Art Therapy: Journal of the American Art Therapy Association, 29(2) pp.

80–86

C AATA, Inc. 2012

brief reports
Efficacy of Group Art Therapy on Depressive Symptoms
in Adult Heterogeneous Psychiatric Outpatients

Shambhavi Chandraiah, Susan Ainlay Anand, and Lindsay Cherryl Avent,

Jackson, MS

Abstract a single-group pre- and post-intervention design with treat-

ment varying from 6 weeks to 2 years for such populations as
This study evaluated the potential benefit of weekly group children, students, patients, and family members of patients,
art therapy in groups of adult psychiatric outpatients at a uni- using measures of behavior, anxiety, depression, grades, and
versity medical center. Eighteen patients participated in 4 suc- so on.
cessive 8-week groups of 6 to 8 patients each that met weekly Most of the studies listed in the Reynolds et al. (2000)
and were led by 2 therapists (a board-certified art therapist review found significant improvement in primary and often
and a psychiatry resident). The standardized Center for Epi- secondary outcomes. Of four non-randomized controlled
demiological Studies Depression Scale (CES-D) was adminis- studies there were varying outcomes from significant to no
tered pre- and post-treatment. Ten patients who attended 4 or advantage of art therapy as compared to verbal therapies.
more sessions of group art therapy were included in the study. In five randomized controlled studies the authors found
The mean group CES-D scores for the study patients decreased some with beneficial results and others without. Slayton,
significantly from pre- to post-treatment. This is the first pilot D’Archer, and Kaplan (2010) reviewed art therapy research
study report of the efficacy of group art therapy using a stan- from 1999–2007 including qualitative studies, pre- and
dardized depressive measure in heterogeneous adult psychiatric post-intervention studies (the most common type), studies
with a control group, and clinical trials with random
outpatients.
assignment. They reported a “small body of quantifiable
data to support the claim that art therapy is effective in
Introduction treating a variety of symptoms, age groups, and disorders”
(p. 108).
Art therapy has been used with individuals, groups, and In review of literature that informs the present study
families as a primary or adjunctive therapy to address var- we limited our search to those studies that used quantifi-
ious issues including low self-esteem (Green, Wehling, & able measures with psychiatric patients in a group context.
Talsky, 1987), physical and sexual trauma (Brooke, 1995), Franks and Whitaker (2007) conducted weekly group art
sexual abuse (Pifalo, 2002), depression (Ponteri, 2001), anx- therapy using primarily mentalization techniques with eight
iety (Chambala, 2008), eating disorders (Rehavia-Hanauer, adult patients who had been diagnosed with a personality
2003), and grief (Schut, de Keijser, van den Bout, & Stroebe, disorder and who also received weekly individual verbal psy-
1996). Early reports documenting the benefits of art ther- chotherapy over the 9 months of the study. They found that
apy were primarily subjective and descriptive case studies. there was a statistically significant improvement using the
Reynolds, Nabors, and Quinlan (2000) reviewed empirical Positive Symptom Distress Index of the Brief Symptom In-
studies of the efficacy of art therapy and found 17 studies ventory (Derogatis & Melisaratos, 1983) from pre- to post-
from 1971–1998 that measured treatment improvement on treatment as well as at 8 months follow-up, although social
a measurable outcome. They noted that most studies used functioning at 8 months had somewhat worsened. Körlin,
Nybäck, and Goldberg (2000) used weekly or twice weekly
multiple treatment modalities (body awareness, receptive
Editor’s Note: Shambhavi Chandraiah, MD, FRCPC, is a
psychiatrist and Associate Professor in the Department of Psychi-
music therapy, occupational therapy, verbal group therapy,
atry and Human Behavior at the University of Mississippi Medi- and art therapy) for 4 weeks as an alternative to medi-
cal Center in Jackson, MS. Susan Ainlay Anand, ATR-BC, LPAT, cations and conventional psychotherapies for 58 heteroge-
LMFT, and Lindsay Cherryl Avent, MS, LPC, are clinical instruc- neous chronic psychiatric inpatients and outpatients. They
tors in the same department. Correspondence concerning this re- found statistically significant improvement on the Symptom
port may be addressed to the first author at [email protected] Checklist-90 (Derogatis & Melisaratos, 1983) total scores

