Art Therapy and the Coronavirus (COVID-19) Pandemic - Public Mental Health and Emotional Well-Being

http://sites.google.com/site/deborahhilton/

https://www.researchgate.net/profile/Deborah_Hilton

Corresponding author: Deborah Hilton, [email protected].

Received Date: November 03, 2020

Published Date: January 28, 2021

Copyright: Hilton D. © 2021.

Citation: Hilton D. (2021). Art Therapy and the Coronavirus (COVID-19) Pandemic - Public Mental Health and Emotional Well-Being. Mathews J Psychiatry Ment Health. (6)1:30.      

ABSTRACT

Introduction: Hilton published a manuscript titled; do researchers have their heads in the clouds, bogged down with scientific medical detail? [Art therapy maybe a simpler alternative]. It discusses how a diagnostic pathway maybe crucial to eliminate sinister reasons for stress [example insomnia possibly caused by sleep apnoea where breathing stops during sleep]. In many cases of stress, depression, and/or anxiety - job, work, family, financial stress or reasons such as COVID-19 maybe causal. Art therapy maybe an alternative option and Hilton’s manuscript lists seven publications [either review, meta-analysis, clinical trial or case study] providing evidence.

Methods: The Australian yellow pages online directory was searched - search terms [art therapist/s and/or art therapy]. 107 hits were retrieved, 21 were art therapists with email whom were emailed details of the manuscript, in addition to being asked ‘Are you currently doing any art therapy work with clients related to the COVID-19 pandemic?’.

Results: In reply to the question above, 7 people replied stating ‘yes’ while 3 replied stating ‘no’. 6 did not reply. The results suggest some art therapists are consulting with clients with COVID-19 related stress, anxiety or depression. Art therapy works created maybe displayed at exhibitions such as the black dog art exhibition that focuses on depression and anxiety. Either this year or next year Hilton is entering an art creation as a tribute to Dr. Li Wenliang an ophthalmologist whom passed away of coronavirus.

Discussion and/or Conclusion: World Mental Health and RUOK days should incorporate messages about art therapy effectiveness.

KEYWORDS: Art therapy, Coronavirus, Mental health

TAKE-HOME MESSAGE: Evidence for effectiveness of art therapy treatment is documented in the literature and during 2020 a number of art therapists indicate clients are consulting with them regarding mental health and the COVID-19 pandemic.

INTRODUCTION

There is a long history of art therapy for treating psychosocial and mental health conditions. A manuscript by Finkel and Bat Or encompasses a systematic scoping review of literature and research pertaining to the art therapy open studio approach, which had origins with the work of artists in the 1940's in psychiatric hospitals [1]. This scoping review was not restricted to specific times, cultures, populations or settings. This describes how it became a profession in itself, gaining recognition by taking up theories from other disciplines. More recently there is an increase in studio practice prevalence. Contemporary art therapy approaches have moved further from the original classification. Publications are apparent since the 1990s onwards, yet there has been a remarkable increase in the volume of literature in the last decade. This literature identifies core principles and unique characteristics that are different depending upon the context and therapeutic method, varied setting and /or population and identifies gaps in knowledge that warrant further research.

Other scientific research identified relates to papers that encompass the main mental health conditions that include depression, anxiety, psychosocial and psychological medical conditions. Several will be mentioned below.

Firstly, Newland and Bettencourt published a manuscript titled - Effectiveness of mindfulness-based art therapy for symptoms of anxiety, depression, and fatigue: A systematic review and meta-analysis [2]. They included studies that assessed symptoms and quality of life outcomes identifying fourteen studies sampling adolescents and adults. The results found significant improvements in psychological and physical symptom indices compared to controls; hence they concluded that mindfulness-based art therapy is a promising intervention for symptom relief, yet state that the findings are limited by the small number of studies.

