Research Article
Siu-Ki Chung, Fiona Yan-Yee Ho, Henri Chun-Yiu Chan
Importance: Zentangle® is a self-help art modality purported to have repetitive, mindful, and meditative qualities. It
can be a cost-effective intervention, but its effect on affective well-being has been underresearched.
Objective: To evaluate the immediate and 2-wk postintervention effects of Zentangle delivered by a certified
Zentangle teacher on affective well-being in the general population.
Design: Two-armed parallel-groups pilot randomized controlled trial.
Participants: Thirty-eight participants from a nonclinical population.
Intervention: Participants were randomized into the Zentangle group, which participated in a 2-hr Zentangle class
and were encouraged to practice for 2 wk, or the waitlist control group. Participants learned basic Zentangle
principles and drew two Zentangles under the teacher’s instructions.
Outcomes and Measures: The Positive and Negative Affect Schedule, 21-item Depression Anxiety Stress Scale,
and Self-Compassion Scale–Short Form were used to assess positive and negative affect; depression, anxiety,
and stress symptoms; and self-compassion.
Results: Significant reductions in negative affect were found in the Zentangle group compared with the waitlist
control group at both immediate and 2-wk postintervention assessments (ds 5 1.04 and 0.79, respectively, p <
.001). Participants who practiced Zentangle for >80 min per week had a significant reduction in anxiety symptoms
and an improvement in self-compassion (ds 5 0.84 and 0.24, ps < .05 and .005, respectively). No significant
between-groups difference was found for other measures.
Conclusions and Relevance: Our results shed light on the effects of Zentangle on improving affective well-being
in the general population. With sufficient practice, Zentangle can also help improve self-compassion and reduce
anxiety.
What This Article Adds: The results of this study could provide information to determine whether Zentangle can
be used as a tool in occupational therapy intervention to improve affective well-being.
Chung, S.-K., Ho, F. Y.-Y., & Chan, H. C.-Y. (2022). The effects of Zentangle® on affective well-being among adults: A pilot randomized controlled
trial. American Journal of Occupational Therapy, 76, 7605205060. https://doi.org/10.5014/ajot.2022.049113
ental illness is a global issue. About 30% of the
global population has had a mental disorder at
some point in time (Steel et al., 2014). The global economic cost of mental disorders is expected to reach $6
trillion by 2030 (Marquez & Saxena, 2016). Because
positive mental health can help to reduce the prevalence of mental illness (Keyes et al., 2010), discovering
alternative interventions to promote mental health that
are efficacious and cost-effective is important. According to the World Health Organization (2001), mental
health is not just the absence of mental illness but a
M
state of well-being. Affective well-being is one of the
core components of the broader construct of subjective
well-being (Fredrickson & Losada, 2005). It refers to
the emotions and moods people experience in daily
life (Hudson et al., 2017), which differentiates it from
psychological well-being, which emphasizes a sense of
meaning and fulfillment in life.
In recent decades, growing evidence has suggested
the therapeutic value of art intervention and its positive effects on well-being, such as mood enhancement
and reduction of stress, anxiety, and depressive
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The Effects of Zentangle® on Affective
Well-Being Among Adults: A Pilot
Randomized Controlled Trial
according to Zessin et al. (2015), self-compassion is
correlated with affective well-being, and self-compassion interventions are effective in reducing depression,
anxiety, and stress (Neff & Germer, 2013). Proving
that Zentangle is an effective tool for the enhancement
of self-compassion would be beneficial.
Although Zentangle has become more popular,
research on it is still nascent. Using self-report questionnaires, Chen et al. (2016) examined the effect of
an 8-wk Zentangle intervention for patients with
schizophrenia who had social interaction anxiety and
low self-esteem. Their study had 44 participants who
were randomly assigned to either the experimental
group or the control group. In addition to regular
therapy activities, the experimental group attended a
1-hr Zentangle program for 8 wk. Although this study
had a control group, Chen et al. (2016) conducted
only within-group comparisons. The experimental
group showed a significant reduction in social interaction anxiety and an improvement in self-esteem after
the intervention compared with the baseline. No significant within-group differences were found for the
control group. Another research study (Sufrin, 2016)
also found that Zentangle can be beneficial in the
form of a brief intervention. In a study with 24 caretakers of patients with Parkinson’s disease, results
from self-report questionnaires showed that both stress
and anxiety decreased significantly after drawing a
Zentangle for 20 min.
Nevertheless, whether Zentangle is effective in
stress reduction is debatable; the only other study of
Zentangle in relation to stress reported a contradictory
result (Yu, 2017). In that study, 8 undergraduates
joined a 3-hr Zentangle destress group for 4 wk. After
the 4-wk intervention, the self-report questionnaires
indicated that participants had no significant reduction
in stress. These two studies are thus far the only Zentangle research related to stress reduction, and both
used a single-group design. Clearly, this topic is insufficiently researched.
