Review

Art therapy for people with psychosis: a narrative

review of the literature
Angelica Attard, Michael Larkin

Art therapy enables individuals to use art to creatively express themselves and communicate di erently with Lancet Psychiatry 2016
themselves, others, and their reality. The National Institute for Health and Clinical Excellence guidelines for Published Online
psychosis and schizophrenia suggest that arts therapies, which include art therapy, are considered to improve August 12, 2016
http://dx.doi.org/10.1016/
negative symptoms of psychosis. We examined the e ectiveness of art therapy for people with psychosis and
S2215-0366(16)30146-8
explored whether art therapy is a meaningful and acceptable intervention in this Review. Seven electronic
See Online/Comment
databases were searched for empirical papers that concerned the use of art therapy for adults with psychosis that http://dx.doi.org/10.1016/
were published from 2007 onwards. The search identified 18 papers. High-quality quantitative articles provided S2215-0366(16)30210-3
inconclusive evidence for the e ectiveness of art therapy in adults with psychosis. However, high-quality School of Psychology,
qualitative articles indicated that therapists and clients considered art therapy to be a beneficial, meaningful, and University of Birmingham,
Edgbaston, Birmingham, UK
acceptable intervention, although this conclusion was based on a small number of studies. In this Review, we
(A Attard ClinPsyD,
discuss the theoretical, clinical, and methodological issues in light of the development of more robust research, M Larkin PhD)
which is needed to corroborate individuals’ experiences and guide evidence-based practice. Correspondence to:
Dr Angelica Attard, School of
Introduction have di culties with identifying their own or others’ Psychology, University of

Psychosis and schizophrenia can have a debilitating impact
on people’s lives and mortality.1 Pharmacotherapy is a
common treatment for schizophrenia; however, the long-
term use of antipsychotic medications often has unpleasant
side-e ects.2 Patients might become treatment resistant1
and continue to experience symptoms together with
psychological, social, and functional di culties.3 Therefore,
the National Institute for Health and Clinical Excellence
(NICE) highlighted the need for psychological therapies to
be o ered in conjunction with medication to support
individuals with psychosis and schizophrenia through their
recovery.4
In addition to cognitive behavioural therapy and family
intervention, arts therapies are recommended,
particularly for people with negative symptoms. NICE
identifies that arts therapies include “art therapy or art
psychotherapy, dance movement therapy, body
psychotherapy, drama therapy and music therapy”. 5 The
aim of using arts therapies is to enhance an individual’s
creativity, emotional expression, communication, insight,
and ability to relate to themselves and others. 5 The
therapies should be delivered by arts therapists
registered with the Health and Care Professions Council
who have worked with people with psychosis. 5
The use of art therapy, specifically for people with
psychosis, is the main focus of this Review. According to
the British Association for Art Therapy (BAAT), art
therapy is defined as “a form of psychotherapy that uses
art media as its primary mode of expression and
communication” to support people in distress.6 This
primarily involves using art media in a group or individual
setting.6 Throughout this Review, art therapy is
understood in line with this explanation.
Art therapists have advocated for art therapy to be used
with this client group routinely. Negative psychotic
symptoms can hinder people’s ability to identify and explore
their experiences.7 People with schizophrenia often
mental states,8 and can withdraw socially.9 Art therapy Birmingham, Edgbaston,
Birmingham B15 2TT, UK
has a long-standing role in facilitating engagement when angelica.attard@gmail.com
direct verbal interaction becomes di cult. 9,10 Art is
considered to be a mediator (between the person with
psychosis and the therapist), which o ers a safe and
indirect means of connecting with oneself and others. 9,11
People with psychosis might also experience unclear
boundaries between their internal and external worlds,
which can feel overwhelming. 12 Art therapy enables
people to express and project their emotional, cognitive,
and psychotic experiences in their art, and process them
at a pace that feels comfortable.9,12 Furthermore, art
therapy commonly occurs in group settings where art is
a communal means of self-expression; this setting can
increase an individual’s sense of belonging. 7
This support for the helpfulness of art therapy is rooted in
theory and clinical experience, and is weakly substantiated
by rigorous, controlled research. National guidelines on the
treatment of specific conditions are based on the highest
quality scientific evidence, which includes randomised
controlled trials (RCTs) and systematic reviews that have at
least one RCT.13 By comparison, studies using cohort, case-
control, cross-sectional, or single case designs are
considered to provide weaker evidence.14
The e ectiveness of art therapy is primarily
established through RCTs. In an early Cochrane
review, the shortage of RCTs prevented conclusions
from being drawn regarding the e ectiveness of art
therapy for people with schizophrenia. 15 However,
two studies16,17 contributed to the 2009 NICE
guidelines, and their results indicated that arts
therapies (including art therapy) can enable recovery,
especially for people with negative symptoms.18
Green and colleagues16 found that a 10-week art
therapy outpatient group showed improvements in social
interaction and self-esteem when compared with
treatment as usual (TAU). Richardson and colleagues 17

www.thelancet.com/psychiatry Published online August 12, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30146-8 1

 Review
explored the e ect of a 12-week art therapy outpatient group
compared to TAU. Despite an underpowered sample size
and high dropout rates, negative symptoms in the art
therapy group decreased significantly post-intervention and
at follow-up. Another RCT showed that a 15-week art
therapy group intervention reported some improvements in
mental health, quality of life, and functioning among
inpatients with psychosis compared with TAU. 19 However,
these outcomes have been contradicted by the largest
three-armed RCT, the MATISSE trial.20,21 This trial has
provoked a wave of clinical and academic responses, and
concerns regarding the future of art therapy for people with
schizophrenia.22,23
The growing interest in art therapy is also evident in
systematic reviews. These reviews assessed some
literature on schizophrenia but did not comprehensively
synthesise it. Slayton and colleagues24 reviewed the general
e ectiveness of art therapy within clinical and non-clinical
populations from 1999 to 2007. They concluded that art
therapy was e ective, but did not specify for which clinical
populations or how it was e ective. Van Lith and
colleagues25 reviewed the implications of art-based
practices on recovery and concluded that these practices
aided social and psychological recovery. The articles that
focused on schizophrenia were published in 2009 or earlier,
although in some, the interventions focused on skill
development and were not facilitated by art therapists.26,27
The most recent systematic review of RCTs, published in
2014, also highlighted the benefit of art therapy and referred
to a range of client groups.28
In this Review, we build upon and address the gaps in
previously published reviews by specifically focusing on
research regarding art therapy in people with psychosis
from 2007 onwards. We report on the e ectiveness of art
therapy as an intervention for people with psychosis in
comparison with a control group receiving another
therapy, no therapy, or TAU. We also discuss whether
art therapy is suitable and meaningful for people with
psychosis from the perspective of service users and art
See Online for appendix therapists by including all research methods.
Searching the art therapy literature
When searching for evidence for this Review, we used
the term “art therapy” in line with the BAAT definition, 6
and the term “psychosis” as an umbrella term for a
cluster of psychotic disorders, such as schizophrenia,
schizotypal and schizoa ective disorders, in accordance
with the NICE guidelines for schizophrenia and
psychosis,29 and the British Psychological Society.30
Our search elicited 774 papers, of which we discuss 18
relevant articles in this Review (figure). As mentioned, the
focus of our Review is on art therapy in adults with
psychosis, so we do not discuss the evidence for drama,
music, and dance therapy. We include evidence from
papers published in 2007 onwards, to build on the 2005
Cochrane review on art therapy for schizophrenia, which
reviewed RCTs published until 2007,15 and on later
2 www.thelancet.com/psychiatry Published online August 12, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30146-8
systematic reviews of art therapy and psychosis
published from 2007 onwards.24,25,28 We consider the
e ectiveness of art therapy in comparison with any
control groups or TAU, and put no restriction on the
outcomes measured. We discuss quantitative and
qualitative research done in all settings.
When screening the literature, we found that
interventions were sometimes ambiguously defined,
making it di cult to distinguish between art
psychotherapy and the use of art for enjoyment and
artistic skill acquisition. Following discussion with a
consultant art therapist, we decided that a reliable
indicator of the provision of art therapy was the
involvement of registered art therapists as intervention
facilitators or supervisors. Applying this rule to studies in
which the intervention was ambiguous ensured that we
reviewed only studies exploring art therapy.
We included the papers relating to the MATISSE
trial, which were identified in the search, to review
them in light of the wider research.22
Methods of quality appraisal
The 18 articles included various methodologies, so we
developed a multimethod quality framework to review
the articles’ quality according to standardised criteria.31
The framework was based on quality criteria for mixed-
method studies.32 When we deemed criteria to be
missing, we added items from qualitative, 33 mixed
methods,34 and RCT quality frameworks.35 We collated a
set of criteria for case studies from three papers, 36–38
and integrated them into the multimethod framework. In
accordance with the Centre for Reviews and
Disseminations’ recommendations, we piloted the
framework with an independent researcher. 31
The final framework was organised into four main quality
categories against which AA rated every article: truth value,
applicability, consistency, and neutrality. Each category was
scored and the average score across the four categories
indicated the articles’ overall quality rating and robustness
as good, moderate, or poor (appendix). ML and the
independent researcher calibrated the quality ratings for a
sample of the 18 studies. Di erences in ratings were
resolved through discussion.
AA extracted data from each study using a grid that
summarised the information that was relevant to the
Review’s aims (table 1). ML checked a random
sample of the extraction summaries for accuracy to
increase consistency. Di erences in opinion between
AA and ML were discussed.
In this Review, we present a narrative synthesis of the
quality and methodological considerations within and across
the papers, in line with the four quality categories.
Analysis of the art therapy literature
Quality of the studies
Overall, the evidence within this Review was weak, and
consisted of two RCTs (one of which is two papers), a
 Review

