Active Visual Art Therapy in the General Hospital: Facts and Challenges from an Ethical Perspective

Abstract

For decades, art in its many forms has been used to improve patients’ quality of life and mental health. A growing amount of literature has shown the effectiveness of active visual art therapy (AVAT) on different patient outcomes and highlighted the need for international collaboration and harmonization of research methods. Evidence regarding AVAT inside the general hospital is still limited. This context poses unique challenges in terms of feasibility, heterogeneity, settings, and type of participants, together with significant ethical implications in terms of humanization of care. This narrative review aimed to report the available data on the effectiveness of visual art therapy in the general hospital and discuss them through the lens of the key bioethical principles of autonomy, beneficence, non-maleficence, and justice introduced by Childress and Beauchamp. Current evidence supports the effectiveness of AVAT on children and adult inpatients’ outcomes, particularly in the areas of pain control, anxiety, and depression, therefore supporting the individual’s autonomy and beneficence. With regard to justice and equity, AVAT proved to be a safe and cost-effective adjunct intervention to medical management inside the hospital. A more in-depth understanding of the ethical aspects implied in using AVAT in the general hospital may add a further contribution to the implementation of art interventions in patient-centered care.

Full text

Academic Editor: Paul B. Tchounwou
Received: 15 December 2024
Revised: 10 February 2025
Accepted: 14 February 2025
Published: 19 February 2025
Citation: Martinelli, V.; Lumer, E.L.L.;
Fusar Poli, L.; Chiappedi, M.; Politi, P.
Active Visual Art Therapy in the
General Hospital: Facts and
Challenges from an Ethical
Perspective. Int. J. Environ. Res. Public
Health 2025,22, 316. https://doi.org/
10.3390/ijerph22020316
Copyright: © 2025 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
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Review
Active Visual Art Therapy in the General Hospital: Facts and
Challenges from an Ethical Perspective
Valentina Martinelli 1,2, *, Estella Linda Luisa Lumer 2, Laura Fusar Poli 3, Matteo Chiappedi 4
and Pierluigi Politi 3
1General Surgery Unit 2, IRCCS Policlinico San Matteo, 27100 Pavia, Italy
2Harvey Medical Course, Department of Molecular Medicine, University of Pavia, 27100 Pavia, Italy;
estellalindalu.lumer01@universitadipavia.it
3Department of Brain and Behavioral Sciences, University of Pavia, 27100 Pavia, Italy;
laura.fusarpoli@unipv.it (L.F.P.); pierluigi.politi@unipv.it (P.P.)
4Istituto Dosso Verde, 27100 Pavia, Italy; matteo_chiappedi@asst-pavia.it
*Correspondence: valentina.martinelli@unipv.it
Abstract: For decades, art in its many forms has been used to improve patients’ quality
of life and mental health. A growing amount of literature has shown the effectiveness
of active visual art therapy (AVAT) on different patient outcomes and highlighted the
need for international collaboration and harmonization of research methods. Evidence
regarding AVAT inside the general hospital is still limited. This context poses unique
challenges in terms of feasibility, heterogeneity, settings, and type of participants, together
with significant ethical implications in terms of humanization of care. This narrative review
aimed to report the available data on the effectiveness of visual art therapy in the general
hospital and discuss them through the lens of the key bioethical principles of autonomy,
beneficence, non-maleficence, and justice introduced by Childress and Beauchamp. Current
evidence supports the effectiveness of AVAT on children and adult inpatients’ outcomes,
particularly in the areas of pain control, anxiety, and depression, therefore supporting the
individual’s autonomy and beneficence. With regard to justice and equity, AVAT proved to
be a safe and cost-effective adjunct intervention to medical management inside the hospital.
A more in-depth understanding of the ethical aspects implied in using AVAT in the general
hospital may add a further contribution to the implementation of art interventions in
patient-centered care.
Keywords: visual art therapy; ethics; general hospital; mental health; physical health
1. Introduction
For decades, art in its many forms has been used to improve people’s quality of life
and mental health. Poetry, theater, music, and visual arts have been employed to process
traumatic events, mitigate psychological distress, and promote communication and well-
being. The concept of “art therapy” was introduced by the British artist Adrian Hill in 1942,
grounded on his personal experience of a long hospitalization, where artwork alleviated
his suffering [
1
]. Since then, art therapy programs have spread throughout countries and
medical disciplines, including psychiatry, neurology, pain management, and oncology [
2
–
5
].
Across different art forms and clinical contexts, increasing evidence suggests that art-based
methods support patients and healthcare providers’ psychosocial well-being, agency, and
empowerment. Active visual art therapy, in particular, is defined as any type of artistic
activity in which patients actively manipulate materials with their hands, such as painting,
drawing, sculpting, and craft works [5].
Int. J. Environ. Res. Public Health 2025,22, 316 https://doi.org/10.3390/ijerph22020316

