- Email: [email protected]
Emotion regulation strategies and effects in art-making: A narrative synthesis
Accepted Manuscript Title: Emotion regulation strategies and effects in art-making: a narrative synthesis Authors: Harald Gruber, Renate Oepen PII: DOI: Reference:
S0197-4556(17)30005-9 https://doi.org/10.1016/j.aip.2017.12.006 AIP 1498
To appear in:
The Arts in Psychotherapy
Received date: Revised date: Accepted date:
14-1-2017 1-8-2017 15-12-2017
Please cite this article as: Gruber, Harald., & Oepen, Renate., Emotion regulation strategies and effects in art-making: a narrative synthesis.The Arts in Psychotherapy https://doi.org/10.1016/j.aip.2017.12.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Emotion regulation strategies and effects in art-making: a narrative synthesis
Title Page: Title: Emotion Regulation Strategies and Effects in art-making: A Narrative Synthesis
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Author: Prof. Dr. Harald Gruber,
Villestrasse 3, 53347 Alfter/Bonn, Germany Phone: +49-(0)2222-9321-1800; Fax: +49-(0)2222-9321-1860
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Email: [email protected]
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Alanus University of Arts and Social Sciences, Department of Arts Therapies and Therapy Science
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Short biographical note:
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Professor for Art Therapy at Alanus University of Arts and Social Sciences
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Dean of the Creative Arts Therapies & Therapy Sciences Department, Co-Director of the Research Institute for Creative Arts Therapies RIArT
Dr. Renate Oepen,
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Co-author and corresponding author:
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Alanus University of Arts and Social Sciences, Department of Arts Therapies and Therapy Science Villestrasse 3, 53347 Alfter/Bonn, Germany
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Phone: +49-(0)2222-9321-1800; Fax: +49-(0)2222-9321-1860 Email: [email protected]
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Short biographical note: MA Art Therapy, Research Assistance, Occasional Teacher Department of Arts Therapies and Therapy Science, Alanus University
Acknowledgements This work was conducted at Alanus University of Arts and Social Sciences, Alfter. It was supported by Alanus University. 1
The author and co-author declare that there are no conflicts of interest in relation to the subject of this study. Highlights:
the mood-elevating effects of art-making were stronger when art was used to distract art therapy interventions are most effective when they entail a structured task leading to a specific end result or goal state the importance of psychological models of emotion regulation for research in art therapy
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Abstract
Questions concerning the regulation or dysregulation of emotions in mental distress
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states are not only of fundamental concern in psychotherapy research but also a key issue in
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the art therapy field. Nevertheless, few studies have investigated the effectiveness of artistic
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activities in emotion regulation. This review aims to identify and analyze studies that
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investigate art-making to regulate emotions. Most studies to date have examined the effects of short-term mood repair, but some did investigate emotion regulation models in a
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psychotherapy setting. They revealed that in positive mood enhancement resulted from artmaking. A few comparative studies suggested that art-making was more effective than other
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therapies, with distraction strategy demonstrating special success in regulating emotion. Future research on emotion regulation in art therapy should also address psychological
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models and take specific active factors of art into consideration.
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Keywords
emotion regulation; art therapy; narrative synthesis; mood enhancement
Introduction Scientific knowledge in the creative arts therapies (art, music, dance and drama 2
therapy) is heterogeneous. Compared to psychotherapy, arts therapies as a field are less systematically investigated. However, in recent years a growing number of systematic studies on various arts therapies have been published, for example, on oncology (Boehm, Cramer, Staroszynski, & Ostermann, 2014; Bradt, Dileo, Grocke & Magill, 2011; Gruber, Rose, Manheim, & Weis, 2011), psychiatry (Crawford, H.J., Killapsy, H., Barnes, T.R., Barrett,
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B., Byford, S., Clayton, K., & Waller, A., 2012; Montag, C., Haase, L., Seidel, D., Bayerl,
M., Galliant, J., Herrmann, U., & Dannecker, K., 2014) and on child therapy (Geretsegger,
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Elefant, Mössler, & Gold, 2014). In a systematic meta-analysis, Boehm et al. (2014) were
able to demonstrate a significant decrease in anxiety in individuals living with a diagnosis of cancer. Nevertheless, the extant corpus in this relatively young research discipline suggests a
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need for studies that are better controlled by adhering to the requirements of evidence-based
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medicine (EBM) standards.
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Working with emotions is a core activity of both art therapy (Malchiodi, 2012) and psychotherapy (Greenberg, 2011). The connection between art and emotion regulation has
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been described, studied and confirmed in art therapy literature (Dannecker & Herrmann, 2017; Kramer, 1958; Naumburg, 1966; Rubin, 1984). Thus, Franklin (2010) pointed out that
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creating art helps to modulate emotions that arise concomitantly with attachment relationships. Working in an art psychotherapeutic setting with children acting out
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troubled early childhood experiences, Armstrong (2013) applied attachment theory to discussing the development of an individual´s capacity for emotion regulation. Working
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with borderline personality disorders, Springham, Findlay, Woods & Harris (2012) showed that art therapy is an essential factor in helping to develop greater mentalization capabilities. Killick & Schaverien (1997) found that, for the psychotic individual, pictures mediate in the actual space in-between psychotic client and therapist. This relationship mediated by an object seems to create a less threatening environment for the client with a 3
fragile personality than having to relate directly to another human being. Man & Ho (2014) also asserted that art therapy – as one major, nonverbal psychotherapeutic approach – has attracted growing attention got its efficiency in treating depression and anxiety. Another study explored the relationship between prevention and art therapy for clients suffering from burnout and found a significant increase in positive mood after just one art
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therapy project day (Oepen & Gruber, 2012; 2014). Nonetheless, despite the growing number
of studies on art therapy, little systematic, fundamental research has been carried out to date to
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investigate the connection between art-making interventions and emotion regulation.
Psychotherapy has shed additional light on this problem. Finding by Berking & Wuppermann (2012), by Berking, Ebert, Cuijpers & Hofmann (2013) and Webb, Miles, &
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Sheeran (2012) point out lead to the conclusion that new studies addressing emotion
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regulation in the fields of psychotherapy and neuro-psychotherapy need to be validated and
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integrated with the development of treatment concepts and art therapy research. Current
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models of emotion regulation in psychotherapy research assign high importance to the
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(dys)regulation of emotions in the presence of mental distress (Gross & Munoz, 1995).
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Research questions
Given the significant questions involved in functional emotion regulation and the
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hypothesized regulation of emotions through art, we scanned relevant databases for studies that investigated emotion regulation or emotion regulation effects stemming from artistic
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activities to synthesize them in this study. By doing so, the present review seeks to answer the following questions: - What are the identifying characteristics (e.g. research questions, sample population, type of intervention, study design) of studies on art-making for emotion regulation?
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- What types of emotion regulation strategies did these studies examine? - What kinds of effects of art-making on emotion regulation did these studies describe? - In the studies reviewed, what specific active therapeutic factors in art therapy (see
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Koch, 2017) effected positive changes in emotions? - What do the present review’s findings imply for the future development of studies on
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art therapy and its effects on emotion regulation?
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Theoretical Background
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Emotion regulation – definitions and models
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In recent years, the concept of emotion regulation has emerged as a topic in
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psychological and mental health research (Berking et al., 2012). It has been variously defined in the psychological literature (Eisenberg & Fabes, 1992; Thompson, 1994; Huang & Guo,
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2001; Cole, Martin & Dennis, 2004; Meng, 2005 as cited in Hu, Zhang, Wang, Mistry, Ran, & Wang, 2014). There is general agreement, however, that “emotion regulation is the set of automatic and controlled processes involved in the initiation, maintenance, and
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modification of the occurrence, intensity, and duration of feeling states” (Webb et al.,
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2012, p. 775). Strategies for regulating emotions focus on positive and negative emotions producing special behavioral and physiological states. Initiating, maintaining, inhibiting or
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moderating emotional reactions may lead to emotion regulation in association with processes that influence experience and the expression of emotions (Gross & John, 2003; ibid.). Emotion regulation refers to the downregulation of negative affects or the upregulation of positive affects (Webb et al., 2012).
