Changes in General Self-Efficacy and Mindfulness Are Associated With Short-Term Improvements in Mood During Art-Making in A Partial Hospital Program

Journal Pre-proof
Changes in General Self-Efficacy and Mindfulness are Associated with

Short-Term Improvements in Mood during Art-Making in a Partial
Hospital Program
Marie Forgeard, Alexandra Silverman, Jennifer Buchholz, Courtney

Beard, Thröstur Björgvinsson
PII: S0197-4556(21)00044-7
DOI: https://doi.org/10.1016/j.aip.2021.101799
Reference: AIP 101799
To appear in: The Arts in Psychotherapy
Received Date: 13 May 2019

Revised Date: 17 March 2021
Accepted Date: 21 March 2021
Please cite this article as: Forgeard M, Silverman A, Buchholz J, Beard C, Björgvinsson T,
Changes in General Self-Efficacy and Mindfulness are Associated with Short-Term
Improvements in Mood during Art-Making in a Partial Hospital Program, The Arts in
Psychotherapy (2021), doi: https://doi.org/10.1016/j.aip.2021.101799
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ART-MAKING AND MOOD 1
Changes in General Self-Efficacy and Mindfulness are Associated with Short-Term
Improvements in Mood during Art-Making in a Partial Hospital Program
Marie Forgeard1,2 Alexandra Silverman3, Jennifer Buchholz4, Courtney Beard1, Thröstur
Björgvinsson1
1
McLean Hospital and Harvard Medical School
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2
William James College
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3
University of Virginia
4
University of North Carolina at Chapel Hill
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Author Note
Corresponding Author: Marie Forgeard, McLean Hospital/Harvard Medical School & William
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James College, 115 Mill Street, Belmont MA 02478, 617-855-4456,
mforgeard@mclean.harvard.edu. The authors do not have conflicts of interests to disclose. They

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would like to thank Allen Bailey and Shannon Haley, as well as the staff and patients of the
Behavioral Health Partial Program at McLean Hospital.

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Highlights
 •Art-making may improve mood; more research is needed to examine what might explain
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such benefits
 •Intensive treatment programs often offer art groups to patients
 •Increases in self-efficacy and mindfulness may relate to mood improvements during art-
making
Abstract
A growing body of scholarship suggests that art-making provides symptom relief as well as
short-term mood benefits. However, more research is needed to explore how artistic activities
may lead to mood improvements within the course of sessions conducted in clinical contexts.
To this end, we examined short-term outcomes of participation in an art group offered within a
brief partial hospital program in which intensive day treatment is delivered. In a preliminary
study (Study 1) conducted on Amazon MTurk (N = 193), we validated the use of a brief 7-item
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self-assessment scale to capture potential outcomes of art-making identified based on a review of
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the literature: positive/negative mood, general self-efficacy, creative self-efficacy, activation,
mindfulness, and social connectedness. In our main study (Study 2), 175 patients in a partial
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hospital program completed the brief instrument validated in Study 1 at the beginning and end of
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a 50-minute unstructured art group. All psychological outcomes improved over the course of the
group. Changes in general self-efficacy and mindfulness were associated with improvements in
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mood over and above changes in other outcomes. Results are limited by the naturalistic,
uncontrolled, design of the group, which was not led by art therapists. These findings suggest
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that further studies examining patients’ experiences during art-making in clinical settings may
provide useful insights into how this activity enhances mood.

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Keywords: art; mood; self-efficacy; mindfulness

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A growing body of scholarship suggests that art-making provides symptom relief as well
as short-term mood benefits. However, more research is needed to explore how artistic activities
may lead to mood improvements within the course of sessions conducted in clinical contexts. To
date, most of the research specifically examining what might account for mood improvements
during art-making has been conducted in experimental laboratory settings and more work is
therefore needed to understand what might account for mood improvements associated with art-
making in real-world clinical contexts (Gruber & Oepen, 2018). Relatedly, intensive
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psychological treatment programs often offer patients the opportunity to engage in art groups
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alongside other interventions (Malchiodi, 2013), but little research has examined associated
short-term benefits beyond changes in mood. Many clinicians not trained in art therapy and its
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scientific foundation intuitively see art as a useful medium (Rosal, 2016). Nonetheless, others
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may at first glance regard artistic activities as unrelated to the main goals of treatment. Further
research can therefore help clarify the nature and extent of the potential short-term benefits of
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art-making during psychological treatment. To address this gap in the literature, this project
examined short-term outcomes of an art group delivered within a partial hospital program
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delivering intensive treatment for individuals experiencing acute psychiatric symptoms.
Treatment in a partial program takes place during the day (typically for 1-2 weeks), with
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individuals returning home in the evenings/weekends.
The Benefits of Art-Making

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Clinicians and mental health institutions often offer opportunities for creative self-
expression during treatment, using an array of possible modalities (e.g., the visual arts, music,
drama, dance, or play) to provide individuals with opportunities to generate potentially original
and valuable ideas or products (Malchiodi, 2013; Stein, 1953; Sternberg & Lubart, 1995). A
growing body of evidence suggests that art-making may be beneficial for individuals presenting
with psychological difficulties (American Art Therapy Association, 2017). Most of the evidence
bearing on this question has however examined medium- to long-term outcomes of participation
in art-making for psychological symptoms, general health, and/or quality of life. Comparatively
less research has examined short-term changes in mood and other outcomes experienced within
one session, as further explained below. Reviews of controlled and uncontrolled studies in this
area conclude that art-making interventions (delivered as a primary intervention, or as an
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adjunctive intervention to treatment-as-usual) overall appear to be useful for symptom reduction
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and psychological adjustment (Maujean, Pepping, & Kendall, 2014; Slayton, D’Archer, Kaplan,
2010) for a wide range of problems including depression (e.g., Gussak, 2006, 2007, 2009;
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Thyme et al., 2007), schizophrenia (e.g., Richardson, Jones, Evans, Stevens, & Rowe, 2007), and
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trauma-related symptoms (e.g., Decker, Deaver, Abbey, Campbell, & Turpin, 2018; Schouten, de
Niet, Knipscheer, Kleber, & Hutschemaekers, 2015), among others. Despite these promising
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results, some studies have found either minimal or no effect of art-based interventions (primary
or adjunctive) on symptom outcomes (e.g., Crawford et al., 2012). Existing evidence speaking to
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the benefits of art therapy for specific populations remains limited. For example, a systematic
review of both randomized and non-randomized controlled trials of art therapy for anxiety
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disorders only found three eligible studies; in spite of preliminary evidence of effectiveness,
results were hampered by the paucity of high quality controlled trials and risk of bias in existing
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research (Abbing et al., 2018).
To complement research assessing medium- to long-term outcomes of participation in
art-based interventions, additional work is needed to investigate potential short-term benefits for
participants (Gruber & Oepen, 2018). Examining participants’ immediate experiences could help
maximize the effectiveness of artistic interventions by clarifying the conditions under which art-
making improves mood in clinical settings. In other words, such research can help shed light on
not just whether but also how these experiences might serve the goals of treatment (Forgeard &
Elstein, 2014).
Experimental research conducted with nonclinical samples has started to address this
question by examining participants’ changes in mood resulting from art-making. More
specifically, much of this research has assessed whether and how engaging in artistic activities
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(mostly drawing) can help repair mood following an experimental negative mood induction. For
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example, De Petrillo and Winner (2005) found that participants who were asked to draw a
picture based on their feelings exhibited improved mood after drawing, whereas those who were
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asked to copy shapes or to complete a word puzzle did not. In addition, participants’ mood
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improvements did not differ based on whether they expressed negative emotions or redirected
their attention toward positive content in their pieces (as observed by examining the contents of
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the drawings produced). These results suggest that creating a personally relevant product (not
just the physical act of drawing) is important for mood improvement to occur. Additional studies
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have shown that drawing may be particularly effective for mood repair when it is used to
implement a specific emotion regulation strategy - redirecting one’s attention toward positive
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content. Dalebroux, Goldstein, and Winner (2008) demonstrated that drawing to elicit positive
mood (e.g., drawing something happy) led to larger improvements in mood than drawing to vent
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(i.e., drawing to express negative mood), or engaging in a control activity (scanning a sheet for
specific symbols). Similarly, Drake, Coleman, and Winner (2011) found that drawing was a
more effective means of immediate mood repair than writing, and that both activities repaired
mood more effectively through distraction than through venting negative mood (see also
Diliberto-Macaluso & Stubblefield, 2015; Drake, Hastedt, & James, 2016; Drake & Winner,
2012, 2013; Kimport & Robbins, 2012; Smolarski, Leone, & Robbins, 2015).
Despite the growing body of work documenting mood benefits of art-making in
experimental settings, little empirical evidence speaks to predictors of such benefits in real-world
clinical settings in which art is offered as a complement to other treatment modalities. Related to
this, little research speaks to whether the mood benefits of art-making are best explained by
general processes common to most therapeutic activities or by processes specific to creative
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activities such as art (Forgeard & Elstein, 2014). Understanding how art-making influences a
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range of psychological experiences during psychological treatment has the potential to (a) more
accurately and comprehensively capture the benefits of art-making, (b) help identify the types of
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psychological changes that are most closely related to mood improvements during art-making,
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and (c) enhance clinicians’ ability to target goals other than mood repair through art-making,
thus potentially enhancing engagement with, and the effectiveness of, the specific type of
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treatment(s) received.
To that end, the present study examined associations between changes in