80
 CHANDRAIAH/AINLAY ANAND/AVENT 81

and on 7 of 9 subscales (except hostility and psychoticism) for Epidemiological Studies Depression Scale (CED-S;
with a better outcome seen in traumatized patients. Radloff, 1977) to study depressive symptoms in particular,
Fryrear and Stephens (1988) studied patients already in as depression was a common primary or concurrent diagno-
individual psychotherapy (for self-improvement) with ad- sis among our group art therapy referrals.
junct art/video group therapy for six weekly sessions. They
found no change in psychiatric symptoms on the Min-
nesota Multiphasic Personality Inventory although patients Method
reported improved states of self-actualization on the Person-
ality Orientation Inventory (Shostrom, 1964). Schut et al. At the university medical center’s Adult Outpatient Psy-
(1996) compared an integrated group behavior and art ther- chiatric Clinic, group art therapy was offered to psychiatric
apy approach versus regular group and individual therapy outpatients who had been referred by their primary psychi-
for grieving inpatients over the course of 3 months of weekly atric team (a third year psychiatry resident and the attend-
sessions using the General Health Questionnaire (Goldberg, ing physician). The Adult Outpatient Psychiatric Clinic is a
1978). The authors noted some non-significant advantage relatively short-term, pharmacologically-based stabilization
for the integrated group behavior and art therapy treatment. clinic, where patients generally are seen monthly for medica-
Finally, three studies of adult psychiatric outpatients tion management. Some psychological mindedness, a com-
using group art therapy have been reported. Green et al. mitment to attend all sessions, and a desire for change in
(1987) compared 28 chronic psychiatric outpatients who symptoms or behavior were the inclusion criteria for group
received adjunct group art therapy and regular verbal ther- art therapy. Exclusions were current substance abuse or pri-
apy biweekly for 10 sessions with a control group receiving mary mental retardation. There was no charge for the group
only verbal therapy. They reported significant improvement art therapy sessions.
on the Progress Evaluation Scales (Ihilevich, Gleser, Gritter, Each sequential group was comprised of 6 to 8 patients
Kroman, & Watson, 1982), notably on “attitude to self ” who met weekly for 8 weeks. The group was led by two ther-
in patient self-reports and on “getting along with others” as apists: a board-certified art therapist and a third year psychia-
rated by the therapist. In a follow-up study 9 months later try resident who participated in one course of group therapy
(Borchers, 1985), the benefits were still greater for the study while rotating through the clinic. As a part of the learning
group but not at a statistically significant level for patient experience, the residents were expected to use art materials
and therapist ratings. A recent study by Drapeau and in session along with other group members and to discuss
Kronish (2007) reported on the use of group art therapy their artwork in a manner therapeutic to the development
for 26 patients over four consecutive 12-week groups. The of the group or attainment of individual and group goals. At
patients were adult psychiatric outpatients with diagnoses times the resident was also the resident physician in charge
that included depression, schizophrenia, schizoaffective of the patients’ medication management in separate clinic
disorder, bipolar disorder, dissociative disorder, and bor- appointments.
derline personality disorder. Although no objective measure Patients were contacted by the resident after any missed
was used, specific patient benefits that were described session to encourage continued participation in the group.
included increased truthfulness, improved completion of There were no distinct patterns or reasons for patient ab-
tasks, diminished suicidal ideation, decreased perceived sences; returning patient reports indicated various reasons
stress, enhanced self-esteem, increased self-expression, and for absenteeism such as transportation problems, discomfort
improved quality of life. Richardson, Jones, Evans, Stevens, with the group art modality, and illness.
and Rowe (2007) conducted a randomized controlled trial
with patients diagnosed with chronic schizophrenia. The re- Participants
searchers compared 12 sessions of interactive art therapy that
was adjunctive to standard psychiatric care (n = 43) with Patients ranged in age from 18–57 years. There were 6
standard psychiatric care alone (n = 47). Standard care in- females and 4 males included in the study (N = 10). Seven
cluded availability of a variety of day treatment facilities and of the participants were Caucasian and three were African
regular medication review. The researchers measured change American. The majority of the patients had been diagnosed
in positive and negative symptoms, social functioning, and with a depressive disorder; some had more than one concur-
quality of life using several standard assessments including rent psychiatric diagnosis (Table 1). The insurance status of
the Scale for the Assessment of Negative Symptoms (SANS; the patients (used as a possible indication of socioeconomic
Andreasen, 1982). Statistically significant improvement status) is shown in Table 2. Patients were concurrently taking
was seen only on the SANS. The authors postulated that psychotropic medication ranging from primarily antidepres-
the study was underpowered and that 12 sessions may not sants to mood stabilizers and/or benzodiazepines. During
have been enough for a population with a chronic illness to the study, two patients received adjustments to their primary
show a difference on the other scales as well. medications (from one antidepressant or mood stabilizer to
For our study, we hypothesized that short-term group another) and two others had their medications for insomnia
art therapy in conjunction with ongoing psychopharmaco- changed.
logic management would decrease depressive symptoms in A total of 18 patients participated in four successive
an adult heterogeneous psychiatric outpatient population of groups; however, only the 10 patients who attended four
a university teaching clinic. We used the standardized Center or more of the eight sessions and for whom a pre- and
82 GROUP ART THERAPY WITH PSYCHIATRIC OUTPATIENTS

