based elements in achieving impact nor suggest the relative impact from using role play, theatre, film compared to other art forms.

Previous studies show that arts-based interventions have the potential to reduce mental-health-related stigma as they have improved individual components of such stigma, i.e. attitude and knowledge. However, little is known about the effectiveness of arts-based interventions in reducing overall mental-health-related stigma among youth, and whether interventions using specific art forms, duration and content on all stigma components of knowledge, attitude and behavior are more effective in reducing such stigma compared to individual components. The objectives of this study are to: (a) assess the effectiveness of arts-based interventions to reduce stigma associated with mental health among youth; (b) assess effectiveness of arts-based interventions by their duration; (c) assess whether a comprehensive approach to stigma is more effective than a focus on individual stigma components; and (d) identify barriers and facilitators in implementation of arts-based interventions and the role of implementation in building participant engagement and ultimately influencing how effective such interventions are in reducing stigma.

Eligibility criteria

Studies will be included in the review if they contain:

Interventions using any form of art or creative expression or storytelling as a key method were included. Such art forms include (1) using words in literary art (in stories, poetry, creative writing, essays and other forms), and through creation of physical objects and experiences, through (2) visual art (drawing, painting, sculpture, crafts, pottery, installation), and (3) performing art (theatre or dramatic improvisation or role-play, dance, puppetry, music, stand-up comedy, folk dance-drama). In this review, participants in included arts interventions should either be exposed to art (e.g., as an active observer/audience interpreting and responding to scenarios in a theatre production) or create their own art (e.g., as generating thought, meaning, aesthetic or object/s).

Interventions delivered to youth aged 10–24 years.

Outcomes related to at least one component of mental-health-related public stigma (three components outlined by Thornicroft et al. as problems of knowledge, attitude and behavior). Based on the literature any of these factors individually or in combination with one another contribute towards such stigma.

Qualitative, quantitative and mixed methods research. Study designs include controlled studies, including randomised trials, controlled clinical trials, cohort analytic studies and case-control studies. Pre-and post-studies with a single cohort and post-test only studies, qualitative and mixed methods studies were also included. Conference abstracts and case studies were included to capture all interventions. Mixed methods studies were defined as studies which involved “sequential or simultaneous use of both qualitative and quantitative data collection and/or data analysis techniques.” [ 24 ]

Studies were excluded from the review if they met one of the following criteria:

Target clinical, high-risk or at-risk populations (youth with mental disorders, including outpatients, in schools for special needs, in prisons, foster homes/ shelters and conflict zones or exposed to violence) or caregivers as these groups have unique personal experiences that might distinguish them from the general population.

Use mass media (newspapers, television and radio programmes, advertising, popular culture, cinema and songs, social media, blogs and other Internet or mobile phone).

Combine art with other strategies, where the effect of art is not separately reported.

Focus on intimate partner violence, sexual violence and gender-based violence, cyberbullying and domestic abuse.

Search strategy

The broad categories of terms used included art; mental health disorders/conditions; youth; and stigma (see Supplementary Table 1 for exact search terms used). The search strategy included Medical Subject Headings (MeSH) terms, where appropriate. Thirteen academic databases were searched: PubMed, Medline, Global Health, EMBASE, ADOLEC, Social Policy and Practice, Database of Promoting Health Effectiveness Reviews (DoPHER), Trials Register of Promoting Health Interventions (TRoPHI), EPPI-Centre database of health promotion research (Bibliomap), Web of Science, PsycINFO, Cochrane trials and database of systematic reviews and Scopus. Additional articles were searched using Google Scholar. The search was not limited by publication dates, countries or languages. This initial search for inclusion of papers was completed on 19 July 2018. From 28 March 2021 to 3 April 2021, the search was updated in all databases, except Global Health, Social Policy and Practice and Scopus (which the first author could no longer access). If two or more articles on the same intervention and target population were found, the most relevant article was retained for analysis. The Preferred Reporting Items for Systematic reviews and Meta-analyses (PRISMA) guidelines were used to report updated study findings (see Supplementary Table 2 for checklist) [ 25 ].

Data extraction

All titles and abstracts were assessed by a single reviewer (SMG). A second reviewer (SU) assessed 10% of all titles and abstracts to confirm accuracy of inclusion. The updated search was conducted by the first author and 895 additional articles were retrieved. Using the Quality Assessment Tool for Quantitative Studies developed by the Effective Public Health Practice Project (EPHPP), [ 26 ] a framework for data extraction was developed. The framework captured additional data on intervention characteristics and study design, related to review objectives. Full-text articles were independently assessed as per the EPHPP framework and data were entered in to tables by a single reviewer (SMG). The second reviewer assessed all full-text articles and cross-checked data in the framework. Discussion between reviewers compared quality ratings and key findings. Where consensus was not reached, a third reviewer (MP) was consulted.

Summary measures

The main study outcome was mental-health-related public stigma, which is composed of three components: knowledge, attitude and behaviour. Measures of these components include means and standard deviations, difference between means and level of significance ( p -value).

Synthesis and reporting of results

Demographic information of participants and qualitative themes were compiled in a narrative form. Firstly, means, standard deviations and sample sizes were pooled for each stigma-component/outcome for all studies, followed by art form or intervention type, to assess whether the type of intervention was responsible for a difference in outcomes. Change in stigma was plotted by pooling study-wise difference of means and standard deviations per component of stigma among studies with a study design rating of 1 or 2 per the EPHPP component ratings. As an illustration, for the behavior component of stigma we pooled mean differences from the Social Distance scale (a common proxy measure for behavioral intent) [ 27 ] and the Reported and Intended Behavior Scale [ 28 ]. If a study reported on multiple items within each stigma component, then the item with the lowest (stigmatising) mean score change was included. We calculated the mean score change from data available in the study text and tables, wherever available. Change in outcomes related to stigma (knowledge, attitude and actual or intended behaviour) were pooled by intervention type or art form, i.e. multiple art forms, film, theatre and role play. Next, a post-hoc sub-group analysis of data was conducted by intervention duration (single versus multiple sessions). Finally, studies which took a comprehensive approach to stigma (measured knowledge, attitude and behaviour components, together and likely also included content addressing each of these components) were pooled for their the impact on individual stigma components. These analyses were presented alongside pooled studies measuring individual stigma components such as knowledge or behaviour alone. This was done in order to assess whether a comprehensive approach leads to better outcomes within each stigma component. Meta-analysis, where appropriate, was conducted using Review Manager software (Version 5.3.5) [ 29 ]. Heterogeneity of studies was assessed through I 2 values> 0, and random-effects models were generated to calculate the effect size on stigma. A random-effects model with standardized mean differences was preferred as study populations and locations, recruitment processes, points of time for implementation and assessment measures varied. Narrative synthesis was used to collate findings regarding barriers and facilitators in reducing stigma.

The search produced 19,892 articles, of which 187 articles were identified for full-text review (Fig.  1 ). Of these, 132 were either contextual articles without an arts intervention, epidemiological studies assessing impact from exposure to media, reviews on related aspects of stigma or youth or studies that did not meet the inclusion criteria. Finally, 57 studies (53 full-text articles and four conference abstracts) were included in this systematic review.

figure 1

PRISMA flow chart

Study characteristics

Of the 57 included studies, 43 quantitative studies, [ 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 39 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 49 , 50 , 51 , 52 , 53 , 54 , 55 , 56 , 57 , 58 , 59 , 60 , 61 , 62 , 63 , 64 , 65 , 66 , 67 , 68 , 69 , 70 , 71 , 72 ] six qualitative studies [ 73 , 74 , 75 , 76 , 77 , 78 ] and eight mixed methods studies [ 79 , 80 , 81 , 82 , 83 , 84 , 85 , 86 ] were identified. Data from 57 studies (by intervention type) on sample size, participant profile, study design, intervention description, duration and frequency, number of follow-ups, and outcomes related to knowledge (K), attitude (A) and actual/ intended behaviour (B) are summarised in Table 1 . Quantitative studies reached 26,634 youth and eight mixed methods studies reached 14,021. Qualitative studies engaged 966 youth, however the number of participants is unclear in two studies [ 73 , 87 ].

