Colors of the mind: a meta-analysis of creative arts therapy as an approach for post-traumatic stress disorder intervention

Abstract

Background

In clinical practice, creative arts therapy is frequently utilized for the treatment of traumatized adults, with reports of favorable outcomes. However, the effectiveness of this intervention in post-traumatic stress disorder (PTSD) treatment has not yet been definitively established through meta-analysis. In this meta-analysis, we aim to assess the effectiveness of creative arts therapy in the management of PTSD.

Methods

We conducted systematic literature searches through electronic databases from the extended inception of each database to November 2023. We utilized the Cochrane risk of bias tool to evaluate the quality of evidence. Standardized mean differences (SMDs) were calculated as the effects of creative art therapy on the improvement of PTSD.

Results

Seven controlled, comparative studies investigated the use of creative arts therapy in treating adults with PTSD. Meta-analysis demonstrated a significant decrease in PTSD symptoms following creative arts therapy (SMD = -1.98, 95% Confidence Interval (CI): -3.8 to -0.16, p < 0.03, I2 = 98%). Subgroup analysis indicates that drama therapy was notably effective, while music, art, and dance/movement therapies exhibited less pronounced effects.

Conclusion

Despite the limitations, including a limited number of studies, participant size, study heterogeneity, and methodological quality, these results provide valuable understanding regarding the efficacy of creative arts therapies in treating PTSD and highlight the urgent need for additional research in this area.

Introduction

Mental health is a key public health issue [1], Mental health can be defined as the presence of mental health and the absence of mental disorders [2]. Post-traumatic stress disorder (PTSD), depression, anxiety, and suicidal ideation have been related to it [3]. PTSD symptoms adversely affect the development of physical health status, comorbid mood disorders, and the risk of suicidal behavior [4]. PTSD is a serious and potentially disabling mental disorder that can occur after exposure to actual or threatened death, serious injury, and/or sexual violence [5]. This can occur through direct experience, witnessing the event, or learning about it secondhand. Symptoms of PTSD may include intrusive flashbacks or nightmares, active avoidance of stimuli associated with the trauma (such as specific people or places), alterations in thoughts and moods (e.g., a sense of detachment from others), and heightened alertness or reactivity (manifesting as hypervigilance or startle responses). These symptoms persist for over a month [6, 7]. Studies have shown that the prevalence of PTSD in the community over 12 months is typically around 5% or more, with higher rates observed among specific high-risk populations such as war veterans, being black, and in women compared to men [8–10].

PTSD is characterized by persistent distress that can markedly diminish the functional capacity of those who have endured traumatic incidents. The repercussions of this condition extend beyond the individual, often affecting their family members as well. The condition can severely affect a person's ability to function socially, at work, and in personal relationships, leading to a decline in overall physical health [11, 12]. Individuals with PTSD commonly present with comorbid mental health conditions, including depression, chronic pain, anxiety, and substance use disorders [8, 13–15], and significantly increased risk for suicide [16]. PTSD impacts individuals personally and imposes significant economic burdens on society through healthcare costs, decreased productivity, and increased social services spending [17]. Therefore, creating successful therapies for PTSD is essential for public health and presents a significant challenge in clinical practice.

The first-line treatment for PTSD typically includes a comprehensive approach combining psychotherapy and medication. The American Psychological Association and the World Health Organization recommend evidence-based pharmacological and psychological interventions [18, 19]. Among the FDA-approved medications are selective serotonin reuptake inhibitors (SSRIs) such as paroxetine and sertraline, and serotonin-norepinephrine reuptake inhibitors (SNRIs) like venlafaxine. A comprehensive meta-analysis by Hoskins et al. in 2021 systematically reviewed 52 randomized controlled trials, confirming the moderate to high efficacy of SSRIs and SNRIs in reducing PTSD symptoms, with effect sizes ranging from 0.4 to 0.6 compared to placebo [20].