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positive/negative mood and changes in five psychological variables hypothesized to be
associated with mood improvements based on a review of the literature (general self-efficacy,
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creative self-efficacy, activation, mindfulness, and social connectedness) during an art group
occurring in a partial hospitalization program for acute psychopathology. More specifically, this
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naturalistic setting allowed us to examine how patients might benefit from an art group delivered
as part of an intensive treatment program delivering Cognitive-Behavioral Therapy (CBT; Beck,
Rush, Shaw, & Emery, 1979) and Dialectical Behavior Therapy (DBT; Linehan, 1993) skills
training, two modalities known to be effective in acute settings (e.g., Webb, Beard, Kertz, Hsu,
& Björgvinsson, 2016). Although other variables besides the five reviewed below may be
relevant to understand changes in mood associated with art-making, we selected these in order to
(1) construct and validate a very brief measure that is feasible and acceptable to use in a clinical
setting, and (2) select variables most relevant to the type of treatment participants were receiving,
and that they might therefore find useful to assess and reflect on during an art group.
General Self-Efficacy
Self-efficacy, also often called “mastery,” is defined as the degree to which individuals
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perceive that they can control events in their lives, and take action to cope with challenges or to
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attain valued goals (Bandura, 1997; Pearlin & Schooler, 1978). Self-efficacy is associated with
lower levels of depression and anxiety, as well as higher levels of well-being (Bandura,
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Pastorelli, Barbaranelli, & Caprara, 1999; Chorpita, Brown, & Barlow, 2016; Zalta &
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Chambless, 2011). Helping individuals recognize which activities provide them with feelings of
self-efficacy and mastery is an important strategy in cognitive-behavioral therapy. In particular,

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the partial program in the present study emphasized practicing behavioral activation techniques
to address symptoms. Behavioral activation refers to a specific set of strategies used to increase
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activity levels and structure; engaging in activities even when motivation or mood is low can
help break the vicious cycle of depressive/anxious avoidance, maintain functioning, and facilitate
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learning which behaviors produce positive reinforcement (Dimidjian et al., 2006; Jacobson,
Martell, & Dimidjian, 2001). When practicing behavioral activation, individuals are explicitly
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encouraged to monitor both mood and feelings of self-efficacy (or mastery) before and after
activities. In keeping with this skill, artistic activities may provide a fertile ground for developing
general self-efficacy (Kaimal & Ray, 2017) by enabling individuals to select activities at
appropriate levels of challenge in relation to their skills (Csikszentmihalyi, 1996); this may in
turn lead to feelings of competence and accomplishment (Fisher & Specht, 1999).
Creative Self-Efficacy
We also examined a more specific form of self-efficacy – creative self-efficacy. Creative
self-efficacy is defined as the subjective belief that one is able to come up with novel and useful
(i.e., creative) ideas, products, or behaviors (Beghetto, 2006; Tierney & Farmer, 2002), and has
been linked to psychological adjustment and well-being (Forgeard & Benson, 2019; Karwowski
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& Lebuda, 2016). To date, and perhaps surprisingly, studies examining the benefits of art-
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making have rarely empirically examined whether creativity-related variables account for art-
making’s effects on mood. With the exception of the nonclinical experimental studies cited
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above that compared the effects of drawing novel material vs. copying images, past studies have
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typically not tested whether the act of generating a novel and valuable product (Stein, 1953;
Sternberg & Lubart, 1995) could account for the benefits of art-making. Examining changes in
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creative self-efficacy in addition to general self-efficacy can help researchers understand whether
the benefits of art-making are specific to creative activities, or whether they may be shared by
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other non-creative activities.
Activation
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Perhaps more simply, engaging in art-making may provide participants with beneficial
stimulation, leading them to feel more activated, alert, and energized. Again, this outcome could
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reflect participants’ use of behavioral activation strategies during a group. Although activation is
often conceptualized as a component of mood, we decided to include this construct separately
from positive/negative mood in order to isolate changes in participants’ arousal and energy levels
during the art group.

Mindfulness
Art may also help participants feel more mindful, by focusing on a specific activity and
set of stimuli during a defined time period. Mindfulness is a key component of several evidence-
based treatments for psychological disorders including Dialectical Behavior Therapy (DBT;
Linehan, 1993), Acceptance and Commitment Therapy (Hayes & Lillis, 2012), and Mindfulness-
Based Cognitive Therapy (Segal, Williams, & Teasdale, 2012), among others. This skill is
defined as “paying attention in a particular way: on purpose, in the present moment, and
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nonjudgmentally” (Kabat-Zinn, 1994, p. 4). The benefits of mindfulness may stem from
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individuals’ enhanced ability to intentionally and flexibly allocate their attention, by increasing
awareness and understanding of, as well as the ability to cope with, external circumstances and
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internal states (Chambers, Gullone, & Allen, 2009). Several authors have described how art-
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making can be used within the framework of DBT to practice mindfulness and help with emotion
regulation (for reviews see Clark, 2016; Rosal, 2016). Focusing on a concrete activity, as is done
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in art groups, may provide a fertile space for individuals to practice mindful awareness of the
present moment (Monti et al., 2006).

