Subject: Psychology Research Question: To what extent has art therapy been used in treating anxiety disorders in adolescents (18 and above) within the 21st century? Word count: 3979 TABLE OF CONTENTS INTRODUCTION 3 ART THERAPY IN REDUCING INTERNALIZING AND EXTERNALIZING BEHAVIORS THROUGH COGNITIVE DISTORTIONS AS ANXIETY TRIGGERS 5 INTERNALIZING BEHAVIORS AND ART THERAPY 6 SOCIOCULTURAL BEHAVIORS IN TERMS OF EXTERNALIZING BEHAVIORS AND ART THERAPY 7 ART THERAPY AS A TOOL OF ENGAGEMENT AND TRANSFORMATION 11 EVALUATION 13 ADVANTAGES AND DISADVANTAGES OF ART THERAPY 13 ART THERAPY VS OTHER FORMS OF THERAPY 14 CONCLUSION 15 WORK CITED 17 INTRODUCTION In the 21st century, and living in this high -pressure society, it is no wonder that anxiety has become an ever - increasing problem, impacting millions of individuals world wide. Behavioral psychologists view anxiety as a “learned response to frightening life events'' (“Anxiety | Psychology | Britannica ''); the anxiety is then reflected based on the surrounding circumstances associated with the trigger of the fear causing the person experiencing it to react in a strong way. Aggressive and Impulsive actions can be seen within people prone to anxiety (“The Causes of Anxiety | Psychology Today”). Anxiety results from subjective, internal emotional conflicts, the reasons of which may not be obvious to the person themselves, or it is a reaction to conditions that appear to be unimportant. Anxiety disorders can be identified through repeated episodes of sudden strong feelings of intense fear and terror that reach a very high intensity very quickly known as panic attacks. These feelings of anxiety and panic interfere with simple activities which are done daily and can be very difficult to control, it makes the person remain in constant fear of danger or of something going wrong. This leads to one avoiding certain places which can cause them this sort of stress leading to their panic. Symptoms for anxiety can start as early as childhood or the teen years during their puberty stage, which can further lead into adulthood, possibly worsening their disorder. Anxiety comes in various forms, for example generalized anxiety disorder, social anxiety disorder, specific phobias,(Annualreports) separation anxiety disorders and many more(Annualreports). These can result in medical conditions which need to be treated (Mayo Clinic). This is something seen quite frequently among children and adolescents, especially during the 21st century. Art therapy is one of these various forms which assists in treating anxiety disorders. Art therapy is a type of therapy that helps people enhance their mental, emotional, and physical well-being by using artmaking as a communication and expression tool. In order to promote emotional healing, personal development, and self-discovery, it blends therapeutic techniques with creative processes (Yassin). People can explore their feelings, ideas, and experiences in a non-verbal and safe way by engaging in these art-making methods. Through the creation of art, the client can acquire a deeper understanding of themselves and their struggles by gaining insights into their subconscious. As the process and individual expression are more important than the outcome, art therapy does not require creative ability or expertise. The goal of the collaborative process between the art therapist and the client is to support personal empowerment, self-expression, and self-discovery. The discipline of art therapy first emerged in the 1940s and gained popularity in the 1970s. It makes use of creativity, just like other expressive arts therapies like dance therapy or music therapy (“The Benefits of Art Therapy for Mental Health | Priory Group”). Art therapy has shown to help reduce symptoms of anxiety, (Jaruševičiūtė, 2023)depression, and stress by 73%(Lindner, 2023), It can yield a 50% improvement in symptoms of post-traumatic stress disorder in U.S. veterans(Lindner, 2023), it has also been found to decrease self-harm tendencies in adolescents by 54%, group art therapy can lead to a 45% reduction in negative emotions and feelings of isolation in individuals with serious mental illnesses(Lindner, 2023), art therapy interventions in hospital settings have been shown to reduce patient anxiety and stress by 40%, in elderly patients, it has been found to improve cognitive function by up to 35%(Lindner, 2023), and lastly having sessions can benefit those in chronic pain by improving mood, self-esteem, and pain perception by up to 71%(Lindner, 2023) According to a thorough analysis of studies carried out in 27 different nations, anxiety problems in children are present in 6.5% of children globally; a common psychiatric disease is childhood anxiety. According to estimates from the National Institute of Mental Health, 1 in 4 teenagers, between the ages of 13 and 18 have anxiety disorders / conditions. 