Psychotherapy recommendations are individualized, considering symptom severity, comorbid conditions, personal preferences, and previous treatment history. Trauma-focused psychological therapies are widely regarded as the primary evidence-based interventions for PTSD. The primary evidence-based psychotherapeutic interventions include Cognitive Behavioral Therapy (CBT), Eye Movement Desensitization and Reprocessing (EMDR) etc. Furuta et al. conducted a systematic review and meta-analysis on trauma-focused therapies for women experiencing PTSD symptoms following childbirth in 2018. Their findings underscored the effectiveness of interventions such as CBT and EMDR, which showed significant symptom reduction in this population [21].

Despite the demonstrated effectiveness of these first-line treatments, the heterogeneous nature of PTSD means that not all individuals respond equally. Many continue to experience residual symptoms, underscoring the complexity of the disorder and the need for continued exploration of novel and tailored treatment strategies. Furthermore, another study emphasized the ongoing challenges in treating PTSD effectively due to the complexity of the disorder and its various symptoms, which can include intrusive memories, avoidance behaviors, and hyperarousal [22]. This complexity necessitates the continued development of new treatment modalities and better management strategies.

Creative arts therapy has emerged as a promising alternative treatment for individuals with post-traumatic stress disorder (PTSD), offering both verbal and non-verbal means to process and express traumatic experiences [23, 24]. This therapeutic approach encompasses a wide range of modalities, including visual arts, music, drama, dance/movement, poetry, and writing [25]. By engaging with these diverse artistic forms, individuals are able to access and articulate their inner emotional states through sensory, embodied, and expressive experiences [26, 27]. Among these, visual and performing arts therapies, such as painting, music, and drama, have been more extensively studied in the context of PTSD and form the primary focus of this paper. While other modalities, such as poetry and writing, hold potential in creative arts therapy, their application to PTSD has been less frequently documented, warranting further exploration in future research.

Evidence-based treatment guidelines acknowledge creative arts therapy as an effective adjunct therapy for alleviating PTSD-related symptoms such as depression, alexithymia, dissociation, anxiety, nightmares, and sleep disturbances [28]. Furthermore, creative arts therapy has been associated with improved emotional regulation, enhanced interpersonal relationships, and a more positive body image perception [29].

The neurobiological and psychological mechanisms underlying creative arts therapy's effectiveness in PTSD treatment are increasingly understood through emerging neuroscientific research. Neuroimaging and neurophysiological studies suggest that creative arts interventions activate alternative neural processing pathways, particularly in brain regions associated with emotion regulation and trauma memory encoding [25, 30]. By engaging right-hemisphere processes and non-verbal neural networks, these therapies provide a unique avenue for processing traumatic experiences that may be difficult to verbalize through traditional talk therapies [31]. Neuroplasticity research indicates that creative expression can modulate the hypothalamic–pituitary–adrenal axis, potentially reducing stress response hyperactivity characteristic of PTSD, while simultaneously promoting neural connectivity and emotional integration [32, 33]. Moreover, the embodied nature of creative arts therapies enables bottom-up emotional processing, allowing individuals to externalize and symbolically represent traumatic experiences without direct linguistic confrontation [34, 35].

Despite its recognized benefits, creative arts therapy has not yet been widely endorsed as a first-line treatment due to the limited availability of robust empirical evidence. Existing studies on creative arts therapy efficacy are predominantly expert opinions and case reports, which do not provide conclusive insights into its effectiveness [36]. Although prior systematic literature reviews have examined the role of creative arts therapy in trauma treatment [37], these reviews lack quantitative meta-analyses to consolidate research findings.

To address this gap, the present study aims to conduct a comprehensive meta-analysis to systematically evaluate the effectiveness of creative arts therapy in treating PTSD. By providing quantitative evidence, this research seeks to advance understanding of creative arts therapy's therapeutic potential and establish its place within evidence-based treatment frameworks.

Method

This systematic review adheres to the guidelines set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement proposed by Moher et al. in 2009 [38]. It has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) under CRD42024505399.