Nearly all studies were conducted in high-income countries, 44% were located in USA, 26% in the UK, and 9% each from Canada and the rest of Europe, and another 9% from Hong Kong, Japan, Australia and UAE. Only three studies were carried out in upper-middle-income countries of Brazil, [ 81 ] Turkey, [ 30 ] and Malaysia [ 39 ]. No studies were conducted in low-income countries. Six studies were published before 1995, 16 studies from 1996 to 2005 and 35 studies were published after 2006. Over half the studies focused on middle and high school students (53%), and the remaining studies targeted college students (42%) and youth in the community (5%). About 72% of college-based studies concentrated on health professionals’ in-training (medicine, health sciences, psychiatry, psychology, pharmacy or nursing) [ 30 , 32 , 34 , 38 , 39 , 40 , 42 , 50 , 51 , 58 , 68 , 72 , 77 , 78 , 81 , 83 ]. Diverse stigma assessment measures were used by 33 of all quantitative and mixed methods studies (including modified instruments), [ 30 , 31 , 33 , 34 , 35 , 37 , 38 , 39 , 40 , 42 , 43 , 44 , 45 , 47 , 49 , 50 , 51 , 52 , 54 , 55 , 57 , 62 , 63 , 65 , 66 , 67 , 68 , 71 , 72 , 79 , 83 , 84 , 85 ] while 5 remaining studies used newly developed measures [ 36 , 58 , 61 , 64 , 69 ] and 13 studies did not specify instruments used or used informal/oral feedback or open-ended questions [ 32 , 41 , 46 , 48 , 53 , 56 , 59 , 60 , 70 , 80 , 81 , 82 , 86 ].

Study designs

Quantitative studies.

Seventy-five percent ( n  = 43) of included studies used a quantitative design. Eight studies were randomised controlled trials (RCT) [ 31 , 34 , 39 , 43 , 45 , 52 , 53 , 72 ]. Other quantitative studies include 10 controlled clinical trials, [ 33 , 38 , 40 , 49 , 50 , 51 , 54 , 55 , 57 , 68 ] nine studies used a two group, pre-post design, [ 30 , 41 , 47 , 58 , 59 , 61 , 66 , 67 , 69 ] 12 studies used a single group pre-post design, [ 35 , 36 , 37 , 42 , 44 , 46 , 56 , 60 , 62 , 63 , 65 , 71 ] and four studies employed a post-test only design [ 32 , 48 , 64 , 70 ].

Qualitative studies

Of six qualitative studies, one did not clearly define the method of qualitative research, [ 73 ] two used in-person and/or telephonic semi-structured interviews, [ 75 , 77 ] a study used focus group discussions (FGD), [ 76 ] another used ethnographic procedures, [ 74 ] a study used students’ reflective essays, short films, and course evaluations, [ 78 ] and two used field notes and observation [ 74 , 76 ].

Mixed methods studies

Mixed methods were used to supplement studies, which were overtly quantitative: a RCT, [ 86 ] a controlled clinical trial, [ 79 ] a one-group pre and post study [ 80 , 83 , 84 , 85 ] and two qualitative studies, included surveys [ 81 , 82 ]. These studies reported the use of observations [ 79 , 82 , 86 ] open-ended questionnaires, [ 79 , 82 , 83 , 84 , 86 ] semi-structured interviews, [ 80 ] group interviews, reflective groups and FGDs, [ 81 , 82 ] drawing and explanatory writing, [ 84 ] and field notes [ 86 ].

Intervention design

Eighteen quantitative studies involved multiple art forms (creative writing, role-play, theatre, film/ slideshow, collage), [ 30 , 32 , 36 , 37 , 40 , 44 , 48 , 49 , 50 , 53 , 54 , 56 , 58 , 62 , 63 , 66 , 67 , 69 ] 15 studies involved film (including two RCTs), [ 31 , 33 , 34 , 35 , 39 , 42 , 43 , 45 , 46 , 51 , 52 , 55 , 59 , 64 , 68 ] eight used theatre (including puppetry and stand-up comedy), [ 38 , 41 , 47 , 57 , 60 , 61 , 65 ] and three used role-play [ 70 , 71 , 72 ]. Complementary lectures and educational material were used in 16 studies [ 30 , 32 , 33 , 36 , 39 , 40 , 44 , 49 , 50 , 53 , 58 , 63 , 66 , 67 , 69 , 70 ] and social contact was included in eight studies [ 30 , 31 , 33 , 34 , 39 , 42 , 51 , 68 ]. Professionally created art was used in 34 (79%) of studies [ 30 , 31 , 32 , 33 , 34 , 35 , 36 , 37 , 38 , 40 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 50 , 51 , 52 , 54 , 55 , 56 , 58 , 59 , 60 , 61 , 62 , 64 , 66 , 67 , 68 , 72 ] and only nine studies reported some form of voluntary participation or participant input [ 34 , 38 , 45 , 47 , 51 , 56 , 57 , 65 ]. Twenty-four studies evaluated single sessions (mostly of 1 hour’s duration) [ 30 , 32 , 33 , 34 , 38 , 39 , 41 , 42 , 43 , 44 , 45 , 46 , 47 , 48 , 50 , 51 , 52 , 55 , 56 , 57 , 61 , 63 , 68 , 72 ] and 12 studies reported between two six sessions, [ 31 , 36 , 41 , 49 , 54 , 58 , 60 , 62 , 65 , 66 , 67 , 71 ] and in the remaining seven interventions, the number of overall sessions is not clear [ 35 , 37 , 40 , 59 , 64 , 69 , 70 ].

Among eight RCTs, varied combinations of stigma components improved in a majority of studies, except a study using role play which reported no significant change in any aspect of stigma [ 72 ]. Only one RCT measured and improved all components of mental health stigma (KAB) using film [ 34 ]. Other RCTs improved: attitude and behaviour using film [ 39 ]; knowledge and attitude using multiple art forms [ 53 ] and film [ 31 ]; attitude using film [ 43 , 45 ]; and behavior using film [ 41 , 52 , 56 ]. Intervention content included facts on incidence, causes, symptoms and warning signs of mental illness, broadly and about specific disorders, including bipolar disorder, schizophrenia, depression, substance abuse and suicidal behaviours. Social contact was used to describe negative experiences of stigmatisation using filmed or dramatised interventions. Even single session interventions included multiple art forms [ 30 , 48 , 63 ].

From the six qualitative studies, three studies employed theatre interventions, [ 74 , 75 , 77 ] two used multiple arts forms, [ 73 , 78 ] such as music, radio, documentary and visual arts or students’ reflective essays and short films [ 78 ] and another used dance [ 76 ]. In four out of six qualitative studies, participatory or collaborative approaches involved students as performers of art or as collaborators in co-creating art with persons living with mental health problems [ 73 , 75 , 76 , 78 ]. Only one intervention study comprised a single session [ 74 ] and other the other five studies involved multiple sessions, with intervention duration ranging from 2 weeks [ 73 ] to 8 months [ 75 ].