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Social Connectedness
Art groups may also help participants develop a sense of social connection based on a
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shared experience. Fostering the development of meaningful, rewarding, and supportive
relationships may constitute an important positive factor in treatment (regardless of orientation),

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whether between patients and treatment providers, or with each other (e.g., Martin, Garske, &
Davis, 2000; Marziali, Munroe-Blum, & McCleary, 1997). In a review and case study of the
usefulness of art therapy for older adults, Johnson and Sullivan-Marx (2006) suggested that
creating art in small group settings may help foster social connectedness by decreasing isolation,
participating in an exchange, and creating a safe place for offering/receiving support. In addition,
engaging in altruistic behavior during groups (e.g., helping others with their artistic projects,
providing support and validation for others, etc.) can help connect individuals with their
strengths. For this reason, some clinicians use approaches specifically designed to foster social
connectedness, for example by asking participants to explore experiences they have in common
(Levine-Madori, 2013).
The Present Studies
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This project investigated short-term outcomes of an art group offered within a naturalistic
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partial hospital program delivering intensive CBT/DBT skills training for acute
psychopathology. These outcomes were specifically selected because they may help explain
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mood improvements experienced by participants engaged in art-making. More specifically, we
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examined relationships between changes in positive/negative mood and changes in five other
outcomes hypothesized to be associated with mood improvements (general self-efficacy, creative

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self-efficacy, activation, mindfulness, and social connectedness). Because we needed a very brief
instrument to measure these constructs in a clinical setting to minimize the burden placed on
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participants and facilitate the completion of the questionnaire within the regular course of a brief
art group session, we conducted a preliminary study (Study 1) to validate a scale for this purpose.
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In the main study (Study 2), which was conducted in a partial hospital program, we expected
participants attending a 50-minute art group to report significant increases in all outcomes except
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negative mood (for which we expected participants to report significant decreases). We also
hypothesized that changes in general self-efficacy, creative self-efficacy, activation, mindfulness,
and social connectedness would all be independently associated with changes in mood.
Study 1
We conducted a preliminary study to develop and validate the brief Art Group
Questionnaire used in Study 2. We needed a very brief instrument that would be feasible to use
without disrupting the normal sequence of the 50-minute art group, and that participants might
find acceptable/useful as a self-assessment exercise. Thus, instead of using existing measures
which were too long for use during the art group given the number of variables were interested
in, we designed and validated a new brief instrument. Because it was therefore also not feasible
to validate this instrument within a sample of patients at the partial hospital program (which
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would have been ideal), we used Amazon MTurk to collect a large enough sample of participants
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who would be able to complete a longer survey. Amazon MTurk is an online crowdsourcing
marketplace through which individuals (or businesses) can recruit others to perform tasks
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virtually in exchange for monetary compensation. This platform is increasingly being used by
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researchers to find participants and enroll them in online studies or experiments; participants
recruited through MTurk tend to be diverse (for reviews see Buhrmester, Kwang, & Gosling,
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2011; Paolacci & Chandler, 2014), though they may present with elevated mood and anxiety
symptoms in comparison to the general population (Arditte, Çek, Shaw, & Timpano, 2016;
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Shapiro, Chandler, & Mueller, 2013). This was not a limitation for the present study given that
we aimed to use the instrument developed in a clinical population.

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Method
Participants. We recruited 193 participants through Amazon MTurk (Mage = 34.60 years,
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SDage = 9.93, 38.3% women, 75.1% White and non-Latinx). They were compensated $0.75 for
completing a 5 to 10-minute survey. All participants provided informed consent to participate in
this study and procedures were reviewed and approved by our local Institutional Review Board.
Materials and Procedures. Participants completed all measures through the survey
administration platform REDCap (Harris et al., 2009). These included the brief Art Group
Questionnaire to be validated for use in Study 2, a disaggregated version of the same
questionnaire, and previously validated measures to assess convergent/divergent validity. In
addition, participants completed two attention check items (e.g., “please select ‘extremely’ for
this question”). We excluded 14 participants who failed one (n = 7) or both (n = 3) attention
checks or had missing data (n = 4) on these variables, resulting in a final sample size of 179
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participants for analyses. All measures had adequate levels of internal consistency in the present
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study (all αs > .70, as described below). For all instruments presented below, we invited
participants to report on their experiences “right now, in the present moment” (modifying
original instructions if needed).

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Art Group Questionnaire. As explained above, participants completed a very brief 7-
item questionnaire designed for this project in order to assess different states in the present
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moment (see Appendix). Participants indicated how they were feeling “right now” on a 5-point
Likert-type scale (from “not at all,” to “extremely”). Each item assessed one construct of interest
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using three adjectives: general self-efficacy (“competent, effective, capable”), creative self-
efficacy (“creative, imaginative, innovative”), activation (“energized, invigorated, stimulated”),

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mindfulness (“mindful, present, attentive”), social connectedness (“supported, connected, cared
for”), positive mood (“pleased, content, happy”), and negative mood (“frustrated, anxious, sad”).
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The order of items was determined using a random number generator. The content of items was
designed by examining existing measures of similar constructs (e.g., Baer, Smith, Hopkins,
Krietemeyer, & Toney, 2006; Beghetto, Kaufman, & Baxter, 2011; Carver & White, 1994;
Diener et al., 2010; Schwarzer & Jerusalem, 1995; Zimet, Dahlem, Zimet, & Farley, 1988) and
through piloting with research team members to ensure feasibility and clarity of the terms used.
Single-item measures, though usually inferior to multi-item instruments, can be acceptable if the
constructs measured are narrow enough (Wanous, Reichers, & Hudy, 1997) and when their use
enables the feasibility of measurement in clinical settings (Zimmerman et al., 2006), which was
the ultimate goal of this validation effort.
Disaggregated version of the Art Group Questionnaire. To validate the use of items
combining three adjectives in the brief 7-item scale described above, we also asked participants
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in this preliminary study to complete a 21-item version of the same scale in which adjectives
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were presented one by one (instead of in groups of three).
Positive and negative affect. Participants completed the International Positive and
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Negative Affect Schedule – Short Form (I-PANAS-SF; Thompson, 2007), a 10-item
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questionnaire assessing broad positive (α = .80) and negative affect (α = .93) in the present
moment using a 5-point rating scale.

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General and creative self-efficacy. Participants completed two brief 6-item scales
measuring state general (α = .94) and creative self-efficacy (α = .92) using a 5-point rating scale
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(Forgeard & Benson, 2019). These two scales assessed the degree to which participants currently
felt (a) generally able to accomplish their goals and persevere through obstacles, and (b) able to
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use their imagination and come up with novel and useful ideas.
Activation. Participants completed the Vigor subscale of the Abbreviated Profile of Mood
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States questionnaire (A-POMS; Grove & Prapavessis, 1992), a 5-item subscale assessing current
levels of vigor (α = .93) using a 5-point rating scale.
Mindfulness. Participants completed the Toronto Mindfulness Scale (Lau et al., 2006), a
13-item measure using a 5-point rating scale which yields two subscale scores corresponding to
Curiosity about the present moment (α = .92) and Decentering, defined as disidentification with
one’s immediate thoughts and feelings (α = .83).
Social connectedness. Participants completed the Social Connectedness Scale – Revised
(SCS-R; Lee, Draper, & Lee, 2001), a 20-item scale assessing perceived social connection (α =
.96) using a 6-point rating scale.
Data Analytic Strategy. First, we used Confirmatory Factor Analysis (CFA) conducted
in Mplus 7 (Muthén & Muthén, 2012) to verify that the three adjectives chosen to measure each
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construct indeed captured the same latent variable using responses from the 21-item
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disaggregated version of the Art Group Questionnaire (as these were combined into a single item
for the briefer 7-item version used in Study 2). We followed recommendations to assess the fit of
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the model using multiple indices given that sample size has an important effect on the
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significance of chi-square tests (Hu & Bentler, 1999; Kline, 2005): we examined absolute values
of the Root Mean Square Error of Approximation (RMSEA = or < .08 indicates adequate fit),
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Comparative Fit Index (CFI = or > .90 indicates adequate fit) and Standardized Root Mean
Squared Residual (SRMR = < .08 indicates adequate fit). We then examined whether items
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loaded significantly on their respective constructs.
Second, we examined bivariate correlations between each single-item measure from the
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7-item Art Group Questionnaire and its corresponding convergent validity measures, expecting
rs to reflect moderate-to-strong associations. We used the negative affect subscale of the