Search strategy

In order to enhance the scope and comprehensiveness of the article search as much as possible, we performed a thorough literature search in both English and Chinese, including major international databases like PubMed, Web of Science, PsycINFO, Embase, the Cochrane Central Register of Controlled Trials, and Clinical Trials.gov, as well as prominent Chinese databases such as Wanfang Data and China National Knowledge Infrastructure (CNKI). The search range was from the inception of each database to November 2023. According to the definition of creative art therapy or art therapy by Malchiodi and Crenshaw in 2015 [39], this study defined creative arts therapy as a multidisciplinary therapeutic approach that integrates various art forms, including visual art, music, dance/movement, poetry, sculpture, panting and drama, to nurture healing and enhance psychological well-being. The search strategy was adapted accordingly for each database. The search terms were as follows: (“creative art* therapy” or “art therapy” or “therapy, art” or “art therapies” or “therapies, art” or “visual art* therapy” or “music therapy” or “dance therapy” or “movement therapy” or “poetry therapy” or “sculpture therapy” or “drawing therapy” or “painting therapy” or "drama therapy") AND PTSD or "post-traumatic stress disorder" AND "randomized controlled trial" OR "randomized" OR "placebo". In this study, we implemented a search strategy targeting titles and abstracts. We thoroughly examined the reference lists from the identified literature to ensure the inclusion of all pertinent articles.

Inclusion and exclusion criteria

We included studies based on the PICOS approach: 1) Participants: Adults over the age of 18 years; 2) Intervention: Creative arts therapy to improve PTSD symptoms. Possible creative arts therapies included but were not limited to listening to music, dancing, singing, drawing, or painting; 3) Comparison: Treatment as usual, interventions, or no interventions; 4) Outcomes: At least one psychological outcome was measured, including but not limited to PTSD symptom severity, depression, anxiety, or emotional regulation difficulties. Participants were required to meet PTSD diagnostic criteria, or exhibit significant related symptoms as determined by standardized diagnostic tools (e.g., Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) criteria) or validated screening instruments. Studies meeting these criteria were included in the analysis; 5) Study Designs: Randomized controlled trials (RCTs), controlled trials with a comparative group; 6) Language: English or Chinese original articles.

Exclusions applied to studies involving children and adolescents or those under 18 years old, family members, healthcare professionals, and those studies with insufficient data or outcomes.

Study selection and data extraction

The study involved two independent reviewers (J. W., & B. Z.) implementing the search strategy to identify eligible studies and extract relevant data. The reviewers removed duplicate data. The two independent reviewers began with an initial exclusion based on the abstract and title of the article. Additionally, they examined each full-text article according to the predetermined inclusion and exclusion criteria. In cases where reviewers disagreed on whether a study met the eligibility criteria or how to extract data, a third reviewer's (R. Y.) opinion was sought to reach a consensus. The extracted information included the first author's name, publication year, study design, participant demographics, intervention characteristics, control conditions, treatment duration and frequency, assessment instruments, and outcomes. The corresponding author was contacted for further information if the data were insufficient.

Quality assessment

In this meta-analysis, two reviewers (J. W., & B. Z.) assessed the quality of the included studies independently applying the Cochrane Risk of Bias tool for systematic evaluation [40]. Any discrepancies between the reviewers were reached to a consensus by consulting the third reviewer (R. Y.). Furthermore, to ensure the precision and neutrality of the assessment, reviewers critically analyzed the study’s design, implementation, data gathering, and analytical techniques to identify any potential biases that could impact the study findings.

Data synthesis and analysis

We performed the meta-analysis using Review Manager 5.3 (RevMan 5.3). Each eligible study utilized various tools to measure post-traumatic stress symptoms and reported at least one set of scores. We selected a single dataset for those studies reporting multiple outcomes. Given the diversity of measurement tools, we applied the standardized mean difference (SMD) and 95% confidence intervals (95% CI); a p-value < 0.05 was deemed statistically significant [41]. We utilized Cochran’s Q test based on the chi-square and the I² statistic to assess study heterogeneity [42]. When studies showed statistical heterogeneity (defined as p ≤ 0.10 or I² ≥ 50%), we used the DerSimonian and Laird random-effects model for the meta-analysis; for studies with no significant heterogeneity (defined as p > 0.10 or I² < 50%), we applied the Mantel–Haenszel fixed-effects model [43]. Heterogeneity among the studies was explored further in subgroup analyses. When necessary, we also performed meta-regression analysis and sensitivity analyses on individual studies that might influence the results to verify the robustness of the findings.