The study reporting a positive improvement in all components of mental health stigma (KAB) used a professional play, followed by role-play [ 74 ]. Among other studies, two using theatre, [ 75 , 77 ] one using music and visual arts [ 73 ] and one using dance [ 76 ] suggest positive gains in knowledge and attitude (KA) related to mental health problems and drug use, and reducing awkwardness and increasing empathy. The study involving music and creation of short films on dementia reported that 27% of participants continued to volunteer in dementia care settings after the intervention was completed [ 78 ].

Six out of eight studies involved professionally created art, [ 79 , 81 , 83 , 84 , 85 , 86 ] while the other studies helped youth create their own rap songs [ 82 ] and participate in a choir [ 80 ]. Three interventions used multiple art forms (film, theatre, rap songs, role play and educational materials) [ 81 , 82 , 86 ] and one each used children’s books, [ 79 ] song lyrics, [ 81 ] film [ 83 ] and interactive theatre [ 84 ]. Collaborative art or co-created art was evaluated using a post-only survey and interviews [ 82 ]. Only one study used an intervention that lasted a single day [ 84 ] and other interventions ranged from between 4 weeks [ 86 ] to 10 weeks [ 80 , 83 ]. In another study follow-up material was mailed to participants for 12 months after the intervention [ 85 ]. Only one mixed-methods study stated that youth participation was voluntary [ 82 ].

Three studies report changes in all components of mental health stigma (KAB), one using theatre, [ 84 ] another using film [ 85 ] and another other using multiple art forms [ 86 ]. These studies include knowledge about drugs, mental health awareness and self-recognition; attitudinal change that anyone could be affected by mental health problems and behaviours such as reduced negative words and desire to help those in need (intended behaviour). A study each improved acceptance and bystander responses (AB), [ 79 ] and knowledge about substances (K) [ 81 ]. and two studies improved knowledge and attitudes related to substances and dementia (KA) [ 82 , 80 ].

Risk of bias

Overall, study quality rated using the EPHPP tool [ 26 ] ranged from weak to moderate, with some studies displaying strong methodological aspects (Fig.  2 ). A detailed quality rating of included studies is in supplementary Table 3 . Regarding study design, eight studies were accurately described as randomised controlled trials (RCT), [ 31 , 34 , 39 , 43 , 45 , 52 , 53 , 72 ] 20 were quasi-experimental studies with control groups, while the remaining had weaker designs. Participants were not representative of the population in 17 studies, mostly because they self-selected [ 35 , 36 , 37 , 38 , 41 , 42 , 44 , 45 , 55 , 56 , 57 , 60 , 62 , 65 , 67 , 69 ] and were partially representative of the population in another 17 studies, where participants were referred from a school or university [ 30 , 31 , 33 , 40 , 43 , 46 , 47 , 49 , 50 , 51 , 54 , 58 , 59 , 61 , 63 , 66 , 71 ]. Six studies had participation rates greater than 80%, [ 35 , 58 , 61 , 63 , 72 ] six studies had participation rates between 60 and 79%, [ 30 , 33 , 34 , 46 , 47 , 54 ] 11 studies had participation below 59%, [ 38 , 45 , 50 , 51 , 52 , 57 ] and remaining studies did not report participation rates. Studies had varied drop-out rates, the highest being 59% [ 60 ].

figure 2

Study quality of quantitative studies (risk of bias as per EPHPP tool) ( n  = 43)

Researchers were blinded to participant exposure in four studies [ 39 , 50 , 51 , 52 ] and in 16 studies participants were unaware of study aims [ 33 , 34 , 39 , 40 , 41 , 42 , 45 , 47 , 50 , 51 , 54 , 55 , 58 , 61 , 68 , 71 ]. Only 17 studies reported and adjusted for potential confounders [ 30 , 33 , 38 , 40 , 41 , 44 , 45 , 47 , 50 , 52 , 54 , 55 , 60 , 61 , 63 , 67 , 69 ]. Seven studies used data collection instruments that were not validated, [ 35 , 41 , 46 , 56 , 59 , 65 , 69 ] of which two studies established reliability of instruments used [ 35 , 59 ]. Of the remaining 36 studies using validated instruments, 10 did not establish reliability [ 30 , 37 , 43 , 44 , 49 , 57 , 60 , 63 , 66 , 70 ]. Approximately half of quantitative studies (53%) did not follow up after post-test (typically 1 month or immediately post-test) ( n  = 43) [ 30 , 33 , 35 , 37 , 38 , 41 , 43 , 44 , 45 , 49 , 50 , 55 , 56 , 57 , 58 , 61 , 63 , 65 , 66 , 67 , 68 , 69 , 72 ]. Several studies in this review highlight short-term measurement of impact as a limitation [ 31 , 35 , 37 , 39 , 41 , 51 , 57 , 58 , 64 , 67 , 79 , 86 ].

Overall, studies using film had good quality, studies using theatre had moderate quality and studies using multiple art forms and role play had weak study designs. Confounders were better addressed by studies using theatre and multiple art forms, compared to role play and film. Valid and reliable data collection instruments were used by studies using theatre and film, followed by multiple art forms and lastly, role play.

From six qualitative studies, a study lacked quotations to assess validity of conclusions, [ 73 ] and one study presented quotations as a response to questionnaires [ 74 ] [ 87 ]. One study reported full participation, [ 75 ] rate of participation varied from 10 to 88% in three studies [ 74 , 76 ] and was not specified in the remaining three studies [ 73 , 77 , 78 ].

Out of eight mixed methods studies, one included a cluster randomized controlled trial, [ 86 ] seven reported quantitative outcomes, [ 79 , 80 , 81 , 82 , 83 , 84 , 85 ] however only two studies included sufficient qualitative data [ 82 , 84 ]. Participant response rate was not specified in five studies, [ 81 , 82 , 84 ] [ 80 , 86 ] below 60% in one study [ 83 ] and above 80% in three studies [ 79 , 85 ].

Synthesis of results

Outcome measures.

All 57 studies reported various combinations of mental-health-related public stigma components as outcomes, i.e., knowledge, attitude and intended behaviours (see area-proportional Venn diagramme [ 88 ] in Fig.  3 ). Six out of eight studies with a randomized controlled study design reported a significant positive change all stigma components reported, [ 34 , 39 , 43 , 45 , 52 , 53 ] including one RCT which reported positive, significant effects on all knowledge, attitude and behaviour outcomes (KAB), [ 34 ] another RCT on attitudes and behaviors (AB), [ 39 ] one RCT on knowledge and attitudes (KA), [ 53 ] two RCTs on attitudes [ 43 , 45 ] and one on behavior [ 52 ]. Of the remaining two studies, one found no significant difference in AB [ 72 ] and another reported no change in behaviour in a study reporting all KAB components [ 31 ]. In 10 controlled clinical trials of strong study design, four studies reported positive significant effects on KAB, [ 33 , 40 , 49 , 50 ] three studies reported positive significant effects on AB, [ 38 , 51 , 68 ] two reported positive significant effects on attitudes [ 54 , 57 ] and only one reported no significant effect [ 55 ]. Per the EPHPP risk of bias assessment, two studies of moderate global study quality show positive effects on AB, [ 39 , 68 ] two show positive effects on attitudes [ 54 , 57 ] and one showed a sustained effect in reducing stigmatizing behavioral intent [ 52 ]. Seven studies collected follow-up data an average of 4 months post-intervention [ 33 , 34 , 38 , 43 , 51 , 54 , 66 ]. Two of these seven studies showed positive and significant results on KAB at follow up, [ 33 , 34 ] and the remaining studies on attitude and behaviour [ 38 , 43 , 51 , 54 , 66 ]. Nearly all quantitative studies ( n  = 40 out of 43) reported positive changes on at least one stigma-related outcome, including 12 studies with strong study design quality [ 33 , 34 , 38 , 39 , 40 , 43 , 45 , 49 , 51 , 54 , 57 , 68 ] and 17 studies with moderate study quality [ 30 , 36 , 37 , 41 , 42 , 47 , 58 , 60 , 61 , 62 , 63 , 65 , 66 , 67 , 69 , 71 ]. No study reported a negative outcome.