re-analysis of an RCT, one mixed-methods study, a

survey design, a non-experimental design, five 1027 records identified through 2 additional records identified
database search through other sources
qualitative studies, and six case studies. Eight studies 223 Embase
were good quality, four were moderate quality, and six 94 Ovid MEDLINE
149 PsycINFO
were poor quality (table 2). We consider the poor-quality
48 PsycARTICLES
studies with caution throughout this Review. 275 Web of Science
The truth value of some studies was adversely a ected 53 CINAHL (EBSCO)
185 ProQuest ERIC
because authors presented compound results for
participants with di erent diagnoses.39–42 This presentation of
the data made it di cult to identify whether art therapy
benefited a subset of participants with psychosis. Whether 774 records after duplicates removed

supporting quotations or images, or both, were a credible

representation of participants’ experience was unclear
774 titles screened
because often no reference was made to the source or
context of such examples.40–45 In the mixed-sample studies,
whether or not quotations came from participants with 567 titles excluded
psychosis was unclear.
Results were sometimes confounded because some 207 abstracts assessed for eligibility
participants receiving art therapy had a previous interest
in art,43,46 and in one study all participants in the control
groups had “no a nity” for art.40 Motivation47 and 139 abstracts excluded

keenness for art were suggested to have positively

influenced the engagement and perceived benefit from
art therapy.43 However, Leurent and colleagues48
identified that interest in art was not a moderating factor
in MATISSE. The RCTs were single-blind studies.20,21,49
Allocation concealment was appropriately done in these
RCTs, although the process was more thoroughly
described in MATISSE.20,21
The applicability of this Review is limited by the numerous
case studies, qualitative studies, and small sample sizes.
Only MATISSE was adequately powered,20,21 although the
low participation rates rendered the secondary analysis
underpowered.48 Few studies provided a rationale for their
choice of research design.39,40,47,50 The method of
recruitment was not given in several qualitative and case
studies,40,42,43,45,47,50,51 and in the study by Montag and
colleagues49 randomisation was not clearly described.
Across the di erent study designs, the structure of the art
therapy intervention was ambiguous
or not described.20,21,39,41,42,44,46
Consistency was a significantly weak category for most
case studies and for the mixed-methods study by de Morais
and colleagues.40 Little46,50 or no41,44,47 information was
provided about analysis methods in several studies, making
identification of whether analyses were reliably executed di
cult. Most case studies and qualitative studies made no
attempt to involve other researchers to confirm the
analysis.42,45,47,51,52 Consistency was enhanced mainly in the
qualitative studies through semistructured interviews,42,45,51–
53
member checks,43,51,53 and an audit.43
68 full-text articles
assessed for eligibility
50 full-text articles excluded
1 not peer reviewed
9 not empirical articles
14 not in English
17 not exploring psychosis
8 not exploring art therapy
1 included in previous
Cochrane review
18 final studies included
Figure: Flow diagram for the included and excluded articles
Neutrality was the weakest quality category for
qualitative and case studies, none of which reported
reflexive monitoring. Teglbjaerg45 used a logbook,
although whether this logbook was used reflectively
was unclear. Only two studies commented on
bracketing preconceptions.51,53 Most case studies did
not consider biases associated with researchers
acting as the art therapists of the intervention.41,46,50,53
The quantitative studies were objective in reporting
the significant and non-significant results, apart from
de Morais and colleagues.40 Several quantitative and
qualitative studies failed to consider potential biases
associated with integrating art therapy with other
psychotherapeutic or psychosocial interventions.

Reliability was generally strong in the quantitative papers, Participant demographics

and cross-checking of the data occurred in a few.20,21,39 In Across the reviewed studies, the recruited participants had
these studies and in the study by Montag and colleagues, 49 diagnoses of schizophrenia, paranoid schizophrenia,
art therapists provided regular supervision of intervention schizoa ective, or bipolar disorder. Four studies included
facilitators who were art therapists themselves. participants with mixed diagnoses, a proportion of whom

www.thelancet.com/psychiatry Published online August 12, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30146-8 3