Subgroup analysis

For subgroup analysis, we categorized the studies based on the focus of the therapy, including art therapy, music therapy, dance/movement therapy, and drama therapy.

Results

Literature search

As depicted in Fig. 1, the database yielded 744 entries. After eliminating 65 duplicates, we examined the titles and abstracts of the remaining 679 articles. This screening process led to the choosing of 12 articles for full-text review. Finally, only seven studies fulfilled the criteria for meta-analysis.

Fig. 1.

The flowchart of the study includes the reasons for exclusion

Study characteristics

The detailed characteristics of the seven included studies [44–50] are provided in Table 1 and publication year ranged between 2007 to 2023, spanning 16 years. The duration for each session varies from 20 min to 10 h, and the total duration for each therapy ranges from one hour to 40 h. Among these, Gever et al. in 2023 conducted a comparative analysis by examining three distinct creative arts therapies—music, art, and drama—each serving as an experimental group compared to a single control group [48]. Dutton et al. focused on holistic healing arts, while the remaining five studies each investigated a single method of creative arts therapy in 2023 [47].

Table 1.

Demographics and characteristics of the included studies (n = 7)

Study author & year	Study type	T vs C (n)	Subject characteristics	Type of art therapy	Control condition	Treatment duration, frequency	Mean Age/ Age	Measure (Type of Assessment)	Result
Beck et al., 2021 [44]	RCT	35/18	Adult refugees diagnosed with PTSD (War-related trauma)	Trauma-focused music and imagery	Treatment as usual	Duration: 1 Frequency: Once a week in total 16 weeks	42	HTQ (Self-Report) DSS-2 (Self-Report) RAAS (Self-Report) WHO-5 (Self-Report)	Decrease PTSD symptoms post-treatment and during a six-month follow-up
Bi et al., 2018 [45]	RCT	39/39	Patients with severe psychological stress reactions following trauma (Potential disaster/violence-related)	Yishu psychological drama therapy	Treatment as usual	Duration: 0.5 to 1 h Frequency: Once a week in total 3 months to 0.5 year	Study group: 46.3 years, control group: 45.7 years	PCL-C (Self-Report)	Yishu psychological drama is more effective
Carr et al., 2011 [46]	Exploratory RCT	8/8	Patients with PTSD who inadequately respond to cognitive-behavioral therapy (Multiple trauma types)	Group music therapy	Standard care	Duration: 1 h Frequency: Once a week for a total of 10 weeks	34	IES-R (Self-Report) BDI-II (Self-Report)	The severity of PTSD symptoms significantly reduced
Dutton et al., 2023 [47]	RCT	49 / 60	Women exposed to childhood physical or sexual abuse, assault, or domestic violence	Holistic Healing Arts Retreat	Art Control	5 days, involving two 5-h days and three 10-h days	41	PCL-5 (Self-Report) PHQ-9 (Self-Report) PSS (Self-Report) SCS (Self-Report) FFMQ (Self-Report) AAQ-II (Self-Report)	Statistically significant improvements in post-traumatic symptoms at 1, 4, and 7 months post-retreat
Gever et al., 2023 [48]	Quasi-experiment	165/165	Nigerian evacuees from the Russia-Ukraine war	Music, art and drama therapy	Did not receive the intervention	Duration: one hour and 30 min Frequency: Once a week in total 7 weeks	25–32	ITQ (Self-Report)	Effectively reduced PTSD symptoms
Henderson et al.,2007 [49]	Empirical study	19/17	Undergraduate students with clinical levels of traumatic distress, specifically PTSD	Mandala-drawing	Drew objects	3 consecutive days, with 20-min drawing sessions each day	18.4	PDS (Clinician-Administered) BDI-II (Self-Report) STAI (Self-Report) SMS (Self-Report) PILL (Self-Report)	Significantly reduce PTSD symptoms
Özümerzifon et al.,2022 [50]	RCT	25/18	Female survivors of intimate partner violence	Virtual creative dance/movement program	Usual care	Duration: 90 min Frequency: Twice a week over approximately 6 weeks	35	PCL-5 (Self-Report) Kessler K-6 (Self-Report)	PTSD symptoms and psychological distress lessened