figure 3

All studies, by combinations of stigma outcomes reported ( n  = 57)

Out of six qualitative studies one reported positive changes in KAB, [ 74 ] three studies improved knowledge and attitudes (KA) associated within mental health [ 75 , 77 , 78 ] and the remaining two studies improved knowledge (K) by way of recall and the level of awareness about mental health problems [ 73 , 76 ]. Three studies focused on reducing stigma associated with drug-related issues, [ 73 , 74 , 76 ], one study on dementia, [ 78 ] one study on depression, anxiety, panic and stress, [ 75 ] and one on trauma [ 77 ]. Studies focused on the process of using art as a stimulus for discussion and narratives focused on achieving attitudinal change, positive self-esteem, purpose and satisfaction from participation . Some of these studies highlight the emotional impact of art as a tool to relate stories and personal experiences, [ 77 , 78 ] changes in how youth use labels and describe interactions with people living with mental health problems, [ 75 ] and one reportedly led to substantial increases in requests for counselling [ 74 ].

From five mixed methods studies, three studies reported positive results on KAB, one study reported positive impact on attitude and behaviour (AB), [ 79 ] another two studies reported positive changes in knowledge and attitude (KA), [ 82 , 86 ] one study improved specific attitudes only [ 83 ] and lastly, one study improved knowledge [ 81 ].

  • Meta-analysis

Effectiveness of art in reducing components of stigma

There was no significant difference in whether arts interventions improved behaviour towards people with mental health problems compared to a control group (effect size = 0.12, 95%CI -0.01-0.25; p  = 0.07) (Fig.  4 ), and moderate heterogeneity was reported across studies (I 2  = 47%). High heterogeneity of studies on knowledge and attitude outcomes made meta-analysis inappropriate (88–94%).

figure 4

Meta-analysis of arts interventions on mental-health-related knowledge, attitude and behaviour

Effectiveness of different art forms

The largest positive effect on knowledge may be attributed to interventions using multiple art forms (effect size = 1.47, 95%CI -0.19-3.13; p  = 0.08), followed by film (effect size = 0.14, 95%CI -0.21-0.50; p  = 0.42) (Fig.  5 ). However, the I 2 value for pooled studies in this meta-analysis, reporting knowledge-related outcomes, was between 84 and 98%. No data were available for theatre, role play or other studies with respect to knowledge. Similarly, the impact of interventions using theatre, film, multiple art forms and role play on changing attitudes was not significant. Studies pooled by each of these art forms had heterogeneity, ranging from I 2  = 80–94%. Interventions using multiple art forms were the only ones that significantly reduced stigmatising, practised or intended behaviours (effect size = 0.28, 95%CI 0.08–0.48; p  = 0.007) (Fig. 5 ). Theatre-based interventions pooled by behavioural outcomes showed low heterogeneity (I 2  = 20%) and film-based studies pooled by behavioural outcomes showed moderately high heterogeneity (I 2  = 67%). No data were available from studies using role play and other art forms, due to lack of precise measurement or poor quality of reporting.

figure 5

Meta-analysis of mental-health-related knowledge, attitude and behaviour, by intervention art form

Effectiveness of interventions by duration

Studies pooled by duration, i.e., whether single session interventions or multi-session interventions, displayed moderate to high heterogeneity (I 2  = 51–99%) and did not show any significant effect on knowledge, attitude or behavior (Fig.  6 ).

figure 6

Meta-analysis by intervention duration and studies focusing on all stigma components

Comprehensive approach versus focus on individual stigma domains

Studies that took a comprehensive view of stigma showed no significant improvement in behavior (effect size = 0.12, 95%CI -0.03-0.27; p  = 0.11). The I 2  = 0% indicates that pooled studies had low heterogeneity, and therefore that the meta-analytic approach was appropriate (see Supplementary material 4 : figure). These studies focused on all components of knowledge, attitude and behaviour (KAB) in measurement and possibly also in intervention content. For knowledge- and attitude-related outcomes in studies reporting KAB, there appeared to be a positive effect (effect size = 0.09–0.25), but there was high heterogeneity among pooled studies (I 2  = 84%) and these results were not significant. There were no studies that focused on knowledge, attitude and behavior components of stigma alone and that met study design quality benchmarks for meta-analyses.

Barriers and facilitators in implementation and reducing stigma

Overall, multiple mechanisms and contingencies were reported to influence implementation and participant engagement, especially attendance and quality of delivery. Fluctuating intervention attendance, [ 82 ] awkwardness and scepticism, [ 57 , 59 , 86 ] language-related issues, [ 74 , 82 ] group and gatekeeper dynamics [ 57 , 66 , 75 ] and logistical issues [ 70 ] influenced implementation in several studies. In a large number of studies females were overrepresented [ 32 , 38 , 42 , 45 , 50 , 51 , 67 , 75 , 76 ]. Unintended consequences were reported in a study using multiple art forms (professional theatre, quiz and games) with school children, where mental health problems were normalised to the extent that participants felt that these problems did not have much of an adverse impact [ 37 ].

Active ingredients that facilitate successful delivery of arts-based interventions include institutional endorsement for the initiative at educational institutions [ 39 , 75 ] and scheduling sessions during class times [ 31 , 38 , 41 , 49 ]. Clear content, [ 55 , 68 ] a diversity of views from presenters [ 34 , 66 ] and involving people with mental health problems for embedded social contact were perceived to reduce stigma [ 31 , 34 , 42 , 50 ]. Visual stimuli and expressive arts-based techniques were useful tools to facilitate participation [ 64 , 86 ]. Further, high quality, emotionally powerful art performed may help achieve a stronger, anti-stigma stance among participants. Thus, several studies highlight the value of involving professional artists [ 37 , 60 , 73 , 82 , 84 ]. In one study that involved youth in performing scripted theatre, [ 54 ] the authors observed that even deeper participation was needed to reinforce key ideas. A study which enabled youth to act in scripted plays highlighted the importance of public reinforcement of messages through performance, however to align content to participant experiences, it recommended that participants write their own scripts [ 54 ].