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PANAS-SF as a measure of divergent validity (except for the item assessing negative affect, for
which we used the positive affect subscale of the PANAS-SF as a measure of divergent validity),
expecting rs to reflect weak associations. Finally, we compared rs using Fisher’s r-to-z

transformation, expecting correlations with convergent validity measures to be significantly
stronger than correlations with divergent validity measures.
Results
Confirmatory factor analysis. We used CFA to determine whether the three adjectives
comprised within each item of the Art Group Questionnaire reflected the same latent variable.
The fit of the model was adequate, χ2 (168) = 342.24, p < .001, RMSEA = .08 (90% CI = .07-
.09), CFI = .93, SRMR = .06. All items loaded significantly on their hypothesized latent
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variables (see Figure 1). Thus, the three adjectives chosen to measure each construct grouped
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together as expected. All latent variables correlated significantly with each other (ps < .05) with
the exception of social connectedness and negative affect, as well as activation and negative
affect (ps > .05).

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Convergent and divergent validity. As expected, we found moderate-to-strong
associations (rs = .47 - .77) between each item and its convergent validity measure, with one
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exception: the mindfulness item only correlated weakly with the Toronto Mindfulness Scale
Curiosity (r = .28) and Decentering (r = .27) subscales. We also found weak correlations
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between each item and its divergent validity measure (rs = -.12-.25). Fisher’s r-to-z
transformations confirmed that each item’s correlation with its convergent validity measure was
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significantly stronger than with its divergent validity measure (all ps < .001). Table 1 provides all
results.
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Discussion
Results of Study 1 indicated that the brief 7-item Art Group Questionnaire designed for
use in clinical settings demonstrated coherent measurement of several relevant psychological
variables (as assessed using CFA) and adequate convergent/divergent validity. However,
correlations between the mindfulness item and our convergent validity measure (two subscales of
the Toronto Mindfulness Scale) were weaker than expected. It is likely that there was a mismatch
between the brief item designed to capture temporary states of mindfulness (“mindful, present,
attentive”) and this convergent validity measure, which focused on beliefs/attitudes (e.g., “I
experience my thoughts more as events in my mind than as a necessarily accurate reflection of
the way things ‘really’ are”). Despite the instructions provided, it may have been difficult for
participants to rate these items in the present moment. Given that the three adjectives chosen did
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group together in our CFA and the convergent correlations were significantly stronger than the
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divergent measure correlation, we kept this item in our final scale but interpreted any relevant
results with caution in Study 2.
Study 2
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In Study 2, we used the brief Art Group Questionnaire validated in Study 1 to examine
psychological experiences of individuals attending a brief 50-minute art group as part of a partial
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hospital program focusing on CBT/DBT skills training, and to determine whether changes in
mood experienced during the art group were associated with changes in other psychological
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outcomes captured by this questionnaire.
Method
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Participants. Participants included 175 patients attending a partial hospitalization
program at a private psychiatric hospital in the United States between September of 2015 and
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April of 2016. All participants consented for their data to be used for research purposes and
attended at least one art group during treatment at the partial hospital program. Participants were
predominantly in young to middle adulthood (M = 33.68 years old, SD = 13.70), women (54.9%,
men = 42.3%, non-binary= 1.7%, 1.1% missing) and non-Latinx White (86.9%, 13.1% other
race/ethnicity, 5% multiracial). Approximately half of participants (49.1%) had less than a 4-year
college degree, were unemployed (53.7%), and had been hospitalized for psychiatric reasons in
the past 6 months (53.7%). This sample was high in comorbidity, with 58.9% of participants
currently meeting criteria for two or more psychological disorders and 33.3% for three or more
psychological disorders (as determined by a structured clinical interview). The most common
diagnosis was a major depressive disorder (58.2%) (see Table 2 for more information about
training of interviewers and all diagnostic characteristics of this sample).
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Treatment at this brief intensive partial hospitalization program focuses on evidence-
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based treatment to manage acute symptoms. All treatment takes place during the day, with
patients returning home on evenings/weekends. As explained above, the majority of treatment
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focuses on the acquisition and practice of skills drawn from CBT (e.g., behavioral activation,
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cognitive restructuring) and DBT (e.g., mindfulness, distress tolerance, emotion regulation,
interpersonal effectiveness). The program serves individuals with a wide range of psychological
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disorders (principally mood, anxiety, personality, and psychotic disorders). The average length
of stay in the program for this sample was 12.57 days (including non-treatment weekend days).
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Treatment consists of pharmacotherapy, case management, and group and individual therapy
(provided by psychiatrists, social workers, psychologists, and psychology trainees, as well as

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nurses and mental health counselors). Patients attend a variety of 50-minute therapy groups
during the day, including the art group examined in this study (as described below) (for more
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information about this program including its effectiveness see Forgeard, Beard, Kirakosian, &
Björgvinsson, 2018).
Art Group. All participants took part in at least one art group during their stay in the
partial program. These groups were offered four days per week and were led by either a
postdoctoral fellow in clinical psychology, or one of three bachelor’s level community residence
counselors supervised by the postdoctoral fellow. The treatment program in which this study
took place did not have an art therapist on staff. The art group in this treatment program was
originally developed by an occupational therapist with specific training in art therapy, who
trained group leaders prior to leaving her position (and prior to the start of data collection for this
study). This staff member had completed a semester-long course in art therapy with an art
therapist as part of her occupational therapy studies. She had also worked alongside an art
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therapist in several psychiatric facilities following completion of her degree. Nonetheless, the art
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groups offered in this program were not led by art therapists and therefore did not constitute art
therapy. Instead, the primary focus of art groups in this partial hospital program was to build
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coping skills and leisure interests through art-making, allowing group leaders to assess how
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patients function in their everyday life and approach new tasks.
In this partial hospital program, case managers collaborate with patients to determine
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which groups they will attend (including the art group). Because 65 out of 175 participants
attended the group more than once, our main analyses only included each person’s first group
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participation (responses from participants who attended the group twice were used for the
purpose of test-retest reliability analyses, see below).