1 in 17 have severe anxiety, and more than 36% of kids with behavioral issues have an anxiety disorder. Estimates that phobia prevalence rates are around 20%, social anxiety disorder prevalence rates are 9%, separation anxiety disorder prevalence rates are 8%, agoraphobia prevalence rates are 2%, and generalized anxiety disorder prevalence rates are 2%. (Kowalchuk et al.). Parental history of anxiety disorders, socioeconomic pressures, exposure to violence, and trauma are risk factors that affect anxiety disorders in children. Similar to adult symptoms, physical and behavioral manifestations of anxiety disorders in children and adolescents might include diaphoresis, palpitations, and tantrums. To what extent can art therapy assist in treating anxiety in adolescents within the 21st century? I will be discussing several factors that increase anxiety and the way art therapy shall assist in treating them. Specifically, how art therapy can help reduce internalizing and externalizing behaviors through reducing cognitive disorders and, how art therapy as a tool of engagement and transformation. I will finally be exploring two main research studies, Yasaman Bazargan and Shahla Pakdaman 2016 , and Rigby 2007 which back up the influence of art therapy and how it has been proven to treat anxiety disorders. ART THERAPY IN REDUCING INTERNALIZING AND EXTERNALIZING BEHAVIORS THROUGH COGNITIVE DISTORTIONS AS ANXIETY TRIGGERS Internalizing and externalizing behaviors are caused by cognitive distortions, Cognitive distortions are negatively biased errors in thinking that are purported to increase vulnerability to depression(Grinspoon). They are also caused by irrational thinking. The content of automatic thoughts is typically consistent with an individual's core beliefs (Rnic et al.). When negative cores are activated and negative thoughts accelerate, a negative, neutral, or even positive occurrence may have an impact on negative affect and inappropriate behaviors when negative automatic thoughts which are made up of incorrect interpretations devoid of supporting evidence are triggered and negative core beliefs are evoked. This pattern of ideas, feelings, and actions throughout time can either create or sustain depressive symptoms(Rnic et al.). The process of internalizing impairs one’s judgment because they perceive themselves in a negative way, this could lead to one suffering from anxiety disorders and refraining from communication and asking for help. Anxiety not only influences one's self esteem and their emotional and psychological state, but also one's behavioral traits. This brings in the aspect of internalizing and externalizing behaviors. INTERNALIZING BEHAVIORS AND ART THERAPY Negative sentiments, ideas, and/or behaviors that are internally focused are known as internalizing behaviors. As a result, they are rarely observed as opposed to individuals who exhibit externalizing habits(“Internalizing Behaviors Definition | Psychology Glossary | AlleyDog.com”). Some individuals who internalize their emotions conceal them so completely that even their families are unaware of them. People that exhibit these behaviors frequently avoid social situations or suppress their emotions when under stress. Examples of internalizing behaviors include not talking, being unable to concentrate, sleeping more or less, eating more or less, being irritable, anxious, or suffering from depression, abusing drugs or alcohol, having suicidal thoughts or talking negatively to oneself, feeling unloved, or experiencing illnesses like head or stomach aches that are unrelated to any physical conditions (“What Are Internalizing Behaviors? | Betterhelp”). Art therapy can contribute to reducing internalizing behaviors as an anxiety trigger in several ways. Art therapy provides a non – verbal outlet for self-expression for individuals (Devi, 2023) who find it difficult to convey their internalizing behaviors and thoughts to get help(Devi, 2023). It creates a safe place to release pent up emotions and provides a sense of relief, it encourages the exploration and expression of various emotions which can be particularly beneficial for anxiety management(Rou). Participating in art therapy may improve a person's sense of self-worth and self-awareness. People who create art have a sense of mastery and success that can help offset negative self-perceptions that are frequently linked to internalizing activities. SOCIOCULTURAL BEHAVIORS IN TERMS OF EXTERNALIZING BEHAVIORS AND ART THERAPY The social learning theory by the psychologist Albert Bandura states that people learn behavior from their environment through observation, imitation, and modeling(robcondon). Bandura's social learning theory is relevant to externalizing behaviors. Externalizing behaviors refer to behaviors that are directed outwardly, such as aggression, defiance, and impulsivity.The theory states that individuals are more likely to copy actions they see if they think the behavior will benefit them or if they think the model is being rewarded for it(“What relation does Bandura's social learning theory have to externalizing behaviors”, 30th November version 3.5, Open AI, 13th February, 2024). According to Bandura's theory, violent or antisocial models can be observed and imitated, leading to the learning and reinforcement of externalizing behaviors(“What relation does Bandura's social learning theory have to externalizing behaviors”, 30th November version 3.5, Open AI, 13th February, 2024, chat.openai.com). Examples of externalizing conduct include defiance and physical aggression, both of which violate societal norms or rules. They result from the externalization of aggressive and angry feelings. Serious externalizing disorders in early children, such as strange in children, conduct disorder, antisocial personality disorder, and intermittent explosive disorder in teenagers, can develop if untreated (Li, 2023). Externalizing behavior can occur due to several factors; Biological risk factors, family factors and environmental factors interact intricately to create behavioral issues(Li, 2023). Researchers and