RCT Randomized Controlled Trial, T Trial, C Control, HTQ Harvard Trauma Questionnaire, DSS-20 Depression Status Inventory, RAAS Relationship Assessment Scale, WHO-5 World Health Organization-Five Well-Being Index, PCL-C PTSD Checklist—Civilian Version, IES-R Impact of Event Scale – Revised, BDI-II Beck Depression Inventory-II, PCL-5 PTSD Checklist for DSM-5PHQ-9, Patient Health Questionnaire-9, PSS Perceived Stress Scale, SCS Self-Compassion Scale, FFMQ Five Facet Mindfulness Questionnaire, AAQ-II Acceptance and Action Questionnaire-II, ITQ International Trauma Questionnaire, PDS Post-traumatic Stress Diagnostic Scale, STAI State-Trait Anxiety Inventory, SMS Stress Management Scale, PILL Pennebaker Inventory of Limbic Languidness

Meta-analysis

The overall analysis

This meta-analysis examined the intervention effects of creative arts therapy on PTSD, integrating data from seven clinic trials to ascertain the treatment’s actual effectiveness. The total sample included was 665 subjects, divided into 340 subjects in the experimental group and 325 in the control group. The overall SMD using a random-effects model was −1.98, with a 95% CI from −3.80 to −0.16; p < 0.05, indicating a statistically significant effect size in favor of the experimental group. However, considerable heterogeneity among the studies (I² = 98%) suggested that the effect sizes varied substantially between studies, as shown in Fig. 2. The effect sizes ranged from a high favoring the control group in the study by Bi et al. in 2018 (SMD = −8.19) to a study with a large negative mean for the experimental group by Dutton et al. in 2023 (SMD = −0.64). A few studies, such as those by Beck et al. in 2021and Henderson et al. in 2007, showed negligible effect sizes close to zero. Each study contributed differently to the overall analysis, with weights ranging from 13.6% to 14.6%. The test for the overall effect size (Z = 2.13) was statistically significant (p = 0.03), suggesting a genuine difference between experimental and control groups across the studies included in this meta-analysis.

Fig. 2.

Forest-plot of creative art therapy on PTSD

Subgroup analysis on therapy interventions

Our subgroup analysis aimed to assess the differential impacts of various therapeutic interventions on experimental versus control groups (Fig. 3). The therapies that have been examined included Music, Art, Drama, and Dance Therapy. For music therapy, the pooled SMD across 3 studies was −1.74 (95% CI: −4.52, 1.05), which did not reach statistical significance. This suggests the effect of music therapy was not significantly different from the control condition. In the case of art therapy, the SMD across 2 studies was −5.79 (95% CI: −17.71, 6.13), indicating a large effect size. However, the high heterogeneity (I² = 100%) implies variations in study designs, intervention protocols, or sample characteristics across the included studies. For drama therapy, the pooled SMD from 2 studies was −11.16 (95% CI: −16.96, −5.35), suggesting a robust beneficial effect compared to control. Yet, the high heterogeneity (I² = 97%) warrants further investigation into the sources of variability. Given that only a single study evaluated dance therapy, we did not conduct a subgroup analysis for this intervention type.

Fig. 3.

Forest-plot of the subgroup analysis of the creative art therapies on PTSD

Overall, the total SMD across all therapy types was −4.81 (95% CI: −7.77, −1.86), indicating a beneficial effect of the interventions compared to controls. However, the substantial heterogeneity (I² = 99%) observed underscores the need to explore potential moderators and sources of variability in the treatment effects.