Int. J. Environ. Res. Public Health 2025,22, 316 2 of 12
A growing amount of literature has highlighted the effectiveness of AVAT on different
patient outcomes. A recent systematic review of 69 randomized controlled trials found
that AVAT was associated with improvements in health outcomes, especially in the area
of mental health or when treating somatic conditions associated with impaired mental
health [
5
]. Of interest, the majority of the included studies have been conducted in the
areas of psychiatric or physical rehabilitation aftercare or for chronic conditions, mainly
in outpatient settings or residential facilities. Contrariwise, evidence on the use of AVAT
inside the general hospital is still limited, although hospitalization represents a highly
stressful and potentially traumatic experience per se and depressive and anxiety symptoms
are common in medically hospitalized patients [
6
,
7
]. Art therapy has been shown to help
inpatients’ unaddressed psychosocial distress and to improve not only the management of
physical symptoms but also overall well-being and socialization [
8
]. AVAT reduced pain
and anxiety during acute hospital treatments in adults [9,10] and adolescents [11].
The general hospital poses unique challenges in terms of feasibility, heterogeneity of
setting, participants, and underlying medical conditions. At the same time, it represents an
area of great interest, need, and potential to improve inpatients’ well-being and quality of
life, with significant ethical implications in terms of the humanization of care.
In this regard, the four key principles of biomedical ethics introduced in 1979 by
Childress and Beauchamps may represent a useful paradigm to critically evaluate the
use of AVAT inside the general hospital, integrating the evidence derived from more
traditional psychosocial and physical outcomes [
12
]. The issues of autonomy, beneficence,
non-maleficence, and justice still provide a meaningful conceptual framework to reflect on
medical dilemmas and controversial matters in clinical practice.
The present narrative review aims to describe the use of AVAT in the general hospital
through the lens of the four core ethical principles of bioethics. Potential implications for
future research and clinical application for effective, patient-centered care in the general
hospital are discussed.
2. Materials and Methods
A search of the literature was conducted in December 2024 on the Medline and
Pubmed databases to identify articles that explored the efficacy of active visual art therapy
in hospital settings with the following keywords: visual art therapy; general hospital;
inpatients; ethics; psychosocial outcomes; autonomy; beneficence; non-maleficence; and
justice. These keywords were used as alternatives (i.e., connected with the logical operator
“OR”) in order to reduce the risk of missing relevant papers. Two authors
(V.M. and E.L.)
independently screened articles by title and abstract to identify relevant papers. The
inclusion criteria were: considering the use of AVAT in inpatient settings; having been
published between 2004 and 2024; and being written in English or Italian or French. The
exclusion criteria were: considering other forms of art therapy (not including AVAT);
reporting data regarding outpatients or community samples; and failing to meet inclusion
criteria. The selected papers were critically revised, and any disagreement was solved
through discussion with two other authors (L.F.P. and M.C.) to reach a consensus. The
selection process followed the PRISMA model [13], as shown in Figure 1.
All the co-authors reviewed and discussed the resulting draft to provide a theoretical
point of view concerning the main ethical implications of providing AVAT in the general
hospital. The final version of the manuscript was then recirculated and approved by all
the co-authors.

Int. J. Environ. Res. Public Health 2025,22, 316 3 of 12
Int. J. Environ. Res. Public Health 2025, 22, 316 3 of 13
Figure 1. Flow diagram of paper selection process.
All the co-authors reviewed and discussed the resulting draft to provide a theoretical
point of view concerning the main ethical implications of providing AVAT in the general
hospital. The nal version of the manuscript was then recirculated and approved by all
the co-authors.
3. Results
3.1. Autonomy
The concept of autonomy refers to an individual’s right to self-determination and
their ability to make decisions about their medical treatment based on their own values
and beliefs. Autonomy is essential for expressing informed consent to medical and surgi-
cal treatments. Autonomy encompasses three main aspects: understanding (i.e., the ability
to understand what will happen during the intervention and comprehend its expected,
possible, or probable benecial and/or harmful consequences), intentionality (i.e., the will-
ingness to undergo the specic intervention), and non-control (i.e., the absence of external
inuence or coercion) [14,15]. Moreover, the patient autonomy model needs to consider
the impact of the disease on the individual’s capacity for autonomous decisions. The ill-
ness itself, with its burden of emotional reactions, especially in the context of hospitaliza-
tion, may represent a main obstacle to the patient’s autonomy [15].
Although the specic eects of art therapy on the patients’ autonomy have not di-
rectly been evaluated, studies suggest that visual art therapy could help patients’ auton-
omy as it improves self-condence and enhances communication. Concerning the hospital
seing, Brady et al. [10] investigated the role of art therapy within an acute adult admis-
sion psychiatric unit using a mixed-method research design involving service users and
mental health team members during a 3-month study period. The key elements reported
by study participants included developing condence and improved communication
with others, which helped to make sense of their own situation, together with a sense of
achievement or renewed self-condence. The main benets perceived by the interviewed
sta members were reducing social isolation, building condence, and providing a posi-
tive activity with opportunity for self-expression for inpatients. Notwithstanding the lim-
itations of the study in terms of the small sample size and the lack of a control group, these
ndings support the role of art therapy in enhancing patients’ self-condence and com-
munication, ultimately leading to improved autonomy in the context of a multidiscipli-
nary adult acute psychiatric service.
Potentially relevant pa-
pers identified (N = 110)
Irrelevant or duplicated
papers removed (N = 46)
Papers screened (N = 64)
Excluded:
•
not inpatient setting (N = 20)
• other forms of art therapy (N = 22)
Included papers (N = 22)
Figure 1. Flow diagram of paper selection process.
3. Results
3.1. Autonomy
The concept of autonomy refers to an individual’s right to self-determination and their
ability to make decisions about their medical treatment based on their own values and
beliefs. Autonomy is essential for expressing informed consent to medical and surgical
treatments. Autonomy encompasses three main aspects: understanding (i.e., the ability
to understand what will happen during the intervention and comprehend its expected,
possible, or probable beneficial and/or harmful consequences), intentionality (i.e., the will-
ingness to undergo the specific intervention), and non-control (i.e., the absence of external
influence or coercion) [
14
,
15
]. Moreover, the patient autonomy model needs to consider the
impact of the disease on the individual’s capacity for autonomous decisions. The illness
itself, with its burden of emotional reactions, especially in the context of hospitalization,
may represent a main obstacle to the patient’s autonomy [15].
Although the specific effects of art therapy on the patients’ autonomy have not directly
been evaluated, studies suggest that visual art therapy could help patients’ autonomy
as it improves self-confidence and enhances communication. Concerning the hospital
setting, Brady et al. [
10
] investigated the role of art therapy within an acute adult admission
psychiatric unit using a mixed-method research design involving service users and mental
health team members during a 3-month study period. The key elements reported by study
participants included developing confidence and improved communication with others,
which helped to make sense of their own situation, together with a sense of achievement or
renewed self-confidence. The main benefits perceived by the interviewed staff members
were reducing social isolation, building confidence, and providing a positive activity with
opportunity for self-expression for inpatients. Notwithstanding the limitations of the
study in terms of the small sample size and the lack of a control group, these findings
support the role of art therapy in enhancing patients’ self-confidence and communication,
ultimately leading to improved autonomy in the context of a multidisciplinary adult acute
psychiatric service.
With regard to understanding, art could also be used more specifically to help patients
comprehend their disease or a particular medical procedure. Using 3D models, drawings,
or other forms of visual arts may help doctors better communicate, to patients, information
about their condition or the surgery/treatment they need to undergo, hence improving their
ability to provide informed consent. In this regard, a scoping review by
Traynor et al. [16]