Apart from stress reduction, Zentangle’s effect on
positive affect has also been studied. Hui and Ma’rof
(2019) conducted a study with 44 Malaysian undergraduates. The Zentangle class and the data collection
process lasted for around 3 hr. The self-report data
showed that a single-session Zentangle intervention
could lead to a significant increase in positive affect
compared with preintervention. Currently, most research studies suggest that Zentangle can have positive
psychological effects. To our knowledge, the only randomized controlled trial (RCT) of Zentangle (Chen
et al., 2016) did not include between-group comparisons and targeted only patients with schizophrenia. To
fill the research gap, we conducted the first pilot RCT
to examine the effects of Zentangle on affective wellbeing among Hong Kong adults, compared with a
waitlist control (WL) group. We hypothesized that
practicing Zentangle would lead to better affective
well-being. To capture potential changes in affective
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symptoms (Heenan, 2006; Jensen & Bonde, 2018;
Secker et al., 2007). Researchers have found that drawing can be a better medium for short-term emotional
regulation than writing (Drake et al., 2011), which has
been more effective in reducing negative affect when
used for distraction rather than self-expression (Drake
& Winner, 2012). Compared with free drawing, structured drawing has been demonstrated to be more
effective in anxiety reduction because participants may
enter a meditative state during the process (Curry &
Kasser, 2005). Yet, one possible drawback of art interventions is that a person’s desire to make the drawing
perfect may undermine the mood regulation effect of
drawing (Halprin, 2002; Zimmermann & Mangelsdorf,
2020).
Zentangle®, a self-help art intervention, can
minimize this drawback because it emphasizes the acceptance of one’s imperfections. Therefore, it could
potentially become an alternative tool to improve affective well-being. Zentangle is a meditative drawing
practice where a pen and small pieces of paper are
used to draw repetitive and structured patterns called
tangles, which are combinations of five elemental
strokes: dots, lines, orbs, simple curves, and S curves.
The art form, created by Rick Roberts and Maria
Thomas in 2003, was originally used as a tool for relaxation and focus improvement (Roberts & Thomas,
2012). Roberts and Thomas (2012) found that advantages of this doodling practice were that it was not
time consuming (it can be finished in 15 min) and
that it is easy for almost everyone to learn.
According to its founders, Zentangle is a form of
mindfulness practice (Roberts & Thomas, 2012). The
two core elements of mindfulness are (1) being aware
of one’s moment-to-moment experience and (2) acting nonjudgmentally and with acceptance of one’s
creation of art (Kabat-Zinn, 2003; Keng et al., 2011).
Zentangle urges participants to focus on every stroke
of the doodling process and stresses that there is no
right or wrong, which prevents participants from
judging their work and retains their attention on
the process (Roberts & Thomas, 2012). Zentangle’s
motto is “one stroke at a time, everything is possible,”
which to some extent echoes the core values (e.g.,
nonjudgmental and present-moment awareness) of
mindfulness. As a mindfulness practice, Zentangle has
been shown to have positive effects on health (Brown
& Ryan, 2003; Robins et al., 2014). Kopeschny (2016)
shared a phenomenological study that used focus
groups and interviews and concluded that Zentangle
was a mindfulness process that was fully integrated
with meditation.
In addition to the emphasis that fosters mindfulness, Zentangle has been used as a tool to enhance
self-compassion (Super, 2015), nonjudgmental awareness, and self-kindness and to minimize self-criticism
(Neff, 2003). Likewise, self-compassion stresses selfkindness and mindfulness, which are in line with the
core values of Zentangle (Neff, 2003). Moreover,
well-being, we assessed positive affect (PA) and negative affect (NA) and levels of depressive, anxiety, and
stress symptoms because they are closely related to
affective well-being and are frequently used in art interventions as outcome measures (Drake & Winner,
2012; Jensen & Bonde, 2018). We also evaluated selfcompassion, in consideration of its close relationship
to affective well-being (Zessin et al., 2015).
Method
After randomization, both groups received a standardized email with details on the Zentangle class.
The treatment evaluation form and the engagement
questionnaire were provided to only the ZEN group
immediately postintervention and at the 2-wk postintervention assessment. Aside from these two questionnaires, both groups completed three identical sets of
questionnaires at baseline, immediate postintervention,
and 2-wk postintervention. The Zentangle class was
provided to the WL group after the collection of all
postintervention data.
This study was a two-armed, parallel-group RCT. Participants were randomly assigned to the Zentangle
(ZEN) group or the WL group in a 1:1 ratio. Research
ethics approval was obtained from the Survey and Behavioral Research Ethics Committee of The Chinese
University of Hong Kong (SBRE-19–152).