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Concurrently, we know from Schore (2003) that psychobiologically regulated affect transactions that maximize positive affects und minimize negative affects cocreate a safe attachment between mother and child. “The responsive relationship supports healthy development by containing affective states and promoting the discrimination …” needed to maintain proximity to attachment figures (Franklin, 2010, p. 161). In the
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context of art therapy, Kramer (1971) informs us that considerations of sublimation and the use of art materials demonstrate how art regulates affects. Arnheim (1966) also saw
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expression and perception as intimately related.
The psychological literature describes various models for classifying emotion regulation strategies. In this respect, the studies by Gross & Thompson (2007) are
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fundamental in the field of psychology (Barnow, 2012). The model proposed by Gross et al.
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(2007) differentiates five emotion regulation processes in a temporal dimension of antecedent-
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focused and response-focused strategies (see Fig. 1). The antecedent-focused strategies
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include situation selection (choosing more positive characteristics and the avoidance of
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problematic situations), situation modification (e.g., actively shaping an interview situation), attentional deployment (e.g., reacting to positive, neutral or negative aspects) and cognitive change such as reappraisal, (e.g., observation from a neutral perspective). An example of a
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response-focused strategy is response modulation, i.e., suppressing emotion or emphasizing
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(positive or negative) emotional reactions (Barnow, 2012; Webb et al., 2012).
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Figure 1. The process model of emotion regulation (adapted from Gross & Thomson, 2007, quoted in Webb et al., 2012).
Strategies of emotion regulation 6
Based on the model proposed by Gross et al. (2007), Webb et al. (2012) in their metaanalysis developed a taxonomy of emotion regulation processes associated with emotion regulation strategies. The taxonomy also contained subtypes that eventually yielded different outcomes within the same process (Webb et al., 2012). In the context of the strategy of "attentional deployment" (“how individuals direct their attention within a given situation so as
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to influence their emotions” [Gross & Thompson, 2007, p. 13]), "distraction" was revealed as an effective regulation strategy and "concentration" on the current feeling as an ineffective
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one. Distraction strategy focuses “on different aspects of the situation or moves attention
away from the situation altogether” and “may also involve changing internal focus, such as when individuals invoke thoughts or memories that are inconsistent with the undesirable
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emotional state” (Gross & Thompson, 2007, p. 13).
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The meta-analysis by Webb et al. (2012) revealed additional determining factors that
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modulate the level of emotion regulation. These included the kind of emotion to be regulated (sadness, anxiety, etc.), the type and timing of inducing emotion (type of medium, personality
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based vs. neutral, before or after the intervention), the frequency of application (single, multiple times), the intended outcome (e.g. positive vs. neutral), the strategy used, the study
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design (object of the control group) and study parameters (e.g., gender, age of subjects) (Webb et al., 2012).
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A major problem with this model is that the strategies developed by Gross & Thompson (2007) partially operate in a similar manner. Furthermore, no safe statements about
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the importance of specific emotion regulation strategies for coping with mental distress can be assumed, since their findings are based on interventions with healthy students (Barnow, 2012). Webb et al. (2012) confined their meta-analysis to studies of healthy subjects because, in their view, clinical subjects may resort to different emotion regulation processes. For example, they held that rumination (i.e., “self-immersed, directed attention toward feelings 7
and their consequences) as an emotion regulation strategy” is particularly problematic if subjects are already in a “dysphoric mood” (Webb et al., 2012). More recent studies dealing with the relationship between emotion regulation and mental health tend to show inconsistent results (Hu et al., 2014). A few studies have investigated how the type of artistic intervention technique
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correlates with emotion regulation. Positive emotional experiences were generated especially
if subjects of the art therapy intervention were instructed to focus on positive personal issues,
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such the positive feelings stimulated by common and decorative objects (Oepen & Gruber,
2012; Wilkinson & Chilton, 2013), or to “create artwork about ‘you at your best’” (Chilton & Wilkinson, 2009, p. 36).
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Since studies in this field have not paid much attention to the importance of
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effective emotion regulation for mental health and of art-making activities (Berking,
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2010), it seems reasonable to call for future studies that not only focus on demonstrating
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applied methods, intervention techniques (e.g. the kind of presentation or instruction)
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and the kind of emotion regulation strategies realized, but that also dwell on how they may relate to observed outcomes. We applied these preferences as criteria during our
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Method
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extensive database search for our sample of studies in this field.
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Database search We employed the narrative synthesis methodology for our review. One of the
features of this methodology is the reliance on multiple data sources. Another characteristic is that the results are reported in a narrative, story-telling format (Edwards & Kaimal, 2016). 8
For our review, we did an extensive search of the Psyndex, PsycINFO, Medline and PsycARTICLES data bases spanning the period 1933-2015 on “art therapy” and “mood” as the search terms. As they imply, the first search cast a very wide net designed to let us capture an overview of all the application areas and target groups (clinical and
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non-clinical) (see Fig. 2).
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Figure 2. Information flow during all review phases.
Inclusion/Exclusion criteria
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The initial search resulted in identifying 478 studies (Psycinfo 315, Medline 107,
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Psyndex 49, PsycArticles 7), of which 442 studies remained for further investigation after
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duplications had been eliminated. The studies were selected against the so-called "PICOS
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criteria" (patient, intervention, control, outcome, study design) (Al-Nawas, Baulig, & Krummenauer, 2010). For the “patient” criterion, following the review articles by Gross et al.
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(2007) and Webb et al. (2012), we only included studies referencing healthy, mentally unburdened subjects on the grounds that emotion regulation based on different kinds of mental health conditions (internalizing or externalizing) is influenced by different types of
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mechanisms (overregulation- or underregulation) (Barnow, 2012). Utilizing only studies of
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healthy subjects made it possible to concentrate on the emotion regulation process supported by art-making activities. Comparable studies in psychology generally tend to deal with
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healthy adults, especially students. Under the “intervention” criterion, we only included studies that intervened with art
making to keep the focus on art therapy. Hence, we excluded studies that dealt with other forms of artistic therapy, such as dance, music, poetry and drama therapy. Since research on emotion regulation is relatively rare in the art therapy field, psychological studies that 9
examined emotion regulation strategies and a specific connection to artistic activity were included. Also included in the sample were studies in psychotherapy that did not investigate emotion regulation strategies per se, but that did explore other emotion regulation mechanisms, for instance, the application of art media techniques, specific active factors of art as plausible emotion regulation strategies and that also addressed the how and the degree
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of the emotional change. In this way, the present study incorporates the part of the
psychological research realm that focuses on specific emotion regulation mechanisms in the
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context of art therapy.
Studies that did not cover outcome-oriented investigations, such as studies dealing with how pictures express different emotions, were excluded, as were pure case studies.
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As previously noted, art therapy research is still a nascent research field. Hence, in
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designing the study, we expanded our search to identify studies of all evidence types (I-IV).
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The study design did not include the use of a control group. An additional, important selection
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criterion was that the studies employed established, validated empirical methods, e.g., by
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using quantitative and/or qualitative data collection instruments. Ultimately, we identified a total of 10 studies for the period 1933–2015 (see Table 1). The studies were carried out in non-clinical areas with healthy, normal adult subjects and their
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findings pertained to the regulation of one or multiple emotions through artistic activity.
Results
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Overview
The following overview (Table 1) details the 10 identified studies. We deemed it
essential to describe the characteristics of the interventions and the outcomes since our findings are intended to serve as a basis for further study.
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Table 1. Overview of the sample studies.
Characteristics of included studies and emotion regulation strategies The 10 studies comprising our sample were completed in the United States during the past decade. Each examined the regulation of short-term mood through art-making. Four
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studies compared the effects of applying artistic versus non-artistic activities (De Petrillo & Winner, 2005; Drake, Coleman &Winner, 2011; Drake & Winner, 2012; Drake & Hodge,
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2015; Kimport & Robbins, 2012). Two studies by Drake and colleagues (2011; 2015)
compared writing with drawing activity, while Kimport et al. (2012) examined the effects of
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working with clay versus ball handling (throwing a stress softball). Three studies (Kimport &
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Robbins, 2012; Sandmire, Gorham, Rankin, & Grimm, 2012; Van der Vennett & Serice,
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2012) were conducted in university art therapy departments. They all clearly feature research
Target groups
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into emotion regulation from a psychological research perspective.
The study subjects were healthy adult university students and artists (Nageeb, 2013).
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Interestingly, a majority of the experimental subjects were women. Seven studies had more
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than 50 participants; one study had just ten subjects.