Int. J. Environ. Res. Public Health 2025,22, 316 4 of 12
analyzed the use of 3D models in enhancing patient–doctor communication in pediatric
and adult hospital settings. The review found that, although the use of 3D models appears
as a promising method, more research is needed as many of the studies were heterogeneous,
and often focused on education rather than communication. Shi and Wang [
17
] reviewed
the use of virtual reality as a form of art therapy to improve health communication. Future
research should assess the efficacy of visual reality -art therapy as an intervention to
improve communication in general hospital settings.
3.2. Beneficence and Non-Maleficence
Beneficence is defined as the responsibility of the healthcare worker to ensure the
well-being of patients by only acting in ways that will benefit them. Non-maleficence
refers to the idea that healthcare workers should not cause any harm [
14
]. Both beneficence
and non-maleficence are very important ethical aspects to consider when deciding what
interventions to administer, keeping in mind the risks versus benefits that may be associated
with it.
Recent years witnessed a growing interest in assessing the impact of AVAT in clinical
settings on different physical and psychosocial health measures. Joschko et al. [
5
] conducted
a systematic review to assess the use of active visual therapy in improving health outcomes
in patients. The authors analyzed 69 randomized controlled trials, assessing 217 outcomes,
including psychological distress, self-esteem, quality of life, and social adjustment. The
review included approximately 4200 participants, aged between 4 and 96 years, and
described a variety of art interventions, mainly focused on drawing/sketching or painting,
followed by arts and craft works, sculpting, and coloring in/mandalas. The majority of
included research investigated AVAT in the field of mental health (37 studies), neurologic
symptoms, and prevention. Art therapy interventions were found to be beneficial in 18%
of the outcomes studied, especially in the area of mental health or when treating somatic
conditions that may be associated with impaired mental health. However, many of the
studies included were of low quality, so more research is needed to assess the true effects
of visual art therapy on mental health, focusing specifically on general hospitals.
Mengqin et al. [
18
] compared the use of mandala art therapy (MAT) and standard
preoperative care in a prospective nonrandomized controlled trial involving 126 gyneco-
logical cancer patients in a university hospital in China. Participants were assigned to
either receive the MAT program or standard perioperative care. The interventions took
place before surgery following preoperative preparation, on postoperative day 2 or day
3 and on the discharge day. Results suggest that mandala art therapy helps reduce stress
(with a significant reduction in the Visual Analog Scale for Stress) and anxiety (with a
significant reduction in the State-Trait Anxiety Inventory score), before undergoing surgery.
Additionally, perceived waiting time before surgery and blood pressure values were both
significantly improved in the intervention group compared to standard of care. Of note,
there were no statistically significant differences between groups regarding hope and self-
acceptance assessed by the Herth Hope Index (HHI) and Self-acceptance Questionnaire
(SAQ). One possible explanation regards the limited duration of the MAT intervention in
the perioperative period, compared to outpatient settings. In this study, the sessions were
limited by the length of stay of perioperative patients, suggesting that follow-up with MAT
services once discharged may be necessary. Although the study presents methodological
caveats—mainly the single-center nonrandomized design, affecting the generalizability
of data—it provides a valuable contribution to a deeper understanding of the potential
benefits of AVAT for gynecological cancer patients during the perioperative period in the
hospital setting, also in terms of feasibility and acceptance.