 Review

Study type Study aims
Crawford et al Three-arm RCT To investigate impact
(2010);20 of art therapy on
and health and social
Crawford et al functioning of people
(2012);21 with schizophrenia
UK compared with an
activity group or
standard care alone,
and to examine
engagement, benefits,
and cost-e ectiveness
Caddy et al Non- To explore changes in
(2012);39 experimental, mental health across a
Australia non-randomised 5-year period for
inpatients who
participated in art and
craft creative therapy
groups in a private
hospital
de Morais et al Mixed methods: To investigate the
(2014);40 non-randomised e ect of a clay work
Brazil controlled study group on depression
and qualitative and anxiety among
interviews inpatients in a day
hospital
Drapeau and Case report To investigate benefits
Kronish and e ectiveness of
(2007);41 creative art therapy
Canada group for outpatients
with psychiatric
disorders
de Morais et al Qualitative To understand the
(2014);42 study significance of clay art
Brazil therapy for psychiatric
patients who attend a
day hospital
Colbert et al Qualitative To explore whether
(2013);43 study art-gallery group with
UK sta improves
personal narratives of
psychosis and
wellbeing, and creates
new community
narratives
Participants Methodology
417 participants Weekly art therapy,
with schizophrenia. activity, or standard care
140 people alone groups for 1 year.
randomly allocated Primary outcomes:
to art therapy with functioning (GAF scale),
standard care, and symptoms (PANSS) at
140 to activity with 2 years. Secondary
standard care, and outcomes: functioning
137 to standard care and symptoms at 1 year;
alone and attendance,
functioning, medication
adherence, satisfaction,
wellbeing, and quality of
life at 1 and 2 years
Existing Group attended by
de-identified data of 16 patients daily. Involved
403 patients art, craft, and expressive
participating in at projects. Outcome
least 6 sessions; measures: DASS-21,
14·1% had diagnosis Q-LES-Q, medical
of schizophrenia outcome SF-14, and
HoNOS
24 participants: Eight weekly clay therapy
12 in control group, sessions. Participants
12 in clay work described sculptures and
group, with feelings. Beck Depression
diagnoses of Inventory and Spielberger
depression, bipolar State-Trait Anxiety
disorder, anxiety, Inventory completed.
dementia, Interviews explored
schizophrenia, and participants’ feelings
psychotic disorder about art. Unclear if all
participants were
interviewed
26 participants with Psychodynamic art
depression, therapy groups provided
schizophrenia, for 1 year. Groups lasted
schizoa ective, 12 weeks. Sessions were in
dissociative, English and French.
borderline, and No data collection
bipolar disorders method specified
Seven of Two open groups.
16 participants had Participants attended at
a diagnosis of least seven sessions.
schizophrenia or Semistructured interviews
schizoa ective asked about participants’
disorder experience before, during,
and after clay therapy
Five men and Two groups took place for
two women had 4 weeks. First part:
diagnoses of discussion of paintings
psychosis; and sketching in the
two female gallery. Second part:
gallery sta , production and reflection
one female art on art in art studio.
therapist, and Interviews explored
one male and participants’ experience
one female NHS and their wellbeing
sta member
Analysis Acceptability and E ectiveness of art
meaning of art therapy therapy
ITT analysis. An Nearly 40% of the art At 2 years follow-up no
ANCOVA examined therapy group did not significant di erence was
group di erences and attend. Art therapy noted between groups
controlled for outcome, attendance was better than for primary or secondary
site, sex, and age, for activity group attendance. outcomes. Participants in
primary and secondary Withdrawal from the study the activity group had
outcomes. A secondary occurred because fewer positive symptoms
analysis, two-level and participants were not than those in the art
three-level interested in attending or therapy group.
heteroscedastic model, found it di cult to attend Art therapy had no
and two-stage clinical advantage and
least-squares estimate was not more
were done coste ective
Descriptive and NA Participation positively
inferential statistics to correlated with better
investigate correlations mental health, with
between mental health moderate to strong e ect
outcomes and sizes. Largest significant
participation. Paired improvement was seen
t tests to investigate on HoNOS. Large e ect
changes in measures sizes were noted on Q-
from admission to LES-Q and DASS-21
discharge
Psychologist who was Some participants found Clay work significantly
not involved in clay work enjoyable and it improved depression.
research administered helped them reflect. Clay work group had mild
and interpreted the Unclear whether these depression and control
measures. quotations appertained to group had moderate
Mann-Whitney test participants with depression. Clay work
compared group schizophrenia. had no e ect on anxiety
scores. No information Two participants were
was provided about excluded from the analysis
the qualitative analysis because they found
sessions overwhelming
and attended only half
No analysis method Drawings enabled clients NA
was specified. to explore issues, connect
Discussion of changes with reality, trust, deal
in participants’ with loss, and socialise.
wellbeing and the Sharing drawings increased
meaning of drawings self-acceptance. Their
created in earlier and self-esteem, quality of life,
later sessions and humour improved
Content analysis Clay therapy increased NA
involving the ordering participants’ creativity
and classification of and self-awareness,
data into final themes, reduced distress, and
but the information mostly improved
provided was scarce relationships with
themselves and others.
For some it triggered
di cult memories and
symptoms
Literary context Some changed their NA
narrative analysis to personal narrative of
understand thoughts, psychosis. New
aims, and themes in community narrative
narratives. Social developed regarding the
context narrative sta –client relationship.
analysis explored Group improved recovery,
personal stories of inclusion, and wellbeing.
psychosis and Five clients attended all or
community narratives most sessions with sta
(Table 1 continues on next page)

4 www.thelancet.com/psychiatry Published online August 12, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30146-8

 Review

Study type Study aims Participants Methodology Analysis Acceptability and E ectiveness of art
meaning of art therapy therapy
(Continued from previous page)
Gajic (2013);44 Case report To present clinical One woman with Weekly sessions for Qualitative analysis of Participants regularly For both participants,
Serbia observations of paranoid 2 months. Measures: drawings’ form and attended. Art therapy minimal improvement
two clients with schizophrenia and CGIS and GAF at content and group enhanced creativity, shown on CGIS, GAF, and
schizophrenia one man with admission and discharge; therapy protocols. self-esteem and CGI-I. Minimal
attending art therapy schizophrenia CGI-I scale at discharge Details about analysis self-confidence. The group improvement was
group in a day hospital not provided provided validation, attributed to severity of
and to investigate support, security, psychosis and the need
their health and acceptance, and social for longer intervention
functioning connection
Teglbjaerg Qualitative To understand how art One group of Weekly formative group Modified grounded All found art therapy NA
(2011);45 study therapy a ects mental five outpatients art therapy for 1 year. theory used involving helpful. Main benefits:
Denmark health of outpatients with schizophrenia Participants were four analysis levels: strengthened self as they
with schizophrenia and one group of interviewed before describing therapy, expressed themselves,
and whether patients five patients with therapy, after therapy, and identifying themes, problem solved, socialised,
with and without depression or at 1-year follow-up about comparing themes to and felt included. Patients
psychosis use it personality experiences of mental the research questions, with psychosis used art to
di erently disorders illnesses, life, and art and assessing whether become creative, find
therapy. Data were they were answered meaning, and connect
gathered from logbooks, with themselves and
art, and evaluation forms others
Banks Case study To explore One man with Attended individual and 11 key images and Art improved his NA
(2012);46 development of art paranoid group art therapy and audio-image emotional expression,
UK therapy in a male schizophrenia recovery group for recordings were hope, alleviated his
low-secure ward, how 12 months. He co-created chosen to describe the worries, and provided
art can build security, an audio-image recording, model of art therapy containment. His sense of
and how violence can and took part in an and the client’s self strengthened as he
be understood interview to reflect on art experience. No made sense of his
through art making analysis method was experiences through his art
described
Hung and Ku Case report To present cases of Patient A: Semistructured art Analysis of patients’ Improvements in PANSS Patient A had improved
(2015);47 two patients with 19-year-old woman therapy four times a clinical symptoms, and SANS attributed to PANSS score from 90 to
Taiwan schizophrenia who with schizophrenia. month. Photo card psychosocial issues, motivation to attend art 65 and SANS score from
received Patient B: collection guided what and images produced. therapy. Patient A was 69 to 45. Patient B had
semistructured art 37-year-old woman patients drew, after which No detail about more likely to share stories improved PANSS score
therapy with schizophrenia they reflected on images. analysis provided of images than patient B from 114 to 92 and SANS
PANSS and SANS from 94 to 69
completed at
two timepoints
Leurent et al Secondary To reanalyse MATISSE 140 people were Weekly groups for 1 year. ITT analysis. Groups No significant di erences No significant di erence
(2014);48 analysis of the results for subgroups allocated to the art Primary outcomes: were compared for in rates and reasons for was noted in
UK MATISSE RCT in art therapy and therapy and functioning and mental interest in art therapy attrition were noted. Only e ectiveness of art
standard care when standard care group health symptoms. and symptoms at site of recruitment was therapy on symptoms
considering gender, and 137 to the Secondary outcomes: 12 months using a relevant. Art therapy between subgroups
treatment compliance, standard care alone functioning and mixed-e ect linear attendance was poor which had di erent
interest in art, group symptoms at 1 year, and model. Intervention because 39% attended no severities of negative
emotional expression, attendance, social e ect was investigated sessions. Previous interest symptoms and those
and time since referral. functioning, medication by stratifying by in art and comfort-sharing which had di erent
adherence, care subgroup and emotions influenced interests in art therapy.
satisfaction, wellbeing, examining the e ect attendance positively No significant di erences
and quality of life at 1 and of interaction and in other subgroup
2 years continuous variables analyses were noted
Montag et al Pilot To investigate e cacy 58 inpatients with Twice weekly groups for Analysis based on Data at 6 weeks were Per-protocol results:
RCT (2014);49 of psychodynamic art schizophrenia: 6 weeks. Primary per-protocol sample. based on 59% of art therapy group had a
Germany therapy for people 29 received art outcomes: scale for the t test and χ²-test were participants from art significant decrease in
with acute psychosis therapy with assessment of negative/ used to investigate therapy and 69% from positive symptoms and
on symptoms, treatment as usual, positive symptoms, di erence between treatment as usual. functioning, and in
functioning, and 29 received Calgary depression scale groups. ANCOVA At 12 weeks follow-up, negative symptoms at
mentalising abilities, treatment as usual for schizophrenia, and compared primary data were based on 55% in follow-up. ITT results:
self-e cacy, care GAF. Secondary outcomes: outcomes, while art therapy and 66% in art therapy improved
satisfaction, and mentalisation, controlling for baseline treatment as usual. positive symptoms
quality of life self-e cacy, locus of ratings, verbal IQ, and Reasons for dropout were
control, quality of life, and gender. ITT analysis of unplanned discharge and
care satisfaction primary outcomes di culty attending
(Table 1 continues on next page)

www.thelancet.com/psychiatry Published online August 12, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30146-8 5