Table 1 Diagnoses of Study Patients and Excluded cluded patients are also shown in Tables 1 and 2. All of these
Patients patients were taking antidepressant medication.
Study Excluded Instruments
Diagnosis Patients (n) Patients (n)
All patients were evaluated using the CES-D question-
Major Depressive Disorder 3 7
naire (Radloff, 1977) at the beginning of the first group ses-
Dysthymic Disorder 3 0
sion and at the end of the final group art therapy session.
Depressive Disorder Not 1 1
This instrument is a 20-item self-report scale that measures
Otherwise Specified
the level of depression experienced in the past week. A score
Bipolar II Disorder 1 0
of 16 or higher has been used as the cut-off point for high
Bipolar Disorder Not 1 0
depressive symptoms.
Otherwise Specified
Posttraumatic Stress 3 1
Disorder Art Therapy Group Procedure
Generalized Anxiety 2 0
All of the group sessions took place in the art therapy
Disorder
room with a central table and chairs arranged so that partic-
Panic Disorder With 0 1
ipants were able to face each other. The beginning of each
Agoraphobia
session was devoted to art making, usually 45–60 minutes,
Anxiety Disorder Not 0 1
and the remaining 30 minutes was reserved for discussion.
Otherwise Specified
Patients were encouraged to interact with each other through
Adjustment Disorder With 1 0
the use of materials and the process of discussing their art-
Mixed Disturbance of
work. Patients left their artwork in the group room after each
Emotions and Conduct
session but were allowed to take their art with them after the
Paranoid Schizophrenia 1 0
last group session.
Borderline Personality 0 1
A variety of art media was utilized including different
Disorder
sizes and types of paper, pencils, markers, oil pastels, chalk
Personality Disorder Not 1 0
pastels, watercolor and acrylic paints, clay, and collage mate-
Otherwise Specified
rials. The art therapist selected media based on their inherent
Asperger’s Disorder 1 0
qualities (e.g., fluid materials such as paints, pastels, and clay
Borderline Intellectual 0 1
allow for less control and a loosening of psychological de-
Functioning
fenses; resistive media such as pencils, markers, and collage
Note. Some patients had more than one diagnosis. provide more control and a greater release of energy along
with neatness and precision). She offered instruction on the
use of these materials and also encouraged group members
to explore the unique properties of the art media as they de-
post-treatment CES-D score was available were included for veloped their imagery. Patients typically chose materials ac-
analysis. Eight of the study participants attended more than cording to their own preferences unless the group was asked
6 sessions. to engage in a particular art process.
Of the original 18 patients, the 8 excluded patients The art therapist suggested a topic or theme as a direc-
had no pre- and/or post-treatment CES-D scores available. tive for patient participation in the group each week. How-
These patients ranged from 33–54 years of age and included ever, after a particular theme or directive was suggested, the
7 females and 1 male (5 African Americans and 3 Cau- group could discuss and suggest alternative themes or ex-
casians). The diagnoses and insurance status of these ex- pand on a given directive. All directives selected by the art
therapist were aligned with established group goals. These
included: (a) fostering growth and development for the indi-
vidual in conjunction with interpersonal group experiences,
Table 2 Insurance Status of Study Patients and Ex- (b) helping patients gain insight, (c) offering creative outlets
cluded Patients for self-expression, (d) enhancing participants’ social skills,
(e) developing growth in participants’ introspection and self-
Study Excluded awareness, (f ) establishing better coping skills, and (g) help-
Insurance Status Patients (n) Patients (n) ing patients to reestablish self-identity and self-confidence.
Self Pay 3 3 During the first session of each 8-week group, patients
Medicare (U.S. 3 1 introduced themselves to each other through their artwork.
federal program) Figure 1 is an example of artwork completed in a first group
Medicaid (U.S. 2 3 session that illustrates a patient’s introduction of herself to
state program) the group and depicts her feelings of isolation and depres-
Private Insurer 2 2 sion. Subsequent group sessions provided opportunities
to identify life stressors and to learn methods for reducing
 CHANDRAIAH/AINLAY ANAND/AVENT 83