Secondly, Bosgraaf and colleagues published a manuscript titled; Art Therapy for Psychosocial Problems in Children and Adolescents: Systematic Narrative Review on Art Therapeutic Means and Forms of Expression, Therapist Behaviour, and Supposed Mechanisms of Change [3]. This systematic narrative review was conducted to give an overview of art therapy interventions for children and adolescents with psychosocial problems. Fourteen databases and four electronic journals up to January 2020 were systematically searched and thirty-seven studies met the inclusion criteria [16 randomized controlled trials, eight controlled trials, and 13 single-group pre-post design studies]. Three forms of therapist behaviour were seen: non-directive, directive, and eclectic. These three forms in combination with a variety of means and expression, showed significant effects on psychosocial problems.

Thirdly, Masika and colleagues investigated the effects of visual art therapy (VAT) on cognitive and psychological outcomes in older people, again performing a systematic review [4]. Their comprehensive search of peer reviewed articles was extensive and included; Medline, EMBASE, Global Health, Cochrane Library, Ovid Nursing database, PsycINFO, British Nursing Index, and CINAHL. This was complete from inception of the databases to September 2019. The systematic review included twelve articles with 831 participants. The results found that this non-pharmacological approach could be effective in improving cognitive functions and accompanying psychological symptoms.

A fourth manuscript is mentioned below and while depression maybe associated with cancer, aging, or exceptional circumstances such as COVID-19,Brandão and co-authors, don’t specifically focus on the reason for depression, but assess the use of art therapy for depressive disorders, investigating what the main effects are as a result [5]. The authors searched MEDLINE/PubMed, American Psychological Association (APA) and Web of Science databases, selecting 14 articles that included; manual work (drawing, painting, and modelling), music, poetry, photography, theatre and contemplation of art pieces. Much of this research was conducted in European countries, with findings being that art therapy is safe and reliable as a tool for the treatment of not only depression but also other mental health conditions.

The background information above mentions one manuscript outlining the scoping review of literature and research pertaining to the art therapy open studio approach, and follows with four manuscripts focusing on general mental health conditions of anxiety, depression, fatigue, psychosocial problems, cognitive and psychological conditions and depressive disorders.

If we look further at the scientific research literature, there are manuscripts that are more focused on specific medical conditions and there is a wealth of publications that assess art therapy for cancer patients. Bosman and colleagues evaluated the effects of art therapy on anxiety, depression, and quality of life in adults with cancer by performing a systematic literature review. Seven papers met the inclusion criteria and hence data was extracted from three non-randomized intervention studies and four randomized controlled trials with four articles describing positive effects of art therapy on anxiety, depression, or quality of life in adults with cancer [6]. Numerous other publications that focus on cancer patients will be detailed in the discussion. In addition, in the discussion other specific medical conditions where art therapy was assessed will be mentioned and this includes post-traumatic stress disorder and schizophrenia.

Hilton’s previous presentation [7] and manuscript [8] included a literature review listing research on art therapy and identified there were numerous clinical research studies that report art therapy benefit as it relates to a number of clinical objective and subjective outcomes. Positive outcomes were reported for people with psychosis [9], for healing trauma among refugee youth [10], stroke patients in their rehabilitation process [11], Alzheimer’s disease and other dementias [12], non-psychotic mental health disorders [13], type 1 diabetes mellitus [14] and depression and cognitive function of the elderly [15].

More specifically, in 2020, the focus of global scientific research has turned and veered towards the pandemic, and includes research encompassing or related to either basic science, prevalence, epidemiology, vaccine development and there are also some manuscripts on art therapy. The worldwide pandemic is causing extreme mental, physical and financial hardship and many people are using different therapies for ways to alleviate stress, depression and anxiety.

According to reports, an outbreak of pneumonia of previously unknown aetiology was reported in Wuhan, China in Dec 2019 and a novel coronavirus was identified as causative [16]. Coronavirus [COVID-19] causes a severe pneumonia characterized by fever, cough and shortness of breath [17].