 Review

Study type Study aims Participants Methodology Analysis Acceptability and E ectiveness of art
meaning of art therapy therapy
(Continued from previous page)
Michaelides Case report To explore how art One man with Art therapy group for No analysis method Art therapy was acceptable NA
(2012);50 therapy helps a client schizophrenia 14 months. Clients with described. Changes in for the client with negative
UK with schizophrenia functioning at a di erent diagnoses participant’s symptoms. His reflective
who has poor negative reflective attended. Following art presentation discussed functioning improved,
reflective functioning functioning level creation, drawings were and changes in he became interested and
and whether it is a safe discussed. Observations imagery produced in vocal in the group, and
way of exploring took place of the client’s second, fourth and used art for expression.
mental states group engagement and 32nd sessions Group reflections
drawings strengthened his
connection with himself
Patterson et al Qualitative To understand 24 art therapists: Interviews and focus Grounded theory using Art therapy was considered NA
(2011);51 study therapists’ views of three key groups for 20 months. constant comparative to be valuable. Therapists’
UK process and outcomes informants Questions addressed method and roles, therapeutic
of art therapy (from MATISSE), nature, process, and three levels of coding; relationship, art making,
(what changes, how it 14 MATISSE art outcomes of art therapy, initial, focused, and and group work increased
changes, and for therapists, and therapists’ theoretical expression, wellbeing,
whom), and how to seven non-MATISSE understanding of identity, and acceptance.
improve its provision therapists schizophrenia and The interaction between
concerns. 33·3% therapists, clients, and art
substantiated interviews was important
with documents
Patterson et al Qualitative To understand client 19 trial participants Interviews explored Constructive grounded Some participants did not NA
(2013);52 study experiences of diagnosed with reasons for participating, theory involved attend MATISSE because of
UK MATISSE, who to refer schizophrenia and and response to the constant comparison no interest in art therapy.
to art therapy, how to four who took part allocation and and multilevel coding Those who dropped out
assess its e ectiveness, in a separate focus intervention. Trial data, strategies, in line with were not motivated and
and the generalisability group at 12-month field notes, and analysis in Patterson disliked group work.
of MATISSE results follow-up experiences of therapists et al (2011)51 Six who attended enjoyed
considered as presented in social and therapist
Patterson et al (2011)51 contact, and art
Havenik et al Multiple case To describe usefulness Five women with Weekly group for Group notes and All felt able to explore NA
(2013);53 study of expressive art diagnoses of bipolar, 9 months in psychiatric interviews analysed psychosis, express
Norway therapy for women schizoa ective, hospital. Group involved: using seven-step themselves, interact,
with psychotic schizophrenia music, poetry, movement method for case provide support, gain
diagnoses and how and paranoid therapy, and art to explore studies involving: awareness, and feel alive.
and why it helps with disorders psychosis. Observations of literature searching, All learnt how to cope and
psychotic experiences therapeutic process and analysing information felt valued. Spiritual and
and coping interviews occurred at sources, time-series existential themes were
8 months’ follow-up analysis, pattern identified
matching, and
member checking
Patterson et al Survey design To describe availability, 71 art therapists Piloted questionnaire Descriptive statistics Most therapists used a NA
(2011);54 accessibility, structure, were randomly asked about assessment for questionnaire non-directive approach,
UK and delivery of art recruited from process, outcome items. Univariate and believed art-making
therapy for people 27 NHS Trusts measures, and art therapy statistics for and reflection were
with schizophrenia, mechanisms. Therapists associations between fundamental to art therapy.
and to explore rated levels of agreement therapists’ traits, Art therapy enhanced
therapists’ views of its on benefits of art therapy practice, and views of self-understanding,
helpfulness using a 5-point Likert scale co-working. Thematic control, expression, and
analysis for conflict resolution. Access
open-ended questions to art therapy was
considered poor

RCT=randomised controlled trial. PANSS=Positive and Negative Syndrome Scale. GAF=Global Assessment of Functioning. ITT=intention-to-treat. IQ=intelligence quotient. NHS=National Health
Service. DASS-21=Depression and Anxiety Stress Scale-21. Q-LES-Q=Quality of Life Enjoyment and Satisfaction. SF-14=Short Form 14. HoNOS=Health of the Nation Outcome Scales. NA=not
available. CGIS=Clinical Global Impression Severity. CGI-I=Clinical Global Improvement. SANS=Scale for the Assessment of Negative Symptoms.

Table 1: Data extraction of the final studies included in the Review

had diagnoses of psychosis.39–42 The articles included a
total of 299 male and 155 female participants. These
numbers do not include studies in which gender
demographics were unclear or not provided (128
participants).39–42,45 Most studies were done in the UK by
the same authors.20,21,43,46,48,50,52,54 The rest were done
in Brazil,40,42 Australia,39 Norway,53 Canada,41 Serbia,44
Germany,49 Taiwan,47 and Denmark.45
Treatment method
Study comparison was complicated because art
therapy had di erent titles, including art therapy or

6 www.thelancet.com/psychiatry Published online August 12, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30146-8