Int. J. Environ. Res. Public Health 2025,22, 316 5 of 12
Shella [
9
] investigated the impact of a single art therapy session administered at
bedside in a sample of 195 study participants admitted to a general hospital through a
retrospective chart review. Study participants were engaged in a 50 min art therapy session
and were asked to rate their perception of mood, anxiety, and pain before and after the
intervention. Types of media included paints, beads, and mixed media. The authors
highlight that a strong emphasis was placed on patients’ choice in terms of materials chosen
and the decision to participate. Diagnoses included malignancies, neurological diseases,
gastrointestinal conditions, cardiovascular diseases, transplants, and patients undergoing
surgical and orthopedic procedures. The authors found significant improvements in pain
control, mood, and anxiety, assessed through a self-administered tool (i.e., the Roger’s
Happy Sad face), following the art intervention. Important limitations of the study include
the retrospective design, the lack of a control group, and the immediate evaluation of
the effects of art therapy in a single session. However, the findings provide a useful
insight in terms of the benefits and feasibility of art therapy at bedside in an inpatient,
acute-care setting.
Mollaogl
˘
u et al. [
19
] investigated the effects of art therapy in breast cancer hospital
patients enrolled in a randomized controlled trial. The study compared 30 women in
the intervention group (marbling and ney music) to 30 women in the control group (no
intervention). The intervention group showed significantly lower pain levels, less anxiety,
better quality of life, and less nausea, as assessed by the Pain Intensity Measurement
Visual Analog Scale (VAS), Beck Anxiety Inventory (BAI), Functional Assessment of Cancer
Therapy Scale General (FACT-G), and the Rhodes Index of Nausea, Vomiting, and Retching
(RINVR) respectively.
Zahmatkesh et al. [
20
] investigated the impact of four sessions of art therapy on the
experience of grief and the quality of life of women who experienced abortion or stillbirth
in the previous 6 weeks, referring to the maternity wards of two Iranian hospitals [
20
].
The trial involved 60 women, randomly assigned to the intervention group (N = 30),
including active visual art therapy, and the control group (N = 30), in which routine
care was performed. Art therapy was associated with a significant improvement in the
mean total quality of life score assessed by the World Health Organization quality of life
questionnaire, short version 26. Also, all physical, psychological, social, and environmental
dimensions of quality of life improved in the art therapy group compared to the control
group eight weeks after the intervention.
An important area of application of visual art therapy is its use with inpatient children
and adolescents. As cited in Hen [
21
], previous studies found long-term art therapy with
hospitalized children with cancer, chronic diseases, or mental illness to be
effective [22,23]
and contribute to their healing process [
24
,
25
]. Ferrari et al. recently provided a description
of creative and artistic activities and laboratories, including active visual art therapy, devel-
oped for adolescents and young adults with cancer promoted by the Italian Association
for Pediatric Hematology-Oncology (AIEOP) adolescents working group [
26
]. The authors
reported different experiences from 10 hospitals in Italy and discussed the main goals
of creative projects, as a way for patients to share their difficulties with peers, to find a
sense of light-heartedness during their hospital stays, and regain a sense of future, working
on projects expected to take several months. Of note, the authors underline the value of
dedicated spaces and opportunities for socializing and recreation, but also the need to
preserve privacy and provide respect and protection for cancer patients, stating how art
projects should be professionally organized and realized within the hospital [26].
In a different context, recent research by Bifano and Tsze [
11
] found that visual art
therapy could reduce levels of pain and anxiety in children in the emergency room. The
study included a convenience sample of 50 patients presenting with a painful condition

Int. J. Environ. Res. Public Health 2025,22, 316 6 of 12
to a tertiary-care children’s hospital emergency department. The mean duration of art
therapy was 34.7 min. Mean baseline pain assessed by the Verbal Numerical Rating Scale
(scored 0–10) was 6.2 and decreased by 23.2% and 28.6% immediately after and 1 h after art
therapy completion, respectively. Mean baseline anxiety assessed by the State-Trait Anxiety
Inventory short form was 48 (moderate) and decreased to 38 (low) and 43 (moderate) at
the same time points. Patients reported feelings of relaxation, decreased pain intensity,
and/or empowerment. The study presents important methodological limitations, in terms
of the absence of a control group, the administration of analgesic as a potential confounder
with regard to the impact of art therapy on perceived pain, and the risk of observer and/or
participant bias. However, the potential benefits in reducing anxiety and improving the
qualitative experience of adolescents with painful conditions in the high-stress environment
of the emergency department deserve attention. Moreover, participants reported that art
therapy gave them a sense of control and empowerment, suggesting the role of art therapy
in promoting autonomy.
Additionally, Versitano et al. [
27
] found that visual art therapy reduces the use of
restrictive practices in children in the acute inpatient child and adolescent mental health
service unit. The rate, frequency, duration, and total number of incidents of seclusion,
the frequency and total number of incidents of physical restraint, and the rate, frequency,
and total number of incidents of intramuscular sedation showed a statistically significant
reduction during phases of art therapy service provision over a 6-year period. The art
therapy service in the study was a fixed component of the therapeutic group program. Bore-
dom, which can be a result of occupational deprivation commonly occurring in restrictive
environments such as a locked unit, often precipitates increased agitation or aggression,
potentially leading to restrictive practices. Art therapy can effectively engage young peo-
ple, support emotional regulation, and promote social interaction, preventing increased
aggression or agitation.
Of note, implementing AVAT in general hospitals can help humanize them and fur-
ther aid in the recovery of patients. Hospitals can often look sterile and impersonal to
patients, which can be detrimental to their well-being and recovery. Visual art has the
potential to beautify hospitals, and in doing so make them more relatable and more humane.
Lankston et al. [28]
discussed the role of visual art displayed in hospitals in promoting
not only patients’ well-being but also that of healthcare workers and other service users.
The authors evaluate and discuss the visual art of three Scottish hospitals and explain
that specific colors, such as blue and green, and paintings of nature may be especially
calming. Although this study did not imply an active intervention, it provides a broader
reflection and some suggestions with regard to the potential benefits of visual art inside
the hospital in terms of promoting individual and group well-being, supporting autonomy.
More recently, a systematic review by Law et al. (2021) [
29
] found that viewing visual
artworks in hospitals may reduce stress in patients, evidencing biological benefits such as a
decrease in systolic blood pressure and decreased heart rate.
Art therapy is beneficial not only for patients in hospitals but also for healthcare
workers. Working in hospital settings, although rewarding, can often cause psychological
distress and burnout. Moss et al. (2022) investigated the feasibility, acceptability, and
psychosocial outcomes of four creative art therapy (CAT) interventions, including active
visual art therapy, in a cohort of 146 healthcare professionals during the COVID-19 pan-
demic [
30
]. Participants included nurses (52%), physicians, and other professionals (i.e.,
behavioral therapists, social workers) practicing in a hospital setting for at least 20 h/week
experiencing significant burnout symptoms assessed by the Maslach Burnout Inventory.
Participants were randomized to one of the four CAT intervention groups, which met in
person for a total of 12 consecutive 90 min weekly sessions. The program proved to be

