Journal of Psychiatric and Mental Health Nursing, 2012, 19, 327–333

‘Painting a path to wellness’: correlations between

participating in a creative activity group and improved
measured mental health outcome
L . C A D D Y 1 r m n , F. C R A W F O R D 2 p h d & A . C . P A G E 3 p h d
1
Credentialed Mental Health Nurse, Perth Clinic Postgraduate Researcher, 2Associate Professor, School of
Occupational Therapy and Social Work, Curtin Health Innovation Research Institute, Curtin University, and
3
Professor, School of Psychology, University of Western Australia, Perth, WA, Australia

Keywords: creative activity, evidence- Accessible summary

based practice, group therapy, mental
health,
quantitative methodology
Correspondence:
L. Caddy
Medical Centre, University of Western
Australia, 35 Stirling Highway WA
6009 Australia
E-mail: lizcaddy@aapt.net.au
• Despite the long-standing popularity of creative activity groups with mental health
patients, there has been a lack of measurement evidencing a positive relationship
between participation in such groups and improved mental health.
• This study used de-identified hospital records covering the period 2004–2009 to
chart measured mental health outcomes for 403 patients attending a creative activ-
ity group in an acute inpatient psychiatric setting.
• Four different clinical assessment tools were used to measure changes in mental
health from admission to discharge for participants of the creative activity group.

Accepted for publication: 27 July 2011

• Research findings establish that participation in creative activity positively corre-
lates with improved mental health.
doi: 10.1111/j.1365-2850.2011.01785.x • In the context of this research project, the term ‘creative activity’ includes partici-
pation in art, craft or expressive art-based activity.

Abstract

Responding to a call for quantitative outcome evidence about the therapeutic relation-
ship between creative activity and mental health, this study examined the mental health
outcomes of inpatients participating in art- and craft-based creative therapies at a
private psychiatric hospital over a 5-year period. The creative activity group sample (n
= 403) improved from admission to discharge across four different psychometric
measures with moderate to strong mean effect sizes. Reductions from pre- to post-
treatment in both self-reported and clinician-rated symptoms are clearly demonstrated
for the creative activity group participant sample. Research findings establish that
participation in creative activity has potential benefits for people experiencing mental
health problems.

counsellors, occupational therapists, social workers, psy-

Background
The therapeutic use of creative activity has been recognized
as a valuable method of working with people with mental
health problems since the early 19th century (Reynolds
2000, Mee & Sumsion 2001, Gladding 2005, Spandler
et al. 2007, Tubbs & Drake 2007) and can be utilized by
mental health practitioners such as art therapists,
chologists and mental health nurses.
A substantial body of literature details common themes
of positive change and benefits for people experiencing
mental health problems as they engage in art- and craft-
based creative activity. Significant improvements in
self-esteem, self-worth and self-efficacy are consistently
reported for participants (Goldie 2006, Heenan 2006,