Youth arts projects meet social needs of young people to engage in a popular programme [ 76 ]. They involve people external to educational institutions, which studies felt youth appreciate [ 65 ]. Additionally, youth projects accord an equal status among participants, [ 39 ] which according to Fernandez et al. is ideal for ‘cooperational education,’ where students learn and evaluate key programme messages collaboratively. Such interventions simultaneously use skills-building and educational appeals, rather than purely emotional ones, an approach which has been suggested as longer lasting. The Studio 3 Arts project among 13–21 year olds in the United Kingdom created participatory music, radio, documentary and visual arts for drugs-related awareness [ 73 ]. However, findings were inadequately reported from the perspective of effective intervention components. The project was reported in a brief, non-technical, magazine style which described the process and provided limited participant quotations or summaries of their experience as support. A pilot mixed methods study of VoxBox, co-creating rap music with high school students in Australia showed non-significant positive changes in knowledge, attitude and intended behaviour related to alcohol users [ 82 ]. Twardzicki et al. conducted a study in the UK in 2008 which generated theatre productions through discussion between people with mental health problems and college students [ 65 ]. Rowe et al. conducted a similar study in 2013 with students belonging to a theatre major, who co-created art on the theme of mental health with users of mental health services [ 75 ]. Although this study had a small sample size, its authors suggest that ‘shared, theatre-making may create an environment that challenges stereotypes and reduces prejudice.’ [ 75 ] Studies that used participatory, co-creation of art in this review, predominantly used qualitative and mixed methods for evaluation. These studies also demonstrate the impact of youth participatory arts projects focused on mental-health-related public stigma as a theme on critical thinking, problem-solving and building team spirit.

Summary of evidence

This review finds positive indications for the use of art to address mental health stigma among youth. Although, strong assertions about effectiveness are not plausible given poor methodological quality of studies, results from this meta-analysis are indicative of a direction of travel supporting the effectiveness of art-based interventions.

Arts interventions are generally effective when they use multiple art forms, but with a small effect. This study also demonstrates that we do not affirmatively know whether interventions with multiple sessions had a greater effect on stigma, relative to single day interventions. Further, it remains inconclusive whether a comprehensive approach to stigma (including all stigma components of knowledge, attitude and behaviour in an intervention study), translates to significant improvements in knowledge, attitude and/or behaviour relative to studies focused on changing each of these individual stigma components. Common challenges faced by interventions related to buy-in from school or college stakeholders and youth engagement. No studies were reported from low- and lower-middle-income countries, and this highlights the need to develop, and report results from arts-based interventions in those contexts. No studies reported negative outcomes or unintended harms.

This review does not provide evidence to support conclusions from reviews by Schachter [ 13 ] and Mellor [ 12 ] on school-based interventions to reduce mental health stigma, that use of multiple art forms may coincide with multiple exposures and a more intensive engagement. The use of multiple art forms may have attracted and engaged participants with varied interests to reinforce concepts related to the theme of mental-health-related stigma. Overall, the most commonly reported underlying theory is Bandura’s social learning theory, where youth are likely to emulate [ 89 ] less stigmatizing behaviour if they observe stereotypes or are able to concretize their experiences through art. Film-based studies were too heterogenous, likely due to varying educational content including filmed theatre or social contact or documentary; varying duration of films and varying complementary activities such as discussion or role-play.

Multiple art forms are potentially more impactful than other art forms in lowering stigma as a combination of art forms likely aims for a more intense experiences compared to use of a single art form [ 90 ]. These programs have the potential for greater interactivity and longer duration as well as the possibility of attracting youth who may be interested in using or engaging with at least one art form among several deployed. Findings related to the effect of theatre and role play in this review, are supported by Joronen’s review on school-based drama, which showed short-term effects on health-related knowledge and behaviour [ 91 ]. Our findings related to implementation barriers such as inconsistent participant attendance may be overcome by recommendations by authors of included studies to use participatory student arts-based projects that involve direct youth engagement. Given that including voluntary role play as 20% of an intervention on mental illness led to changes in youth knowledge and attitudes in a recent study, [ 92 ] one may expect a positive response and increased acceptability in studies where participant-created art is a complementary component. However, most intervention studies in this review involved mandatory attendance of professionally created art.

In this review, collaborative art or co-created art involving students was evaluated using mixed methods (post-test only for one group) or qualitative research. Other recent studies place the responsibility of creating art directly in the hands of young people through a variety of art forms: photo-voice; scripting, filming, and editing a public service announcement targeted to peers, and words and messages in response to a participatory public art project on mental health [ 93 , 94 , 95 , 96 ]. Study outcomes relate to enabling participants to describe their perceptions in relation to mental health, share personal experiences of stigmatized topics and the ability to participate in a project that validates that mental illness is real and acknowledges the need for shame-free mental health awareness [ 95 ]. As more rigorous evaluations of these participatory interventions are conducted, and an expanded range of outcomes are studied, their effectiveness in changing participants’ knowledge, attitudes and behavior associated with people with mental health problems will become clearer.

Most arts-based interventions target health professionals in-training. College students from other backgrounds should justifiably have access to age-appropriate interventions on mental health stigma for prevention, early detection and acceptance of people with mental health problems. Further, three studies in this review observed that their interventions were likely more effective for older adolescents compare to children, [ 62 , 69 , 79 ] potentially because older adolescents have the confidence to communicate and skills to analyse complex, social and individual emotional responses.

Study strengths

This review is unique because it collates evidence on pragmatic dilemmas of mental health promotion faced by policy-makers, researchers, practitioners and communicators/educators. It is also unique in its comprehensiveness, as it explores the effectiveness of arts-based interventions across a range of mental health stigma-related outcomes, study designs, art forms and intervention durations. This review takes a broad view of art and mental-health-related stigma. Other systematic reviews of interventions in mental health prevention include creative, artistic or entertainment techniques, and also do not acknowledge them as ‘art.’ [ 97 , 98 , 99 , 100 , 101 , 102 , 103 , 104 , 105 , 106 , 107 , 108 , 109 , 110 , 111 , 112 , 113 ] Many studies in this review use arts-based interventions, but do not explicitly recognise or state that they use art, expand on the purpose of art or define a clear pathway to change or theory of change through arts interventions. This review included all such studies in addition to including a wide range of arts-based techniques and mental health conditions.

This review examines the theoretical understanding that comprehensively addressing all components of stigma is likely to impact intended behaviour towards people with mental health problems and towards help-seeking, rather than focusing on knowledge or attitude alone. The sub-group analysis by stigma components, extends the approach in a systematic review by Hanisch et al. in 2016, where they assessed and plotted successful impact on knowledge, attitude and behaviour outcomes from workplace interventions [ 114 ]. While duration of follow-up has been a subject of investigation for many systematic reviews, the impact of intervention duration (single vs multiple sessions) is explored by this review, although we observed inconclusive results.

Limitations

As per the EPHPP tool, [ 26 ] none of the quantitative studies received a strong overall rating. Studies scored poorly in terms of blinding of researcher awareness to intervention allocation, and selection bias due to convenience sampling and participant self-selection, which is common in researcher-led communication or public engagement interventions. Our search returned few randomized and/or controlled trials assessing the effectiveness of arts-based interventions on mental-health-related stigma overall, and its components of knowledge, attitude and behavior. Since interventions are continuously being designed and developed, this review sought to analyse all available evidence to inform stigma-reduction initiatives amongst young people. Thus, we have included all studies (including quasi-experimental studies) of generally high quality in our meta-analyses, to identify a direction of impact, no impact or negative impact rather than focus on estimates of expected change in outcomes. Readers are encouraged to review confidence intervals and heterogeneity to gauge the level of certainty of expected outcomes when implementing a study using arts interventions.

Specific subgroup analyses were affected by high heterogeneity (I 2 values). In addition, several studies provided inadequate data and therefore, were not pooled. For the sub-group analysis by duration, varying time-points for follow-up and lack of follow-up implied that studies could not be pooled and that only short-term effects at post-test (up to 1 month) could be feasibly calculated. Sub-group analysis by middle school, high school and university was not conducted due to fewer pooled studies. Other aspects that may have led to general heterogeneity include complementary components such as social contact [ 10 , 13 , 115 , 116 ] and differences in measuring stigma. Finally, the concept of art, relationship of participants with observing and creating different art forms and therefore the relative effectiveness of interventions based on arts, are likely influenced by the cultural context in which such art interventions are applied. It was not feasible for this study to factor in cultural differences in how the impact of arts interventions vary across cultures.