Int. J. Environ. Res. Public Health 2025,22, 316 7 of 12
feasible and acceptable in terms of attendance and clients’ satisfaction assessed by the
Client Satisfaction Questionnaire (CSQ-8). Participants randomized to the intervention
showed significant improvements in anxiety and depression scores, total post-traumatic
stress disorder score, burnout scores, and turnover intention. According to a further study
by
Avallone Mantelli et al. [31]
, the intervention group showed sustained improvements
in anxiety, depression, and total PTSD score compared to baseline at 1-year follow-up.
Moreover, compared to control participants, the intervention group showed improvements
at one year in anxiety, depression, positive affect, and negative affect using the Positive
and Negative Affect Scale (PANAS). Of interest, Moss et al. underlined the limited costs of
the CAT interventions and the absence of safety concerns: the intervention’s risk or cost-
to-benefit ratio for improving healthcare professional’s psychological distress is therefore
potentially large, with potential indirect benefits to assisted persons too.
Recent meta-analytic evidence [
32
] explored the use of art therapy in improving mental
health in nurses. The study found that art therapy helped reduce anxiety, with a significant
reduction in the Self-Rating Anxiety Scale scores. Depression was also significantly lower
in nurses undergoing art therapy compared to the control group. Similarly, pressure was
significantly reduced in the intervention groups compared to the controls. The study also
found that positive copying style was higher in the intervention group. Although the
meta-analysis included overall high-quality studies, it examined different modalities of art
therapy, such as painting, music, psychodrama, drama, and sculpture therapy, making it
harder to assess the specific effects of visual art therapy. Additionally, the authors focused
on nurses in different clinical settings, making it hard to understand the efficacy of art
therapy specifically in general hospitals.
Ong et al. [
33
] analyzed the effectiveness of art therapy (creating collages and boxes) in
improving empathy and well-being in junior doctors during their palliative care rotations.
The study found that participants enjoyed the experience but lacked pre-existing knowledge
of humanities and their relations to medical training. The participants mentioned improved
empathy and connecting with both patients and fellow doctors, but at the same time,
concerns about the program being implemented at their hospitals due to concerns about
having a safe space and sharing feelings with peers.
3.3. Justice
Justice refers to the need for appropriate, fair, and equitable distribution of medical
resources [14].
In a systematic review evaluating the clinical benefits and cost-effectiveness of group
art therapy for people with non-psychotic mental disorders, art therapy appeared to be
cost-effective compared to waiting list, but the strength of the results was limited by
methodological issues like the substantial heterogeneity in the patient clinical profiles and
the low quality of the included trials [
34
]. Notwithstanding these caveats, these findings
are relevant to the implementation of art therapy in the general hospital, given the fact that
non-psychotic mental disorders, including depressive and anxiety symptoms, represents
the most common comorbid psychiatric issues in hospitalized patients across different
specialties [6,7].
Of interest, in a study investigating a single brief art therapy intervention at bedside
during acute hospital treatment, art therapy proved to be a safe and cost-effective adjunct
intervention to traditional medical management [9].
Equitable access to healthcare is a fundamental ethical issue. In this regard, the
systematic review by Joshko et al. [
5
] underlined huge differences across countries in AVAT
research, with the vast majority of studies conducted in the USA (23) and the UK (5). This
discrepancy may reflect different factors influencing research priorities but also calls for

Int. J. Environ. Res. Public Health 2025,22, 316 8 of 12
the need to promote equitable healthcare access by extending the benefits of AVAT to
diverse populations.
4. Discussion
The presence of art therapy programs in healthcare has become widespread in the
21st century. Current evidence supports the effectiveness of visual art therapy on chil-
dren and adult patients’ outcomes across different disciplines, particularly in the area
of mental health [
5
]. Additionally, studies suggest that art therapy may be effective for
healthcare workers to ameliorate their communication and avoid burnout. Improving
patient–doctor communication can be especially beneficial for patients—children and
adults—who have difficulties in using traditional forms of verbal communication, as re-
quired by more standard forms of treatment for mental health problems. Art therapies can
provide an alternative means of expression to help patients understand, make sense of, and
cope with their distress [10,34].
This narrative review aimed to reflect on the use of AVAT from an ethical perspective
in the context of the general hospital, as summarized in Table 1. During his Nobel Lecture
in Literature in 1987, Joseph Brodsky commented that “On the whole, every new aesthetic
reality makes man’s ethical reality more precise. For aesthetics is the mother of ethics” [
35
].
This quote exemplifies how ethics and the arts are intertwined. AVAT may support pa-
tients’ autonomy, contribute to their beneficence with no or limited risks, and represent
an equitable and cost-effective treatment in the general hospital. The recent literature has
explored the need for humanization of care, a concept that extends patient-centered care in-
troduced by Balint in 1969 to involve all stakeholders—patients, caregivers, and healthcare
professionals—and their interactions. A systematic review by Busch et al. [
36
] identified an
empathetic and respectful approach to patients, sufficient human and material resources
in healthcare institutions, and a balanced workload for healthcare providers as the key
elements for establishing meaningful, mutually beneficial relationships with patients and
delivering humanized care [
37
]. Research has shown how AVAT may contribute to all these
aspects in the general hospital.
Previous authors underlined the importance of art therapy in restoring hope, fun,
and the enjoyment and value of creative play in mental health as a means to overcome
psychological stiffness and become involved in artwork [
10
,
37
]. These observations recall
Donald Winnicott’s “Squiggle Game”, and the use of art and doodling to break bound-
aries between a patient and professional to narrate a story through a simple squiggle [
1
].
Research suggests that the active manipulation of art materials elicits interoceptive and
somatosensory processing that may decrease pain and anxiety by amplifying positive
emotional reactions and feelings, with potential clinical applications for treating painful
conditions and managing procedural pain and anxiety in the general hospital [11,38].
General hospitals are particular settings, as they can include different staff, patients,
and clinical conditions. Therefore, it is not easy to conduct homogeneous studies and
randomized controlled trials, especially in the context of ethical aspects and the specific
impact that art has on them.
Methodological challenges faced by the majority of studies exploring AVAT in the
hospital setting include the small sample size, heterogeneity of study participants, and lack
of a control group in single sites studies [
9
,
10
]. Research needs to balance the potential
tension between scientific requirements in terms of outcome measures using standardized
validated reproducible instruments and the unique experience of art therapy, implying a
variety of theories and methods.