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At the beginning of each art group session, the group leader introduced the brief Art
Group Questionnaire validated in Study 1 as a self-assessment exercise, asking participants to

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take a few minutes to think about how they were currently feeling. Participants then worked on
an artistic project of their choice during the next 45-minute period. Group leaders encouraged
participants to explore materials available in the art studio: 34.3% engaged in coloring, 20.6% in
drawing, 15.4% in painting, 3.4% in collage, 7.4% in crafts, 5.7% in origami/paper-folding,

9.1% in jewelry-making, 2.3% in writing, and 8.6% in other activities (e.g., clay/sculpting,
crochet, etc.)1. Group leaders did not structure the session around specific instructions, with one
exception: one session per week (out of four) also included a facilitated discussion in which
participants were asked to specifically describe a transition they were currently experiencing,
thus adding a “processing” component. In the other three sessions, participants were free to
informally converse with peers on topics of their choice. Because we wanted to examine
participants’ experiences in art groups as they ran in naturalistic settings, we did not modify the
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group protocols in place, but still took care to examine in our analyses whether outcomes
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differed by group type (processing vs. no processing).
After working on a project of their choice for 45 minutes, participants were asked to
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repeat the self-assessment exercise they completed at the beginning of the session by filling out
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the 7-item Art Group questionnaire again. They also indicated which type of activity they chose
(using the list of activities provided above) and provided optional open-ended comments
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regarding their experience in the group. The session concluded with a 5-minute discussion about
what participants learned by doing self-assessment (i.e., filling out the Art Group Questionnaire
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at the beginning/end of the group).
Materials and Procedures. All participants provided consent for their data to be used in
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research and the local Institutional Review Board approved all study procedures.
Art Group Questionnaire. Participants completed the 7-item Art Group Questionnaire
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validated in Study 1 at the beginning and end of the art group. As explained above, the brevity of
the questionnaire was necessary to help patients monitor and reflect on what they experienced
during the art group without creating undue burden or limitations on the way the group would
1 Some participants engaged in more than one activity.

typically run. To further validate this brief instrument, we also used examined test-retest
reliability in the subset of participants who attended the art group twice (n = 65), as this measure
can help establish the appropriateness of single-item measures (Youngblut & Casper, 1993;
Zimmerman et al., 2006). Correlations between the first and second administrations were
moderate and significant (positive mood r = .49, negative mood r = .50, general self-efficacy r =
.49, creative self-efficacy r = .52, activation r = .36, mindfulness r = .36, social connectedness r
= .58, all ps < .005), as expected given that items assessed how participants were feeling “right
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now” (Crocker & Algina, 2006).
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Depressive symptoms at admission. Participants completed the Patient Health
Questionnaire-9 (PHQ-9; Kroenke & Spitzer, 2002) upon admission to the partial program as
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part of routine clinical care. This measure was administered using REDCap (Research Electronic
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Data Capture), a secure, web-based application designed to support data collection for research
studies (Harris et al., 2009). The PHQ-9 is a validated 9-item self-report measure assessing the
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frequency of symptoms of depression (e.g., “feeling tired or having little energy”) over the past
two weeks on a 4-point scale. We used this measure to determine whether patients who attended
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the art group during their stay in the program differed in depression symptom severity from those
who did not.

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Data Analytic Strategy.
Attendance to art group. We conducted preliminary one-way ANOVAs and chi-square

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tests to assess whether participants who took part in art groups differed from patients who did not
based on demographic characteristics (age, gender, race/ethnicity, education level) and baseline
depressive symptoms.
Overall outcomes during group. We conducted a repeated-measures MANOVA to
assess whether participants experienced significant changes in all outcomes measured by the Art
Group Questionnaire during the art group.
Predictors of outcomes. To prepare for building a path model (see below), we ran
correlations and one-way ANOVAs to determine whether changes in all outcomes during the art
group were associated with demographic variables (age, education, depressive symptoms at
admission), group features (group leader, group size, group type: processing vs. no processing),
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and artistic medium/activity selected by participants.
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Relationships between mood and other outcomes. Finally, we examined relationships
between changes in positive/negative mood and changes in all other outcomes simultaneously
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(general self-efficacy, creative self-efficacy, activation, mindfulness, social connectedness) using
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path analysis. The model controlled for variables associated with changes in outcomes in
preliminary analyses, as well as all outcomes at the beginning of the art group. Path analysis was
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implemented in Mplus 7 using full-information maximum likelihood (FIML) estimation (Muthén
& Muthén, 2012). We tested saturated models in order to assess relationships between all
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variables; thus, fit indices are not available. We opted for path analysis rather than multiple
regression analyses in order to take advantage of FIML to adjust results for missing data, and to
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be able to simultaneously assess and examine how changes in outcomes related to both changes
in positive and negative mood.

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Results
Attendance to art group. A total of 391 participants received treatment at the partial
program during the period of time this study was conducted and consented for their data to be
used in research. Individuals who attended at least one art group (n = 202)2 did not differ from
non-attenders (n = 189) on gender3, ethnicity (non-Latinx White vs. others), age, education level,
or depressive symptoms at admission (all ps > .05). Attenders had longer lengths of stay in the
program (M = 12.66 days, SD = 3.63) compared to non-attenders (M = 10.71 days, SD = 5.57), F
(1, 387) = 16.90, p < .001, Cohen’s d = .41.
Overall outcomes during group. A repeated-measures MANOVA (including all
outcomes as dependent variables) revealed a significant overall effect of time, Wilks’ Lambda =
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.44, F (7, 151) = 27.66, p < .001, η2 = .56. Follow-up ANOVAs indicated significant changes in
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the expected direction for all outcomes (all ps < .05, Cohen’s ds = .15-.68, see Table 3).
Participants therefore reported experiencing decreases in negative affect, but increases in positive
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affect, general self-efficacy, creative self-efficacy, activation, mindfulness, and social
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connectedness over the course of the art group.
Predictors of outcomes. Age, depressive symptoms at admission, and group size were
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not related to any of the outcomes (all ps > .05). Education was negatively related to changes in
positive mood (partial r = -.17, p = .03), but not to any other outcomes (all ps > .05). Women (M
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= .64, SD = .88) reported larger increases in general self-efficacy than men (M = .15, SD = .84),
F (1, 157) = 4.70, p = .03, Cohen’s d = .57. Outcomes did not vary according to race/ethnicity,
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group type (processing vs. no processing), and group leader. Change in positive affect was the
only outcome to vary by medium/activity selected by participants, F(7, 128) = 2.18, p = .04;
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2
Attenders (n = 202) included patients who attended any art groups, even if they did not complete the main
questionnaire for this study and were not included in the sample described above or used in our statistical analyses
(n = 175).
3
Because of the low number of individuals identifying as a gender other than man or woman, statistical analyses do
not include them.
however, Bonferroni-corrected posthoc tests did not detect any reliable differences (all ps > .05).
Based on these results, education and gender were covaried in path analyses.
Relationship between mood and other outcomes. We ran a path-analytic model to
assess differential relationships between changes in positive/negative mood and changes in other
outcomes during the art group. We covaried education, gender, and all outcomes measured at the
beginning of the group by entering them as additional predictors in the model. Table 4 presents
the raw correlation matrix among all variables in the model. These correlations indicated that
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changes in positive mood were significantly associated with changes in all other outcomes
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during the art group (all ps < . 001), and changes in negative mood were significant associated
with changes in all outcomes (ps < .05) except activation and social connectedness (both ps >
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.05). Figure 2 and Table 4 present results for the path model. Examination of standardized path
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coefficients indicated that changes in general self-efficacy (β = .22, p = .046) and changes in
mindfulness (β = .30, p = .001) were significantly associated with changes in positive mood
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when controlling for other predictors. Changes in general self-efficacy (β = -.23, p = .03) were
associated with changes in negative mood when controlling for other predictors. All other paths
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were not significant (all ps > .05). The covariance path between changes in positive and negative
mood was significant (β = -.15, p = .02).