Figure 1 Patient’s Introduction of Self to Others in First

Session (Color figure available online)

stress through collage and drawing tasks, to identify

individual strengths and feelings using mask making or
sculpting techniques, and to establish personal goals (or
identify barriers to achieving goals) through sculpture and
drawing directives. The last session offered patients an
opportunity to review all of the artwork they had completed
and to use the art-making process to reflect on gains that Figure 2 Painted Clay Figure Holding a Mirror (Color fig-
were made through participation in the art therapy group. ure available online)
Although the directives varied from group to group and
were dependent on goals established for each group of pa-
tients, all of the patients who participated in the art therapy tients’ CES-D scores improved from pre- to post-treatment
process were encouraged to express ideas, thoughts, feelings, by 3–19 points (see Table 3) with an average improvement
and experiences in their art making and artwork. For exam- of 8.2 points (the group average CES-D score dropped from
ple, Figure 2 shows a clay figure holding a mirror that the 26.7 to 18.5). A paired Student’s t test was used to com-
patient said reflected her feelings of sadness. Group dynam- pare the 10 patients’ pre-treatment CES-D scores and their
ics emerged through the art and group interactions. Themes
evolved based on individual patient contributions to the
group or from discussions and interactions among patients
and group leaders. Themes included patient strengths and
weaknesses, self in relation to the world, grief and loss, ef-
fects of illness on lives, family issues, independence versus
dependence, and trauma. As an example, one patient de-
scribed a clay bridge piece (Figure 3) as a self-representation
and explained that the figure on the bridge had emerged
from flames of past trauma, depicted on the right, and was
moving toward a better place, depicted on the left. In later
sessions, artwork was often discussed in relationship to pre-
vious artwork and patients were able to view their art as a
record of development over time.