Studies measured different combinations of mental-health-related stigma components. The most common methodological issue cited by nearly all studies was the extent to which participant responses were affected by social desirability. Several studies used intended behaviour as a reasonable measure of actual behaviour, since measuring actual stigma-related behaviour is challenging [ 31 , 33 , 34 , 36 , 47 , 55 , 79 ]. A study argued that intended behaviour consisted of beliefs, self-efficacy to act on those beliefs and perceived benefit from behaviour [ 62 ]. To address these issues, this review focused on a multi-pronged concept of stigma, which is more comprehensive (included a combination of knowledge, attitude and behaviour components) and also focused on intended behavior. If studies found that both knowledge and attitude or any combination of knowledge, attitude and behavior (as mental-health-stigma-related components) changed after an arts intervention, we found that such studies did not correlate or discuss the relationship between knowledge, attitude and behavior components. We believe these findings could be important for readers interested in implementing arts interventions who may need to understand whether incremental changes in knowledge may or may not be correlated with changes in attitude and intended behavior.

Conclusion and implications

Overall, the studies reviewed demonstrate that arts interventions have limited effects on reducing young people’s discriminatory behaviour towards people living with mental health problems. The review specifically indicates that using multiple art forms in arts-based interventions likely impact youth behaviour towards people living with mental health problems. While the quality of evidence included in this review is modest, the number of interventions using arts-based methodologies and a strong direction of travel for impact on stigma indicate the scope for application of its findings.

This review identifies several opportunities to develop arts-based education to reduce mental-health-related stigma. First, the dearth of such interventions in low- and lower-middle- income countries calls for the development of new, contextual initiatives. Second, since most interventions are implemented in partnership with the education sector, school and college authorities should be sensitized to the need for mental health promotion and should consider including arts-based educational interventions as part of their curriculum. Third, interventions may focus on young adults in college and not just those who are training for healthcare-related careers. Fourth, student-led arts projects may be useful to explore mental-health-related stigma in an interactive format, which may then serve to reinforce social norms that are anti-stigma. Future intervention development may involve empirical development of student arts projects or participatory arts-based interventions to reduce stigma. Finally, robust, real-world evaluations are needed in the future that go beyond short-term follow-up periods.

The review suggests that conceptualization of art and content also require closer attention. For instance, the purpose of using art may be expanded beyond information-sharing to a transformative process, providing a sense of agency to participants to take supportive decisions and actions when confronted by a person with a mental health problem or attending situation. Student art projects or co-creation of art to reduce mental-health-related stigma may embody such a concept, and finds support in two theories: 1) Fisher’s communication narrative theory where art is a form of communication and storytelling and storytelling has the potential to re-shape the social world [ 117 ] and 2) Goldblatt’s interpretation of Dewey’s theory of art as experience, which highlights the transformative role of art in removing fear and prejudice, spurring critical analysis and empowering youth to achieve social justice [ 18 ]. With regard to content, future research on stigma-related theories may define conceptual boundaries between stigma components of knowledge, attitude and behaviour, and interrelations and possible hierarchies among these components. Such research would strengthen and guide intervention content, for example, by informing intervention planners whether a gain in knowledge about causes of mental health problems or change in attitude that people with mental health problems are to be feared could be instrumental in reducing negative behaviours, such as the use of harsh words against people with mental health problems. Such research must be based on cultural understanding and interpretations of mental health problems.

Notably, this is the first global review of arts-based interventions to reduce stigma associated with mental health problems. Practical and action-oriented findings from the review may inform anti-stigma interventions and other mental health promotion interventions using youth engagement strategies. Continuous knowledge-sharing of active ingredients in effective interventions and implementation research is needed to ensure the successful adaptation of arts-based interventions across settings.

Availability of data and materials

The data supporting the conclusions of this article are included within the article tables and figures.

Abbreviations

Preferred Reporting Items for Systematic reviews and Meta-analyses

Standard Error

Confidence Interval

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This work was supported by a Wellcome Trust Capacity Strengthening Strategic Award to the Public Health Foundation of India and a consortium of UK universities. The funders did not play a role in data analysis or preparation of this manuscript.

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Shivani Mathur Gaiha

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Shivani Mathur Gaiha & Mark Petticrew

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Tatiana Taylor Salisbury & Mirja Koschorke

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SMG conceptualized the study purpose and method. SMG searched all databases, and jointly reviewed inclusion of studies with SU through discussion. SMG extracted relevant data, updated the search and wrote the manuscript with support from TTS and MP, who also helped supervise the project. TTS, MK, UR and MP provided detailed comments and edited the manuscript. All authors read and approved the final manuscript.

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Supplementary Information

Additional file 1..

 Search strategy for arts-based interventions to reduce mental-health-related public stigma among youth.

Additional file 2.

PRISMA checklist.

Additional file 3: Table S3.

Quality rating of all quantitative studies using the Quality Assessment Tool from the Effective Public Health Practice Project (EPHPP).

Additional file 4. 

Meta-analyses of studies focusing on all KAB aspects of stigma (a comprehensive approach to measurement and possibly intervention. content).

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Gaiha, S.M., Salisbury, T.T., Usmani, S. et al. Effectiveness of arts interventions to reduce mental-health-related stigma among youth: a systematic review and meta-analysis. BMC Psychiatry 21 , 364 (2021). https://doi.org/10.1186/s12888-021-03350-8

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components of creative arts therapy

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Early study shows health benefits of creative arts therapies and nutrition education for postmenopausal women

T ransition to the menopausal stage of women's lives can be a negative experience for women, with changes in emotional well-being and cardiovascular health that impact their quality of life. A recent study from Drexel University's College of Nursing and Health Professions explored a new way to ease the transition with an art therapy intervention to address the health needs of overweight, postmenopausal women.

Published in Art Therapy , the pilot study tested the feasibility of an intervention of combined nutrition education and creative arts therapies (art therapy and dance/movement therapy) to address cardiometabolic risk and psychosocial well-being for overweight, postmenopausal women.

The study showed the integrated approach was beneficial for the participants' psychosocial well-being, with significant improvements in the areas of quality of life, self-efficacy, stress, anxiety, and body image. All participants also showed decreased body mass index (BMI) and blood pressure readings.

"We learned that the participants—being part of a relatively understudied and neglected population: women who are overweight and in the post-menopause stage of life—appreciated having a special time and space set apart just for them that permitted mindful art, writing, and movement experiences," said Rebekka Dieterich-Hartwell, Ph.D., lead author and research fellow in the College of Nursing and Health Professions.

Three participants attended a 16-week online intervention called I2CAN (Integrative Intervention with Creative Arts therapies and Nutrition). Participants who were postmenopausal and over a BMI of 25Kg/m 2 were selected for this study. The sessions were facilitated by a nutritionist and two creative arts therapists—a dance movement therapist and an art therapist—weekly on a secure videoconferencing platform.

The sessions alternated weekly between nutrition and creative arts therapies. The creative arts therapy sessions focused on quality of life, emotional regulation, body image, and stress management and included a verbal introduction to the session's theme, a movement warm-up relating to the theme (stretching, breathing, light movements), an art therapy directive (collage, scribble drawing, etc.), journaling, a movement cool-down, and verbal processing.