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Discussion
Results of our main study showed that participants enrolled in a partial hospitalization
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program reported experiencing improvements in mood as well as in general self-efficacy,
creative self-efficacy, activation, mindfulness, and social connectedness while engaging in a 50-
minute art group. Changes in positive and negative mood during art groups were differentially
associated with changes in other outcomes. Specifically, increases in general self-efficacy and
mindfulness related to increased positive mood, and increases in general self-efficacy related to
decreased negative mood. Changes in other psychological variables (creative self-efficacy, social
connectedness, and activation) did not relate to changes in mood when all variables were
simultaneously entered as predictors in the model.
General Discussion
Results of the present study provide new insights into experiences of patients attending
art groups offered as part of intensive psychiatric partial hospitalization. These results contribute
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to the literature examining the benefits of art-making in several ways. They highlight that the
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mood benefits of such activities could be predicted by other variables (Gruber & Oepen, 2018),
including variables not specifically contingent on the creative and/or artistic process. Indeed, to
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date, past research has not yet demonstrated that creativity-related variables account for the
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benefits of creative activities such as art (Forgeard & Elstein, 2014).
Increases in general self-efficacy following the art group predicted improvement in both
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positive and negative mood. More research is needed to assess whether/how art groups foster
general self-efficacy defined as the belief that one is competent and able to execute and
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accomplish personal goals (see also Kaimal & Ray, 2017). In contrast, creative self-efficacy was
not associated with changes in mood when both types of self-efficacy were examined
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simultaneously. Similarly, in a recent study, general self-efficacy derived from extracurricular
activities for youths was also more closely related to psychological adjustment than creative self-
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efficacy (Forgeard & Benson, 2019). Our findings are consistent with the literature documenting
associations between self-efficacy and psychological adjustment across pathologies (Maddux,
2009). Providing brief and concrete activities for individuals experiencing acute psychological
difficulties (such as creating a piece of art during a 50-minute period) may set the stage for
increasing beliefs in one’s abilities to take action that lead to satisfying outcomes.
This study also showed that increases in mindfulness related to increases in positive
mood over the course of the art group. Art-making may be particularly useful in this regard by
encouraging patients to focus their attention on an experiential process, moving past verbal
description and intellectual comprehension to facilitate direct personal experience (Clark, 2016).
Of note, participants attended other therapy groups in our program, including groups where DBT
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skills (such as mindfulness) were discussed and practiced. It is therefore possible that
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participants took advantage of art groups to apply the mindfulness skills they had previously
learned, though more research would be needed to substantiate this hypothesis. Findings
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pertaining to mindfulness are limited by the fact this item showed limited convergent validity
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with another measure assessing mindful attitudes and beliefs in Study 1 (the Toronto
Mindfulness Scale; Lau et al., 2006), though Confirmatory Factor Analysis confirmed that the
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three adjectives used (“mindful, present, attentive”) adequately captured the same construct. The
state captured by the item used in the Art Group Questionnaire might therefore differ from
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mindfulness conceptualized more broadly, and most likely simply referred to whether
participants felt attentive and present in the current moment they completed the questionnaire
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(regardless of whether they more generally practiced principles of mindfulness in their lives).
This study was conducted in a naturalistic setting, which enhances the external validity
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of findings by testing questions among patients experiencing clinically significant and
transdiagnostic challenges. This consideration is important given that previous research
investigating the short-term benefits of art-making for mood has typically been conducted in
nonclinical settings (Gruber & Oepen, 2018). This naturalistic setting however also presents
important limitations. First and foremost, this study did not include a control group to assess
short-term changes in mood and other outcomes during another intervention. Thus, this study
could not determine whether the benefits experienced by participants were unique to the art
group; rather, it sought to investigate which psychological variables most closely related to mood
improvements during art-making. Changes in mood and other outcomes during art groups may
not differ from changes occurring in other groups. In fact, our results suggest that it is likely that
similar experiences are involved (since the most specific outcome to art-making activities,
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creative self-efficacy, was not more highly correlated with mood than other outcomes). Our
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uncontrolled pre/post design also did not allow us to examine whether the outcomes assessed
here may also act as processes explaining the benefits of the group. Future research using
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controlled and mediational designs, which would require measurement at more time points
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during the group, is needed to ascertain the degree to which changes in specific variables actually
cause changes in positive/negative mood (Kazdin, 2007) and may act as mechanisms of change.
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It is possible changes in mood drove changes in other outcomes, or that third variables (e.g.,
constructs not measured in this study) accounted for the present results. For example, it may be
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interesting to further study the degree to which variables related to the therapeutic relationship
(e.g., alliance with clinician, quality of interactions with other group members) could explain the
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benefits of art-making in clinical settings.
Second and related, approximately half of patients attending the partial program did not
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attend art groups during their stay, raising the possibility of a selection bias. Preliminary analyses
however showed that the only distinguishing feature of individuals attending these groups was
that they tended to, on average, attend the program for a longer period of time. Individuals who
attended art groups did not differ from others on a range of demographic variables (age, sex,
race/ethnicity, education levels) or on depressive symptoms at admission.
Third, the art groups in this study were not led by art therapists (as these were not on staff
at this program) but by other treatment team members who also delivered CBT and DBT skills
groups. Although this is a common practice in clinical settings and makes our results relevant to
other similar contexts/interventions, this also means that results can only speak to the use of
unstructured art-making during treatment, and not to the use of other art-based interventions
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including art therapy more specifically. Further research should assess whether outcomes might
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differ based on the content of the session, including whether group leaders implemented a
specific art-making intervention. It might be especially informative to study short-term outcomes
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of CBT- and DBT-informed art therapy which directly and explicitly integrate relevant cognitive
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and behavioral principles within sessions (e.g., Clark, 2016; Heckwolf, Bergland, & Mouratidis,
2014; Rosal, 2016). Indeed, artistic activities may be well-suited to help clinicians flexibly
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implement principles of CBT and DBT by tailoring interventions to the needs and preferences of
each individual (e.g., Kendall & Beidas, 2007; Kendall, Chu, Gifford, Hayes, & Nauta, 1999). A
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therapist may, for example, encourage a patient to engage in artistic activities to increase energy
levels and encourage value-driven behavior, to practice mindfulness by focusing on the task at
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hand, or to gradually confront anxiety-provoking memories by using art as a vehicle for
expression (among other possible uses).

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Fourth, this study used a very brief measure (the Art Group Questionnaire) to assess
constructs of interest; the brevity of the measure was needed for the study to be feasible in a
clinical context, and to balance the burden/benefit ratio in order to maximize clinical relevance
and usability for patients (see also Zimmerman et al., 2006). This method allowed us to directly
compare outcomes to one another and isolate relationships between each outcome and
positive/negative mood. Although we took care to validate this measure in a preliminary study
and to examine its test-retest reliability in our main study, future research should ideally use
multi-item scales whenever feasible.
Despite these limitations, the present studies extend the scientific understanding of the
benefits of art-making during psychological treatment as delivered in real-world clinical settings.
In particular, Study 2 suggested that patients perceived a number of adaptive consequences of art
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group participation beyond mood improvements. The roles of general self-efficacy and
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mindfulness should be further studied given the links between these outcomes and mood benefits
during art-making. Though we could not assess this directly in the present study, it possible that
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participants used this activity to implement skills learned during treatment without being
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specifically prompted to do so (though the self-assessment questionnaire likely acted as a
reminder). Future research could assess the usefulness of art groups explicitly designed to
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practice specific skills, as well as potential moderators of the usefulness of art in treatment (e.g.,
patient preferences and motivation, personality traits, previous experience with treatment, etc.).
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Nonetheless these findings suggest that studying patients’ experiences while they make art in
naturalistic clinical settings may help further shed light on how artistic activities may benefit
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mood.
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Figure 1. Results of the confirmatory factor analysis on the 21-item disaggregated version of the
Art Group Questionnaire. From left to right: residual variances, indicator variables (items),
standardized path coefficients, and latent variables (constructs).