The novel coronavirus disease spread quickly nationwide [18]. As of Feb 11, 2020, as reported in China's Infectious Disease Information System, 1386 counties across all 31 provinces were affected. Gulati and colleagues in 2020 reported that the global pandemic as of April 2020 had spread to over 210 countries, with 2,400,000 confirmed cases and over 170,000 deaths [17]. The European Centre for Disease Prevention and Control on the 13^th December reports 70 957 979 cases of COVID-19 worldwide and 1 605 595 deaths worldwide [19].

Inchausti and colleagues [20], discuss how the coronavirus COVID-19 global pandemic is causing substantial disruptive impact on society, and challenging mental health service provision, with this burden including existing psychiatric conditions, along with emerging distress as a result of the pandemic. The burden includes healthcare workers, people diagnosed with COVID-19 and / or those whom have lost family or loved ones to the illness, or those who are suffering due to the prolonged social distancing whom also may have existing mental health conditions in addition to the possibility of being diagnosed with COVID-19. Some of these people have added vulnerabilities.

There are various manuscripts published that report beneficial outcomes associated with art therapy specifically during COVID-19. These authors have focused their manuscripts on therapies that aim to alleviate the burden and anguish of the pandemic.

Potash and colleagues published a manuscript titled; Art Therapy in Pandemics: Lessons for COVID-19 [21]. This special report brings together art therapists experienced in working with pandemics (Ebola, SARS), and builds a creative virtual community. Art therapy work is important for disseminating information, guiding expression and inspiration, modulating media, developing resilience, for stress, relationships and it also intensifies hope.

Braus and Morton published a manuscript with the title; Art therapy in the time of COVID-19 [22]. They state there is a battle of two invisible adversaries: COVID-19 and mental health issues, which result in unmitigated stress associated with the limits and rules that are in place to curtail the virus spread. Art therapy is a tool that can be utilised during the time of isolation to benefit individuals and maybe used throughout the life course.

Renzi and co-authors also published a paper that focuses on the coronavirus disease 2019 pandemic, specifically detailing how a lady living in a nursing home, used drawings to express her own emotional experience during the pandemic [23]. The abstract however was not available online so that further details of the art works or therapeutic benefit were not obtainable.

Methods

The Australian yellow pages online directory was searched - search terms [art therapist/s and/or art therapy]. 107 hits were retrieved, 21 were art therapists with email [others were massage therapy, counselling, psychotherapy, or alternative therapies]. These 21 were emailed details of Hilton’s manuscript [8], as background reference material. In addition, the question was asked ‘Are you currently doing any art therapy work with clients related to the COVID-19 pandemic?’, with a request for a simple yes or no answer. Follow up phone calls were made if there was no reply to the email.

RESULTS

The replies from art therapists were as follows; seven art therapists replied stating ‘yes’ while three replied stating ‘no’. Six did not reply. The other emails sent returned a message undeliverable and/or the phone number was invalid or disconnected.

DISCUSSION

These results have been presented as an e-poster at the virtual Australian Public Health Conference as titled; Art therapy and the COVID-19 pandemic - public mental health and well-being [24]. In addition, this e-poster was an award finalist for best e-poster award, whereby five abstracts from each award category were selected as finalists.

The results suggest some art therapists within Australia are consulting with clients with COVID-19 related stress, anxiety or depression. As the pandemic continues worldwide art, music, exercise or relaxation therapy will be crucial for many people in order to deal with stress and the physical, emotional and financial impact of lockdown and quarantine.

Aside from manuscripts mentioned in the introduction, there are many websites that discuss how art therapists are working with clients through the pandemic, approaching depression through art, as people cope with the new normal. They describe how art therapy, being an approach in psychotherapy utilises art as way of helping people express their emotions. The American Art Therapy Association is a website that contains a plethora of resources many of which relate to COVID-19 [25]. A report by Todd in Medill Reports Chicago, states that many art therapists are adapting their work to the pandemic, by addressing depression through art, as they assist their clients to transition to the new normal [26].