Sample Size
Participants
Intervention
Participants were recruited via a university mass mailing system and social media. The inclusion criteria
were (1) Hong Kong resident, (2) ages 18 to 65 yr, (3)
able to communicate in Cantonese, (4) having the essential equipment to join a webinar, and (5) willing to
provide informed consent and comply with the research protocol. No monetary incentives were offered
to participants, but they were offered one Zentangle
class free of charge.
The exclusion criteria were as follows: (1) having
suicidal ideation; (2) currently using medication or
psychotherapy for any psychiatric disorder; (3) having
depression or anxiety, which was identified by a score
of at least 14 points on the Depression subscale and at
least 10 points on the Anxiety subscale of the 21-item
Depression Anxiety Stress Scale (DASS–21); (4) not
able to join the study as a result of major medical, psychiatric, or neurocognitive disorders; and (5) currently
participating in any mindfulness practice.
Procedure
During the preparation stage, the coronavirus disease
2019 (COVID-19) outbreak made it impossible to
hold a face-to-face Zentangle class. Thus, the entire
study was conducted online from April 2020 to May
2020. All interested participants first completed a
screening questionnaire. Eligible participants were invited to fill out the baseline questionnaire and provide
informed consent. Participants were informed that
they would be randomized to either the ZEN group or
the WL group. The simple randomization procedure
was performed by an independent assessor using a
computer-generated list of random numbers. Although
there was no blinding to the participants’ group
assignment after the randomization, all outcome
measures were collected online and calculated with
computer programs and formulas.
Julious (2005) calculated that at least 12 participants
per group were needed for a pilot study; therefore, we
planned to recruit 15 participants per group. However,
due to interest, we had 19 participants in each group,
exceeding the minimum.
The intervention consisted of one 2-hr Zentangle, delivered by a certified Zentangle teacher. The instructor
first introduced the history of Zentangle and the
essential elements of a Zentangle drawing (i.e., the elemental strokes). He also explained the principles of
Zentangle, such as “no right or wrong,” “no eraser,”
and “one stroke at a time.”
The pattern of the first drawing is called Keeko,
which is a simple Zentangle pattern made up solely of
straight lines (Supplemental Figure A.1, available online
with this article at https://research.aota.org/ajot). It is
used for warm-up and lets participants know that Zentangle can be easily accomplished even using just a
single stroke. Participants spent 15 min on this drawing.
The second Zentangle drawing consists of four different
patterns, namely “Hollibaugh,” “Crescent Moon,” “Diva
Dance (Rock and Roll),” and “Hemp,” in which all five
elemental strokes are used (Supplemental Figure A.2).
Fundamental Zentangle techniques such as “drawing behind” and “aura-ing” were used in this drawing. It took
80 min for the participants to finish this Zentangle. During the Zentangle process, the instructor kept reminding
participants to focus on each stroke and wait to appreciate the drawings they created after the creation process.
Before the end of the meeting, participants were encouraged to practice Zentangle daily for 2 wk. A weekly
email reminding participants to practice Zentangle daily
was also sent to them at the beginning of each week.
Measures
All questionnaires were administered in Chinese.
Primary Outcome
The Positive and Negative Affect Schedule (PANAS) is a
20-item self-report scale that is made up of two 10-item
subscales that evaluate PA and NA. This scale is widely
used in both clinical and community settings to measure
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Study Design
Secondary Outcomes
The DASS–21 is a 21-item self-report measure consisting of three subscales that measure depression,
anxiety, and stress (Lovibond & Lovibond, 1995).
Items are rated on a 4-point Likert scale ranging from
0 (did not apply to me at all) to 3 (applied to me very
much, or most of the time). Example items are “I felt
that life was meaningless” (Depression), “I felt I was
close to panic” (Anxiety), and “I felt that I was rather
touchy” (Stress). The total score for each subscale
ranges from 0 to 21, with a higher score indicating a
higher level of depression, anxiety, or stress. The internal reliability of the Depression (Cronbach’s a 5 .94),
Anxiety (Cronbach’s a 5 .87), and Stress (Cronbach’s
a 5 .91) subscales is high (Antony et al., 1998).
The Self-Compassion Scale–Short Form (SCS–SF) is
a self-report scale that consists of 12 items evaluating
degree of compassion. It assesses how the person treats
themself in difficult times. This scale is made up of six
components: self-kindness, self-judgement, common
humanity, isolation, mindfulness, and overidentification. Items are rated on a 5-point Likert scale ranging
from 1 (almost never) to 5 (almost always). An example
item is “I’m disapproving and judgmental about my
own flaws and inadequacies.” The total score ranges
from 12 to 60, with higher scores indicating higher selfcompassion. The SCS–SF has demonstrated high internal reliability (Cronbach’s a 5 .86; Raes et al., 2011).