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Figure 2. Results of the path analysis examining relationships between changes in
positive/negative mood and changes in other outcomes during the art group (controlling for
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gender, education, as well as all outcomes measured at the beginning of the art group),
including significant standardized path coefficients and residual variances (nonsignificant paths
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are omitted).
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Table 1
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Correlations Examining Convergent and Divergent Validity of Items Included in the Brief 7-Item Art Group Questionnaire, and
Fisher’s r-to-z Transformation Comparing Correlation Coefficients.
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Convergent Validity Divergent Validity
Art Group Questionnaire Item Pearson's r Pearson's r Fisher's r-to-z
Measure Measure
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1. creative, imaginative, innovative State CSE .582*** PANAS-SF NA 0.246** 3.89***
2. supported, connected, cared for SCS-R .475*** PANAS-SF NA .013 4.72***
3. energized, invigorated, stimulated
4. mindful, present, attentive

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A-POMS Vigor
TMS Curiosity
.773***
.284***
PANAS-SF NA
PANAS-SF NA
0.216**
-.115
7.58***
3.82***
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TMS Decentering 269*** PANAS-SF NA -.115 3.67***
5. pleased, content, happy PANAS-SF PA .468*** PANAS-SF NA -.101 5.71***
6. competent, effective, capable State GSE .507*** PANAS-SF NA -.111 6.29***

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8. frustrated, anxious, sad PANAS-SF NA .714*** PANAS-SF PA .035 8.07***

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Note. *** p < .001, ** p < .01, * p < .05

Table 2
Diagnostic Characteristics of the Present Sample, Based on the Miniature International
Neuropsychiatric Interview.
MINI Diagnosis N Percentage of Sample
Major Depressive Disorder (lifetime) 93 69.4%
Major Depressive Episode (current) 78 58.2%
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Bipolar Disorder (lifetime) 28 20.9%
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Major Depressive Episode (current) 19 14.2%
Mania or hypomania (current) 2 1.48%
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Generalized Anxiety Disorder (current) 54 40.3%
Social Anxiety Disorder (current) 40 29.9%

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Alcohol Use Disorder (current) 31 23.1%
Panic Disorder (current) 25 18.7%

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Posttraumatic Stress Disorder (current) 20 14.9%
Obsessive-Compulsive Disorder (current) 15 11.2%

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Psychotic Disorder (current) 6 4.5%
Note. Participants completed the Mini International Neuropsychiatric Interview (MINI; Sheehan et al.,
1998) to assess for DSM-IV disorders. The MINI was completed by 134 participants (77% of the sample);
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41 participants did not complete the MINI due to a variety of clinical reasons including early discharge,
symptom acuity, or other concerns. Participants completed the MINI with a clinician at the beginning of
treatment in the PHP (typically on their second day of treatment). The MINI has strong reliability and
validity in relation to the Structured Clinical Interview for DSM-IV (SCID-IV), with inter-rater
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reliabilities ranging from kappas of .89-1.0 (Sheehan et al., 1998). In this study, the MINI was
administered by doctoral practicum students and interns in clinical psychology who received weekly
supervision by a postdoctoral fellow. Training included reviewing administration manuals and
completing mock interviews, as well as participating in bi-annual reliability ratings.
Table 3
Means and Standard Deviations for All Outcomes Before and After Group; Results of One-Way
ANOVAs Including F Statistics, P-Values, and Effect Sizes (Cohen’s d).
Before After
Group Group
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Cohen's
Outcome M SD M SD F(1,157) p d
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Positive Mood 2.64 1.02 3.32 0.99 94.38 <.001 0.68
Negative Mood 2.58 1.12 2.01 1.05 58.02 <.001 0.52
Creative Self-Efficacy 2.64 1.11 3.28

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1.02 83.27 <.001 0.60
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General Self-Efficacy 2.91 1.07 3.32 0.90 34.34 <.001 0.41
Activation 2.55 1.11 3.23 0.98 84.56 <.001 0.65

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Mindfulness 2.92 0.96 3.50 0.93 57.44 <.001 0.61
Social Connectedness 3.39 1.00 3.54 0.96 5.59 .02 0.15

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Table 4
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Bivariate Correlations (r) for all Variables Included in the Path Model.
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pm nm cse gse act mind soc edu gender pm nm cse gse act mind soc
(chg) (chg) (chg) (chg) (chg) (chg) (chg) (pre) (pre) (pre) (pre) (pre) (pre) (pre)
pm (chg) 1
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nm (chg) -.29*** 1
cse (chg) .23** .18* 1
gse (chg) .22** -.27*** .17* 1
act (chg) .36*** -.15 .29*** .33*** 1
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mind (chg) .39*** -.24** .24** .28*** .40*** 1
soc (chg) .35*** -.06 .15* .17** .44*** .27*** 1
edu -.15 .12 .03 .05 .00 -.08 -.16* 1
gender -.19* .15 -.15 -.28*** -.14 -.18* .04 -.24** 1
pm (pre)
nm (pre)
cse (pre)
gse (pre)
act (pre)
-.48***
.17*
.02
-.11
-.12
.26***
-.51***
.21**
.26***
.16*
-.08
.14
-.50***
-.14
-.18*
-.02
.08
-.13
-.58***
-.10
lP-.21**
-.08
-.15
-.24**
-.56***
-.10
.06
.01
-.07
-.15
-.06
-.04
.10
.05
-.11
-.01
-.06
-.10
-.14
-.08
.20**
-.22**
.09
.25***
.14
1
-.45***
.43***
.56***
.65***
1
-.19*
-.33***
-.29***
1
.56***
.61***
1
.60*** 1
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mind (pre) -.15 .27*** -.09 -.14 -.23** -.55*** -.04 -.01 .19* .56*** -.33*** .39*** .54*** .58*** 1
soc (pre) -.21** .08 -.03 -.03 -.23** -.19* -.48*** .13 -.01 .52*** -.19* .32*** .40*** .58*** .42*** 1
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Note. *** p < .001, ** p < .01, * p < .05; chg = change score; pre = pretest score; pm = positive mood; nm = negative mood; cse =
creative self-efficacy; gse = general self-efficacy; act = activation; mind = mindfulness; soc = social connectedness; edu = education;
gender = gender (1 = woman, 2 = man)
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Table 5
Unstandardized and Standardized Path Estimates, Standard Errors, and P-Values for the Path
Model.
Unstd B SE Std β SE p
cse (chg) → pm (chg) 0.13 0.10 .13 .10 .17
gse (chg) → pm (chg) 0.21 0.11 .22 .11 <.05
act (chg) → pm (chg) 0.22 0.12 .23 .13 .07
mind (chg) → pm (chg) 0.28 0.09 .30 .09 <.001
soc (chg) → pm (chg) 0.05 0.10 .05 .10 .60
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pm (pre) → pm (chg) -0.81 0.08 -.93 .09 <.001
nm (pre) → pm (chg) -0.06 0.04 -.08 .05 .12
cse (pre) → pm (chg) 0.05 0.09 .06 .10 .59
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gse (pre) → pm (chg) 0.17 0.12 .20 .14 .15
act (pre) → pm (chg) 0.29 0.13 .36 .17 .04
mind (pre) → pm (chg) 0.25 0.11 .27 .11 .02
soc (pre)
gender
edu
→
→
→
pm (chg)
pm (chg)
pm (chg)
0.00
-0.08
-0.05
0.10
0.08
0.05
.00
-p
-.05
-.05
.11
.05
.05
.98
.32
.32
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cse (chg) → nm (chg) 0.04 0.09 .04 .09 .64
gse (chg) → nm (chg) -0.24 0.11 -.23 .10 .03
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act (chg) → nm (chg) 0.04 0.10 .04 .10 .72