The introduction detailed one systematic review manuscript that assessed outcomes of art therapy in persons with cancer. There are many research publications including systematic reviews that focus on persons with cancer. These are detailed below. Rieger and colleagues completed a Systematic Review on Mindfulness-based Arts Interventions for Cancer Care and the Effects on Wellbeing and Fatigue [27]. Their comprehensive literature search of quantitative research included a systematic search of MEDLINE, CINAHL, Cochrane CENTRAL, Art Full Text, ART bibliographies Modern, PsycINFO, Scopus, and EMBASE. 13 studies met the inclusion criteria (8 RCTs and 5 quasi-experiments). Several psychosocial outcomes [quality of life, psychological state, spiritual wellbeing, and mindfulness] showed a significant effect in this oncology research.

Jiang X-H and colleagues also assessed the effect of art therapy in cancer care, in particular assessing quality of life and psychological symptoms [28]. Their search was also comprehensive including; the databases as follows; PubMed, Embase, Web of Science, The Cochrane Library, Clinical Trial.gov, the China National Knowledge Infrastructure (CNKI), Wanfang and the Chinese Biomedical Literature Database (CBM) which were searched from their inception up to 20 August 2019. Twelve studies involving 587 cancer patients were included. The results revealed that art therapy significantly reduced anxiety, depression symptoms and fatigue, as well as significantly improving the quality of life in cancer patients and hence it is useful as a complementary treatment.

Another manuscript, a systematic review more specifically assessing art therapy in relation to gynaecologic cancer was performed by Fu and colleagues [29]. Nine articles met the inclusion criteria which showed that the initial evidence was suggestive that art therapy may have benefit in terms of improving psychological outcome and QOL, reducing fatigue, and improving subjective overall health condition. However, the efficacy of these findings was limited by the quality of the current evidence and hence the author concludes that more rigorous research is needed.

Including art therapy, but encompassed by the broader term of mindfulness-based therapies, Xunlin and co-authors performed a literature search of studies that assessed mindfulness-based interventions again for patients with cancer [30]. The search included 10 electronic databases whereby they only selected randomized controlled trials. Twenty-nine studies were included, which comprised 3476 participants. There was a strong intervention effect of mindfulness-based art therapy (MBAT) on anxiety (SMD = - 2.48) and depression (SMD = - 2.21). They concluded that these therapies maybe useful as adjunct therapies for persons with cancer.

Jang and colleagues also reviewed mindfulness-based art therapy (MBAT) in breast cancer patients. 24 breast cancer patients were selected, and randomly assigned to either the MBAT therapy group or the control group [31]. The personality assessment inventory was used to measure depression and anxiety, while health-related quality of life was evaluated using the European Organization for Research and Treatment of Cancer Quality of Life Questionnaire (EORTCQLQ-C30). Depression and anxiety decreased significantly and health-related quality of life improved significantly in the MBAT group, yet there were no significant changes in the control group. These results show that MBAT is an effective treatment method for improving psychological stability and quality of life.

While the above research focuses on cancer, there are other publications focused upon various other medical conditions, and two examples are detailed below. Baker and co-authors reviewed the creative arts therapies including music therapy, art therapy, dance/movement therapy, and drama therapy, in the treatment of post-traumatic stress disorder [PTSD][32].Seven studies met the inclusion criteria for review, with four studies investigating art therapy, with the GRADE being used to rate the overall evidence for each intervention. While the evidence for art therapy was ranked as low to very low, the trial quality was very poor, so future research directions could involve focusing on scientific quality improvement. Ruddy and Milnes, reviewed the effects of art therapy as an adjunctive treatment for schizophrenia in comparison with standard care and other psychosocial treatments [33]. Two studies (total n = 137 patients) met the inclusion criteria. Data from one mental state measure (SANS) showed a small but significant difference favouring the art‐therapy group (n = 73, 1 RCT, WMD ‐2.3 CI ‐4.10 to ‐0.5). They stressed the requirement for further evaluation of art therapy for serious mental illnesses, in order to clarify the possible benefits or harms that maybe attainable.