 Review

psychotherapy,20,44,46,47,50 clay work or clay therapy,40,42 creative

Truth Applicability Consistency Neutrality Overall quality
activity group,39 art gallery-based project,43 psychodynamic art
value rating (average
therapy,41,49 expressive art therapy,53 and formative art score)
therapy.45 Some of these titles reflected di erent theoretical
Quantitative studies
orientations. Formative art therapy stemmed from expressive art
Crawford et al (2010);20 5 5 5 5 Good (5)
therapy, which considered art as a means of understanding Crawford et al (2012)21
emotional, bodily, and psychotic experiences.45,53 Alternatively, Leurent et al (2014)48 5 5 5 5 Good (5)
in analytical art therapy art enabled the understanding of Montag et al (2014)49 4 4 6 5 Good (5)
unconscious experiences.45 Non-experimental study
Therapists’ orientation was infrequently stated or Caddy et al (2012)39 4 3 5 4 Moderate (4)
described in the literature. In MATISSE,20,21 art therapy was Patterson et al (2011)54 3 4 5 4 Moderate (4)
adapted according to the participants’ needs. More than half Mixed-methods study
the therapists in the study by Patterson and colleagues51 de Morais et al (2014)40 1 2 2 1 Poor (2)
were MATISSE therapists, and the most common Qualitative studies
orientation was psychodynamic, with a minority adopting
de Morais et al (2014)42 3 3 3 1 Moderate (3)
humanistic, psychoanalytic, or eclectic orientations. This
Colbert et al (2013)43 5 4 6 3 Good (5)
variation reflects the theoretical orientations of art therapists
Teglbjaerg (2011)45 2 3 3 1 Poor (2)
recorded in a national survey.54
Patterson et al (2011)51 6 6 5 4 Good (5)
Art therapy was often described in two stages; the
Patterson et al (2013)52 6 5 4 2 Good (4)
focus was on the process of creating art, which then
Case studies
shifted to reflecting on its meaning, usually in a group
Drapeau and Kronish (2007)41 1 2 1 1 Poor (1)
format.43,44,46,47,49,50 Interventions varied in structure,
Gajic (2013)44 3 2 2 1 Poor (2)
because sometimes participants initially learnt about art
Banks (2012)46 3 3 2 1 Poor (2)
history and techniques,43 reflected on their feelings,45 or
Hung and Ku (2015)47 1 1 1 0 Poor (1)
listened to music and poetry, and did movement
Michaelides (2012)50 3 3 3 1 Moderate (3)
therapy.53 Some studies did not specify how art therapy
Havenik et al (2013)53 5 4 4 5 Good (5)
was delivered.39,41,42 Art therapy was sometimes
incorporated with music therapy,46,49 unspecified Table 2: Summary of the quality of the art therapy studies
psychosocial interventions,20,21 or psychotherapies.39,49
Art therapy was provided in a group format in 12 studies,
and one provided both individual and group art therapy.46 On the basis of an intention-to-treat (ITT) analysis,
Patterson and colleagues54 identified that 94·4% of art MATISSE20,21 illustrated no significant di erences in primary
therapists provided individual therapy and 70·4% provided or secondary outcomes between trial arms, at 12 or 24
group art therapy. Art therapy was delivered in open42,44,50 or months. The only significant di erence was that at 24
closed groups,20,21 although most studies did not specify this months, people in the activity group had fewer positive
information. Art therapy was most commonly delivered in art symptoms than those in the art therapy group. The
studios in outpatient or inpatient settings. The length of art secondary analysis indicated no significant symptomatic
therapy varied between 1 and 14 months. The sessions improvements for art therapy participants who had severe
generally occurred weekly for 1·5–3 h. Some studies negative symptoms or a preference for art.48
concluded that longer interventions were more suitable for Results from Montag and colleagues49 were based on the
participants with severe symptoms than were shorter per-protocol sample because most participants who
interventions.40,44,49 dropped out were lost to follow-up. When verbal IQ and
gender were controlled for, at post-therapy and follow-up,
The e ectiveness of art therapy the art therapy group had significantly greater improvements
The two RCTs that we found investigated the e ectiveness in positive symptoms and global functioning compared with
of art therapy by measuring symptoms of psychosis and TAU. At follow-up, negative symptoms decreased for the art
global functioning as primary outcomes,20,21,49 together with therapy group and increased for TAU. Depression did not di
depression in one RCT.49 Both RCTs measured quality of er significantly between groups. The only significant di
life and care satisfaction as secondary outcomes. erence for secondary outcomes was a stronger emotional
Additionally, MATISSE20,21 measured social functioning, awareness of others following the art therapy intervention. In
medication adherence, and wellbeing, whilst Montag and the ITT analysis, only the art therapy group had a significant
colleagues49 measured mentalisation, self-e cacy, and locus improvement in positive symptoms.
of control. The outcome measures in the lower quality
studies included anxiety and depression,39,40 quality of life, Among the other studies, clay work resulted in a
medical outcomes, and health.39 The measures’ reliability, statistically significant decrease in depression and no di
validity, and standardisation for people with psychosis were erence in anxiety compared with no therapy.40 In the study
not always described.39 by Caddy and colleagues,39 creative activity groups

www.thelancet.com/psychiatry Published online August 12, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30146-8 7

 Review
correlated positively with improved depression, anxiety, and
stress. Large significant improvements in quality of life,
health, and distress, and moderate changes in vitality were
reported. These studies provided very weak evidence
because of their poor design and quality. Considering the
scarce studies and variable quality, our Review provides
preliminary, although inconclusive, evidence for the e
ectiveness of art therapy in people with psychosis.
The meaningfulness and acceptability of art therapy
In relation to the second research question, several
themes regarding the meaningfulness and
acceptability of art therapy were identified across the
qualitative and case studies. We interpreted the
findings from poor-quality studies with caution.
A common finding was that the art-making process
enhanced people’s ability to identify, express, and explore
their emotional distress.42,46,51,54 Through art, some
participants expressed themselves at a deeper level than
they usually would verbally.46,53 Art therapy gave some the
freedom to be creative in the absence of stressful
atmospheres where they feared being judged. 43,46,52 Art was
a safe, contained way for people to focus their attention on
something external, while making sense of internal
experiences of psychosis.42,46,50,51 This process was not
always considered to be easy because it triggered di cult
memories.42
The creation of art and reflection on its meaning was
believed to allow people to strengthen their sense of
self.41,42,45,50,51,53,54 Through self-expression, participants
could connect with themselves and this helped them feel
more alive.51,53 This self-integration was enhanced
through the groups’ reflection on the symbolism and
meaning of art.46,50 Through art therapy, some
participants distinguished what was real from what was
not real, and connected with their reality.44,51
Art therapy was reported to enhance participants’
emotional wellbeing, self-confidence, and self-esteem.41–
45,52
Some experienced achievements as they developed
artistic skills.43,44,54 Art therapy was believed to enhance
psychosocial functioning as it encouraged engagement
in meaningful social activities.42,43,51,53 It decreased
participants’ isolation as they trusted, bonded, and
communicated with group members.43,44,50,53,54 Sharing
similar experiences helped participants feel less
alone.52,53 They felt valued, respected,53 and accepted
by the therapist.51 Participants52,53 and therapists51 also
valued the therapeutic relationship.
Increased self-awareness through art therapy allowed
participants to understand their psychosis. For some, this
understanding contributed towards improved health53 and
management of daily problems.45 The physical process of
art making was also considered soothing and distracted
participants from their symptoms.42,43,52
The acceptability of art therapy was also considered in
light of participant attendance. Most studies provided no
information about rates or reasons for attendance or
8 www.thelancet.com/psychiatry Published online August 12, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30146-8
dropout, apart from two in which almost all participants
attended most sessions.43,45 Attendance in MATISSE
was low because 39% attended no art therapy
sessions.20,21 Participants who consistently attended did
so because they were committed and motivated about
recovery.52 People interested in art, and who felt
comfortable expressing themselves, attended more. 48
The attrition rates in MATISSE20,21 were due to death,
disinterest in art therapy, di culty attending, and being lost to
follow-up. In the study by Montag and colleagues,49
dropping out of the study was mostly linked to unplanned
hospital discharge. However, attendance was generally
high, with 59% of the art therapy group completing outcome
measures at post-treatment and 66% completing outcome
measures at follow-up.
Interpretation of the art therapy literature
Our review of the literature provides inconclusive
evidence for the e ectiveness of art therapy for people
with psychosis. MATISSE20,21 indicated that art therapy
was not clinically or financially e ective in improving
psychotic symptoms and functioning. Conversely, the
ITT analysis by Montag and colleagues 49 showed that
art therapy decreased the positive symptoms of
inpatients. The per-protocol results indicated significant
improvements in functioning and negative symptoms.
These per-protocol results were consistent with earlier
RCTs.17,19 Other studies in this Review that investigated
e ectiveness added little weight to the evidence.
This Review indicated that art therapy was experienced as
meaningful and acceptable by clients and therapists. Most
commonly, art therapy strengthened the clients’ emotional
expression, self-awareness, self-esteem, and connection
with themselves, their reality, and social networks. However,
our findings are based on small samples and few good-
quality qualitative studies, and require cautious
interpretation.
Clinical practice and future research considerations
The scarcity of robust research and discrepancy
between the evidence regarding the utility of art
therapy and the voice of clients and therapists
highlights a need for more rigorous studies. Several
theoretical, clinical, and methodological issues that
arose from this Review might require consideration.
Definition of art therapy
Comparison across studies was di cult because art therapy
had various theoretical approaches, definitions, titles, and
structures, which were not always clearly defined. Similarly,
another art therapy review identified that research was
characterised by inadequate descrip-tions of art therapy
approaches and structure.55 A primary criticism of MATISSE
was that the art therapy model and the therapists’
theoretical orientations were unspecified. 22 However,
Patterson and colleagues56 clarified that, despite variation in
art therapy structure and orientation in