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Research focus, duration of interventions and instruction method The sampled studies primarily investigated the effect of artistic activities on the
process of emotion regulation. The majority of the studies used the approach of testing
mechanisms of short-term mood repair, with interventions lasting between 5 to 30 minutes. To induce an initial negative mood in the subject, most of the interventions screened a film with negative content. Alternatively, subjects were verbally prompted to recall negative 11
personal life events. In both cases, the negative mood had to be described in writing (Kimport & Robbins, 2012; Drake et al., 2011, 2012). In one study only, it was not necessary for the researchers to induce a negative mood, given that the student subjects suffered from anxiety because of impending final examinations the next week (Sandmire et al., 2012).
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Design
Nine of the studies investigated the degree of mood change by applying quantitative
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methods in a controlled pre-post design. One pilot study (Nageeb, 2013) relied exclusively on qualitative methods for the investigation. Three studies (Kimport & Robbins, 2012; Sandmire et al., 2012; Van der Vennett & Serice, 2012), centered on measuring anxiety, while two
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studies (Drake et al., 2011; 2012) examined mood modification in the subjects. Eight studies
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et al., 2012; Van der Vennett et al., 2012).
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were performed as randomized controlled trials (inter alia, Drake et al., 2011; 2012; Kimport
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Efficacy of art-making activities in achieving emotion regulation Nine of the 10 studies we reviewed reported significant effective short-term mood repair through art-making. A longer-term emotion regulation through art-making could not be
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definitively described (Nageeb, 2013). The most successful short-term mood repair was
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achieved by using artistic techniques instead of other activities such as writing, throwing a
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ball, or sitting (Drake et al., 2011; Kimport & Robbins, 2012; Drake & Hodge, 2015).
Distraction and venting With reference to the Gross model, it was suggested that the mood-elevating effects of art-making were stronger when art was used as a distraction, i.e., by focusing on a neutral
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topic such as drawing a house rather than as a vehicle for venting negative feelings, or in various strategic settings such as sitting quietly (Drake & Winner, 2012). The same study, in examining positive and negative affects, found using art-making for distraction induced positive emotions. This effect was significant as compared with a second type of strategy (sitting quietly). A stronger effect on mood improvement was further
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achieved by making associations with positive emotions (Dalebroux et al., 2008). Use of the venting strategy resulted in the most negative affects being recorded, with higher negative
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values than were measured for the control group using the sitting strategy. Gender also
impacted use of the venting strategy: the impact was worse for men using the strategy than for women (Drake et al., 2012). The preferred distraction strategy was artistic activity; writing
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activity was preferred for expressing feelings (Drake & Hodge, 2015).
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Directive approach in art therapy
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Regarding the methods used, the studies suggest that art therapy interventions are most
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effective in alleviating negative mood states when they entail a structured task leading to a specific outcome or goal state (Kimport & Robbins, 2012). The strength of the regulatory effect appears to depend on the specific type of pattern to be colored: coloring a mandala
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reduced anxiety significantly more than did coloring a plaid pattern or blank sheet of paper
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(Van der Vennett et al., 2012; Babouchkina & Robbins, 2015). Thus, art-making activities seem to be superior to other methods for elevating short-term mood enhancement. The
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distraction strategy had more impact than venting when using art-making activities. Some studies noted the influence exerted by the artistic method and form of instruction on the extent of the mood enhancement.
Discussion 13
We examined the “intervention” and “outcome” parameters of the ten studies that met our criteria for this narrative synthesis, to develop starting points for further research projects on the topic of emotion regulation in the field of art therapy. As noted previously, the studies in our sample only examined healthy subjects, mostly students and, in one study, artists. Most of the subjects were women. We found that emotion
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regulation strategies as described and observed in psychological models and studies (e.g.,
Gross & Thompson, 2007) had been examined in half of the ten selected studies (Dalebroux
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et al., 2008; De Petrillo & Winner, 2005; Drake et al., 2011; 2012; 2015). The authors
primarily investigated two emotion regulation strategies based on findings from psychological research: the venting of negative feelings and distraction strategy, a form of attentional
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deployment that focuses on positive or neutral emotions to distract from negative emotions
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Thayer, et al, 1994 quoted in Drake et al., 2011).
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(Gross & Thompson, 2007; Gross & John, 2003; Larsen, 2000; Parkinson & Totterdell, 1999;
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In addition, our review confirmed the results produced by Gross & Thompson (2007),
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who found that distraction strategy, a form of attentional deployment, is better suited for short-term mood repair than a strategy of concentrating on current emotion. Applying the distraction strategy through artistic activities while stressing positive emotions proved to be
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particularly effective (Dalebroux et al., 2008). The positive effect of distraction strategy was
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also demonstrated in other studies that examined subjects suffering from illness or mental burdens (Dalebroux et al, 2008; Oepen & Gruber, 2012; 2014; Oepen, 2015).
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Our review therefore points to the need for further research on distraction strategy with a focus both on positive and neutral emotions. Our findings confirm that it is possible to observe efficient emotion regulation strategies (Webb et al., 2012) resulting from the use of art-making. Participants who often used the reappraisal strategy showed more positive than negative emotions (see Gross & John, 2003; Gross & Thompson, 2007; Hu et al., 2014). 14
The type of artistic tasks and of art-making instructions appear to influence the degree of mood enhancement. Thus, the results strongly suggest a need for investigating different effects by a variety of artistic techniques on emotion regulation, including free-form painting, collage making, drawing still life pictures, etc. Clearly, it will be important to carry out more fundamental art therapy research. “Creative activity has also been used in psychotherapy and
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counseling, not only because it serves as another language but also because of its inherent
ability to help people of all ages explore emotions and beliefs, reduce stress, resolve problems
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and conflicts, and enhance their sense of well-being” (Malchiodi, 2003). The power of art
therapy lies in its ability to evoke a practically-oriented experience with primarily nonverbal access embedded in artistic activities (Koch & Eberhard-Kaechele, 2014; Koch, Steinhage,
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Haller, Kende, Ostermann, & Chyle, 2015).
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In line with the significant improvements in levels of emotional awareness observed
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by Montag et al. (2014) in the randomized controlled trial (RCT) of a psychodynamic group
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art therapy in acute psychotic episodes (Montag et al. 2014), more detailed research into
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which (art) intervention has the most potential for helping clients recommends itself as a topic of interest. Current attempts to identify the function of the arts from a health perspective (Koch, 2017), would benefit from investigating which active factors of the arts therapies are
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of key importance (Tüpker & Gruber, 2017). As Crawford et al. (2012) point out in the
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MATISSE study, which found no difference between art therapy and standard care in the improvement achieved for schizophrenics, an approach combining different creative
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arts therapies (for example, music therapy and body movement therapy) may be more effective. Worth mentioning in this context also is the debate on whether a directive or nondirective approach is to be preferred in art therapy. According to McNeilly (1983), the nondirective approach in art therapy plays an additional, important role in art therapy 15
interventions. He argues that resorting to direct suggestions in theme-centered art therapy may possibly result in uncovering a powerful feeling too rapidly, creating a problem for the client , the group and/or the art therapist in containing or understanding it. This argument contrasts with the results of other studies represented in this narrative synthesis that argue instead for the advantages of a directive, theme-centered approach, especially when using distractive,
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positively focused instruction (inter alia, Dalebroux, Goldstein, & Winner, 2008; Kimport & Robbins, 2012).
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In practice, falling between these two poles are a variety of group experiences which use art structures that can be interesting, revealing, and, moreover, enjoyable (Liebmann, 1999 quoted in Edwards, 2004). In this regard, the experiences of clients in art therapy
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treatment can lend additional perspectives on the effects of art-making. As Rankanen
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(2016) found in her study, 98% of the clients felt that art therapy had a positive impact
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on their psychological health, 82% recognized positive effects on their social
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relationships, and 67% noted positive physical health effects.
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More exploratory research is needed to discover in which specific context goaloriented instruction (distraction or concentration strategy) is more effective than a non-
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efficiently.