Once art therapy works are created, they may be displayed at exhibitions such as the black dog art exhibitions that focus on depression and anxiety [34]. The Black Dog Community Art Project is a free community art exhibition, showcasing creativity as a powerful source of healing during periods of depression and anxiety. The author whom has attended in previous years was advised that this year in 2020 it was to be a virtual exhibition, however as yet the date has not been confirmed. If indeed it doesn’t proceed this year, she will plan to enter this next year in 2021 as a display. Hilton has prepared an art creation, a suited mannequin, surrounded by protective masks, gloves, sanitizer, eyewear and signage depicting outrage associated with; Wuhan whistle-blower Doctor [Dr. Li Wenliang] an ophthalmologist arrested for rumormongering, altering people of potential serious outbreak. He subsequently died of coronavirus [35].

Figure 1: The Black Dog Community Art Project – art creation by D. Hilton [Dr Li Wenliang tribute [(34,35)].

Dr Li Wenliang [12.10.1986 – 7.2.2020] was a Chinese ophthalmologist at Wuhan Central Hospital. Late in Dec 2019, he posted on a WeChat group to his medical colleagues details about seven confirmed cases of SARS reported to the hospital from Huanan seafood market and later posted reports, CT images and confirmation that it was coronavirus. These WeChat messages were shared on the Chinese Internet, and he was summoned by the hospital, whom blamed him for leaking information and he was subsequently dubbed a ‘whistleblower’. On 3 January 2020, Wuhan police summoned and interrogated him & warned him issuing him a formal written warning for he was making false comment on the Internet. He contracted the virus on 8 Jan 2020. He died of the novel coronavirus infection at an intensive care unit on 7 Feb 2020, at age 33. The Chinese government later exonerated & issued a solemn apology to the family.

Figure 2: Writing on the pillowslip – chronology of events.

World Mental Health Day in 2020 was on 10/10/20 and is a day for global mental health education, awareness and advocacy [36].

R U O K? Day in 2020 was on 10/9/20 [R U O K] but is now a year-round call, in that every day is a day to support people whom maybe having a difficult time and struggling [37], These awareness days, along with art therapy, mindfulness-based therapy and other psychotherapies have a very important role and place as treatments for mental health illnesses. What works for someone, may not work for someone else, and it must be remembered that in some instances you cannot alter the circumstances that a person finds themselves in which is leading or contributing to mental health illness. Contributing factors that may exacerbate or lead to depression or anxiety include being diagnosed with cancer or dementia, or being in the midst of a natural disaster or pandemic, where therapies cannot change these causal factors or circumstances, which contrasts to when someone has a temporary illness where recovery is possible. Regardless of this, therapy may assist someone to deal with, cope, view or reflect upon their situation with more optimism or through a different lens. Often people in life have blinkers on and if we consider the viewpoint from an ophthalmology perspective, we may just need new prescription glasses in order to see ahead or more clearly with clarity. Art therapy, like much psychotherapy can’t reverse history or circumstances, so that point in fact maybe a stumbling block and for that reason some people may see any therapy as a waste of time and money as you can’t alter the situation. However, the hope is that it may assist a person whom is suffering to manage their situation or re-focus their view on the future with an added degree of hope and / or optimism. This hence makes these options very valuable and worthwhile with systematic review evidence and clinical trial evidence as mentioned above also showing effectiveness outcomes related to art therapy modalities.

CONCLUSIONS

World Mental Health and RUOK days should incorporate messages about art therapy effectiveness. There is evidence in the literature such that art therapy can be recommended for people with many medical conditions and /or for those whom are caught up in situations such as the COVID-19 pandemic.