Sensitivity analysis

In this study, we performed a sensitivity analysis to evaluate the stability of the meta-analysis outcomes by systematically excluding each study. Notably, the exclusion of the study by Bi et al. in 2018 led to a notable shift in the overall effect size, increasing from 0.03 to 0.26. While this alteration highlights the substantial impact of Bi et al.’s study on aggregate analysis, it does not inherently imply a systematic flaw or pervasive publication bias. It could be indicative of the study’s unique characteristics. Consequently, the overall analysis, which demonstrates a significant effect of creative arts therapy compared to the control group in reducing PTSD symptoms, remains robust despite the influential role of this particular study.

Quality assessment

Our assessment of the risk of bias within the included studies is summarized in Fig. 4. Overall, most studies displayed a low risk of bias across several domains. Beck et al. in 2021 and Bi et al. in 2018 showed a low risk of bias in all categories, indicating robust methodological approaches. Allocation concealment was adequately addressed in all studies except for Henderson et al., which showed an unclear risk, suggesting a potential avenue for selection bias. Blinding of participants and personnel was generally well-managed. Still, two studies, which are Carr et al. in 2012 and Gever et al. in 2023, demonstrated a high risk in this domain, which could introduce performance bias. The blinding of outcome assessment was effectively maintained across all but one study, with Dutton et al. in 2023 displaying a high risk of bias, raising concerns regarding detection bias. Most studies adequately addressed potential attrition bias concerning incomplete outcome data, except Gever et al., which reported a high risk. This discrepancy suggests a possible impact on the reliability of the study outcomes. The potential for selective reporting bias was indeterminate in the study by Özümerzifon et al. in 2022, which raises concerns that not all pre-specified outcomes may have been reported. Other biases were minimal, with only occasional issues arising in individual studies.

Fig. 4.

Quality assessment of studies

Discussion

Summary of main findings

This meta-analysis provides important insights into the effectiveness of creative arts therapy in alleviating PTSD symptoms. With a total of 665 participants, the findings generally support the efficacy of creative arts therapy, showing a significant reduction in PTSD symptoms. However, the large confidence intervals and high heterogeneity (I² = 98%) across studies suggest that the effect sizes vary considerably. These variations likely reflect differences in study populations, interventions, treatment durations, intensities, and outcome measures, highlighting the complexity of assessing the overall effectiveness of creative arts therapy. Given this heterogeneity, it is crucial to interpret the findings with caution and consider the influence of individual study characteristics on the outcomes.

The variability in treatment duration and intensity, for instance, may partially explain these differences. Longer interventions, such as the 16-week program in Beck et al. in 2021, often allow for more sustained therapeutic effects, while shorter and more intensive interventions, like the five-day holistic retreat in Dutton et al. in 2023, may produce immediate but possibly variable results. Additionally, cultural factors may significantly shape the outcomes, as demonstrated by Bi et al. in 2018, whose use of Yishu psychological drama, a culturally grounded approach, yielded distinctive results that contrast with other studies. These variations in study design and implementation suggest that tailoring creative arts therapy to the cultural and psychological context of the population may enhance its effectiveness. The notable impact of Bi et al.’s study on the overall effect size further underscores the importance of study-specific factors, such as participant characteristics, cultural relevance, or the quality of intervention implementation. These variations in study design and implementation suggest that tailoring creative arts therapy to the cultural and psychological context of the population may enhance its effectiveness.

The subgroup analysis provides additional nuance to these findings. Music therapy showed a trend toward beneficial effects, although it did not achieve statistical significance. The relatively small sample sizes and varying intensity of interventions across studies may have contributed to this result. For example, Beck et al. conducted a robust randomized controlled trial comparing music therapy with verbal therapy [44], while Carr et al.’s study included only 17 participants, limiting the generalizability of their findings [46]. The study by Gever et al. involved 330 participants [48], was the largest in this subgroup, further demonstrating that study design, participant number, and intervention structure can substantially impact the results.