© 2011 Blackwell Publishing 327

L. Caddy et al.
Stickley et al. 2007, Timmons & MacDonald 2008).
Engagement in creative activity is described as a welcome
distraction and a relief from worry, rumination and nega-
tive thinking (Reynolds 2000, Bedding & Sadlo 2008).
The intense concentration and altered sense of time
often experienced by people as they become deeply
absorbed in what they are creating has been conceptualized
by Csikzentmihalyi as ‘flow’ (1975, 1990, 1993, 1997). In
a co-written journal article, a patient (from the creative
activity group under study) describes a ‘flow-like’ experi-
ence while painting intricate patterns – ‘It’s almost like time
stands still, and whatever is bothering me, or on my mind,
melts away while I am actually painting’ (Caddy & N.
2009, p. 32).
The ‘doing’ of creative activity generates a complex
interaction of mind and body processes, which can stimu-
late the growth of new neuron networks in the cerebral
cortex (Perrin 2001, Gabora 2002). Both sides of the brain
become involved during engagement in creative activity, the
mind being activated and ‘energised by the use of our
hands’ (Perrin 2001, p. 130). Using imagination accesses
right brain function and can bypass rigid thinking patterns.
Bedding & Sadlo (2008, p. 376) suggest that ‘the self
awareness part of the brain “switches off” during periods
of deeply engaging sensorimotor activity’.
Art for self-expression can provide a safe, non-verbal
and acceptable way to deal with difficult emotions (Lamb
2009, p. 61). It can provide a means of structuring time,
and facilitating purpose and direction for people struggling
with negative mental health symptoms (Mee & Sumsion
2001, Lloyd et al. 2007). Other reported benefits include
an increased sense of satisfaction, empowerment, confi-
dence and achievement (Cohen 2006, Hacking et al. 2006,
Heenan 2006, Griffiths 2008), which contributes to intrin-
sic motivation (Spandler et al. 2007) and may lead to
increased activity levels.
A limited number of randomized trials have evidenced
that involvement in creative therapies can contribute to
improved mental health and social functioning for people
experiencing schizophrenia (Crawford & Patterson 2007).
The positive experience of creating alongside others can
also provide a non-threatening opportunity for social inter-
action (Griffiths 2008).
Despite this extensive literature, a difficulty resides in
the fact that much of it has been based on small-scale,
qualitative, community-based research studies. Quantita-
tive research into the use of creative activity as a therapeu-
tic medium in acute mental health inpatient settings is
lacking and ‘most’ empirical ‘trials of art therapies con-
ducted to date share a number of methodological weak-
nesses’ (Crawford & Patterson 2007, p. 70). For clinicians
working in the domain of creative activity and mental
328
health, it may seem ‘churlish (and positivism gone mad)’
(Hamilton et al. 2003, p. 402) to have to evidence the
therapeutic use of creative activity with quantitative clini-
cal outcomes. While acknowledging a need to ‘challenge
and broaden current understandings of evidence-based
practice to incorporate multiple forms of knowledge
claims’ (Fielding et al. 2009, p. 164), undeniably a recog-
nized requirement in contemporary health settings is for
systematic quantified evaluation and outcome evidence-
based practice. This research project responds to this call
for more empirical research in the area of creative activity
and mental health (White 2004, Macnaughton et al. 2005,
Hacking et al. 2006, Staricoff 2006, Putland 2008).
There are generally ‘few opportunities for mental health
nurses to facilitate engagement in artistic activities’ in acute
health care settings (Stickley et al. 2007, p. 789); however,
at the hospital under study mental health nurses have been
involved in the facilitation and co-facilitation of the cre-
ative activity group for over 15 years. During the 5-year
period of the research study the group was facilitated by a
mental health nurse who has postgraduate training
in counselling and Art Therapy. This clinician accessed
regular supervision from a qualified Art Therapist in order
to maximize the potential of the therapeutic opportunities
in the creative activity group. Training and in-service super-
vision was also provided for nursing staff involved in the
co-facilitation of the group during the 5-year period.
The creative activity group is an integral part of the
hospital therapy programme and is attended, on average,
by 16 patients daily. Patients are referred to the creative
activity group as part of an individualized treatment plan.
Referring psychiatrists understand that ‘creative activity’ in
the context of the group may not only encompass recre-
ational art and craft work but may also extend to expres-
sive arts projects conceptualized to address clinical issues
and individual patient need.
For creative activity to have therapeutic benefit ‘it must
have purpose, value and meaning to the individual’ (Grif-
fiths 2008, p. 50), hence a diverse range of creative projects
(e.g. painting, beading, sewing, clay work, paper craft and
so on) were made available to participants of the group.
This research study did not require active patient
involvement; rather, existing de-identified patient data were
utilized by the researchers, assuring confidentiality and
anonymity for the research sample.
Research design and analysis
The hospital provided de-identified patient data to the
researchers in the form of an Excel spreadsheet, which was
imported into Predictive Analytics SoftWare (pasw) (for-
merly spss) for analysis. pasw is the hospital’s preferred
© 2011 Blackwell Publishing
 Painting a path to wellness