REFERENCES

1. Finkel D, Bat Or M. (2020). The Open Studio Approach to Art Therapy: A Systematic Scoping Review. Front Psychol. 11:568042.
2. Newland P, Bettencourt BA. (2020). Effectiveness of mindfulness-based art therapy for symptoms of anxiety, depression, and fatigue: A systematic review and meta-analysis. Complement Ther Clin Pract. 41:101246. doi: 10.1016/j.ctcp.2020.101246. 
3. Bosgraaf L, Spreen M, Pattiselanno K, van Hooren S. (2020). Art Therapy for Psychosocial Problems in Children and Adolescents: A Systematic Narrative Review on Art Therapeutic Means and Forms of Expression, Therapist Behavior, and Supposed Mechanisms of Change. Front Psychol. 11:584685. doi: 10.3389/fpsyg.2020.584685.
4. Masika GM, Yu DSF, Li PWC. (2020). Visual art therapy as a treatment option for cognitive decline among older adults. A systematic review and meta-analysis. J Adv Nurs. doi: 10.1111/jan.14362.
5. Brandão FMV, Silva CV, da Silva Gonçalves de Oliveira KR, da Silva Pedroso J. (2019). Art as a Therapeutic Tool in Depressive Disorders: a Systematic Review of the Literature. Psychiatr Q. 90(4):871-882. doi: 10.1007/s11126-019-09672-x.
6. Bosman JT, Bood ZM, Scherer-Rath M, Dörr H, Christophe N, et al. (2020). The effects of art therapy on anxiety, depression, and quality of life in adults with cancer: a systematic literature review. Support Care Cancer. doi: 10.1007/s00520-020-05869-0.
7. Hilton DJ. (2018). Australian society for medical research. Inspired creativity. When art meets science. Adelaide. Do researchers have their heads in the clouds, bogged down with scientific medical detail? [art therapy maybe a simpler alternative]. Poster and rapid-fire presentation.
8. Hilton DJ. (2020). Do researchers have their heads in the clouds, bogged down with scientific medical detail? [art therapy maybe a simpler alternative]. MedCrave International Physical Medicine and Rehabilitation Journal. 5(1):57‒62.
9. Attard A, Larkin M. (2016). Art therapy for people with psychosis: a narrative review of the literature. Lancet Psychiatry. 3(11):1067–1078.
10. Rowe C, Watson-Ormond R, English L, Rubesin H, Marshall A, et al. (2017). Evaluating art therapy to heal the effects of trauma among refugee youth: the burma art therapy program evaluation. Health Promot Pract. 18:26–33.
11. Eum Y, Yim J. (2015). Literature and art therapy in post-stroke psychological disorders. Tohoku J Exp Med. 235(1):17–23.
12. Chancellor B, Duncan A, Chatterjee A. (2014). Art therapy for Alzheimer's disease and other dementias. J Alzheimers Dis. 39(1):1–11.
13. Uttley L, Stevenson M, Scope A, Rawdin A, Sutton A. (2015). The clinical and cost effectiveness of group art therapy for people with non-psychotic mental health disorders: a systematic review and cost-effectiveness analysis. BMC Psychiatry. 15:151.
14. Harel S, Yanai L, Brooks R, Bar Y, Bistritzer T, et al. (2013). The contribution of art therapy in poorly controlled youth with type 1 diabetes mellitus. J Pediatr Endocrinol Metab. 26(7-8):669–673.
15. Im ML, Lee JI. (2014). Effects of art and music therapy on depression and cognitive function of the elderly. Technol Health Care. 22:453–458.
16. Wang W, Tang J, Wei F. (2020). Updated understanding of the outbreak of 2019 novel coronavirus (2019-nCoV) in Wuhan, China. J Med Virol. 92:441-447. doi: 10.1002/jmv.25689.
17. Gulati A, Pomeranz C, Qamar Z, Thomas S, Frisch D, (2020). A Comprehensive Review of Manifestations of Novel Coronaviruses in the Context of Deadly COVID-19 Global Pandemic. Am J Med Sci. 360:5-34. doi: 10.1016/j.amjms.2020.05.006.