psychologists have carefully compiled the causes and risk factors for childhood external conduct. Four categories: child features, family factors, peer influences, and environment; can be used to categorize the risk factors. The four categories claim: Several child characteristics have been shown to be associated with high levels of behavior problems such as: difficult-irritable-oppositional characteristics, impulsive behavior and lack of inhibition,(Li, 2023) A deficit in executive function and attention, lack of remorse, empathy, or emotional understanding, young maternal age, smoking, alcohol use, and substance abuse during pregnancy (Li, 2023). The family risk factors consist of: Unresponsive parenting, Lack of involvement or monitoring, Harsh discipline and parental hostility, Controlling parents, Antisocial behavior, delinquency, and criminal behavior in biological parents, Marital conflicts between parents(Li, 2023). Peer influence consists of: Rejected by peers, being bullied, Aggressive and deviant friends. And lastly, the external environmental influence: Low socioeconomic status (SES), low household income, Aggressive culture in community or school environment, Denser population, Higher crime rate (Li, 2023). These aspects then come into play and develop several disorders within adolescents, one of the main being anxiety, the person had to have been exposed to several different experiences to have acted violently, or aggressively towards others. Internalizing behaviors on the other hand can be practiced by anyone. The following, however, are typical risk factors that might suggest someone would engage in these behaviors: loneliness, sadness, embarrassment, guilt, and fear, the idea that one is unloved or undesired, abandoning social activities, being agitated or anxious, particularly when under stress or emotional, difficulty focusing or paying attention to tasks, significantly more or less sleep than normal, eating significantly more or less than normal, Suicidal ideas, plans, or actions. Art therapy can be effective in reducing externalizing behaviors as an anxiety trigger through several mechanisms; Engaging in art-making can help individuals gain insights into their own emotional states and triggers. They might become more conscious of their feelings, ideas, and behavioral patterns that could lead to externalizing behaviors when they produce art. People who engage in this self-reflection may become more self-aware and have the chance to create new coping mechanisms(Rou). Additionally, Art therapy offers a distraction from situations and stimuli that cause anxiety. One technique to distract oneself from these thoughts and feelings is to concentrate on the process of creating art. Making art can also trigger the relaxation response, which lowers physiological arousal linked to worry and fosters a sense of peace(Rou). Art therapy can assist in reducing internalizing and externalizing behaviors as anxiety triggers, this is proven through a study performed by Yasaman Bazargan and Shahla Pakdaman. This study aims to determine the effectiveness of art therapy for reducing internalizing and externalizing issues in teenage girls ages 14 to 18(Sample records for american art therapy). This was a semi-experiment study carried out in the form of a pre-test/post-test design with control groups(Sample records for american art therapy). The population of this study included female students of Gole Laleh School of Art in district 3 of Tehran, Iran, out of which 30 students had internalizing issues and 30 students had externalizing issues which were gathered through targeted sampling(Sample records for american art therapy). Experimental groups participated in 6 painting sessions designed based on Art therapy theories and previous studies(Sample records for american art therapy). The material used for diagnosis of the problems in post-test and pre-test was an Achenbach self-assessment form(Rice). The study performed a mixed analysis of variance to assess the data, and the findings indicated that art therapy was effective in lowering internalizing difficulties (F = 17.61, P < 0.001) but not externalizing problems (F = 3.93, P = 0.06). The application of art therapy as a realistic therapeutic approach can help with internalizing issues. Additional sessions could be required to lessen externalizing difficulties. Therefore, more research is needed to confirm these results (Bazargan and Pakdaman). Based on internalizing and externalizing behaviors as they are considered a cause for anxiety triggers, art therapy can be used as a tool to assist in reducing these behaviors. Specifically, it is considered easier to reduce internalizing behaviors than externalizing behaviors according to the study conducted by Yasaman Bazargan and Shahla Pakdaman 2016. It was specifically tested on adolescent females as females are also prominently seen to be prone to both internalizing and externalizing behaviors due to insecurities set in by themselves or others. Although there is reduced generalizability to the public, the study did not fail to prove that Art therapy is a strong tool in reducing both internalizing and externalizing behaviors. These studies are highly applicable because according to the results found in the study conducted by Yasaman Bazargan and Shahla Pakdaman. It was specifically tested on adolescent females as females are also prominently seen to be prone to both internalizing and externalizing behaviors due to insecurities set