We used the validated Chinese versions of the
DASS–21 (Chan et al., 2012; Moussa et al., 2001) and
SCS–SF (Chen & Chen, 2019). Secondary outcomes
were assessed at two time points (baseline and 2-wk
postintervention).
Intervention Satisfaction and Engagement
Intervention satisfaction was assessed immediately after the Zentangle class. Participants were asked, “How
satisfied were you with the Zentangle class?” and indicated their overall satisfaction on a 5-point Likert scale
ranging from 1 (very dissatisfied) to 5 (very satisfied).
Intervention engagement was assessed at 2-wk
postintervention. Participants were asked to indicate
their average practice days per week and average daily
practice time during the past 2 wk and whether they
intended to practice in the future.
Statistical Analysis
For quantitative data, intention-to-treat analyses were
conducted using maximum likelihood estimation,
with the missing-at-random assumption. Regardless of
whether they completed the postintervention questionnaires, participants in both groups were included in
the analyses. Comparability of groups at baseline
was assessed by means of independent t tests for continuous variables or x2 tests for categorical variables.
Between-group differences from baseline to immediate
and 2-wk postintervention were analyzed by means of
linear mixed-effects models. Separate analyses were
conducted for the ZEN group, who had practiced Zentangle for at least 80 min a week, and the WL group.
All data were analyzed using IBM SPSS Statistics
(Version 25.0) and computed at p ≤ .05 (two-tailed). Effect sizes were calculated with Cohen’s d, which is the
mean difference divided by a pooled standard deviation.
Results
Participant Characteristics
All 225 potential participants completed the online
screening for eligibility, and 187 were excluded
from the study for various reasons (Figure 1).
Thirty-eight participants who completed the baseline questionnaire were randomized into the ZEN
group (n 5 19) or the WL group (n 5 19). Participants’ mean age was 36.0 yr (SD 511.5), and they
were primarily female (92.1%). The majority of the
participants were university educated (86.8%) and
single (73.7%). Roughly two-thirds of participants
worked full time (Table 1). No significant difference
was found between the ZEN group and the WL
group on any of the baseline measures or participant characteristics.
Attrition Rate
Of the 38 eligible participants who completed the baseline measures, 35 (92.1%) filled in the immediate
postintervention questionnaires. Thirty-two (84.2%)
also completed the 2-wk postintervention questionnaires. There were no significant differences on any of
the baseline characteristics or measured variables between participants who dropped out and those who
completed all the questionnaires.
In the ZEN group, 17 (89.5%) participated in the
class and filled in the questionnaires at the immediate
postintervention assessment, and 14 (73.7%) completed the 2-wk postintervention questionnaires. In the
WL group, 1 participant dropped out at the immediate
postintervention assessment, and the rest completed
all questionnaires.
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affective well-being and change in mood over a specific
period. A 5-point Likert scale is used, ranging from
1 (very slightly or not at all) to 5 (extremely). Example
items are “interested” (PA) and “distressed” (NA). The
total score for each subscale (i.e., PA and NA) ranges
from 10 to 50, with a higher score indicating a higher
level of either PA or NA. The momentary mean scores
for PA and NA are 29.7 (SD 5 7.9) and 14.8 (SD 5
5.4), respectively. The PANAS’s internal reliability has
been demonstrated to be high for both PA (Cronbach’s
a 5 .84–.87) and NA (Cronbach’s a 5 .86–.90; Watson
et al., 1988).
The Chinese version of the PANAS was adopted
from a Taiwanese thesis (Lu, 2012), and our team
agreed that the translation was appropriate. The primary
outcome was assessed at three time points (baseline, immediate postintervention, and 2-wk postintervention).
Figure 1. Participant flow diagram.
Screened for eligibility (N = 225)
Excluded (n = 187)
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- Not a Hong Kong resident (n = 1)
- Age <18 yr or> 65 yr (n = 1)
- Unable to read Chinese or communicate in
Cantonese (n = 1)
- Unable to join Zentangle class via webinar (n
- Currently using medication or psychotherapy for
psychiatric disorder (n = 30)
- Had suicidal ideation (n = 3)
- Duplicate registration (n = 10)
- Unable to join on designated dates (n = 13)
- Currently taking part in a mindfulness exercise
(n = 25)
- DASS–21 Depression score ≥14 (n = 8)
- DASS–21 Anxiety score ≥10 (n = 10)
- Nonresponsive (n = 32)
- Did not complete baseline assessment (n = 52)
Randomized (n = 38)
Zentangle group (n = 19)
Waitlist control group (n = 19)
Intervention (n = 17)
Withdrew; did not join the Zentangle class (n = 2)
Immediate postintervention
Completed questionnaire (n = 17)
2-wk postintervention
Completed questionnaire (n = 14)
Withdrew; did not complete questionnaire (n = 3)
Analyzed (n = 19)
Immediate postintervention
Completed questionnaire (n = 18)
Withdrew; did not complete questionnaire (n = 1)
2-wk postintervention
Completed questionnaire (n = 18)
Analyzed (n = 19)
Note. DASS–21 5 21-item Depression Anxiety Stress Scale.