MATISSE, art therapy was provided consistently with
the BAAT principles.
The variation in the reviewed articles might be linked
to a wider ambiguity regarding art therapy. 57 A clear
definition is important because art therapy is a complex
intervention consisting of several elements that interact
with the environment and the people engaging in it. 22,58
This issue raises the question of whether art therapy is
based on a specific model54 and defined clearly enough
by the BAAT.6 Patterson and colleagues52
recommended that this definition be reviewed and that
future researchers operationalise art therapy
accordingly, to enable replication and application of
results. Furthermore, given that art therapy can be
practised in di erent ways, definitions of art therapy
subtypes might be needed. Meta-analyses could then be
done with a su cient number of studies using an art
therapy subtype. The cultural diversity of the reviewed
studies also indicates the need to explore cultural
variations in art therapy definitions, approaches, and
structures, and clients’ experiences of this variation.
The mechanisms of art therapy
The influence of the MATISSE trial20,21 remains undeniable
given its size and power. However, arguably, it was done
prematurely. Springham and Brooker59 suggested that
RCTs are usually done at later stages when researchers
understand how interventions work and what changes can
arise from di erent aspects of them.
Few studies in this Review defined the mechanisms of art
therapy, and these mechanisms were not easily named by
art therapists.51 Some identified that the mechanisms of
change were the therapeutic relationships, the therapist’s
role in therapeutically holding or supporting individuals
through the process of therapy, the process of creating art,
the final art products,51,54 and the group process.50
Although this Review highlights several mechanisms
of change, they require further investigation. Robust
qualitative research using interviews, focus groups, and
multiple case studies can increase the insight into what
participants believe elicits change. According to the
Medical Research Council, comprehension of which
processes underpin complex interventions through
qualitative research is fundamental. 60,61 Case studies
can allow analytical generalisation, whereby individual
cases are understood in the context of established
theories.62 Improved theoretical knowledge can then
guide hypotheses of change mechanisms, quantitative
research designs with larger samples, 60 and indicate
how e ectiveness can be measured.63
Outcome measures
Art therapists have described that outcomes of art therapy
are obtained through processes that are both universal and
varied. These outcomes might be influenced by the
individual’s needs and abilities, the therapeutic relationship,
the creation of art, and by therapists’
www.thelancet.com/psychiatry Published online August 12, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30146-8
Review
observations, reflections, and interpretations, which are not
necessarily shared with the individual. 51 These processes
are not easy to measure objectively,59 highlighting the di
culty in measuring change in art therapy.
The primary outcome measures in the two RCTs
(symptoms of psychosis and global functioning) might not
have been the most appropriate targets for art therapy, 28 or
captured what participants found beneficial about it. Clinical
and theoretical rationales for using secondary outcome
measures, such as medication adherence and depression,
were unclear. In this Review, we showed that through art
therapy the participants valued being able to express
themselves, reconnect with themselves and others, and feel
confident, even if symptoms persisted. This finding is
consistent with the focus of psychotherapy on changes in
anguish, coping, and satisfaction, rather than on symptom
reduction.64 Social functioning, wellbeing,20,21 mentalisation,
and self-e cacy49 were secondary outcome measures in the
RCTs and might warrant further research. These secondary
outcome measures, together with self-confidence and
intrapersonal and interpersonal connectedness, are
recommended as possible outcome measures for art
therapy.
Art therapy as a targeted or universal intervention
In this Review, we were unable to understand for whom
art therapy specifically worked. Art therapy was
experienced uniquely,51 and therapists were pragmatic,
adapting their approach to fit the individual’s needs. 65
Therapists suggested that willingness to partake in art
therapy predicted who found it beneficial, and not client
diagnoses or clinical presentations. 51 Patterson and
colleagues54 indicated that participants were mostly
referred to art therapy on the basis of readiness to
attend, ine ectiveness of previous therapies, and
motivation. Furthermore, MATISSE20,21 suggested that
art therapy was ine ective because participants were
unwilling to engage, resulting in high dropout rates.
Holttum and Huet22 argued that even if those who
attended found art therapy e ective, this e cacy was lost in
the ITT analysis. An intervention’s e ectiveness is assessed
in all participants who are randomly assigned to a trial arm,
irrespective of whether they attended the intervention.66
Follow-up results in MATISSE20,21 were based on more than
85% of participants, even though 39% attended no art
therapy sessions. Therefore, any dose e ect might have
been diluted. Additional per-protocol analyses would have
been desirable because of such high dropout rates,67 as in
Montag and colleagues’ study.49 Despite the limitations of a
per-protocol analysis, it can be a relevant alternative in the
case of interventions like art therapy, which although o ered
to all participants, might not be accepted by everyone. This
alternative is relevant because this Review indicated that
people who engaged in art therapy seemed to benefit from
it.
Recruitment of all people with psychosis for research is
important, if we assume that art therapy should be o ered
9
 Review
to everyone.5 However, also doing analyses with people
specifically willing to engage in art therapy might indicate
whether this subgroup is more likely to benefit than those
not willing to engage,51 and how to adapt the intervention
accordingly.61 Such evidence might allow clients to receive
their treatment of choice, clarify art therapy referral criteria,
and increase the understanding of art therapy by services. 68
This approach might fit well in clinical practice by preventing
participants from being randomly allocated to treatment
groups that they are unmotivated to attend, and is important
for people with psychosis who do not engage with all
treatments,69 or disengage from services because of their
psychotic symptoms.70
Intervention design
Generally, greater statistical power is needed to identify
smaller changes between groups and to minimise risks
of type II errors. Furthermore, the small group sizes in
some studies could have restricted participants’
opportunities to explore their images with others.21,43,49
Future RCTs might need to carefully consider the
development of art therapy groups, which can have
complex dynamics. In clinical practice, members of
therapy groups are often individually engaged to develop
a therapeutic relationship before the group commences.
This preparation can enable integration into the group,
which can be important for people with negative
symptoms or social anxiety.
Several studies o ered art therapy with psychosocial or
psychotherapeutic interventions, making the art
therapy’s influence di cult to disentangle from other
interventions. Addressing this intervention overlap in
future research might increase the validity of results. The
appropriate duration of art therapy remains unclear
because interventions ranged from 1 to 14 months, and
e ectiveness emerged in shorter interventions. 49 For
people with severe di culties
Search strategy and selection criteria
We searched seven electronic databases for original articles
published in English from 2007 onwards (Embase, MEDLINE,
PsycINFO, PsycARTICLES, Web of Science, CINAHL Plus
[EBSCO], and Educational Resources Information Center
ProQuest). We did further searches of the reference lists and
Google Scholar, which elicited two additional papers. We used
the search terms “art therap*” OR “art psychotherap*” OR
“creative art psychotherap*” OR “creative art therap*” AND
“schizophrenia” OR “psychosis” OR “psychotic” OR
“psychiatric”. AA screened these by title, abstract, and full text,
while ML assessed a subsample of these papers for their
suitability based on the inclusion and exclusion criteria. Articles
were omitted if they were published earlier than 2007,
unavailable in English, not empirical papers, or did not focus on
art therapy or adults with psychosis. We did our first search on
Sept 3, 2014, and our last search on May 16, 2016.
10 www.thelancet.com/psychiatry Published online August 12, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30146-8
several studies recommend longer interventions. The
length of the intervention can be associated with degree
of distress, suggesting that longer interventions might
facilitate engagement with art-making.71 This longer
intervention length could allow long-term changes to be
observed (eg, in quality of life).49
Ensuring inclusion of regular follow-up periods in research
might show the sustainability of changes elicited through art
therapy, which was not captured in the reviewed papers.
Follow-up in some studies17,19,49 was much shorter than the
yearly follow-up in MATISSE.20,21 Art therapy gains in
MATISSE might have become suppressed after 1 or 2
years, and short-term improvements might have been
missed.48 E ectiveness could be investigated by collecting
outcome data at regular intervals,21 such as at the
beginning, middle, and end of the intervention; these data
can provide an immediate measure of change.
Review limitations
We excluded several studies written in languages other than
English, which reduced the application of the findings to the
general population. Additionally, the consideration of di
erent psychotic diagnoses under the term psychosis might
have overlooked unique di erences within this population.
This Review included three studies with mixed populations,
to avoid the exclusion of studies with participants with
psychosis. However, their relevance to the Review was
restricted because of small sample sizes and we had to
treat them with caution. Furthermore, we had to interpret
qualitative results with caution because of the small sample
sizes and study numbers and because only four articles
were of good quality.
Conclusions
Evidence for the e ectiveness of art therapy in symptom
reduction and functioning for people with psychosis
remains inconclusive. However, discounting the use of
art therapy might deprive people with psychosis of an
intervention that qualitative studies have indicated as
suitable and meaningful. The discrepancy between the
evidence for e ectiveness and service users’ and
clinicians’ experiences highlights a gap in the theoretical
understanding of how, why, and for whom art therapy
works, and how the gap in understanding can be
researched. This Review a rms that investigating the e
ectiveness of art therapy through RCTs is necessary to
economically and ethically support its delivery. 72 Indeed,
NICE recommended that more high-quality trials are
done.5 RCTs should be done in light of qualitative
research to build on and verify the qualitative literature
that we have reviewed. Ethnographic research and
interviews can show individuals’ experiences of art-
making, and whether and how art therapy helps them.
Understanding the mechanism behind the intervention
could increase the theoretical knowledge of art therapy 59
and highlight measurable outcomes,54 which can guide
controlled research.