Art therapy, on the other hand, demonstrated a large effect size despite the high heterogeneity among the included studies. This variation may be attributed to the diversity in methodological approaches, intervention protocols, and the types of art therapy employed. For example, differences in study design, such as randomized controlled trials versus observational studies, and variations in intervention characteristics, such as treatment frequency, duration, and therapist qualifications, could contribute to the observed heterogeneity. Furthermore, the choice of outcome measurement tools and differences in sample characteristics, including trauma type and participant demographics, may also play a role. To illustrate, Henderson et al. examined the effects of mandala creation on PTSD symptoms in a small sample, reporting positive outcomes [49]. In contrast, the larger-scale study by Gever et al. employed a more complex intervention design, integrating multiple therapeutic modalities [48]. These discrepancies in approach likely contribute to the high I² value observed in this subgroup. Nonetheless, the consistently positive therapeutic outcomes across diverse settings underscore the potential of art therapy as a valuable intervention for PTSD.

Drama therapy emerged as the most consistent and effective intervention across the studies, with a substantial effect size and moderate heterogeneity. The relatively consistent positive outcomes across various contexts may be attributed to the immersive and expressive nature of drama therapy, which allows for deeper emotional engagement and psychological processing. This finding aligns with the theoretical perspectives of dual representation theory [51, 52], which suggests that sensory and verbal processing of traumatic memories can promote healing. Drama therapy, as an expressive modality, may facilitate this process by helping participants externalize and process their trauma in a structured, safe environment.

Despite these promising results, dance therapy did not show significant effects in this meta-analysis. As it was analyzed in a single study, the limited data available makes it difficult to draw definitive conclusions about its efficacy. Future studies with larger sample sizes and more rigorous methodological designs are needed to assess the true potential of dance therapy in treating PTSD.

From a theoretical perspective, the dual representation theory provides a compelling framework for understanding how creative arts therapy may alleviate PTSD symptoms. By engaging both sensory-based memories (through non-verbal expression in art) and situational representations (via verbal articulation), creative arts therapy may help integrate traumatic memories into a more cohesive and less distressing narrative. This process of memory integration is supported by neuroimaging research, such as the work by Bolwerk et al., which shows that creative activities enhance connectivity between the posterior cingulate cortex and the frontal-parietal regions, areas involved in memory processing and emotional regulation [53]. These findings reinforce the idea that creative arts therapy can facilitate the reconnection of fragmented memory systems, thereby reducing PTSD symptoms.

In comparison to earlier systematic reviews, our meta-analysis offers a more comprehensive evaluation of creative arts therapy as a unified therapeutic approach. Previous reviews have often focused on specific modalities like art therapy or music therapy, limiting the ability to draw broad conclusions about the overall effectiveness of creative arts therapy. Our findings, however, provide a more complete understanding of creative arts therapy’s therapeutic potential, incorporating diverse artistic interventions and their varying effects on PTSD.

Strengths and limitations

PTSD has consistently been a significant focus within creative arts therapy, highlighting the need for further empirical research [54, 55]. Despite the widespread implementation of art therapy in clinical settings for treating traumatized adults and its recognition as beneficial by experts in the field, controlled outcome trials specifically addressing creative arts therapy remain notably limited [37]. This study marks the beginning of a meta-analysis dedicated to exploring the efficacy of creative arts in PTSD interventions, endeavoring to bridge the existing research gap.

The focus of this analysis was intentionally narrowed to adult populations to provide a clearer understanding of therapeutic outcomes specific to this group. PTSD symptoms and treatment responses in adolescents and children differ significantly due to developmental and psychological factors, warranting separate investigation. Acknowledging this limitation, we plan to conduct future research focused on younger populations to address these unique needs. By emphasizing adult-focused findings, this study lays the groundwork for more tailored analyses while recognizing the critical importance of expanding the scope to include diverse demographics in future work.

While subgroup analyses were conducted to explore potential sources of heterogeneity, the limited number of studies precluded the use of meta-regression, which could have provided deeper insights into study-level moderators. Although this heterogeneity may challenge the generalizability of our findings, it underscores the adaptability of creative arts therapy in tailoring treatments to individual patient needs. Future research should aim to address this variability by employing more rigorous study protocols to enhance therapist consistency and conducting detailed subgroup analyses to evaluate the efficacy of specific treatment modalities for different demographics. This approach would further refine the understanding of how creative arts therapy can be optimized for PTSD treatment.