Results
Of the 10 study patients, 8 scored higher than 16 (indi-
cating a high degree of depressive symptoms) on the CES-D
prior to group therapy; 6 of these 10 participants continued
to score higher than 16 after group art therapy. The pre- Figure 3 Clay Bridge With Figure (Color figure available
treatment CES-D scores ranged from 5–48. However, all pa- online)
84 GROUP ART THERAPY WITH PSYCHIATRIC OUTPATIENTS

Figure 4 Pre- and Post-Intervention CES-D Scores of Group Art Therapy Patients (Color figure available online)

post–group art therapy CES-D scores with respect to change sive symptoms in a heterogeneous sample of psychiatric
in their individual scores. There was a statistically significant outpatients. Other gains observed by the art therapist in-
difference in the pre-treatment (M = 26.70, SD = 13.48) cluded improved interpersonal communication, increased
to post-treatment (M = 18.75, SD = 12.48) CES-D scores, assertiveness, greater appreciation of underlying themes of
t(9) = −5.43, p < .001. Thus the null hypothesis that there loss and hope, enjoyment in utilizing art media, and success-
is no difference between the groups’ pre- and post-treatment ful completion of projects that reflected personal meaning
scores was rejected. for the patient. Some patients enjoyed art therapy so much
that they requested referral to subsequent 8-week groups
Discussion or expressed their intent to continue using art as an ex-
pressive and creative outlet. The psychiatry residents also
This study supports our hypothesis that brief outpa- learned the power of group process and art therapy in un-
tient group art therapy is efficacious in reducing depres- covering underlying themes and improving interpersonal
communication.
Several studies in the literature can be compared to
Table 3 CES-D Scores Pre- and Post–Group Art Therapy our findings. Franks and Whitaker (2007) noted benefit
Intervention in overall psychiatric symptoms in patients diagnosed with
personality disorders who received weekly group art therapy
Pre-Test Post-Test adjunctive to individual psychotherapy over 9 months;
Patient Score Score Pre–Post in contrast, our heterogeneous psychiatric sample showed
improvement after 4 or more sessions of therapy adjunctive
1 5 2 3 to medication. Our study is most similar to Drapeau and
2 25 22 3 Kronish’s (2007) study of adult psychiatric outpatients in a
3 27 21 6 university teaching hospital, but they assessed improvement
4 24 20 4 subjectively over 12 weeks, whereas we assessed efficacy
5 18 9 9 of group art therapy in the shorter time of 4 to 8 sessions
6 41 30 11 and used a standardized depression scale to measure results.
7 41 33 8 Unlike Green et al.’s (1987) group art therapy study, our
8 12 3 9 sample was not composed of chronic psychiatric patients
9 26 7 19 and our participants were currently in the stabilization
10 48 38 10 phase of medication treatment (i.e., more change may be
Group Mean 26.70 18.75 8.20 expected with any form of treatment, including group art
(SD) (13.48) (12.82) (4.78) therapy). Richardson et al.’s (2007) randomized clinical
Note. A score of 16 or higher indicates high depressive trial differed from ours in that their population consisted
symptoms. of patients with the chronic type of schizophrenia, were
sampled from an inner city clinic, and received concurrent
 CHANDRAIAH/AINLAY ANAND/AVENT 85