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directive instructional approach (free art-making) when it comes to regulating emotion
Limitations
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The following are possible limitations of the present review:
1. The focus is only on healthy subjects. We took this approach because we conducted our research based on current models of emotion regulation used by psychologists (Gross et al., 2012), that favored the study of healthy subjects first as a way of gaining initial, fundamental insights into emotion regulating 16
processes before moving on to study subjects with varying illnesses. Our rationale for emulating the psychologist’s approach was that it allowed us to make consistent, valid comparisons. 2. The review concentrated on short-term mood changes. Unquestionably, studying the change of emotions in an art therapy setting over longer periods
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of time will be useful. It may be relevant here that the subjects in the studies we reviewed were mostly women and younger people (students). The study by Shella (2018), with a
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sample composed mostly of women, found significant improvements in pain, mood, and
anxiety levels for all patients during their stay in a hospital regardless of gender, age, or diagnosis.
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3. Inconsistent results between different art therapy settings
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According to Crawford et al., (2012) and Shella, (2018), further research is required to
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analyze emotion regulation adjusted for gender, age, sick and mentally burdened
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subjects, because these variables can be assumed to possibly correlate with the degree of
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Conclusion
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emotion regulation (Webb et al., 2012; Drake & Winner, 2012).
Our findings underline the importance of referring to psychological models of emotion
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regulation in conducting art therapy research. Investigating the specific active factors at work in art appears to be another promising avenue for future research. However, it should also be
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pointed out that, while our findings are useful for describing and evaluating emotion regulation, they are nonetheless preliminary. Further research with larger research teams and patient groups is called for. Also, priority should be given to conducting research into regulation of emotions through art therapies potentially benefiting especially individuals experiencing severe mental distress or undergoing palliative care. 17
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Drake, J. E., Coleman, K., & Winner, E. (2011). Short-Term Mood Repair Through Art: Effects of Medium and Strategy. Art Therapy, 28, 26–30.
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Drake, J. E., & Winner, E. (2012). Confronting sadness through art-making: Distraction is more beneficial than venting. Psychology of Aesthetics, Creativity, and the Arts, 6(3), 255-261. Drake, J. E., & Hodge, A. (2015). Drawing versus writing: The role of preference in
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Man, NJK. & Ho, RTH. (2014). Affect Regulation and Treatment for Depression and Anxiety through Art: Theoretical Ground and Clinical Issues. Annals of Depression and Anxiety (1) 2. Montag, C., Haase, L., Seidel, D., Bayerl, M., Galliant, J., Herrmann, U., & Dannecker, K. (2014). A pilot RCT of psychodynamic group art therapy for patients in acute
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Shella, T. A. (2018). Art therapy improves mood, and reduces pain and anxiety when offered
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Springham, N., Findlay, D., Woods, A., & Harris, J. (2012). How can art therapy contribute to mentalization in borderline personality disorder? In: International Journal of Art
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Replication Study. Art Therapy, 29, 87–92.
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Wilkinson, R.A., & Chilton, G. (2013). Positive Art Therapy: Linking Positive Psychology to Art Therapy Theory, Practice, and Research. Art Therapy, 30, 4–11.
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Figure 1. The process model of emotion regulation (adapted from Gross & Thomson, 2007 quoted in Webb et al., 2012).
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25
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Figure 2. Flow of information through the different phases of the review.
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I Table 1. Overview of the sample studies.
Babouchkina & Robbins (2015)
67 female =51 male= 16
Aims/Hypothesis/ Questions Efficacy of mandala painting for reducing negative mood states
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De Petrillo & Winner (2005)
42 f=12 m=10 age: 18-22
1. Induction of negative mood, 2. Coloring, four conditions:
A) Coloring a blank circle with instructions to express feelings B) Coloring a blank circle with instructions to draw freely C) Coloring a square with instructions to express feelings D) Coloring a square with instruction to draw freely
Examination of two mechanisms of shortterm mood repair: arousal and valence
Induction of negative mood by a war film
Does art-making improve mood, If so,
Experiment 1: induction of negative mood by tragic images drawing a picture based on the feelings or copying shapes
is this effect best explained by “catharsis” or “redirection”
Experiment 2: distraction by making a drawing or completing a word puzzle
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57 f=53 m=22 age: 18-22
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Dalebroux et al. (2008)
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age: 18-42
Interventions
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Size (n)
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Author
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Measures/ Tools Profile of Mood States Drawing Task
Affect grid
Three conditions: 1. Venting: drawing a picture that expresses the feelings in reaction to the movie 2. Positive emotions: drawing a picture that depicts happiness 3. Distraction control: finding and crossing out symbols out of a sheet of symbols Affect Grid
Outcomes
Study Design
Significantly greater mood improvement of the two circle (mandala) groups compared to the two square conditions
Randomized
No effect on arousal, effect on mood valence; most effective when association to positive emotions
Randomized
Art making increases the pleasure dimension of mood and does so via either catharsis or redirection
Randomized
controlled
controlled pre-post
controlled pre-post
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I Drake et al. (2011)
40 f=23; m=17
2. Determination whether mood is more effectively repaired when the medium is used to vent negative feelings or to distract oneself from negative feelings
1. Induction of negative mood by a film
1. Affect Grid
2. writing or drawing condition about anything one would like
2. Self-reported questionnaire: decision whether distraction or venting is the better strategy
80 f=60; m=20
1. Using art to distract more beneficial for mood repair than to vent
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age: 18-22
ED
Drake & Winner (2012)
2. Using art to distract more beneficial for mood repair than sitting quietly or venting
Study 1: 1. Induction of negative mood by a film 2. Drawing condition (n=40): venting by drawing something related to the film distraction condition (n=40): drawing something unrelated to the film: a house Study 2: 1. Induction of negative mood by verbal instructions/writing (personal experience) 2. Three conditions: using art for venting, for distraction, control: quietly sitting
1. Short-term mood repair better by drawing than by writing 2. Drawing better strategy for distraction than for venting
Randomized controlled pre-post
3. Concerning both activities: better mood repair by distraction than by venting
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age: 18-22
1. Comparison of short term-mood repair effects of drawing vs. writing
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PANAS (positive and negative affect schedule)
1. Distraction better strategy than venting and sitting 2. Positive affect: significantly higher in distraction than in venting and higher than in sitting condition
Randomized controlled pre-post
3. Negative affect: least reduction in venting condition Male participants (Study 1): more negative affect after using art to vent than to distract themselves
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I Drake & Hodge (2015)
80 f=62;
1. Indication of preference: drawing or writing 2. Sad mood induction by a film
Investigation of emotion regulation strategy (distraction vs. expression)
3. Half were assigned to their preferred activity, half to their non-preferred activity
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f=74; m=28
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Kimport & Robbins (2012)
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ED
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m=18 age: 18-22
One’s preference for regulating short-term affect: drawing or writing
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age: 18-63
1. More mood enhancement by working with clay than holding and manipulating soft stress balls 2. More mood enhancement by structured activities with a result than doing aimless activities with objects
1. Induction of negative mood by a film, writing about the negative feelings 2. 4 groups: A) Structured instruction: making a pinch pot with clay B) Free instruction: manipulating the clay any way one wished C) Structured instruction: moving the soft balls in the demonstrated way D) Free instruction: handling the balls however anyone wanted
Pilot study
Experience Questionnaire (preference for drawing or writing); Mood Induction Measure (rating sadness of the film); PANAS (Positive and Negative Affect Schedule); Strategy Questionnaire (venting or distraction or other-specify)
Negative affect significantly lower after drawing than after writing (even when the preferred activity indicated was writing)
POMS (Profile of Mood States)
1. More mood enhancement by manipulating clay than stress balls
Randomized
2. More effectiveness of art therapy interventions at alleviating negative mood states when entailing a structured task leading to a result
pre-post
STAI (State-Trait Anxiety Inventory)
controlled pre-post
Participants were more likely to use drawing to distract and writing to express
controlled
3. Most mood enhancement by the structured manipulation of clay
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I
(information s about gender, age not available)
Sandmire et al. (2012)
57 f=45; m=12
50
f=41; m=9
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Van der Vennett & Serice (2012)
age: 21-59
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Significant reduction of anxiety one week before final exam by an artmaking activity compared to a control group that did not participate in art-making
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mean age: 18,8
Creative process of visual artists from conception to completion of a creative work
Qualitative, phenomenological
Results do not strongly support either side of the positive vs. negative mood
Pilot study
5 groups with different art-making tasks: A) Coloring a pre-designed mandala B) Painting free form C) Making a collage D) Drawing a still life picture and coloring it with sepia ink E) Control group: no activity
STAI (State-Trait Anxiety Inventory)
Mean state anxiety score between pre-activity and post-activity decreased significantly in the artmaking group, no difference in the control group
Not randomized
1. Induction of an anxious mood (personal experience) by verbal instructions/writing
SAI (State Anxiety Inventory)