This study represents an important step toward addressing the limited empirical evidence on the effectiveness of creative arts therapy for PTSD through a meta-analytic approach. While the findings provide preliminary evidence supporting the potential effectiveness of creative arts therapy in reducing PTSD symptoms, they should be interpreted with caution due to the high heterogeneity among studies and the limited number of existing studies. Despite creative arts therapy’s widespread clinical use and recognition as beneficial, only seven studies met the inclusion criteria, underscoring the need for a stronger research foundation in this field. The substantial variability observed in this meta-analysis reflects its inherently personalized methodologies, diverse techniques, and varied participant responses. As creative arts therapy continues to develop and gain attention in trauma-focused interventions, further rigorous, large-scale research is essential. Future studies should focus on standardizing methodologies and exploring factors contributing to the observed variability to better establish the role of creative arts therapy in PTSD treatment.

Implications

Our study offers initial evidence supporting the effectiveness of creative art therapy for PTSD and sets the direction for subsequent research. Nevertheless, the limited number of studies and their methodological shortcomings call for further research and enhanced methodologies to reinforce the evidence base for the effectiveness of art therapy in treating traumatized adults. Consequently, we advocate for further research with more rigorous methods to substantiate the benefits of creative arts therapy for this population. Future studies should incorporate larger cohorts, extended follow-up periods, and PTSD-specific metrics to enhance the validity and applicability of the findings. Such endeavors will fortify the scientific underpinnings of creative arts therapy in PTSD interventions and provide more definitive recommendations for its clinical application.

Conclusion

In conclusion, the meta-analysis indicates a potential benefit of creative art therapy as an alternative therapy for those who have PTSD. However, these findings should be cautiously applied in clinical practice due to high heterogeneity and variability among study results. Future research should clarify the factors contributing to this analysis's variability in effect sizes. The subgroup analysis suggests that art and drama therapies may offer substantial benefits in therapeutic settings, although the effectiveness varies. The present study provides preliminary evidence and direction for the effectiveness of creative arts therapies in treating PTSD. These findings provide a foundation for further research to explore and refine therapeutic interventions to enhance patient outcomes.

Abbreviations

CBT

Cognitive Behavioral Therapy

CI

Confidence Interval

DSM-5

Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition

EMDR

Eye Movement Desensitization and Reprocessing

PTSD

Post-traumatic stress disorder

PROSPERO

Prospective Register of Systematic Reviews

RCTs

Randomized controlled trials

SSRIs

Selective serotonin reuptake inhibitors

SNRIs

Serotonin-norepinephrine reuptake inhibitors

SMDs

Standardized mean differences

Authors’ contributions

Firstly, J. W. and B. Z. contributed equally to this work. J. W. and B. Z. conceived the idea, implemented data analyses, and wrote the main manuscript text together. Secondly, R. Y. wrote part of the manuscript text and revised manuscript. Moreover, J. W., B. Z. and A. B. reviewed the content and formatting of the article. Besides that, all authors contributed to manuscript and gave final approval for publication.

Funding

Not applicable, the authors declare that there is no funding for this study.

Data availability

All data used in this meta-analysis were derived from published studies, which are fully cited in the reference list. To ensure transparency and reproducibility of our research, we have uploaded the original data extraction tables, statistical analysis scripts, meta-analysis results, and search strategies to the Open Science Framework (OSF). These materials are accessible through the following link: https://osf.io/7j4wg/?view_only=a66b984c63e84dbaa46ceaba38b06181.

Declarations

Ethics approval and consent to participate

This meta-analysis used data from previously published studies, requiring no direct involvement of human or animal subjects. As such, no additional ethical approval was necessary. To ensure transparency and methodological rigor, we pre-registered our protocol on PROSPERO (registration number: CRD42024505399). Moreover, this article does not contain any studies with human participants or animals performed by any of the authors. All data used in this meta-analysis were derived from previously published studies.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.