in by themselves or others. This leads to the study being less generalizable to all genders, in turn showing gender bias and creates a participant bias as the researchers only utilized female participants. The study only used participants from Gole Laleh School of Art in district 3 of Tehran, Iran which led to strong cultural bias. On the contrary, the study was also conducted in a lab setting which made it easier to establish a cause-and-effect relationship within the condition and the participants' behaviors. ART THERAPY AS A TOOL OF ENGAGEMENT AND TRANSFORMATION People who suffer from anxiety are prone to disengagement from their environment. The disengagement theory refers to a phenomenon that may occur in adolescents suffering from anxiety whereby they withdraw or disengage from various social activities or interactions (Cassata). This theory suggests that individuals experiencing high levels of anxiety may choose to isolate themselves, avoid certain situations, or retreat from relationships to minimize potential anxiety-provoking experiences. This leads to reduced socialization and may impact not only their behavior towards others but to their thoughts and behaviors towards themselves. In the context of adolescents, disengagement can manifest in various ways. For example, they may avoid participating in extracurricular activities, isolate themselves from social gatherings, spend excessive time alone, or withdraw from close friendships or peer groups. This withdrawal behavior can reinforce feelings of loneliness, exacerbate anxiety symptoms, and hinder their personal growth and development (Cassata). Art therapy can enable adolescents who are undergoing art therapy to express themselves freely without worrying about being judged in a secure and encouraging setting. This could facilitate the development of a therapeutic alliance and trust between the patient and the art therapist, improving the efficacy of treatment. It also assists in regulating their emotions by providing a creative outlet for the expression of anxiety. Numerous studies have demonstrated that working directly with art supplies, creating a meaningful art object, channeling emotions into a piece of work, and interacting with a therapist through art mediums all lead to beneficial development (Yassin). Art therapy as a tool of engagement and transformation engages people who may have difficulty expressing themselves using conventional verbal methods. Art therapy also offers a transformative experience for participants. Creating art can be a cathartic and empowering process, enabling individuals to gain insight and perspective on their experiences. It can allow for self-reflection, exploration, and personal growth. Additionally, the act of creating art can be a positive and enjoyable experience, offering a sense of accomplishment, relaxation, and overall well-being(“Art therapy in comparison to other types of therapies”). A study conducted by (Rigby, 2007), This research used a quasi-experimental design with one group pretest-posttest. The variable in this research was art therapy to reduce anxiety in adolescents who became victims of bullying. The participants in this research were five vocational students (Rigby, 2007). The participant ages between 15-17 years old, gender is boy and girl. The sampling technique used in this research was purposive sampling methodThe data collection methods in this research used observation and interview, conducted during the art therapy process. The measurement for the bullying victims’ anxiety used the Anxiety Scale for bullying victims, developed by Yunita A. in 2014 with the calculation results of the Cronbach coefficient reliability of 0.858 as many as 24 items; this scale measured the anxiety in adolescents who became victims of bullying (Rigby, 2007). These results indicated that there was a difference in anxiety before and after being given art therapy, with p = 0.043. The results of the analysis showed that the participants had been able to overcome the anxiety they had experienced so far. The therapy carried out in groups made participants dare to tell their problems by explaining pictures they had drawn, and this made the participants feel more relieved because they could share their unpleasant experiences through the created picture. The support provided by fellow participants made them have the courage to overcome the problems they were facing. The art therapy also made participants feel that there was a positive thing inside of them, and unlike what they had received by being bullied (Rigby, 2007). Art therapy creates a safe place for them to express themselves which is seen in the study conducted by Rigby (2007), The results by Rigby (2007) show that there was significant decrease in anxiety levels to the participants who were victims of bullying, however their number of participants used was quite limited to 5 vocational students which in turn reduces generalizability. Furthermore, they utilized interviews as their way of operationalizing the experiment which increases the risk of participants providing socially desirable answers which in turn reduces the validity of the results. Contrastingly, they did use a purposive sample, the researchers can extract a great deal of information from their acquired data by using purposive sampling which provides an understanding of why Rigby may have only used 5 participants. EVALUATION ADVANTAGES AND DISADVANTAGES OF ART THERAPY Art therapy is being used worldwide and