Int. J. Environ. Res. Public Health 2025,22, 316 9 of 12
Table 1. Ethical issues related to the main outcomes of active visual art therapy (AVAT) in hospitalized patients.
Author Study Design Main Ethical Issues Implied Quantitative Measures Investigated Domains/Main Outcomes Relevance
Bifano and Tsze, 2024 [11] Prospective pilot study Beneficence Verbal Numerical Rating Scale (VNRS);
short-form six-item State-Trait Anxiety
Inventory (STAI:Y-6)
One single session of AVAT was associated with a
reduction in pain and anxiety in a sample of
50 patients
presenting with a painful condition to a
tertiary-care children’s hospital
emergency department
*
Brady et al., 2017 [10] Mixed-method design Autonomy, Beneficence, Justice Ad hoc quantitative questionnaire
Art therapy was reported to reduce patients’social
isolation, help building confidence and promoting
self expression according to a survey of 35 staff
members and 11 service users in an acute adult
admission psychiatric unit
**
Mengqin et al., 2024 [18]Prospective, non-randomized,
controlled trial Beneficence
Visual Analog Scale for Stress (VASS);
State-Trait Anxiety Inventory-state scale
(STAI-S); Herth Hope Index (HHI);
Self-acceptance Questionnaire (SAQ)
Mandala art therapy reduced perceived stress,
anxiety, and blood pressure in gynecological cancer
patients before surgery compared to standard care
**
Mollaogl˘u et al., 2024 [19] RCT Beneficence
Pain Intensity Measurement Visual Analog
Scale (VAS); Beck Anxiety Inventory (BAI);
Functional Assessment of Cancer Therapy
Scale—General (FACT-G); Rhodes Index of
Nausea, Vomiting, and Retching (RINVR)
The art intervention based on marbling and ney
music was associated with lower perceived pain,
lower anxiety, better quality of life, and less nausea
breast cancer hospital patients
**
Shella et al., 2017 [9] Retrospective chart review Beneficence Roger’s Happy Sad face scale A single session of AVAT at bedside improved
mood, anxiety, and pain in inpatients admitted to a
general hospital *
Versitano et al., 2024 [27]Naturalistic observational
retrospective study Beneficence, Non-maleficence
Rate (events per 1000 occupied bed days);
frequency, duration, and number of incidents
of restrictive practice; rate, frequency, and
number of incidents of intramuscular injected
sedation, oral as-needed medication use, and
absconding incidents occurring in conjunction
with an episode of seclusion or restraint
The provision of an art therapy program was
associated with a reduction in the number of
incidents of seclusion, physical restraint, and
intramuscular sedation in one acute inpatient child
and adolescent mental health service unit
compared to periods in which the intervention was
not available
**
Zahmatkesh et al., 2024 [20] RCT Beneficence Perinatal Grief Scale (PGF); World Health
Organization quality of life questionnaire
(WHOQOL-BREF)
Art therapy was associated with a significant
improvement in quality of life in women who
recently experienced abortion or stillbirth referring
to the maternity unit of two general hospitals
**
RCT: randomized controlled trial; relevance: * small sample size and/or methodologically weak; ** fair; *** relevant.

Int. J. Environ. Res. Public Health 2025,22, 316 10 of 12
Joshko et al. underlined the need for established guidelines to enhance research con-
sistency and comparability, including standards for reporting AVAT and suitable control
interventions [
5
]. This is crucial, from a scientific, clinical, and ethical perspective, to pro-
viding a solid foundation for evidence-based decision making and allocation
of resources
.
Several unique ethical considerations emerge when working at the intersection be-
tween art practice and the individual experiences related to the disease condition and in
the context of hospitalization.
With regard to beneficence and non-maleficence, safety is a major concern. Special
attention is required in the general hospital in terms of materials used, hygiene, and sterile
environments. Of note, none of the reviewed studies reported adverse events in this sense.
From a broader psychosocial perspective, safety may refer also to the way art interventions
are delivered to vulnerable individuals or groups, including inpatients (Ferrari et al., 2024,
Pavarini, 2021). In this regard, art therapy is underpinned by its own professional code
of ethics and conduct, with shared central values guiding practice, including respect,
competence, responsibility, and integrity [26,39].
5. Conclusions
Art-based therapy could be a widely accessible and fairly inexpensive therapeutic
approach to improve patient–staff communication and well-being.
We aimed to provide a critical review of the available data on the use of AVAT in the
general hospital. The value of art interventions is often described and well recognized in
non-scientific journals, and a number of clinical experiences seem to support this view;
however, to reach an established scientific status, AVAT still lacks sufficiently solid proofs
supporting its utility in the majority of the contexts where it has been applied. Further
methodologically sound research is particularly needed to understand the effectiveness
and real feasibility of AVAT in general hospitals.
Practical recommendations for further research include to identify key clinical and
psychosocial measurable outcomes to be systematically investigated through validated
measures. Research should expand to include different chronic conditions, including
neurological and cardiovascular diseases, and transplant medicine. Acute settings represent
a major challenge for clinical application and research, in terms of feasibility, acceptability,
and beneficence/non maleficence ratio. In this regard, data on the effectiveness of creative
art therapy in ameliorating burnout and psychological distress in healthcare providers
support the implementation of these practices for the staff working in emergency units,
which in turn may benefit patients and their family members. A more in-depth awareness of
the ethical aspects implied in using AVAT supports the implementation of art interventions
to promote patient-centered and humanized care in the general hospital.
Author Contributions: Conceptualization, V.M., E.L.L.L. and M.C.; methodology, V.M., E.L.L.L.
and M.C.; writing—original draft preparation, V.M. and E.L.L.L.; writing—review and editing V.M.,
E.L.L.L., M.C. and L.F.P.; supervision, L.F.P. and P.P. All authors have read and agreed to the published
version of the manuscript.
Funding: This research received no external funding.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Conflicts of Interest: The authors declare no conflict of interest.