The nutrition education sessions included goal setting and topics such as healthy food and beverage choices, portion sizes, food groups, and hydration. All three participants reported multiple health benefits at the end of the study.

Participants answered standardized pre- and post-intervention questionnaires on quality of life, stress, body image, and other topics. Physical measures included height, weight, BMI, and blood pressure. Researchers analyzed the data through descriptive statistics changes in biomarkers, as well as standardized surveys of well-being and mood.

Additionally, the research team interviewed the participants at the end of the study to learn about their experiences and collect field notes from the creative arts therapy sessions throughout the 16-week process.

"While this was a very small sample and the findings cannot be generalized, they indicate that a multimodal intervention with educational, expressive, and creative components can be beneficial for physiological and psychosocial well-being of postmenopausal women who have an elevated BMI and at-risk for cardiovascular disease," said Dieterich-Hartwell.

The researchers note that this population is often overlooked, and this study suggests that an integrative approach with attention to both physical and psychosocial needs can have an overall positive health impact and give voice to this particular group, according to the co-authors and principal investigators, Girija Kaimal, EdD, an associate professor, and Deeptha Sukumar, Ph.D., an associate professor, both in the College of Nursing and Health Professions.

To further this research, the team is beginning a larger, randomized control trial for the Pennsylvania Department of Health's Commonwealth Universal Research Enhancement (CURE) grant program beginning in January 2024. This larger trial will help the research team to understand the impact of the integrative approach relative to nutrition education alone.

More information: Rebekka Dieterich-Hartwell et al, A Creative Arts Therapy and Nutrition Education Approach for Postmenopausal Women, Art Therapy (2023). DOI: 10.1080/07421656.2023.2267987

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Perceived Stress Scale (PSS). Credit: Art Therapy (2023). DOI: 10.1080/07421656.2023.2267987

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Special Issue: Arts Therapies with Children and Adolescents—Editorial

Dafna regev.

1 The School of Creative Arts Therapies, University of Haifa, Haifa 3498838, Israel; [email protected]

2 The Emili Sagol Creative Arts Therapies Research Center, University of Haifa, Haifa 349838, Israel

Arts therapy dates back to the mid-20th century. It emerged from the conviction that artistic work has a unique meaning for people in general and children and adolescents in particular. Although many professionals use the arts in their work with children and adolescents, arts therapists have specific expertise in observing and encouraging processes in a variety of arts and have the knowledge base necessary to promote connections between artistic creation and stimulate mental processes and personal well-being.

Clinical work in arts therapy is expanding to education, hospitals, informal education, private clinics and other settings. Similarly, the research field has developed rapidly, especially in the last twenty years, and today includes a growing number of in-depth studies that not only examine the effectiveness and meaning of this profession, but also explore therapeutic processes and mechanisms of change and contribute to the formulation of protocols adapted to therapy work in a variety of populations. While many studies have focused on adults in arts therapy, research on arts therapy for children and adolescents still lags behind. This points to the need to find specific ways to treat these clients and for studies on how these approaches can be implemented.

For all these reasons, I am delighted to serve as the guest editor representing the field of arts therapy for this Special Issue in Children . This Special Issue presents a wide range of articles. First and foremost, several deal with arts therapy in the education system. Heynen and her associates [ 1 ] present a specific music therapy intervention developed in the Netherlands for refugee children and adolescents in school settings. Snir [ 2 ] explores the meaning of artmaking as one of the key components of art therapy within the educational system in Israel. Kelemen and Shamri-Zeevi [ 3 ] describe a unique open-studio intervention designed to facilitate identity development in teens recovering from mental health conditions. Korman-Hacohen and her collaborators [ 4 ] specifically refer to the challenges brought about by the COVID-19 pandemic and the creative way in which arts therapists in the education system continued to work with students by harnessing new and different approaches.

The second topic discussed in this Special Issue is arts therapies for children and adolescents with special needs. Bat-Or and Zusman-Bloch [ 5 ] describe art therapy in an open-studio model with at-risk children living in foster care. Schweizer and her colleagues [ 6 ] report on a 15-session art therapy program that aims to reduce difficulties in ‘sense of self’, ‘emotion regulation’, ‘flexibility’ and ‘social behavior’ in children diagnosed with autism spectrum disorders (ASDs). Bitan and Regev [ 7 ] investigate ways to work with clients with ASDs through parent–child art psychotherapy. Cousin and collaborators [ 8 ] describe music therapy interventions in pediatric intensive care units for anxiety and pain management. Ofer and Keisari [ 9 ] present a case study and the core concepts implemented during drama therapy with a young girl who lost most of her functional abilities due to brain damage. During the child’s physiotherapy sessions at the rehabilitation hospital, a medical clown was brought in to work together with the physiotherapist in providing treatment.

Beyond the therapeutic use of the various arts, greater attention is being paid to the diagnostic potential of arts therapies. These diagnostic methods are grounded in the realization that speech is not always the most appropriate channel for diagnosis, especially in children and adolescents. Bat-Or and her partners [ 10 ] describe diagnosis based on the Person Picking an Apple from a Tree (PPAT) drawing assessment scale. They evaluated the subjective experience of 156 preschoolers (aged 4–6.9 years) living in an area exposed to considerable political violence in Israel (on the border with the Gaza Strip) during a period of massive bombing. Gavron and her partners [ 11 ] describe a painting intervention called the Joint Painting Procedure (JPG) where parent and child paint together on the same sheet of paper. This is used to examine key facets of the relationships between adolescents with intellectual disabilities and their mothers. Jaroenkajornkij and her associates [ 12 ] provide a new look at the classic self-figure drawing, which they use to successfully identify three forms of child abuse: child sexual abuse, child physical abuse and child emotional abuse.

The last section deals with more general issues in the field of arts therapy for children and adolescents. Shuper-Engelhard and Vulcan [ 13 ] examine the distinctive qualities of group dance and movement therapy in the context of a remote emotional intervention with young children. Metzl [ 14 ] reviews current theoretical frameworks of working with children and adolescents with regard to their socio-political and developmental implications for art therapy practice within different settings and systems. The systematic review by Berghs and her associates [ 15 ] looks at the ways in which drama therapy contributes to a decrease in psychosocial problems. Moula and collaborators [ 16 ] conducted a pilot randomized controlled study that examines the effects of arts therapies on children’s mental health and well-being. Keidar and her associates [ 17 ] explore the perceptions of 17 ultra-Orthodox parents whose children were receiving arts therapies.

I hope that this Special Issue will serve as a repository of knowledge for arts therapists and fertile terrain for further research in the field. It also aims to help more professionals working with children and adolescents to recognize the meaning and uniqueness of therapeutic work in arts therapies and the dedicated ways in which arts therapists use assessment tools and arts-based interventions to better understand the world of children and adolescents.

Funding Statement

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Conflicts of interest.

The authors declare no conflict of interest.

Disclaimer/Publisher’s Note: The statements, opinions and data contained in all publications are solely those of the individual author(s) and contributor(s) and not of MDPI and/or the editor(s). MDPI and/or the editor(s) disclaim responsibility for any injury to people or property resulting from any ideas, methods, instructions or products referred to in the content.

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  1. What is the scope of practice of creative arts therapies?

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  2. 8 Types of Art Therapy To Help Your Clients (Includes FREE DOWNLOAD)

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  3. Art Therapy

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  4. Art Therapy Fundamentals

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  5. Art Therapy: Definition, Uses and How It Works

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  6. Infographics: Art As Therapy

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COMMENTS

  1. Creative Arts Therapies Explained: 18 Best Courses and Ideas

    Creative arts therapies defined: Comment on "Effects of creative arts therapies on psychological symptoms and quality of life in patients with cancer". JAMA Internal Medicine, 173(11), 969-969. Degges-White, S. (2011). Introduction to the use of expressive arts in counseling.