1. Reduction of anxiety by coloring a mandala to a greater degree than coloring free form
Randomized
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(2013)
Role of emotion in the creative process of visual artists (positive or negative emotion)
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10
ED
Nageeb
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Significantly more reduction of anxiety by coloring pre-drawn mandalas than coloring a plaid design or coloring free form
2. Three art-making groups: coloring a mandala coloring a plaid design coloring free form
Demographic questionnaire
controlled pre-post
controlled pre-post
2. Difference between coloring the mandala and plaid design but no difference between coloring the plaid design and the free-form design
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S0197-4556(17)30005-9 https://doi.org/10.1016/j.aip.2017.12.006 AIP 1498
To appear in:
The Arts in Psychotherapy
Received date: Revised date: Accepted date:
14-1-2017 1-8-2017 15-12-2017
Please cite this article as: Gruber, Harald., & Oepen, Renate., Emotion regulation strategies and effects in art-making: a narrative synthesis.The Arts in Psychotherapy https://doi.org/10.1016/j.aip.2017.12.006 This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
Emotion regulation strategies and effects in art-making: a narrative synthesis
Title Page: Title: Emotion Regulation Strategies and Effects in art-making: A Narrative Synthesis
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Author: Prof. Dr. Harald Gruber,
Villestrasse 3, 53347 Alfter/Bonn, Germany Phone: +49-(0)2222-9321-1800; Fax: +49-(0)2222-9321-1860
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Email: [email protected]
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Alanus University of Arts and Social Sciences, Department of Arts Therapies and Therapy Science
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Short biographical note:
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Professor for Art Therapy at Alanus University of Arts and Social Sciences
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Dean of the Creative Arts Therapies & Therapy Sciences Department, Co-Director of the Research Institute for Creative Arts Therapies RIArT
Dr. Renate Oepen,
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Co-author and corresponding author:
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Alanus University of Arts and Social Sciences, Department of Arts Therapies and Therapy Science Villestrasse 3, 53347 Alfter/Bonn, Germany
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Phone: +49-(0)2222-9321-1800; Fax: +49-(0)2222-9321-1860 Email: [email protected]
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Short biographical note: MA Art Therapy, Research Assistance, Occasional Teacher Department of Arts Therapies and Therapy Science, Alanus University
Acknowledgements This work was conducted at Alanus University of Arts and Social Sciences, Alfter. It was supported by Alanus University. 1
The author and co-author declare that there are no conflicts of interest in relation to the subject of this study. Highlights:
the mood-elevating effects of art-making were stronger when art was used to distract art therapy interventions are most effective when they entail a structured task leading to a specific end result or goal state the importance of psychological models of emotion regulation for research in art therapy
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Abstract
Questions concerning the regulation or dysregulation of emotions in mental distress
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states are not only of fundamental concern in psychotherapy research but also a key issue in
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the art therapy field. Nevertheless, few studies have investigated the effectiveness of artistic
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activities in emotion regulation. This review aims to identify and analyze studies that
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investigate art-making to regulate emotions. Most studies to date have examined the effects of short-term mood repair, but some did investigate emotion regulation models in a
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psychotherapy setting. They revealed that in positive mood enhancement resulted from artmaking. A few comparative studies suggested that art-making was more effective than other
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therapies, with distraction strategy demonstrating special success in regulating emotion. Future research on emotion regulation in art therapy should also address psychological
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models and take specific active factors of art into consideration.
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Keywords
emotion regulation; art therapy; narrative synthesis; mood enhancement
Introduction Scientific knowledge in the creative arts therapies (art, music, dance and drama 2
therapy) is heterogeneous. Compared to psychotherapy, arts therapies as a field are less systematically investigated. However, in recent years a growing number of systematic studies on various arts therapies have been published, for example, on oncology (Boehm, Cramer, Staroszynski, & Ostermann, 2014; Bradt, Dileo, Grocke & Magill, 2011; Gruber, Rose, Manheim, & Weis, 2011), psychiatry (Crawford, H.J., Killapsy, H., Barnes, T.R., Barrett,
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B., Byford, S., Clayton, K., & Waller, A., 2012; Montag, C., Haase, L., Seidel, D., Bayerl,
M., Galliant, J., Herrmann, U., & Dannecker, K., 2014) and on child therapy (Geretsegger,
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Elefant, Mössler, & Gold, 2014). In a systematic meta-analysis, Boehm et al. (2014) were
able to demonstrate a significant decrease in anxiety in individuals living with a diagnosis of cancer. Nevertheless, the extant corpus in this relatively young research discipline suggests a
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need for studies that are better controlled by adhering to the requirements of evidence-based
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medicine (EBM) standards.
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Working with emotions is a core activity of both art therapy (Malchiodi, 2012) and psychotherapy (Greenberg, 2011). The connection between art and emotion regulation has
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been described, studied and confirmed in art therapy literature (Dannecker & Herrmann, 2017; Kramer, 1958; Naumburg, 1966; Rubin, 1984). Thus, Franklin (2010) pointed out that
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creating art helps to modulate emotions that arise concomitantly with attachment relationships. Working in an art psychotherapeutic setting with children acting out
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troubled early childhood experiences, Armstrong (2013) applied attachment theory to discussing the development of an individual´s capacity for emotion regulation. Working
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with borderline personality disorders, Springham, Findlay, Woods & Harris (2012) showed that art therapy is an essential factor in helping to develop greater mentalization capabilities. Killick & Schaverien (1997) found that, for the psychotic individual, pictures mediate in the actual space in-between psychotic client and therapist. This relationship mediated by an object seems to create a less threatening environment for the client with a 3
fragile personality than having to relate directly to another human being. Man & Ho (2014) also asserted that art therapy – as one major, nonverbal psychotherapeutic approach – has attracted growing attention got its efficiency in treating depression and anxiety. Another study explored the relationship between prevention and art therapy for clients suffering from burnout and found a significant increase in positive mood after just one art
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therapy project day (Oepen & Gruber, 2012; 2014). Nonetheless, despite the growing number
of studies on art therapy, little systematic, fundamental research has been carried out to date to
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investigate the connection between art-making interventions and emotion regulation.
Psychotherapy has shed additional light on this problem. Finding by Berking & Wuppermann (2012), by Berking, Ebert, Cuijpers & Hofmann (2013) and Webb, Miles, &
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Sheeran (2012) point out lead to the conclusion that new studies addressing emotion
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regulation in the fields of psychotherapy and neuro-psychotherapy need to be validated and
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integrated with the development of treatment concepts and art therapy research. Current
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models of emotion regulation in psychotherapy research assign high importance to the
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(dys)regulation of emotions in the presence of mental distress (Gross & Munoz, 1995).
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Research questions
Given the significant questions involved in functional emotion regulation and the
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hypothesized regulation of emotions through art, we scanned relevant databases for studies that investigated emotion regulation or emotion regulation effects stemming from artistic
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activities to synthesize them in this study. By doing so, the present review seeks to answer the following questions: - What are the identifying characteristics (e.g. research questions, sample population, type of intervention, study design) of studies on art-making for emotion regulation?
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- What types of emotion regulation strategies did these studies examine? - What kinds of effects of art-making on emotion regulation did these studies describe? - In the studies reviewed, what specific active therapeutic factors in art therapy (see
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Koch, 2017) effected positive changes in emotions? - What do the present review’s findings imply for the future development of studies on
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art therapy and its effects on emotion regulation?
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Theoretical Background
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Emotion regulation – definitions and models
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In recent years, the concept of emotion regulation has emerged as a topic in
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psychological and mental health research (Berking et al., 2012). It has been variously defined in the psychological literature (Eisenberg & Fabes, 1992; Thompson, 1994; Huang & Guo,
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2001; Cole, Martin & Dennis, 2004; Meng, 2005 as cited in Hu, Zhang, Wang, Mistry, Ran, & Wang, 2014). There is general agreement, however, that “emotion regulation is the set of automatic and controlled processes involved in the initiation, maintenance, and
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modification of the occurrence, intensity, and duration of feeling states” (Webb et al.,
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2012, p. 775). Strategies for regulating emotions focus on positive and negative emotions producing special behavioral and physiological states. Initiating, maintaining, inhibiting or
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moderating emotional reactions may lead to emotion regulation in association with processes that influence experience and the expression of emotions (Gross & John, 2003; ibid.). Emotion regulation refers to the downregulation of negative affects or the upregulation of positive affects (Webb et al., 2012).