Intervention Effectiveness
Between-Group Comparison
Table 2 shows that there were significant Group ×
Time interactions in NA at immediate postintervention and 2-wk postintervention. The ZEN group
(M 5 28.89, SD 5 5.59) had significantly greater
reductions in NA than the WL group (M 5 19.00, SD 5
6.91) at the immediate postintervention. For 2-wk
postintervention, the ZEN group still showed greater
reductions (M 5 21.14, SD 5 6.62) in NA than the
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Table 1. Demographic Characteristics of the Participants
n (%)
Characteristic
Whole Sample (N 5 38)
ZEN Group (n 5 19)
WL Group (n 5 19)
p
Age, yr, M (SD)
36.03 (11.46)
35.89 (9.49)
36.16 (13.41)
.945
Gender
Female
Male
.547
35 (92.1)
17 (89.5)
18 (94.7)
3 (7.9)
2 (10.5)
1 (5.3)
Highest education level
.517
0 (0.0)
0 (0.0)
0 (0.0)
Primary
0 (0.0)
0 (0.0)
0 (0.0)
Secondary
0 (0.0)
0 (0.0)
0 (0.0)
Matriculation
1 (2.6)
0 (0.0)
1 (5.3)
Tertiary level (nondegree)
4 (10.5)
3 (15.8)
1 (5.3)
Bachelor’s
20 (52.6)
9 (47.4)
11 (57.9)
Master’s or higher
13 (34.2)
7 (36.8)
6 (31.6)
Single
28 (73.7)
13 (68.4)
15 (78.9)
Married
9 (23.7)
5 (26.3)
4 (21.1)
Widower
0 (0.0)
0 (0.0)
0 (0.0)
Divorced
1 (2.6)
1 (5.3)
0 (0.0)
Marital status
.534
Employment status
.612
Full time
25 (65.8)
13 (68.4)
12 (63.2)
Part time
5 (13.2)
2 (10.5)
3 (15.8)
Unemployed
2 (5.3)
1 (5.3)
1 (5.3)
Retired
1 (2.6)
0 (0.0)
1 (5.3)
Housewife
2 (5.3)
2 (10.5)
0 (0.0)
Student
3 (7.9)
1 (5.3)
2 (10.5)
Note. Percentages may not total 100 because of rounding. WL 5 waitlist control; ZEN 5 Zentangle®.
WL group (M 5 26.61, SD 5 7.22). The betweengroup effect sizes were large at both immediate (d 5
1.04, p < .01, 95% confidence interval [CI] [0.31, 1.72])
and 2-wk postintervention (d 5 0.79, p < .01, 95% CI
[0.05, 1.49]) assessments. For PA and other secondary
measures, no significant differences were found across
all time points (p > .05).
High-Practice Group Analysis
Six participants who had practiced for at least 80 min
per week (M 5 140.83 min, SD 5 67.26) were classified as the high-practice (HP) group. Table 3 presents
the statistical comparison of the HP group and the WL
group. The linear mixed-effects model analysis showed
a significant Group × Time interaction in NA at the
2-wk postintervention assessment. The findings showed
a more significant reductions in NA in the HP group
(M 5 19.00, SD 5 8.03) compared with the WL group
(M 5 26.61, SD 5 7.22) at the immediate postintervention, with a large between-group effect size (d 5
1.00, p < .01, 95% CI [0.00, 1.93]). Secondary outcome
measures showed significant improvements in anxiety
symptoms (M 5 1.83, SD 5 2.23) and self-compassion
(M 5 37.83, SD 5 11.07) in the HP group, compared
with the level of anxiety symptoms (M 5 4.22, SD 5
3.34) and self-compassion (M 5 35.50, SD 5 7.99) in
the WL group at the immediate postintervention. The
between-group effect size was large for anxiety symptoms (d 5 0.84, p < .05, 95% CI [ 0.14, 1.76]) and
low for self-compassion (d 5 0.24, p < .01, 95% CI
[ 0.69, 1.16]). No significant difference was found for
PA, depression, and stress symptoms (p > .05). For the
ZEN group, no significant differences were found between the HP and low-practice (LP) groups on any of
the baseline characteristics or measures.