medication management and day treatment along with Borchers, K. K. (1985). Do gains made in group art therapy per-
group therapy, with results that showed no improvement on sist? A study with aftercare patients. American Journal of Art
most of their scales over 12 weeks. In comparison, ours was Therapy, 23(3), 89–91.
a non-chronic, heterogeneous university hospital sample of
patients receiving adjunctive medication, with results that Brooke, S. L. (1995). Art therapy: An approach to working
with sexual abuse survivors. The Arts in Psychotherapy, 22(5),
showed improvement in depressive symptoms after only 4 447–466. doi:10.1016/0197–4556(95)00036–4
to 8 weeks of group art therapy.
Several limitations of the present study must be con- Chambala, A. (2008). Anxiety and art therapy: Treatment
sidered. The sample was small and was heterogeneous, al- in the public eye. Art Therapy: Journal of the Ameri-
though a majority of the study patients had depression as a can Art Therapy Association, 25(4), 187–189. doi:10.1080/
primary diagnosis. From a clinical standpoint, we noted that 07421656.2008.10129540
the inclusion of patients with other primary psychiatric di-
agnoses actually helped bring different issues to group ther- Derogatis, L. R., & Melisaratos, N. (1983). The Brief Symp-
apy that ultimately benefited all patients as they sought to tom Inventory: An introductory report. Psychological Medicine,
13(3), 595–605.
help each other. We conducted a one group, pre/posttest
design because it was a pilot study and we did not have a Drapeau, M.-C., & Kronish, N. (2007). Creative art therapy
control group. It is possible that patient improvement could groups: A treatment modality for psychiatric outpatients. Art
have resulted from other changes in the patients’ lives, from Therapy: Journal of the American Art Therapy Association, 24(2),
medication-related benefits, or from other reasons. How- 76–81. doi:10.1080/07421656.2007.10129585
ever, these factors were not controlled for in most of the
other studies discussed. Additionally, it is unclear whether Franks, M., & Whitaker, R. (2007). The image, mentalisation and
patients who attended fewer than 4 group sessions did so group art psychotherapy. International Journal of Art Therapy,
because they were more severely impaired, did not see the 12(1), 3–16. doi:10.1080/17454830701265188
benefit of group, or had other logistical reasons.
Fryrear, J. L., & Stephens, B. C. (1988). Group psychotherapy us-
This study adds support for the efficacy of group art ing masks and video to facilitate intrapersonal communication.
therapy to address depressive symptoms in psychiatric pa- The Arts in Psychotherapy, 15(3), 227–234.
tients. The group therapy format allowed patients additional
benefits including the opportunity to learn from others, to Goldberg, D. P. (1978). Manual of the General Health Question-
share distress with like individuals, to experience appropri- naire. Windsor, England: National Foundation for Educational
ate feedback from group members, and to engage in therapy Research.
with less of an individual focus. The latter benefit seemed
particularly helpful for some anxious patients. Using the art Green, B. L., Wehling, C., & Talsky, G. J. (1987). Group art ther-
medium allowed initial focus on the art rather than per- apy as an adjunct to treatment for chronic outpatients. Hospital
and Community Psychiatry, 38(9), 988–991.
sonal themes, which we found particularly helpful for pa-
tients who needed psychological distance early in the group Ihilevich, D., Gleser, G. C., Gritter, G. W., Kroman, L. J., & Wat-
process. Finally, it appeared that working with art materials son, A. S. (1982). The Progress Evaluation Scales: A system for
in the group format over time increased the patients’ sense assessing child and adolescent programs. Professional Psychology,
of mastery and provided them with evidence of progress in 13(3), 470–478.
both art media and individual goals.
In conclusion, this pilot study of group art therapy in Körlin, D., Nybäck, H., & Goldberg, F. S. (2000). Creative
conjunction with medication management for adult psychi- arts groups in psychiatric care: Development and evaluation
atric outpatients with a mix of diagnoses showed statistically of a therapeutic alternative. Nordic Journal of Psychiatry, 54(5),
333–340. doi:10.1080/080394800457165
significant improvement in depressive symptoms after 4 to
8 weeks, using a standardized depression scale. Our find- Pifalo, T. (2002). Pulling out the thorns: Art therapy with
ings would be strengthened by replication studies that uti- sexually abused children and adolescents. Art Therapy: Jour-
lize a larger sample and comparison control group, and with nal of the American Art Therapy Association, 19(1), 12–22.
inclusion criteria limited to patients who may best bene- doi:10.1080/07421656.2002.10129724
fit from group art therapy. Further research could evaluate
other symptoms or improvement measures for anxiety, in- Ponteri, A. K. (2001). The effect of group art therapy on depressed
terpersonal interactions, quality of life, and overall sense of mothers and their children. Art Therapy: Journal of the Amer-
well-being, as well as therapists’ perceptions of change in the ican Art Therapy Association, 18(3), 148–157. doi:10.1080/
patients. 07421656.2001.10129729

Radloff, L. S. (1977). The CES-D scale: A self-report de-

pression scale for research in the general population. Ap-
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