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Concurrently, we know from Schore (2003) that psychobiologically regulated affect transactions that maximize positive affects und minimize negative affects cocreate a safe attachment between mother and child. “The responsive relationship supports healthy development by containing affective states and promoting the discrimination …” needed to maintain proximity to attachment figures (Franklin, 2010, p. 161). In the
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context of art therapy, Kramer (1971) informs us that considerations of sublimation and the use of art materials demonstrate how art regulates affects. Arnheim (1966) also saw
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expression and perception as intimately related.
The psychological literature describes various models for classifying emotion regulation strategies. In this respect, the studies by Gross & Thompson (2007) are
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fundamental in the field of psychology (Barnow, 2012). The model proposed by Gross et al.
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(2007) differentiates five emotion regulation processes in a temporal dimension of antecedent-
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focused and response-focused strategies (see Fig. 1). The antecedent-focused strategies
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include situation selection (choosing more positive characteristics and the avoidance of
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problematic situations), situation modification (e.g., actively shaping an interview situation), attentional deployment (e.g., reacting to positive, neutral or negative aspects) and cognitive change such as reappraisal, (e.g., observation from a neutral perspective). An example of a
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response-focused strategy is response modulation, i.e., suppressing emotion or emphasizing
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(positive or negative) emotional reactions (Barnow, 2012; Webb et al., 2012).
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Figure 1. The process model of emotion regulation (adapted from Gross & Thomson, 2007, quoted in Webb et al., 2012).
Strategies of emotion regulation 6
Based on the model proposed by Gross et al. (2007), Webb et al. (2012) in their metaanalysis developed a taxonomy of emotion regulation processes associated with emotion regulation strategies. The taxonomy also contained subtypes that eventually yielded different outcomes within the same process (Webb et al., 2012). In the context of the strategy of "attentional deployment" (“how individuals direct their attention within a given situation so as
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to influence their emotions” [Gross & Thompson, 2007, p. 13]), "distraction" was revealed as an effective regulation strategy and "concentration" on the current feeling as an ineffective
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one. Distraction strategy focuses “on different aspects of the situation or moves attention
away from the situation altogether” and “may also involve changing internal focus, such as when individuals invoke thoughts or memories that are inconsistent with the undesirable
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emotional state” (Gross & Thompson, 2007, p. 13).
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The meta-analysis by Webb et al. (2012) revealed additional determining factors that
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modulate the level of emotion regulation. These included the kind of emotion to be regulated (sadness, anxiety, etc.), the type and timing of inducing emotion (type of medium, personality
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based vs. neutral, before or after the intervention), the frequency of application (single, multiple times), the intended outcome (e.g. positive vs. neutral), the strategy used, the study
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design (object of the control group) and study parameters (e.g., gender, age of subjects) (Webb et al., 2012).
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A major problem with this model is that the strategies developed by Gross & Thompson (2007) partially operate in a similar manner. Furthermore, no safe statements about
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the importance of specific emotion regulation strategies for coping with mental distress can be assumed, since their findings are based on interventions with healthy students (Barnow, 2012). Webb et al. (2012) confined their meta-analysis to studies of healthy subjects because, in their view, clinical subjects may resort to different emotion regulation processes. For example, they held that rumination (i.e., “self-immersed, directed attention toward feelings 7
and their consequences) as an emotion regulation strategy” is particularly problematic if subjects are already in a “dysphoric mood” (Webb et al., 2012). More recent studies dealing with the relationship between emotion regulation and mental health tend to show inconsistent results (Hu et al., 2014). A few studies have investigated how the type of artistic intervention technique
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correlates with emotion regulation. Positive emotional experiences were generated especially
if subjects of the art therapy intervention were instructed to focus on positive personal issues,
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such the positive feelings stimulated by common and decorative objects (Oepen & Gruber,
2012; Wilkinson & Chilton, 2013), or to “create artwork about ‘you at your best’” (Chilton & Wilkinson, 2009, p. 36).
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Since studies in this field have not paid much attention to the importance of
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effective emotion regulation for mental health and of art-making activities (Berking,
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2010), it seems reasonable to call for future studies that not only focus on demonstrating
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applied methods, intervention techniques (e.g. the kind of presentation or instruction)
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and the kind of emotion regulation strategies realized, but that also dwell on how they may relate to observed outcomes. We applied these preferences as criteria during our
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Method
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extensive database search for our sample of studies in this field.
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Database search We employed the narrative synthesis methodology for our review. One of the
features of this methodology is the reliance on multiple data sources. Another characteristic is that the results are reported in a narrative, story-telling format (Edwards & Kaimal, 2016). 8
For our review, we did an extensive search of the Psyndex, PsycINFO, Medline and PsycARTICLES data bases spanning the period 1933-2015 on “art therapy” and “mood” as the search terms. As they imply, the first search cast a very wide net designed to let us capture an overview of all the application areas and target groups (clinical and
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non-clinical) (see Fig. 2).
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Figure 2. Information flow during all review phases.
Inclusion/Exclusion criteria
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The initial search resulted in identifying 478 studies (Psycinfo 315, Medline 107,
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Psyndex 49, PsycArticles 7), of which 442 studies remained for further investigation after
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duplications had been eliminated. The studies were selected against the so-called "PICOS
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criteria" (patient, intervention, control, outcome, study design) (Al-Nawas, Baulig, & Krummenauer, 2010). For the “patient” criterion, following the review articles by Gross et al.
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(2007) and Webb et al. (2012), we only included studies referencing healthy, mentally unburdened subjects on the grounds that emotion regulation based on different kinds of mental health conditions (internalizing or externalizing) is influenced by different types of
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mechanisms (overregulation- or underregulation) (Barnow, 2012). Utilizing only studies of
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healthy subjects made it possible to concentrate on the emotion regulation process supported by art-making activities. Comparable studies in psychology generally tend to deal with
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healthy adults, especially students. Under the “intervention” criterion, we only included studies that intervened with art
making to keep the focus on art therapy. Hence, we excluded studies that dealt with other forms of artistic therapy, such as dance, music, poetry and drama therapy. Since research on emotion regulation is relatively rare in the art therapy field, psychological studies that 9
examined emotion regulation strategies and a specific connection to artistic activity were included. Also included in the sample were studies in psychotherapy that did not investigate emotion regulation strategies per se, but that did explore other emotion regulation mechanisms, for instance, the application of art media techniques, specific active factors of art as plausible emotion regulation strategies and that also addressed the how and the degree
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of the emotional change. In this way, the present study incorporates the part of the
psychological research realm that focuses on specific emotion regulation mechanisms in the
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context of art therapy.
Studies that did not cover outcome-oriented investigations, such as studies dealing with how pictures express different emotions, were excluded, as were pure case studies.
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As previously noted, art therapy research is still a nascent research field. Hence, in
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designing the study, we expanded our search to identify studies of all evidence types (I-IV).
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The study design did not include the use of a control group. An additional, important selection
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criterion was that the studies employed established, validated empirical methods, e.g., by
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using quantitative and/or qualitative data collection instruments. Ultimately, we identified a total of 10 studies for the period 1933–2015 (see Table 1). The studies were carried out in non-clinical areas with healthy, normal adult subjects and their
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findings pertained to the regulation of one or multiple emotions through artistic activity.
Results
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Overview
The following overview (Table 1) details the 10 identified studies. We deemed it
essential to describe the characteristics of the interventions and the outcomes since our findings are intended to serve as a basis for further study.
10
Table 1. Overview of the sample studies.
Characteristics of included studies and emotion regulation strategies The 10 studies comprising our sample were completed in the United States during the past decade. Each examined the regulation of short-term mood through art-making. Four
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studies compared the effects of applying artistic versus non-artistic activities (De Petrillo & Winner, 2005; Drake, Coleman &Winner, 2011; Drake & Winner, 2012; Drake & Hodge,
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2015; Kimport & Robbins, 2012). Two studies by Drake and colleagues (2011; 2015)
compared writing with drawing activity, while Kimport et al. (2012) examined the effects of
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working with clay versus ball handling (throwing a stress softball). Three studies (Kimport &
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Robbins, 2012; Sandmire, Gorham, Rankin, & Grimm, 2012; Van der Vennett & Serice,
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2012) were conducted in university art therapy departments. They all clearly feature research
Target groups
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into emotion regulation from a psychological research perspective.