Intervention Satisfaction and Engagement
All ZEN group participants (n 5 17) reported that
they were very satisfied (n 5 11; 64.7%) or satisfied
(n 5 6; 35.3%) with the Zentangle class. Their mean
score was 4.65 out of 5 (SD 5 0.48), indicating a high
level of satisfaction.
Participants were encouraged to practice Zentangle
daily for 2 wk. Of the 14 participants who returned
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No schooling or kindergarten
Table 2. Estimated Means, Standard Deviations, p Values, and Effect Sizes at Baseline, Immediate Postintervention, and
2-wk Postintervention
ZEN Group (n 5 19)
M (SD)a
Outcome Variable
M Change
From Baseline
WL Group (n 5 19)
M (SD)a
M Change
From Baseline
Between-Groups
d b [95% CI]
pc
PANAS Negative Affect subscale
Baseline
29.89 (5.59)
27.32 (6.38)
.19
Immediate
postintervention
19.00 (6.91)
10.89
26.56 (7.59)
0.76
1.04 [0.31, 1.72]
.001
2-wk postintervention
21.14 (6.62)
8.75
26.61 (7.22)
0.71
0.79 [0.05, 1.49]
.001
Baseline
26.47 (7.28)
29.37 (9.21)
.29
Immediate
postintervention
29.29 (7.51)
2.82
29.00 (8.19)
0.37
0.04 [ 0.63, 0.70]
.25
2-wk postintervention
25.36 (8.23)
1.11
28.28 (7.17)
1.09
0.38 [ 1.07, 0.34]
.20
DASS–21 Depression subscale
Baseline
5.32 (3.15)
2-wk postintervention
4.14 (3.68)
4.63 (2.71)
1.18
4.61 (3.22)
.48
0.02
0.14 [ 0.57, 0.83]
.19
DASS–21 Anxiety subscale
Baseline
4.47 (2.44)
2-wk postintervention
3.29 (3.38)
4.47 (3.17)
1.18
4.22 (3.34)
1.00
0.25
0.28 [ 0.43, 0.97]
.19
DASS–21 Stress subscale
Baseline
9.89 (3.96)
2-wk postintervention
7.64 (3.39)
9.11 (4.25)
2.25
7.83 (4.84)
.56
1.28
0.05 [ 0.65, 0.74]
.29
SCS–SF
Baseline
32.37 (6.53)
2-wk postintervention
34.21 (8.56)
34.95 (7.81)
1.84
35.50 (7.99)
.28
0.55
0.16 [ 0.85, 0.55]
.10
Note. CI 5 confidence interval; DASS–21 5 21-item Depression Anxiety Stress Scale; PANAS 5 Positive and Negative Affect Schedule;
SCS–SF 5 Self-Compassion Scale–Short Form; WL 5 waitlist control; ZEN 5 Zentangle®.
a
Estimated means and standard deviations were calculated with linear mixed-effects models.
b
Between-group effect sizes were reported as positive if the ZEN group had greater psychological improvement than the WL group.
c
Between-groups p values: Group × Time interactions were calculated with linear mixed-effects models. At baseline, p values were calculated by means of independent t tests.
the 2-wk postintervention questionnaires, 11 (78.6%)
had practiced Zentangle at least once a week, with an
average daily practice time of 30.00 min (SD 513.60),
and their average practice time per week was 96.82
min (SD 5 70.93). In addition, 3 participants (21.4%)
reported that they had not practiced Zentangle at all.
Discussion
This study is the first RCT to examine the effectiveness
of Zentangle on the general public’s affective well-being, compared with a WL group. Participants in the
ZEN group showed significant reductions in NA at
immediate postintervention and 2-wk postintervention
assessments irrespective of their average practice time,
compared with the WL group. With a longer self-practice time (at least 80 min/wk), Zentangle was found to
be effective in lowering anxiety (DASS–21 Anxiety
subscale) and improving self-compassion (SCS–SF).
No significant results were found for PA, depressive
symptoms (DASS–21 Depression subscale), and stress
symptoms (DASS–21 Stress subscale). We showed that
Zentangle is feasible as a cost-effective alternative to
conventional interventions in reducing NA and, with
longer practice time, alleviating anxiety and enhancing
self-compassion. This study can also be used as a basis
to study the potential effects of Zentangle in clinical
populations.