is increasingly growing as a great form of therapy in treating several disorders. Some of the strengths that Art therapy holds are that… They utilize nonverbal communication, where it allows individuals to express themselves without relying solely on verbal communication. This can be beneficial to those who struggle to articulate their thoughts and emotions verbally. It not only assists them with nonverbal communication but also provides a creative outlet, it lets individuals explore and process their emotions, this can be especially helpful for people who find it difficult to discuss or comprehend their emotions through conversation(Beeston, 2023). Engaging in art therapy can help individuals feel empowered and in control of their own healing process which boosts self – esteem and confidence. Lastly art therapy can assist individuals gain insight into their own thoughts and emotions. Through the process of creating art individuals may discover new perspectives and understand themselves better. All these strengths make art therapy a strong suit in treating several disorders but with strengths come its weaknesses (Staff). Art therapy normally requires access to materials and a physical space to create art which may not be feasible for everyone, especially those with disabilities and/or lack resources. There are also interpretation challenges whereas artwork is open to interpretation, it may be challenging for the therapist to understand the exact meaning behind the piece, which can lead to potential miss interpretations or misunderstandings between the therapist and their patients. There is also a skill level bias, this is due to art therapy being a place where an individual’s artistic ability is placed at importance, which may create a barrier for individuals who do not consider themselves to be artistically inclined (YOUHJUNG). This could potentially hinder their engagement and development in the therapy process. There may also be ethical considerations related to the use and storage of the art made during the therapy sessions, additionally, it may be challenging to maintain the confidentiality of the artwork when it is visible and shared with others (YOUHJUNG). ART THERAPY VS OTHER FORMS OF THERAPY In comparison to the use of art therapy cognitive Behavioral Therapy (CBT), focuses on identifying negative thought patterns and behaviors(Guild, 2021), whereas art therapy can be integrated into CBT, It has a unique advantage of enabling people to visually convey their feelings and ideas, especially in situations where verbal communication is difficult (“Art therapy in comparison to other types of therapies”30th November version 3.5, Open AI, chat.openai.com”). Talk therapy entails having conversations with a therapist in order to examine feelings, spot trends, and create coping mechanisms (“Art therapy in comparison to other types of therapies”30th November version 3.5, Open AI, chat.openai.com”). When used alongside talk therapy, art therapy can be seen as a type of experiential therapy that uses artistic expression to help patients process traumatic experiences, develop self-awareness, and acquire insight (Beeston). This therefore sets art therapy as a more engaging form of therapy compared to talk therapy. And lastly Play therapy, although it is frequently utilized with kids, adults can also benefit from play therapy (“art therapy in comparison to other types of therapies”30th November version 3.5, Open AI, chat.openai.com”). It entails using play activities to support people's self-expression, conflict resolution, and problem-solving abilities. Art therapy can be considered a type of play therapy, as it provides a range of creative activities through which individuals can communicate their feelings and thoughts (“Art & Play Therapy”). CONCLUSION In conclusion, Art therapy has been proven to assist in the treatment of anxiety disorders. This is seen through both a cognitive and sociocultural aspects based of how one's thoughts reflect their behavior explained through internalizing and externalizing behaviors which are caused by one's personal thoughts and/or other environmental aspects, about themselves in turn reducing self esteem and causing anxiety disorders, as well as how one's thoughts being projected into their behavior towards their surroundings caused through negative thoughts impairing one's self esteem. It is also seen through how an individual disengages from society and things they enjoy doing which leads to anxiety disorders. These have been proven to be treating art therapy as a therapy method to help with individuals who find it difficult to communicate in words, so art normally assists in helping them communicate their message. Art therapy is also very engaging which enhances and develops one's cognitive processes, increases self esteem and helps them find an engaging activity to assist in treating disengagement as well. Art therapy allows for self reflection and better self treatment, as well as room for personal growth. It offers a distraction as well to help in reducing certain ways of thinking which could lead to a more relaxed and calm environment and feeling within oneself as creating art takes focus and time. Lastly, art therapy may not be the only type of therapy but it works quite well and has been embedded in several forms of therapy because it is proven to be quite effective in treating anxiety related disorders or anxiety disorders itself . 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