The study subjects were healthy adult university students and artists (Nageeb, 2013).
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Interestingly, a majority of the experimental subjects were women. Seven studies had more
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than 50 participants; one study had just ten subjects.
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Research focus, duration of interventions and instruction method The sampled studies primarily investigated the effect of artistic activities on the
process of emotion regulation. The majority of the studies used the approach of testing
mechanisms of short-term mood repair, with interventions lasting between 5 to 30 minutes. To induce an initial negative mood in the subject, most of the interventions screened a film with negative content. Alternatively, subjects were verbally prompted to recall negative 11
personal life events. In both cases, the negative mood had to be described in writing (Kimport & Robbins, 2012; Drake et al., 2011, 2012). In one study only, it was not necessary for the researchers to induce a negative mood, given that the student subjects suffered from anxiety because of impending final examinations the next week (Sandmire et al., 2012).
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Design
Nine of the studies investigated the degree of mood change by applying quantitative
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methods in a controlled pre-post design. One pilot study (Nageeb, 2013) relied exclusively on qualitative methods for the investigation. Three studies (Kimport & Robbins, 2012; Sandmire et al., 2012; Van der Vennett & Serice, 2012), centered on measuring anxiety, while two
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studies (Drake et al., 2011; 2012) examined mood modification in the subjects. Eight studies
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et al., 2012; Van der Vennett et al., 2012).
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were performed as randomized controlled trials (inter alia, Drake et al., 2011; 2012; Kimport
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Efficacy of art-making activities in achieving emotion regulation Nine of the 10 studies we reviewed reported significant effective short-term mood repair through art-making. A longer-term emotion regulation through art-making could not be
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definitively described (Nageeb, 2013). The most successful short-term mood repair was
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achieved by using artistic techniques instead of other activities such as writing, throwing a
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ball, or sitting (Drake et al., 2011; Kimport & Robbins, 2012; Drake & Hodge, 2015).
Distraction and venting With reference to the Gross model, it was suggested that the mood-elevating effects of art-making were stronger when art was used as a distraction, i.e., by focusing on a neutral
12
topic such as drawing a house rather than as a vehicle for venting negative feelings, or in various strategic settings such as sitting quietly (Drake & Winner, 2012). The same study, in examining positive and negative affects, found using art-making for distraction induced positive emotions. This effect was significant as compared with a second type of strategy (sitting quietly). A stronger effect on mood improvement was further
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achieved by making associations with positive emotions (Dalebroux et al., 2008). Use of the venting strategy resulted in the most negative affects being recorded, with higher negative
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values than were measured for the control group using the sitting strategy. Gender also
impacted use of the venting strategy: the impact was worse for men using the strategy than for women (Drake et al., 2012). The preferred distraction strategy was artistic activity; writing
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activity was preferred for expressing feelings (Drake & Hodge, 2015).
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Directive approach in art therapy
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Regarding the methods used, the studies suggest that art therapy interventions are most
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effective in alleviating negative mood states when they entail a structured task leading to a specific outcome or goal state (Kimport & Robbins, 2012). The strength of the regulatory effect appears to depend on the specific type of pattern to be colored: coloring a mandala
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reduced anxiety significantly more than did coloring a plaid pattern or blank sheet of paper
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(Van der Vennett et al., 2012; Babouchkina & Robbins, 2015). Thus, art-making activities seem to be superior to other methods for elevating short-term mood enhancement. The
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distraction strategy had more impact than venting when using art-making activities. Some studies noted the influence exerted by the artistic method and form of instruction on the extent of the mood enhancement.
Discussion 13
We examined the “intervention” and “outcome” parameters of the ten studies that met our criteria for this narrative synthesis, to develop starting points for further research projects on the topic of emotion regulation in the field of art therapy. As noted previously, the studies in our sample only examined healthy subjects, mostly students and, in one study, artists. Most of the subjects were women. We found that emotion
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regulation strategies as described and observed in psychological models and studies (e.g.,
Gross & Thompson, 2007) had been examined in half of the ten selected studies (Dalebroux
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et al., 2008; De Petrillo & Winner, 2005; Drake et al., 2011; 2012; 2015). The authors
primarily investigated two emotion regulation strategies based on findings from psychological research: the venting of negative feelings and distraction strategy, a form of attentional
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deployment that focuses on positive or neutral emotions to distract from negative emotions
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Thayer, et al, 1994 quoted in Drake et al., 2011).
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(Gross & Thompson, 2007; Gross & John, 2003; Larsen, 2000; Parkinson & Totterdell, 1999;
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In addition, our review confirmed the results produced by Gross & Thompson (2007),
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who found that distraction strategy, a form of attentional deployment, is better suited for short-term mood repair than a strategy of concentrating on current emotion. Applying the distraction strategy through artistic activities while stressing positive emotions proved to be
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particularly effective (Dalebroux et al., 2008). The positive effect of distraction strategy was
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also demonstrated in other studies that examined subjects suffering from illness or mental burdens (Dalebroux et al, 2008; Oepen & Gruber, 2012; 2014; Oepen, 2015).
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Our review therefore points to the need for further research on distraction strategy with a focus both on positive and neutral emotions. Our findings confirm that it is possible to observe efficient emotion regulation strategies (Webb et al., 2012) resulting from the use of art-making. Participants who often used the reappraisal strategy showed more positive than negative emotions (see Gross & John, 2003; Gross & Thompson, 2007; Hu et al., 2014). 14
The type of artistic tasks and of art-making instructions appear to influence the degree of mood enhancement. Thus, the results strongly suggest a need for investigating different effects by a variety of artistic techniques on emotion regulation, including free-form painting, collage making, drawing still life pictures, etc. Clearly, it will be important to carry out more fundamental art therapy research. “Creative activity has also been used in psychotherapy and
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counseling, not only because it serves as another language but also because of its inherent
ability to help people of all ages explore emotions and beliefs, reduce stress, resolve problems
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and conflicts, and enhance their sense of well-being” (Malchiodi, 2003). The power of art
therapy lies in its ability to evoke a practically-oriented experience with primarily nonverbal access embedded in artistic activities (Koch & Eberhard-Kaechele, 2014; Koch, Steinhage,
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Haller, Kende, Ostermann, & Chyle, 2015).
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In line with the significant improvements in levels of emotional awareness observed
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by Montag et al. (2014) in the randomized controlled trial (RCT) of a psychodynamic group
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art therapy in acute psychotic episodes (Montag et al. 2014), more detailed research into
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which (art) intervention has the most potential for helping clients recommends itself as a topic of interest. Current attempts to identify the function of the arts from a health perspective (Koch, 2017), would benefit from investigating which active factors of the arts therapies are
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of key importance (Tüpker & Gruber, 2017). As Crawford et al. (2012) point out in the
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MATISSE study, which found no difference between art therapy and standard care in the improvement achieved for schizophrenics, an approach combining different creative
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arts therapies (for example, music therapy and body movement therapy) may be more effective. Worth mentioning in this context also is the debate on whether a directive or nondirective approach is to be preferred in art therapy. According to McNeilly (1983), the nondirective approach in art therapy plays an additional, important role in art therapy 15
interventions. He argues that resorting to direct suggestions in theme-centered art therapy may possibly result in uncovering a powerful feeling too rapidly, creating a problem for the client , the group and/or the art therapist in containing or understanding it. This argument contrasts with the results of other studies represented in this narrative synthesis that argue instead for the advantages of a directive, theme-centered approach, especially when using distractive,
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positively focused instruction (inter alia, Dalebroux, Goldstein, & Winner, 2008; Kimport & Robbins, 2012).
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In practice, falling between these two poles are a variety of group experiences which use art structures that can be interesting, revealing, and, moreover, enjoyable (Liebmann, 1999 quoted in Edwards, 2004). In this regard, the experiences of clients in art therapy
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treatment can lend additional perspectives on the effects of art-making. As Rankanen
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(2016) found in her study, 98% of the clients felt that art therapy had a positive impact
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on their psychological health, 82% recognized positive effects on their social
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relationships, and 67% noted positive physical health effects.