mind (chg) → nm (chg) -0.16 0.10 -.16 .10 .11
soc (chg) → nm (chg) -0.07 0.12 -.06 .11 .54
pm (pre) → nm (chg) 0.09 0.12 .10 .12 .42
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nm (pre) → nm (chg) -0.39 0.07 -.47 .08 <.001

cse (pre) → nm (chg) 0.17 0.09 .20 .11 .06
gse (pre) → nm (chg) -0.05 0.13 -.05 .15 .73
→
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act (pre) nm (chg) -0.06 0.12 -.07 .14 .60

mind (pre) → nm (chg) -0.04 0.12 -.04 .12 .76
soc (pre) → nm (chg) -0.13 0.10 -.14 .10 .19
→
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gender nm (chg) -0.04 0.15 -.02 .08 .79

edu → nm (chg) 0.07 0.06 .07 .06 .26
pm (chg) ↔ nm (chg) -0.07 0.03 -.16 .07 .02
Note. chg = change score; pre = pretest score; pm = positive mood; nm = negative mood; cse =
creative self-efficacy; gse = general self-efficacy; act = activation; mind = mindfulness; soc =
social connectedness; edu = education; gender = gender (1 = woman, 2 = man)
Appendix
Art Group Questionnaire
Part 1 (To be completed at the beginning of group): Please use the scales below to describe
how you feel RIGHT NOW. There are no right or wrong answers! We are asking you to
complete this questionnaire as an opportunity to practice self-assessment.
not at all a little somewhat very extremely

creative, imaginative, innovative 1 2 3 4 5
supported, connected, cared for 1 2 3 4 5
energized, invigorated, stimulated 1 2 3 4 5
mindful, present, attentive 1 2 3 4 5
pleased, content, happy 1 2 3 4 5
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competent, effective, capable 1 2 3 4 5
frustrated, anxious, sad 1 2 3 4 5
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Thanks, you are ready to start working on your project! You will fill out the other side of
this document at the end of the group.
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Part 2 (To be completed at the end of group): Please answer the questions below at the end of
group, in preparation for a brief discussion with other group members.
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First, what activity (or activities) did you choose? Check all that apply.
Coloring ❏ Drawing ❏ Painting ❏ Collage ❏ Crafts ❏
Origami / Paper folding ❏ Jewelry ❏ Writing ❏
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Other ❏ Describe: _____________________________________________________
Second, we’d like you to fill out this questionnaire again. Please use the scales below to
describe how you feel RIGHT NOW.
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not at all a little somewhat very extremely

creative, imaginative, innovative 1 2 3 4 5
supported, connected, cared for 1 2 3 4 5
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energized, invigorated, stimulated 1 2 3 4 5

mindful, present, attentive 1 2 3 4 5
pleased, content, happy 1 2 3 4 5
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competent, effective, capable 1 2 3 4 5

frustrated, anxious, sad 1 2 3 4 5
Finally, we would like to ask you for your opinion about this group. What do you like the
best/least about this group? In what ways do you think that creative self-expression is (or is
not) helpful? Any comments/suggestions?
[Open-Ended Response]

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Changes in General Self-Efﬁcacy and Mindfulness are Associated with

Marie Forgeard, Alexandra Silverman, Jennifer Buchholz, Courtney

To appear in: The Arts in Psychotherapy

Received Date: 13 May 2019

© 2020 Published by Elsevier.

Changes in General Self-Efficacy and Mindfulness are Associated with Short-Term

Improvements in Mood during Art-Making in a Partial Hospital Program

Marie Forgeard1,2 Alexandra Silverman3, Jennifer Buchholz4, Courtney Beard1, Thröstur

James College, 115 Mill Street, Belmont MA 02478, 617-855-4456,

mforgeard@mclean.harvard.edu. The authors do not have conflicts of interests to disclose. They

Behavioral Health Partial Program at McLean Hospital.

 •Intensive treatment programs often offer art groups to patients

provide useful insights into how this activity enhances mood.

Keywords: art; mood; self-efficacy; mindfulness

delivering intensive treatment for individuals experiencing acute psychiatric symptoms.

individuals returning home in the evenings/weekends.

The Benefits of Art-Making

area conclude that art-making interventions (delivered as a primary intervention, or as an

research (Abbing et al., 2018).

To complement research assessing medium- to long-term outcomes of participation in

question by examining participants’ changes in mood resulting from art-making. More

Despite the growing body of work documenting mood benefits of art-making in

general processes common to most therapeutic activities or by processes specific to creative

To that end, the present study examined associations between changes in

positive/negative mood and changes in five psychological variables hypothesized to be

as part of an intensive treatment program delivering Cognitive-Behavioral Therapy (CBT; Beck,

self-efficacy and mastery is an important strategy in cognitive-behavioral therapy. In particular,

We also examined a more specific form of self-efficacy – creative self-efficacy. Creative

other non-creative activities.

often conceptualized as a component of mood, we decided to include this construct separately

during the art group.

present moment (Monti et al., 2006).

shared experience. Fostering the development of meaningful, rewarding, and supportive

relationships may constitute an important positive factor in treatment (regardless of orientation),

The Present Studies

outcomes hypothesized to be associated with mood improvements (general self-efficacy, creative

hypothesized that changes in general self-efficacy, creative self-efficacy, activation, mindfulness,

find acceptable/useful as a self-assessment exercise. Thus, instead of using existing measures

we aimed to use the instrument developed in a clinical population.

completing a 5 to 10-minute survey. All participants provided informed consent to participate in

Questionnaire to be validated for use in Study 2, a disaggregated version of the same

questionnaire, and previously validated measures to assess convergent/divergent validity. In

this question”). We excluded 14 participants who failed one (n = 7) or both (n = 3) attention

original instructions if needed).

efficacy (“creative, imaginative, innovative”), activation (“energized, invigorated, stimulated”),

mindfulness (“mindful, present, attentive”), social connectedness (“supported, connected, cared

the ultimate goal of this validation effort.

moment using a 5-point rating scale.

levels of vigor (α = .93) using a 5-point rating scale.

one’s immediate thoughts and feelings (α = .83).

Social connectedness. Participants completed the Social Connectedness Scale – Revised

.96) using a 6-point rating scale.

loaded significantly on their respective constructs.

rs to reflect moderate-to-strong associations. We used the negative affect subscale of the

expecting rs to reflect weak associations. Finally, we compared rs using Fisher’s r-to-z

transformation, expecting correlations with convergent validity measures to be significantly

stronger than correlations with divergent validity measures.