Contributors
AA and ML designed the manuscript. AA did the systematic literature
search, the data extraction, data analysis, and data interpretation, and
also wrote the first draft of the manuscript. ML provided important
intellectual input to the drafting of the manuscript and feedback on the
data extraction and cross-checking of the quality assessment of the
articles. Both authors contributed to and approved the final manuscript.
Declaration of interests
We declare no competing interests.
Acknowledgments
We thank Neil Springham for o ering comments on the rationale and
relevance of this manuscript in the field of psychosis and art therapy.
Thanks also go to the independent researcher Neena Ramful for
providing support in piloting the quality framework and calibrating the
reviewed studies. There are no relevant funding sources in relation to
this manuscript. AA has full access to the study data and had final
responsibility for the decision to submit for publication.
References
1 Royal College of Psychiatrists. Report of the National Audit of
Schizophrenia (NAS) 2012. http://www.rcpsych.ac.uk/pdf/NAS%20
National%20report%20FINAL.pdf (accessed Jan 20, 2015).
2 Zhao YJ, Lin L, Teng M, et al. Long-term antipsychotic treatment in
schizophrenia: systematic review and network meta-analysis of
randomised controlled trials. BJPsych Open 2016; 2: 59–66.
3 Thornicroft G, Tansella M, Becker T, et al. The personal impact of
schizophrenia in Europe. Schizophr Res 2004; 69: 125–32.
4 Kirkbride JB, Errazuriz A, Croudace TJ, et al. Systematic review of
the incidence and prevalence of schizophrenia and other psychoses
in England, 1950–2009. 2012. http://www.psychiatry.cam.ac.uk/
epicentre/projects/review/ (accessed April 19, 2015).
5 National Institute for Health and Clinical Excellence. Psychosis
and schizophrenia in adults: the NICE guideline on treatment
and management. NICE Clinical Guideline 178. London: NICE,
2014. https://www.nice.org.uk/guidance/cg178/evidence/full-
guideline-490503565 (accessed March 28, 2015).
6 British Association of Art Therapists. What is art therapy?
http://www.baat.org/About-Art-Therapy (accessed March 28, 2015).
7 Schaverien J, Killick K. Art psychotherapy and
psychosis. London: Routledge, 1997.
8 Brüne M. ‘‘Theory of mind’’ in schizophrenia: a review of
the literature. Schizophr Bull 2005; 31: 21–42.
9 Schaverien J. Transference and transactional objects in the
treatment of psychosis. In: Schaverien J, Killick K, eds.
Art psychotherapy and psychosis. London: Routledge, 1997: 13–37.
10 Fonagy P. Art therapy and personality disorder. Int J Art Ther 2012;
17: 90.
11 Killick K. Working with psychotic processes in art therapy.
Psychoanal Psychother 1993; 7: 25–38.
12 Greenwood H. What aspects of an art therapy group aid recovery for
people diagnosed with psychosis? Art Ther Online 2012; 1: 1–32.
13 Rose D, Thornicroft G, Slade M. Who decides what evidence is?
Developing multiple perspectives in mental health.
Acta Psychiatr Scand Suppl 2006; 113: 109–14.
14 Slade M, Priebe S. Are randomised controlled trials the only
gold that glitters? Br J Psychiatry 2001; 179: 286–87.
15 Ruddy R, Milnes D. Art therapy for schizophrenia or schizophrenia-
like illnesses. Cochrane Database Syst Rev 2005; 4: CD003728.
16 Green BL, Wehling C, Talsky GJ. Group art therapy as an adjunct to
treatment for chronic outpatients. Hosp Community Psychiatry 1987;
38: 988–91.
17 Richardson P, Jones K, Evans C, Stevens P, Rowe A. Exploratory
RCT of art therapy as an adjunctive treatment in schizophrenia.
J Ment Health 2007; 16: 483–91.
18 National Institute for Health and Clinical Excellence. Schizophrenia:
core interventions in the treatment and management of
schizophrenia in adults in primary and secondary care 2009.
NICE Clinical Guideline 82. London: National Institute for Health and
Clinical Excellence, 2009. https://www.nice.org.uk/guidance/cg8
2?unlid=805609134201622423457 (accessed July 21, 2016).
19 Meng P, Zheng R, Cai Z, et al. Group intervention
for schizophrenia inpatient with art as medium.
Acta Psychologica Sinica 2005; 37: 403–12.
www.thelancet.com/psychiatry Published online August 12, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30146-8
Review
20 Crawford M, Killaspy H, Kalaitzaki E, et al. The MATISSE
study: a randomised trial of group art therapy for people with
schizophrenia. BMC Psychiatry 2010; 10: 1–9.
21 Crawford MJ, Killaspy H, Barnes TR, et al. Group art therapy
as an adjunctive treatment for people with schizophrenia:
multicentre pragmatic randomised trial. BMJ 2012; 344: e846.
22 Holttum S, Huet V. The MATISSE trial–a critique: does art
therapy really have nothing to o er people with a diagnosis of
schizophrenia? Sage Open 2014; 4: 1–11.
23 Wood C. In the wake of the Matisse RCT: what about art
therapy and psychosis? Int J Art Ther 2013; 18: 88–97.
24 Slayton SC, D’Archer J, Kaplan F. Outcome studies on the e cacy
of art therapy: a review of findings. Art Ther 2010; 27: 108–18.
25 Van Lith T, Schofield MJ, Fenner P. Identifying the evidence-base for
art-based practices and their potential benefit for mental health
recovery: a critical review. Disabil Rehabil 2013; 35: 1309–23.
26 Hacking S, Secker J, Spandler H, Kent L, Shenton J. Evaluating the
impact of participatory art projects for people with mental health
needs. Health Soc Care Community 2008; 16: 638–48.
27 Howells V, Zelnik T. Making art: a qualitative study of personal
and group transformation in a community arts studio.
Psychiatr Rehabil J 2009; 32: 215–22.
28 Maujean A, Pepping CA, Kendall E. A systematic review
of randomized controlled studies of art therapy. Art Ther
2014; 31: 37–44.
29 National Institute for Health and Clinical Excellence. Psychosis
and schizophrenia in adults: prevention and management.
NICE Clinical Guideline 178. London: National Institute for Health
and Clinical Excellence, 2014. https://www.nice.org.uk/guidance/
cg178/resources/psychosis-and-schizophrenia-in-adults-prevention-
and-management-35109758952133 (accessed
April 28, 2015).
30 The British Psychological Society, Division of Clinical
Psychology. Understanding psychosis and schizophrenia.
Leicester: The British Psychological Society, 2014.
https://www.bps.org.uk/system/files/ user-files/Division%20of
%20Clinical%20Psychology/public/ understanding_psychosis_-
_final_19th_nov_2014.pdf (accessed April 28, 2015).
31 Centre for Reviews and Dissemination. Systematic
reviews: CRD’s guidance for undertaking reviews in
health care. York: York Publishing Services Ltd, 2008.
32 Sale JEM, Brazil K. A strategy to identify critical appraisal criteria
for primary mixed-methods studies. Qual Quant 2004; 38: 351–65.
33 Critical Appraisal Skills Programme (CASP). Qualitative research
checklists. 2013. http://media.wix.com/ugd/dded87_29c5b002d9934
2f788c6ac670e49f274.pdf (accessed Jan 28, 2015).
34 Pluye P, Robert E, Cargo M, et al. Proposal: a mixed methods