Significant Reductions in Negative Affect and
Insignificant Changes in Positive Affect
Compared with the WL group, the ZEN group showed
significant effects on reducing NA at immediate postintervention (d 5 1.04) and 2-wk postintervention
(d 5 0.79). It is worth noting that the baseline NA for
both groups (ZEN group, 29.89; WL group, 27.32) was
much higher than the average momentary score of
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PANAS Positive Affect subscale
Table 3. Estimated Means, Standard Deviations, p Values, and Effect Sizes for the HP Group and the WL Group at Baseline
and 2-wk Postintervention
HP Group (n 5 6)
Outcome Variable
M (SD)a
M Change
From Baseline
WL Group (n 5 19)
M (SD)a
M Change
From Baseline
Between-Groups
d b [95% CI]
pc
PANAS Negative Affect subscale
Baseline
29.67 (7.17)
2-wk
postintervention
19.00 (8.03)
27.32 (6.38)
10.67
26.61 (7.22)
.45
0.71
1.00 [0.00, 1.93]
.006
PANAS Positive Affect subscale
28.00 (8.41)
2-wk
postintervention
30.50 (9.29)
29.37 (9.21)
2.5
28.28 (7.17)
.75
1.09
0.27 [ 0.67, 1.19]
.25
DASS–21 Depression subscale
Baseline
5.17 (2.64)
2-wk
postintervention
2.50 (3.02)
4.63 (2.71)
2.67
4.61 (3.22)
.68
0.02
0.68 [ 0.29, 1.59]
.08
DASS–21 Anxiety subscale
Baseline
4.50 (2.88)
2-wk
postintervention
1.83 (2.23)
4.47 (3.17)
2.67
4.22 (3.34)
.99
0.25
0.84 [ 0.14, 1.76]
.046
DASS–21 Stress subscale
Baseline
9.83 (5.15)
2-wk
postintervention
6.33 (3.14)
9.11 (4.25)
3.5
7.83 (4.84)
.73
1.28
0.37 [ 0.57, 1.28]
.21
SCS–SF
Baseline
32.50 (8.22)
2-wk
postintervention
37.83 (11.07)
34.95 (7.81)
5.33
35.50 (7.99)
.52
0.55
0.24 [ 0.69, 1.16]
.004
Note. CI 5 confidence interval; DASS–21 5 21-item Depression Anxiety Stress Scale; HP 5 high-practice; PANAS 5 Positive and Negative
Affect Schedule; SCS–SF 5 Self-Compassion Scale–Short Form; WL 5 waitlist control.
a
Estimated means and standard deviations were calculated by linear mixed-effects models.
b
Between-group effects sizes were reported as positive if the HP group had greater psychological improvements than the WL group.
c
Between-group p values: Group × Time interactions were calculated by linear mixed-effects models. At baseline, p values were calculated
by independent t tests.
14.8 found in a previous study (Watson et al., 1988).
This discrepancy was likely the result of the impact of
COVID-19, as evidenced in a recent survey showing
that the level of NA among Hong Kong people was
high (Gloster et al., 2020). At all assessment time
points, no significant improvements in PA were
found compared with the WL group. The insignificant
change in PA seems to be contradictory to the findings
of the Zentangle study conducted by Hui and Ma’rof
(2019). However, we speculate that their single-group
design using within-group comparisons might have
contributed to the discrepancies with our findings
using between-groups comparisons.
In fact, the asymmetry effects on PA and NA are
congruent with those of previous studies on art interventions. Previous studies have suggested that drawing
can significantly reduce NA, but it has no significant
impact on PA (Drake & Winner, 2012; Northcott &
Frein, 2017). One possible reason is that the Zentangle
drawing process itself serves as a distraction. Because
Zentangle requires people to focus on every stroke
they are drawing, this might serve as a distracting tool
for emotional regulation, shifting the person’s attention to the present moment. Although distraction has
been found to be effective in reducing NA, it does not
lead to an improvement in PA unless positive stimuli
are included in the intervention to arouse positive
emotions (Valim et al., 2019). This notion was also
supported by a study by Dalebroux et al., (2008), which
showed that adding positive elements to drawings can
lead to a significant increase in PA. Nonetheless, according to its founder, Zentangle drawing is itself
nonrepresentational (Roberts & Thomas, 2012), meaning that the patterns and the elemental strokes are
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Baseline
neutral rather than positive. In other words, it focuses
on the present moment and “no right or wrong” in the
drawings in lieu of stimulating positive thoughts or
memories in the drawing process. This distracting and
nonjudging nature of Zentangle can be the reason why
Zentangle intervention is more effective in reducing
negative emotions than in enhancing positive ones.
Reduction in Anxiety Among Participants in the
High-Practice Group
Improvement in Self-Compassion Among
Participants With Longer Practice Time
Another significant effect of the Zentangle intervention
was found in the enhancement of self-compassion in
the ZEN HP group, who practiced Zentangle for at least
80 min, compared with the WL group. This improvement in self-compassion is in line with our expectations
because the core values of Zentangle and self-compassion have many similarities; both emphasize being
mindful and nonjudgmental. The insignificant results
in the ZEN group (both HP and LP groups) could be
explained by the insufficient time spent on Zentangle
practice. According to a systematic review by Kotera
and Van Gordon (2021), self-compassion interventions
with a longer duration (>11 hr) provide the most robust
results for improvement in self-compassion. Another
study on mindful practice also pointed out that longer
daily practice time can lead to a greater rise in self-compassion (Berghoff et al., 2017). Our findings suggest
that Zentangle practice can improve self-compassion if
practice time is long enough.