18. Zhonghua Liu Xing Bing Xue Za Zhi. (2020). Epidemiology Working Group for NCIP Epidemic Response, Chinese Center for Disease Control and Prevention. [The epidemiological characteristics of an outbreak of 2019 novel coronavirus diseases (COVID-19) in China]. 41(2):145-151. doi: 10.3760/cma.j.issn.0254-6450.2020.02.003.
19. European Centre for Disease Prevention and Control. COVID-19 pandemic. https://www.ecdc.europa.eu/en/covid-19-pandemic [accessed on: 26/9/2020].
20. Inchausti F, MacBeth A, Hasson-Ohayon I, Dimaggio G. (2020). Psychological Intervention and COVID-19: What We Know So Far and What We Can Do. J Contemp Psychother. 27:1-8. doi: 10.1007/s10879-020-09460-w.
21. Potash JS, Kalmanowitz D, Fung I, Anand SA, Miller GM. (2020). Art Therapy in Pandemics: Lessons for COVID-19. Art Therapy: Journal of the American Art Therapy Association. 37(2):105-107.
22. Braus M, Morton B. (2020). Art therapy in the time of COVID-19. Psychol Trauma. 12(S1):S267-S268. doi: 10.1037/tra0000746.
23. Renzi A, Verrusio W, Evangelista A, Messina M, Gaj F, et al. (2020). Using drawings to express and represent one's emotional experience during the coronavirus disease 2019 pandemic: a case report of a woman living in a nursing home. Psychogeriatrics. doi: 10.1111/psyg.12638.
24. Hilton D. (2020). Virtual Australian Public Health Conference. E-poster; Art therapy and the COVID-19 pandemic - public mental health and well-being. Award Finalist - Best e-Poster Award.
25. American Art Therapy Association. COVID-19 Resources for Art Therapists. https://arttherapy.org/covid-19-resources/
26. Todd AE. (2020). Medill Reports. Art therapy adapting to COVID-19 and helping those in need. Arts & culture, COVID-19. Medill Reports Chicago.
27. Rieger KL, Lobchuk MM, Duff MA, Chernomas WM, Demczuk L, et al. (2020). Mindfulness-based Arts Interventions for Cancer Care: A Systematic Review of the Effects on Wellbeing and Fatigue. Psychooncology. doi: 10.1002/pon.5560.
28. Jiang XH, Chen XJ, Xie QQ, Feng YS, Chen S, et al. (2020). Effects of art therapy in cancer care: A systematic review and meta-analysis. Eur J Cancer Care (Engl). 29(5):e13277. doi: 10.1111/ecc.13277.
29. Fu W, Huang Y, Liu X, Ren J, Zhang M. (2020). The Effect of Art Therapy in Women with Gynecologic Cancer: A Systematic Review. Evid Based Complement Alternat Med. 8063172. doi: 10.1155/2020/8063172.
30. Xunlin NG, Lau Y, Klainin-Yobas P. (2020). The effectiveness of mindfulness-based interventions among cancer patients and survivors: a systematic review and meta-analysis. Support Care Cancer. 28(4):1563-1578. doi: 10.1007/s00520-019-05219-9.
31. Jang SH, Kang SY, Lee HJ, Lee SY. (2016). Beneficial Effect of Mindfulness-Based Art Therapy in Patients with Breast Cancer-A Randomized Controlled Trial. Explore (NY). 12(5):333-40. doi: 10.1016/j.explore.2016.06.003.
32. Baker FA, Metcalf O, Varker T, O'Donnell M. (2018). A systematic review of the efficacy of creative arts therapies in the treatment of adults with PTSD. Psychol Trauma. 10(6):643-651. doi: 10.1037/tra0000353.
33. Ruddy R, Milnes D. (2005). Art therapy for schizophrenia or schizophrenia-like illnesses. Cochrane Database of Systematic Reviews. Issue 4. Art. No.: CD003728. DOI: 10.1002/14651858.CD003728.pub2
34. The Black Dog Community Art Project. https://blackdogproject.weebly.com/
35. Li Wenliang. https://en.wikipedia.org/wiki/Li_Wenliang
36. World Mental Health Day. https://lookafteryourmentalhealthaustralia.org.au/ 
37. R U O K. https://www.ruok.org.au/