  2. Art Therapy: Definition, Types, Techniques, and Efficacy

    Other types of creative therapies include: Dance therapy Drama therapy Expressive therapy Music therapy Writing therapy Techniques The goal of art therapy is to utilize the creative process to help people explore self-expression and, in doing so, find new ways to gain personal insight and develop new coping skills.

  3. Creative Arts Therapy and Expressive Arts Therapy

    Relaxation techniques often include creative components such as music, movement, or art-making. For example, guided imagery or visualization, meditation, yoga, and other methods of stress...

  4. Creative therapy: Types, benefits, and more

    Summary Creative therapy uses art-based activities, such as music and dance, to help treat emotional and mental health conditions. In 2019, the Centers for Disease Control and Prevention (CDC)...

  5. Expressive Arts Therapy: 15 Creative Activities and Techniques

    In expressive arts therapy, each client is encouraged to use multiple forms of creative expression to articulate their inner world, including drawing and painting, photography, sculptures using a range of materials from clay to paper mâché, music, drama and role-play, poetry, prose, and dance and movement.

  6. From Therapeutic Factors to Mechanisms of Change in the Creative Arts

    The Creative Arts Therapies. The creative arts therapies (CATs) is an umbrella term covering healthcare professions in several disciplines: art therapy, dance/movement therapy, drama therapy, psychodrama, music therapy, and poetry/bibliotherapy (see Table 1).Creative arts therapists complete extensive education and clinical training in using arts-based methods and the creative processes and ...

  7. Editorial: The State of the Art in Creative Arts Therapies

    The creative-expressive process engages physiological sensations, emotions, and cognition; facilitates verbal and non-verbal symbolization, narration, and expression of conscious or unconscious conflicts and meaning-making through internal and external dialogue and communication between oneself and others.

  8. Creative Arts: Enhancing Mental Health and Well-being

    It can involve various treatments, such as theater therapy, dance movement psychotherapy, music therapy, poetry, pottery drawing, painting and craft therapy. Art therapy uses integrative techniques to captivate the soul, body and mind in ways that verbal expression alone doesn't appear to (Shukla).

  9. Art Therapy

    Art Therapy. Art therapy, a hybrid field largely influenced by the disciplines of art and psychology, uses the creative process, pieces of art created in therapy, and third-party artwork to help ...

  10. What Is Expressive Arts Therapy?

    Four of the main types of creative arts that are often used in expressive arts therapy include: Art therapy: This approach involves utilizing the visual arts—such as drawing, painting, and sculpting—to work through emotions, thoughts, or experiences.

  11. Role of Art Therapy in the Promotion of Mental Health: A Critical

    It focuses on visual art therapy since it's a key to reducing variation within the "creative arts" and defines the peculiar elements and effectiveness of art therapy used by mental health services. ... The basic components of art-therapy interventions in the real world are hard to determine because there are currently no effective strategies ...

  12. Effectiveness of creative arts-based interventions for treating

    Psychological interventions based on art, music, drama, dance/movement or poetry are referred to as creative arts-based interventions because of their roots in the arts (Malchiodi, Citation 2015).There are specific forms of therapy developed around each of these, but also broader types of interventions (for example, community psychosocial programs) which incorporate components based on one or ...

  13. Effectiveness of arts interventions to reduce mental-health-related

    Arts interventions are effective in reducing mental-health-related stigma to a small effect. Interventions that employ multiple art forms together compared to studies employing film, theatre or role play are likely more effective in reducing mental-health-related stigma. Peer Review reports Background

  14. Expressive Arts Therapy For Your Healing Journey

    Four components of expressive arts therapy. Expressive arts therapies, also called creative arts therapies or simply expressive therapy, are commonly used for treating young children or adults who are recovering from trauma. ... Creative arts therapy can be used alone or, more likely, in tandem with another, more traditional form of talk ...

  15. Expressive Arts Therapy

    Modalities such as art therapy, music therapy, poetry therapy, dance/movement therapy, and expressive arts therapy are all examples of creative arts therapy. While the majority of these ...

  16. Creative Arts Therapies < 2023-2024 Catalog

    CATX I699 Independent Study in Creative Arts Therapy 0.5-4.5 Credits. ... Independent study provides students with an opportunity to develop various components of their interests in creative arts therapies and health sciences. The course is structured with a contract and is designed to allow students access to avenues and resources (personnel ...

  17. Early study shows health benefits of creative arts therapies and ...

    The creative arts therapy sessions focused on quality of life, emotional regulation, body image, and stress management and included a verbal introduction to the session's theme, a movement warm-up ...

  18. UC Davis Children's Hospital Year in Review now available

    Annual report covers highlights ranging from new clinics to expanded community partnerships. (SACRAMENTO) The latest edition of the UC Davis Children's Hospital Annual Report is now available. The publication covers the past year in review. "All of us at UC Davis Children's Hospital are enormously proud that we've had yet another ...

  19. Expressive Arts Therapy

    Expressive arts therapy may incorporate writing, drama, dance, movement, painting, and/or music. People utilizing expressive arts therapy are encouraged by a qualified therapist to explore...

  20. Art Interventions for Children With Autism Spectrum Disorder: A Scoping

    The findings of this scoping review support occupational therapy practitioners' use of creative arts interventions to enhance occupation-based outcomes for children with autism spectrum disorder (ASD). Autism spectrum disorder (ASD) is a neurological condition characterized by impairments in social interaction, communication, and behavior and ...

  21. Arts

    The purpose of the Arts Commission is to enrich the community by celebrating and cultivating the expression of all forms of art and culture. Fulfillment of this purpose shall be based upon the following values: Recognition and promotion of artists' value by creating opportunities for work to be experienced. Facilitation and promotion of the ...

  22. Moscow Arts Commission

    The Moscow Arts Commission consists of up to twelve voting members, serving without pay. Members are appointed by the Mayor with the advice and consent of the City Council. Not more than three members of the Commission may reside outside the City limits. The term of office of the Commission members is four years, or the remainder of a vacant ...

  23. Special Issue: Arts Therapies with Children and Adolescents—Editorial

    The second topic discussed in this Special Issue is arts therapies for children and adolescents with special needs. Bat-Or and Zusman-Bloch [ 5] describe art therapy in an open-studio model with at-risk children living in foster care. Schweizer and her colleagues [ 6] report on a 15-session art therapy program that aims to reduce difficulties ...

  24. THIRD STREET GALLERY

    The Third Street Gallery is an essential part of this building, as it brings art into the center of civic life in the City of Moscow. Third Street Gallery is located inside Moscow City Hall at 206 E. Third St. Moscow, ID. Gallery hours are 8 a.m. to 5 p.m., Monday through Friday, excluding federal holidays.

  25. Easter basket donations needed for hospitalized children

    The UC Davis Child Life and Creative Arts Therapy Department is accepting donations for Easter basket supplies through its dedicated Amazon wish list. Items requested range in price from $3 baby rattles to $30 ear buds. The gifts ordered online can be shipped directly sent to the Children's Hospital, as noted on the Amazon checkout page. ...

  26. Music, cinema and more: how the city helps creative industries

    The city supports creative industries not only financially, but also in promoting their products and services across the country and the world, providing market analytics, education, creating infrastructure for successful work, conditions for the formation of a creative community. Creative industries include such areas of the economy as the art ...