Insignificant Effects on Symptoms of Depression
and Stress
No significant reductions were found in symptoms of
depression (DASS–21 Depression subscale) and stress
(DASS–21 Stress subscale), irrespective of participants’
Strengths and Limitations
This is the first RCT to demonstrate that Zentangle
can be effective in improving the general public’s
mental health by reducing NA. With longer practice
time, it also helps to reduce anxiety symptoms and
enhance self-compassion. The intervention was implemented with a nonclinical population of adults of
different ages, which sheds light on the potential of
using Zentangle to promote positive mental health in
the general population. The demographics of the two
groups were very similar, which reduced the chance
of results being affected by confounding factors. Moreover, the Zentangle patterns used are clearly listed,
which allows for future replication of the study and
further testing the psychological effects generated
from different patterns.
The sample size for this pilot study was small,
which might have contributed to the insignificant findings. A fully powered RCT is thus recommended in
the future. In addition, the nonrepresentative sample
in this study might affect its generalizability. Because
the Zentangle sessions were delivered online, only participants with basic computer knowledge and stable
internet access were able to join the intervention. The
study sample was recruited using the internet and was
a nonclinical population, also limiting the generalizability of the findings. In addition, the long-term effect
of Zentangle was not assessed. Finally, the study had
no active control group, and because participants were
not blinded to group allocation, the results could
potentially be affected by their grouping.
Implications for Occupational
Therapy Practice
Our study’s results demonstrate that Zentangle may
have the potential to be a cost-effective intervention in
occupational therapy practice in terms of improving affective well-being across different areas of practice, such
as psychiatric rehabilitation and pediatric, geriatric, and
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Higher levels of self-practice with Zentangle are essential
when using Zentangle to reduce anxiety symptoms
(DASS–21 Anxiety subscale). No significant changes in
anxiety were observed in the Zentangle group at 2-wk
postintervention assessment, compared with the WL
group, but a significant reduction in anxiety was found
among participants engaged in at least 80 min of Zentangle practice per week, with a large effect size (d 5
0.84). These results are consistent with those of the
study by Curry and Kasser (2005), which found that
structured drawing helps participants to experience a
meditative state and reduce anxiety. Our findings suggest that, with a longer practice time, Zentangle can be
used as an effective preventive tool to minimize anxiety
in the general population. Because this study focused
only on the nonclinical population, future studies should
evaluate the effectiveness of Zentangle with people with
anxiety and explore the possibility of integrating Zentangle into treatment for anxiety disorders.
average practice time. This result was surprising, given
that Zentangle is commonly regarded as a stress-relieving activity. However, comparing the HP group with
the WL group, the between-group changes on both
measures were in the predicted direction, with a moderate effect size for depressive symptoms (d 5 0.68)
and a small effect size for stress symptoms (d 5 0.37).
Moreover, the between-group effect of Zentangle to
reduce depressive symptoms was close to being statistically significant (p 5 .08). Thus, the insignificant
findings could be attributed to the small sample size,
which may lead to the inability to detect statistically
significant differences. In addition, a previous metaanalysis on positive psychological interventions indicated that positive psychological interventions might
have been more effective with depression if the duration of the Zentangle intervention was longer (Bolier
et al., 2013).
analysis of randomized controlled studies. BMC Public Health, 13,
119. https://doi.org/10.1186/1471-2458-13-119
Brown, K. W., & Ryan, R. M. (2003). The benefits of being present:
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Chen, Y. C., Li, L. Z., Cheng, W. W., Lo, H. M., & Hsu, N. L. (2016). The
effectiveness of using Zentangle to reduce anxiety disorder for
schizophrenia patients. Journal of Health and Architecture, 3, 41–48.
Chen, Y. J., & Chen, S. H. (2019). The Taiwanese version of the SelfCompassion Scale: Psychometric properties, implications for
psychological health and self-compassion across multiple generations.
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Conclusion
Our study demonstrates that Zentangle is effective in
lowering NA in the general population. In addition,
Zentangle with longer practice time appears to be more
beneficial for alleviating anxiety symptoms and improving self-compassion. Future studies with a larger
sample size, longer follow-up, and an active comparison group are warranted to evaluate the effects of
Zentangle in both clinical and nonclinical populations.
Acknowledgments
This trial was registered at ClinicalTrials.gov
(NCT04309279). The authors wish to thank all the
participants in the study and the members of Public
Mental Health Laboratory, The Chinese University
of Hong Kong, for their assistance in data collection
and manuscript preparation.
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