research tool. The researchers were not involved in the this cohort of patients). This participant sample will be
collection of data, allowing impartiality in data collection. referred to as the ‘creative activity group sample’.
Patient outcome data were analysed on the hospital
premises using the secure computer system available. The
researchers ensured that data were carefully screened to Instrumentation
provide a rigorous participant sample for analysis. Records
Three standardized, self-rated measures routinely collected
were cross-checked by two researchers. Not all participants
from all patients on admission and discharge to the hospi-
completed every questionnaire fully on admission and dis-
tal and one clinician-rated measure have provided a frame-
charge, so participants with missing data for any of the
work of reliability and validity to explore the patterns of
independent variables were excluded from that part of the
mental health outcomes for participants who have attended
analysis.
the creative activity group. These standard psychometric
This study conforms to the principles of the National
measures are:
Statement on Ethical Conduct in Human Research. Ethics
1. The Depression and Anxiety Stress Scale (DASS-21)
approval was granted by the Curtin University Ethics Com-
(Lovibond & Lovibond 1995). Designed for use in both
mittee and by the participating hospital.
clinical and non-clinical populations, this self-rated
This outcome study investigates correlations between
measure comprises of three scales (depression, anxiety,
mental health outcomes of the sample population and par-
stress), which were considered separately for analysis in
ticipation in the creative activity group using descriptive
this research study. High scores indicated a more severe
statistics and inferential statistics. Paired t-tests were used
illness.
to compare overall change from admission to discharge
2. The Quality of Life Enjoyment and Satisfaction
across four psychometric measures. Results with a criterion
Questionnaire (Q-LES-Q) (Endicott et al. 1993). The
value of P < 0.01 were viewed as statistically significant. In
Q-LES-Q is a self-rated measure designed to assess the
addition, the effect size (ES) of each correlation was exam-
level of enjoyment and satisfaction experienced by
ined to establish the strength of mental health outcome
patients across 14 domains of daily functioning.
changes.
Q-LES-Q scores were formulated as a percentage of the
maximum possible score of 70.
Participant sample 3. The Medical Outcomes Short Form Questionnaire (SF-
14) (a shortened version of the SF-36) (Ware et al.
Of the 4283 patients admitted to the hospital for 3 or more
1993), is a self-rated measure which utilizes four scales:
days during 2004–2009, the potential sample of this study
mental health distress, vitality, role functioning and
comprised of 1911 individuals who attended at least one
social functioning to measure an individual’s subjective
session of the creative therapy group.
experience of illness. The analyses performed in this
In order to further refine the research sample, the
research only utilized the Mental Health and Vitality
number of sessions of creative therapy anticipated
subscales because of limited variability in potential
adequate to potentially effect change in mental health out-
scores on the other subscales of this measure.
comes for participants was considered. The work of
4. The Health of the Nation Outcome Scale (HoNOS)
Hansen et al. (2002), Howard et al. (1986) and Lutz et al.
(Wing et al. 1998). The HoNOS is a clinician-rated
(2001) on the ‘dose–effect’ relationship in psychotherapy
national measure which assesses patient functioning
suggests that at least 9 h of therapy is required to effect
across 12 domains including behavioural, cognitive and
change for 50% of patients. In recent research conducted at
social problems (in the 2 weeks prior to hospital admis-
the hospital, Page & Hooke (2009) determined that, gen-
sion and within 72 h of discharge). All clinical staff at
erally, inpatients who attend therapy groups in the hospital
the hospital are annually updated to ensure inter-rater
improve more than patients who do not attend. Page and
reliability with the HoNOS measure.
Hooke also determined that inpatients who attend over six
sessions of group therapy in the hospital (which is equiva-
lent to 9 h of therapy) improve more than those who attend
Results
less than six sessions of group therapy.
It was decided to focus initial analyses on the group of
Participant sample characteristics
patients (n = 403) who had only participated in the creative
activity as a group therapy treatment option during the The creative activity group sample comprised 403 indi-
hospital admission (i.e. no other therapy group and at least vidual inpatients admitted to the hospital over a 5-year
six sessions of the creative activity group were attended by period (2004–2009).