Int. J. Environ. Res. Public Health 2025,22, 316 11 of 12
References
1.
Braito, I.; Rudd, T.; Buyuktaskin, D.; Ahmed, M.; Glancy, C.; Mulligan, A. Review: Systematic Review of Effectiveness of Art
Psychotherapy in Children with Mental Health Disorders. Ir. J. Med. Sci. 2022,191, 1369–1383. [CrossRef] [PubMed]
2.
Fancourt, D.; Finn, S. What Is the Evidence on the Role of the Arts in Improving Health and Well-Being? A Scoping Review; WHO
Regional Office for Europe: Copenhagen, Denmark, 2019.
3.
Jiang, X.H.; Chen, X.J.; Xie, Q.Q.; Feng, Y.S.; Chen, S.; Peng, J.S. Effects of art therapy in cancer care: A systematic review and
meta-analysis. Eur. J. Cancer Care 2020,29, e13277. [CrossRef] [PubMed]
4.
Raudenská, J.; Šteinerová, V.; Vodiˇcková, Š.; Raudenský, M.; Fulková, M.; Urits, I.; Viswanath, O.; Varrassi, G.; Jav ˚urková, A. Arts
Therapy and Its Implications in Chronic Pain Management: A Narrative Review. Pain Ther. 2023,12, 1309–1337. [CrossRef]
5.
Joschko, R.; Klatte, C.; Grabowska, W.A.; Roll, S.; Berghöfer, A.; Willich, S.N. Active Visual Art Therapy and Health Outcomes: A
Systematic Review and Meta-Analysis. JAMA Netw. Open 2024,7, e2428709. [CrossRef]
6.
Walker, J.; Van Niekerk, M.; Hobbs, H.; Toynbee, M.; Magill, N.; Bold, R.; Hampsey, E.; Harriss, E.; Frost, C.; Sharpe, M. The
Prevalence of Anxiety in General Hospital Inpatients: A Systematic Review and Meta-Analysis. Gen. Hosp. Psychiatry 2021,72,
131–140. [CrossRef]
7.
Van Niekerk, M.; Walker, J.; Hobbs, H.; Magill, N.; Toynbee, M.; Steward, B.; Harriss, E.; Sharpe, M. The Prevalence of Psychiatric
Disorders in General Hospital Inpatients: A Systematic Umbrella Review. J. Acad. Consult.-Liaison Psychiatry 2022,63, 567–578.
[CrossRef]
8.
Kapitan, L. Does Art Therapy Work? Identifying the Active Ingredients of Art Therapy Efficacy. Art Ther. 2012,29, 48–49.
[CrossRef]
9.
Shella, T.A. Art Therapy Improves Mood, and Reduces Pain and Anxiety When Offered at Bedside during Acute Hospital
Treatment. Arts Psychother. 2018,57, 59–64. [CrossRef]
10.
Brady, C.; Moss, H.; Kelly, B.D. A Fuller Picture: Evaluating an Art Therapy Programme in a Multidisciplinary Mental Health
Service. Med. Humanit. 2017,43, 30–34. [CrossRef]
11.
Bifano, S.M.; Tsze, D.S. Effectiveness of Art Therapy Interventions for Treating Pain and Anxiety in Adolescents in the Emergency
Department. Can. J. Emerg. Med. 2024,26, 564–569. [CrossRef]
12. Beauchamp, T.L.; Childress, J.F. Principles of Biomedical Ethics, 7th ed.; Oxford University Press: New York, NY, USA, 2013.
13.
Tricco, A.C.; Lillie, E.; Zarin, W.; O’Brien, K.K.; Colquhoun, H.; Levac, D.; Moher, D.; Peters, M.D.J.; Horsley, T.; Weeks, L.;
et al. PRISMA extension for scoping reviews (PRISMA-ScR): Checklist and explanation. Ann. Intern. Med. 2018,169, 467–473.
[CrossRef] [PubMed]
14.
Varkey, B. Principles of Clinical Ethics and Their Application to Practice. Med. Princ. Pract. 2021,30, 17–28. [CrossRef] [PubMed]
15.
Pellegrino, E.D.; Thomasma, D.C. For the Patient’s Good: The Restoration of Beneficence in Health Care; Oxford University Press:
Oxford, UK, 1988.
16.
Traynor, G.; Shearn, A.I.; Milano, E.G.; Ordonez, M.V.; Velasco Forte, M.N.; Caputo, M.; Schievano, S.; Mustard, H.; Wray, J.;
Biglino, G. The Use of 3D-Printed Models in Patient Communication: A Scoping Review. J. 3D Print. Med. 2022,6, 13–23.
[CrossRef] [PubMed]
17.
Shi, Z.; Wang, Y. Enhancing Health Communication through Virtual Reality-Based Art Therapy: An Opinion. Front. Psychol. 2024,
15, 1438172. [CrossRef]
18.
Mengqin, Z.; Xing, L.; Yan, H.; Jianhua, R. Does Mandala Art Therapy Improve Psychological Well-Being of Gynecological
Cancer Patients During the Perioperative Period? A Quasi-Experimental Study. Integr. Cancer Ther. 2024,23, 15347354241259180.
[CrossRef]
19.
Mollaogl
˘
u, M.C.; Mollaog
˘
lu, S.; Akin, E.B.; Mollaog
˘
lu, M.; Yanmi¸s, S. The Effect of Art Therapy on Pain, Emesis, Anxiety, and
Quality of Life in Operated Breast Cancer Patients: Randomized Control Trials. J. Integr. Complement. Med. 2024,30, 371–382.
[CrossRef]
20.
Zahmatkesh, M.; Faal Siahkal, S.; Alahverdi, F.; Tahmasebi, G.; Ebrahimi, E. The role of art therapy on quality of life of women
with recent pregnancy loss: A randomized clinical trial. PLoS ONE 2024,19, e0305403. [CrossRef]
21. Hen, M. Art Therapy for Children in Short-Term Hospitalization. Contin. Educ. 2023,4, 83–95. [CrossRef]
22.
Lyshak-Stelzer, F.; Singer, P.; Patricia, S.J.; Chemtob, C.M. Art Therapy for Adolescents with Posttraumatic Stress Disorder
Symptoms: A Pilot Study. Art Ther. 2007,24, 163–169. [CrossRef]
23.
Nainis, N.A. Approaches to Art Therapy for Cancer Inpatients: Research and Practice Considerations. Art Ther. 2008,25, 115–121.
[CrossRef]
24.
Metzl, E.; Morrell, M.; Field, A. A Pilot Outcome Study of Art Therapy and Music Therapy with Hospitalized Children (Étude
Pilote Des Résultats de l’art-Thérapie et de La Musicothérapie Auprès d’enfants Hospitalisés). Can. Art Ther. Assoc. J. 2016,29,
3–11. [CrossRef]
25.
Siegel, J.; Iida, H.; Rachlin, K.; Yount, G. Expressive Arts Therapy with Hospitalized Children: A Pilot Study of Co-Creating
Healing Sock Creatures©. J. Pediatr. Nurs. 2016,31, 92–98. [CrossRef]