appraisal tool for systematic mixed studies reviews.
2011. http://mixedmethodsappraisaltoolpublic.pbworks.com/w/file/
fetch/84371689/MMAT%202011%20criteria%20and%20tutorial%20
2011-06-29updated2014.08.21.pdf (accessed March 28, 2015).
35 Moher D, Hopewell S, Schulz KF, et al. Explanation and
elaboration: updated guidelines for reporting parallel
group randomised trials. BMJ 2010; 340: c869.
36 Atkins C, Sampson J. Critical appraisal guidelines for single
case study research. European Conference on Information
Systems; Gdansk; June 6–8, 2002. 100–09.
37 Huws U, Dahlmann S. Quality standards for case studies in the
European Foundation. European Foundation for the Improvement of
Living and Working Conditions, 2007. http://www.eurofound.
europa.eu/sites/default/files/ef_files/pubdocs/2007/51/en/1/
ef0751en.pdf (accessed March 28, 2015).
38 Lowman RL, Kilburg RR. Guidelines for case study submissions to
consulting psychology journal: practice and research.
Consult Psychol J 2011; 63: 1–5.
39 Caddy L, Crawford F, Page AC. ‘Painting a path to wellness’:
correlations between participating in a creative activity group
and improved measured mental health outcome.
J Psychiatr Ment Healt Nurs 2012; 19: 327–33.
40 de Morais AH, Dalecio MAN, Vizmann S, et al. E ect on
scores of depression and anxiety in psychiatric patients after
clay work in a day hospital. Arts Psychother 2014; 41: 205–10.
41 Drapeau MC, Kronish N. Creative art therapy groups: a treatment
modality for psychiatric outpatients. Art Ther 2007; 24: 76–81.
11
 Review
42 de Morais AH, Roecker S, Jodas S, Denise A, Eler GJ.
Significance of clay art therapy for psychiatric patients admitted in
a day hospital. Invest Educ Enferm 2014; 32: 128–38.
43 Colbert S, Cooke A, Camic PM, Springham N. The art-gallery as a
resource for recovery for people who have experienced psychosis.
Arts Psychother 2013; 40: 250–56.
44 Gajic GM. Group art therapy as adjunct therapy for the treatment of
schizophrenic patients in day hospital. Vojnosanit Pregl 2013;
70: 1065–69.
45 Teglbjaerg HS. Art therapy may reduce psychopathology in
schizophrenia by strengthening the patients’ sense of self:
a qualitative extended case report. Psychopathology 2011; 44: 314–18.
46 Banks L. Free to talk about violence: a description of art therapy
with a male service user in a low secure unit. Int J Art Ther 2012;
17: 13–24.
47 Hung C, Ku Y. Influencing and moderating factors analyzed in
the group art therapy of two schizophrenic inpatients.
Biomedicine 2015; 5: 36–38.
48 Leurent B, Killaspy H, Osborn DP, et al. Moderating factors for the e
ectiveness of group art therapy for schizophrenia: secondary
analysis of data from the MATISSE randomised controlled trial.
Soc Psychiatry Psychiatr Epidimiol 2014; 49: 1703–10.
49 Montag C, Haase L, Seidel D, et al. Pilot RCT of psychodynamic group art
therapy for patients in acute psychotic episodes: feasibility, impact on
symptoms and mentalising capacity. PLoS One 2014; 9: e112348.
50 Michaelides D. An understanding of negative reflective functioning,
the image and the art psychotherapeutic group. Int J Art Ther 2012;
17: 45–53.
51 Patterson S, Crawford M, Ainsworth E, Waller D. Art therapy for
people diagnosed with schizophrenia: therapists views about what
changes, how and for whom. Int J Art Ther 2011; 16: 70–80.
52 Patterson S, Borschmann R, Waller DE. Considering referral to art
therapy: responses to referral and experiences of participants in a
randomised controlled trial. Int J Art Ther 2013; 18: 2–9.
53 Havenik H, Hestad KA, Lien L, Teglbjaerg HS, Danbolt LJ.
Expressive art therapy for psychosis: a multiple case study.
Art Psychother 2013; 40: 312–21.
54 Patterson S, Debate J, Anju S, Waller D, Crawford MJ. Provision
and practice of art therapy for people with psychosis: results of a
national survey. J Ment Health 2011; 20: 328–35.
55 Eaton LG, Doherty KL, Widrick RM. A review of research and
methods used to establish art therapy as an e ective treatment
method for traumatized children. Art Psychother 2007; 34: 256–62.
56 Patterson S, Waller D, Killaspy H, Crawford MJ. Riding the wake:
detailing the art therapy delivered in the MATISSE study.
Int J Art Ther 2015; 20: 28–38.
57 Uttley L, Scope A, Stevenson M, et al. Systematic review and economic
modelling of the clinical e ectiveness and cost-e ectiveness of art therapy
among people with non-psychotic mental health disorders.
Health Technol Assess 2015; 19: 1–120.
12 www.thelancet.com/psychiatry Published online August 12, 2016 http://dx.doi.org/10.1016/S2215-0366(16)30146-8
58 Crawford MJ, Patterson S. Arts therapies for people with
schizophrenia: an emerging evidence base. Evid Based Ment
Health 2007; 10: 69–70.
59 Springham N, Brooker J. Reflect interview using audio-
image recording: development and feasibility study. Int J Art
Ther 2013; 18: 54–66.
60 Medical Research Council. Developing and evaluating complex
interventions: new guidance. London: Medical Research Council,
2008. http://www.mrc.ac.uk/complexinterventionsguidance
(accessed April 19, 2015).
61 Medical Research Council. A framework for development and
evaluation of RCTs for complex interventions to improve
health. London: Medical Research Council, 2000.
http://www.mrc.ac.uk/ documents/pdf/rcts-for-complex-
interventions-to-improve-health/ (accessed March 20, 2015).
62 Yin R, ed. Case study research: design and methods, 2nd
edn. Thousand Oaks: Sage Ltd, 1994.
63 Kelly S, Davies L, Harrop D, McClimens A, Peplow D, Pollard N.
Reviewing art therapy research: a constructive critique. London:
Arts and Humanities Research Council, 2014.
64 Kazdin A. Evidence based treatments: challenges and priorities
for practice and research. In: Burns B, Hoagwood K, eds. Child
and adolescent psychiatric clinics in North America. New York:
Elsevier, 2004: 923–94.
65 Rubin JA. Art therapy: an introduction.
Philadelphia: Taylor & Francis, 1999.
66 Gupta SK. Intention-to-treat concept: a review 2011. Perspect
Clin Res 2011; 2: 109–12.
67 Hernan MA, Hernandez-Diaz S. Beyond the intention-to-treat in
comparative e ectiveness research. Clin Trials 2012; 9: 48–55.
68 Patterson S, Kramo K, Soteriou T, Crawford MJ. The great divide:
a qualitative investigation of factors influencing researcher
access to potential RCT participants in mental health settings. J
Ment Health 2010; 19: 532–41.
69 Breen R, Thornhill JT. Noncompliance with medication for psychiatric
disorders. Reasons and remedies. CNS Drugs 1998; 9: 457–71.
70 Macbeth A, Gumley A, Schwannauer M, Fisher R. Service
engagement in first episode psychosis: clinical and
premorbid correlates. J Nerv Ment Dis 2013; 201: 359–64.
71 Wood C. The history of art therapy and psychosis 1938–95.
In: Schaverien J, Killick K, eds. Art, psychotherapy and
psychosis. London: Routledge, 1997: 144–75.
72 Wood C. Facing fear with people who have a history of
psychosis. Inscape 1997; 3: 41–48.