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More exploratory research is needed to discover in which specific context goaloriented instruction (distraction or concentration strategy) is more effective than a non-
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efficiently.
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directive instructional approach (free art-making) when it comes to regulating emotion
Limitations
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The following are possible limitations of the present review:
1. The focus is only on healthy subjects. We took this approach because we conducted our research based on current models of emotion regulation used by psychologists (Gross et al., 2012), that favored the study of healthy subjects first as a way of gaining initial, fundamental insights into emotion regulating 16
processes before moving on to study subjects with varying illnesses. Our rationale for emulating the psychologist’s approach was that it allowed us to make consistent, valid comparisons. 2. The review concentrated on short-term mood changes. Unquestionably, studying the change of emotions in an art therapy setting over longer periods
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of time will be useful. It may be relevant here that the subjects in the studies we reviewed were mostly women and younger people (students). The study by Shella (2018), with a
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sample composed mostly of women, found significant improvements in pain, mood, and
anxiety levels for all patients during their stay in a hospital regardless of gender, age, or diagnosis.
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3. Inconsistent results between different art therapy settings
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According to Crawford et al., (2012) and Shella, (2018), further research is required to
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analyze emotion regulation adjusted for gender, age, sick and mentally burdened
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subjects, because these variables can be assumed to possibly correlate with the degree of
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Conclusion
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emotion regulation (Webb et al., 2012; Drake & Winner, 2012).
Our findings underline the importance of referring to psychological models of emotion
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regulation in conducting art therapy research. Investigating the specific active factors at work in art appears to be another promising avenue for future research. However, it should also be
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pointed out that, while our findings are useful for describing and evaluating emotion regulation, they are nonetheless preliminary. Further research with larger research teams and patient groups is called for. Also, priority should be given to conducting research into regulation of emotions through art therapies potentially benefiting especially individuals experiencing severe mental distress or undergoing palliative care. 17
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Figure 1. The process model of emotion regulation (adapted from Gross & Thomson, 2007 quoted in Webb et al., 2012).
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Figure 2. Flow of information through the different phases of the review.
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I Table 1. Overview of the sample studies.
Babouchkina & Robbins (2015)
67 female =51 male= 16
Aims/Hypothesis/ Questions Efficacy of mandala painting for reducing negative mood states
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De Petrillo & Winner (2005)
42 f=12 m=10 age: 18-22
1. Induction of negative mood, 2. Coloring, four conditions:
A) Coloring a blank circle with instructions to express feelings B) Coloring a blank circle with instructions to draw freely C) Coloring a square with instructions to express feelings D) Coloring a square with instruction to draw freely
Examination of two mechanisms of shortterm mood repair: arousal and valence
Induction of negative mood by a war film
Does art-making improve mood, If so,
Experiment 1: induction of negative mood by tragic images drawing a picture based on the feelings or copying shapes
is this effect best explained by “catharsis” or “redirection”
Experiment 2: distraction by making a drawing or completing a word puzzle
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57 f=53 m=22 age: 18-22
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Dalebroux et al. (2008)
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age: 18-42
Interventions
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Size (n)
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Author
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Measures/ Tools Profile of Mood States Drawing Task
Affect grid
Three conditions: 1. Venting: drawing a picture that expresses the feelings in reaction to the movie 2. Positive emotions: drawing a picture that depicts happiness 3. Distraction control: finding and crossing out symbols out of a sheet of symbols Affect Grid
Outcomes
Study Design
Significantly greater mood improvement of the two circle (mandala) groups compared to the two square conditions
Randomized
No effect on arousal, effect on mood valence; most effective when association to positive emotions
Randomized
Art making increases the pleasure dimension of mood and does so via either catharsis or redirection
Randomized
controlled
controlled pre-post
controlled pre-post
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I Drake et al. (2011)
40 f=23; m=17
2. Determination whether mood is more effectively repaired when the medium is used to vent negative feelings or to distract oneself from negative feelings
1. Induction of negative mood by a film
1. Affect Grid
2. writing or drawing condition about anything one would like
2. Self-reported questionnaire: decision whether distraction or venting is the better strategy
80 f=60; m=20
1. Using art to distract more beneficial for mood repair than to vent
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PT
age: 18-22
ED
Drake & Winner (2012)
2. Using art to distract more beneficial for mood repair than sitting quietly or venting
Study 1: 1. Induction of negative mood by a film 2. Drawing condition (n=40): venting by drawing something related to the film distraction condition (n=40): drawing something unrelated to the film: a house Study 2: 1. Induction of negative mood by verbal instructions/writing (personal experience) 2. Three conditions: using art for venting, for distraction, control: quietly sitting
1. Short-term mood repair better by drawing than by writing 2. Drawing better strategy for distraction than for venting
Randomized controlled pre-post
3. Concerning both activities: better mood repair by distraction than by venting
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age: 18-22
1. Comparison of short term-mood repair effects of drawing vs. writing
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PANAS (positive and negative affect schedule)
1. Distraction better strategy than venting and sitting 2. Positive affect: significantly higher in distraction than in venting and higher than in sitting condition
Randomized controlled pre-post
3. Negative affect: least reduction in venting condition Male participants (Study 1): more negative affect after using art to vent than to distract themselves
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I Drake & Hodge (2015)
80 f=62;
1. Indication of preference: drawing or writing 2. Sad mood induction by a film
Investigation of emotion regulation strategy (distraction vs. expression)
3. Half were assigned to their preferred activity, half to their non-preferred activity
102
f=74; m=28
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Kimport & Robbins (2012)
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m=18 age: 18-22
One’s preference for regulating short-term affect: drawing or writing
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age: 18-63
1. More mood enhancement by working with clay than holding and manipulating soft stress balls 2. More mood enhancement by structured activities with a result than doing aimless activities with objects
1. Induction of negative mood by a film, writing about the negative feelings 2. 4 groups: A) Structured instruction: making a pinch pot with clay B) Free instruction: manipulating the clay any way one wished C) Structured instruction: moving the soft balls in the demonstrated way D) Free instruction: handling the balls however anyone wanted
Pilot study
Experience Questionnaire (preference for drawing or writing); Mood Induction Measure (rating sadness of the film); PANAS (Positive and Negative Affect Schedule); Strategy Questionnaire (venting or distraction or other-specify)
Negative affect significantly lower after drawing than after writing (even when the preferred activity indicated was writing)
POMS (Profile of Mood States)
1. More mood enhancement by manipulating clay than stress balls
Randomized
2. More effectiveness of art therapy interventions at alleviating negative mood states when entailing a structured task leading to a result
pre-post
STAI (State-Trait Anxiety Inventory)
controlled pre-post
Participants were more likely to use drawing to distract and writing to express
controlled
3. Most mood enhancement by the structured manipulation of clay
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I
(information s about gender, age not available)
Sandmire et al. (2012)
57 f=45; m=12
50
f=41; m=9
CC E
Van der Vennett & Serice (2012)
age: 21-59
A
Significant reduction of anxiety one week before final exam by an artmaking activity compared to a control group that did not participate in art-making
PT
mean age: 18,8
Creative process of visual artists from conception to completion of a creative work
Qualitative, phenomenological
Results do not strongly support either side of the positive vs. negative mood
Pilot study
5 groups with different art-making tasks: A) Coloring a pre-designed mandala B) Painting free form C) Making a collage D) Drawing a still life picture and coloring it with sepia ink E) Control group: no activity
STAI (State-Trait Anxiety Inventory)
Mean state anxiety score between pre-activity and post-activity decreased significantly in the artmaking group, no difference in the control group
Not randomized
1. Induction of an anxious mood (personal experience) by verbal instructions/writing
SAI (State Anxiety Inventory)
1. Reduction of anxiety by coloring a mandala to a greater degree than coloring free form
Randomized
A
(2013)
Role of emotion in the creative process of visual artists (positive or negative emotion)
M
10
ED
Nageeb
N U SC R
Significantly more reduction of anxiety by coloring pre-drawn mandalas than coloring a plaid design or coloring free form
2. Three art-making groups: coloring a mandala coloring a plaid design coloring free form
Demographic questionnaire
controlled pre-post
controlled pre-post
2. Difference between coloring the mandala and plaid design but no difference between coloring the plaid design and the free-form design
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