Int. J. Environ. Res. Public Health 2025,22, 316 12 of 12
26.
Ferrari, A.; Perillo, T.; Milano, G.M.; Silva, M.; Rutigliano, C.; Salvo, A.; Livellara, V.; Conte, M.; Coccoli, L.; Amore, E.; et al. The
power of art and the powers of adolescents with cancer: Age-specific projects at Italian pediatric oncology centers. Tumori J. 2024,
110, 218–226. [CrossRef]
27.
Versitano, S.; Shvetcov, A.; Paton, J.; Perkes, I. Art Therapy Is Associated with a Reduction in Restrictive Practices on an Inpatient
Child and Adolescent Mental Health Unit. J. Ment. Health 2024,33, 481–489. [CrossRef]
28.
Lankston, L.; Cusack, P.; Fremantle, C.; Isles, C. Visual Art in Hospitals: Case Studies and Review of the Evidence. J. R. Soc. Med.
2010,103, 490–499. [CrossRef] [PubMed]
29.
Law, M.; Karulkar, N.; Broadbent, E. Evidence for the Effects of Viewing Visual Artworks on Stress Outcomes: A Scoping Review.
BMJ Open 2021,11, e043549. [CrossRef]
30.
Moss, M.; Edelblute, A.; Sinn, H.; Torres, K.; Forster, J.; Adams, T.; Morgan, C.; Henry, M.; Reed, K. The Effect of Creative Arts
Therapy on Psychological Distress in Health Care Professionals. Am. J. Med. 2022,135, 1255–1262.e5. [CrossRef]
31.
Avallone Mantelli, R.; Forster, J.; Edelblute, A.; Sinn, H.; Torres, K.; Adams, T.; Morgan, C.; Henry, M.; Reed, K.; Moss, M. Creative
Arts Therapy for Healthcare Professionals Is Associated with Long-Term Improvements in Psychological Distress. J. Occup.
Environ. Med. 2023,65, 1032–1035. [CrossRef]
32.
Zhang, N.; Chen, S.; Li, Q.; He, Z.; Jiang, W. Efficacy of Art Therapy in Enhancing Mental Health of Clinical Nurses: A
Meta-analysis. Psychiatr. Ment. Health Nurs. 2024,31, 729–741. [CrossRef]
33.
Ong, E.-K.; Tan, U.-T.E.; Chiam, M.; Sim, W.S. The Employment of Art Therapy to Develop Empathy and Foster Wellbeing for
Junior Doctors in a Palliative Medicine Rotation—A Qualitative Exploratory Study on Acceptability. BMC Palliat. Care 2024,23,
84. [CrossRef]
34.
Uttley, L.; Stevenson, M.; Scope, A.; Rawdin, A.; Sutton, A. Erratum to: 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
2015,15, 212. [CrossRef] [PubMed]
35.
Brodsky, J. Nobel Lecture. NobelPrize.org. Nobel Prize Outreach AB 2024. 2024. Available online: https://www.nobelprize.org/
prizes/literature/1987/brodsky/lecture/ (accessed on 2 December 2024).
36.
Busch, I.M.; Moretti, F.; Travaini, G.; Wu, A.W.; Rimondini, M. Humanization of Care: Key Elements Identified by Patients,
Caregivers, and Healthcare Providers. A Systematic Review. Patient 2019,12, 461–474. [CrossRef] [PubMed]
37.
Molloy, T. Art psychotherapy and psychiatric rehabilitation. In Art, Psychotherapy and Psychosis; Killick, K., Schaverien, J., Eds.;
Routledge: East Sussex, UK, 1997; pp. 237–261.
38.
Czamanski-Cohen, J.; Weihs, K.L. The Bodymind Model: A Platform for Studying the Mechanisms of Change Induced by Art
Therapy. Arts Psychother. 2016,51, 63–71. [CrossRef] [PubMed]
39.
Pavarini, G.; Smith, L.M.; Shaughnessy, N.; Mankee-Williams, A.; Thirumalai, J.K.; Russell, N.; Bhui, K. Ethical issues in
participatory arts methods for young people with adverse childhood experiences. Health Expect. 2021,24, 1557–1569. [CrossRef]
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