© 2011 Blackwell Publishing 329

L. Caddy et al.

Table 1
Summary of mean (and standard deviations in parenthesis) scores of the creative activity group participants from admission to discharge
across all outcome measures
Instrument Admission Discharge Paired t d.f. P ES1
HoNOS 12.84 (5.49) 6.05 (4.47) 24.42 374 <0.001 1.26
Q-LES-Q 32.05 (17.96) 50.39 (18.79) -12.25 156 <0.001 0.98
DASS-21
Depression 29.68 (13.12) 16.01 (12.83) 12.35 158 <0.001 0.98
Anxiety 24.29 (11.52) 14.14 (12.83) 11.34 165 <0.001 0.88
Stress 24.85 (9.80) 16.87 (11.81) 8.52 165 <0.001 0.66
SF-14
Mental health 34.07 (22.77) 56.17 (22.10) -11.39 176 <0.001 0.85
Vitality 28.63 (24.09) 46.08 (23.53) -8.50 176 <0.001 0.63
1
ES (effect size) = discharge mean - admission mean/standard deviation of the data.
HoNOS, Health of the Nation Outcome Scale; Q-LES-Q, Quality of Life Enjoyment and Satisfaction Questionnaire; DASS-21, Depression and Anxiety Stress
Scale; SF-14, Medical Outcomes Short Form Questionnaire.

Approximately 82.4% of the participants who attended
the creative activity group as a therapy option (n = 403)
were female, 17.6% male. This gender imbalance was sig-
nificantly less pronounced in overall hospital admissions of
66.1% female patients and 33.9% male patients in the
same 5-year period (n = 4283). The mean age of the cre-
ative activity group sample (n = 403) was 47.9 years.
On admission to hospital each patient was diagnosed by
their treating psychiatrist according to ICD-10-AM criteria
(International Statistical Classification of Diseases and
Related Health Problems, Tenth Revision, Australian
Modification). The majority of group participants in the
creative activity group sample were given a primary diag-
nosis of mood (affective) disorder (64.8%). Approximately
79% of the patients within the broad category of mood
disorder were diagnosed with depressive disorders, the
remainder with bipolar affective disorder or unspecified
mood disorders. The creative activity group had a higher
proportion of participants (14.1%) within the diagnostic
category of schizophrenia than other therapy groups in the
hospital (2.1%). People diagnosed with neurotic or anxiety
disorders comprised 12.4% of the creative activity group
participants. Smaller diagnostic clusters included partici-
pants diagnosed with substance abuse disorders, organic
disorders and personality and behavioural disorders. It was
not possible to provide an accurate breakdown of second-
ary diagnosis because of the limited recording of secondary
diagnoses on admission.
Male patients in the creative activity sample group were
more likely to have a diagnosis of schizophrenia, substance
abuse or organic disorder than female patients. Female
patients were more likely to experience affective or anxiety
disorders than male patients.
Almost all patients in the research sample (n = 403) were
prescribed pharmacological treatment by their treating psy-
chiatrist on admission to hospital. The proportion of
patients receiving Electro Convulsive therapy (ECT) treat-
ment in the creative therapy group was 18.1%, with 73
participants receiving ECT treatment. Only 3.1% of dis-
cussion group participants were found to have received
ECT treatment during their admission to hospital in the
same 5-year period.
The average length of hospital stay for the creative activ-
ity group was 19.32 days (SD = 12.76, range = 3–112). This
was longer than the overall hospital population who had
an average stay of 14.89 days (SD = 10.48, range = 3–178).
Creative therapy participants were more likely to be read-
mitted to the hospital than the general population and were
twice as likely to have had a previous admission to the
hospital compared with the overall hospital population:
t(513.9) = -3.540, P = 0.002.
Treatment effects
Paired t-tests were used to determine whether there was a
significant difference between admission and discharge
scores for the participant sample in each psychometric
instrument. The creative activity group sample improved
across all measures from admission to discharge with mod-
erate to strong effect sizes. Table 1 gives a summary of
paired t-test results and effect sizes for the creative activity
group sample 2004–2009.
The largest improvements from admission to discharge
for patients attending the creative activity group were seen
in the clinician-rated HoNOS. A decline in score in the
HoNOS measure from admission to discharge indicates
progress in mental health outcomes. These improvements
were shown to be statistically significant (t(374) = 24.42,
P < 0.001), and a 1.26 standard deviation improvement
from admission to discharge was determined (this is con-
sidered a large effect size).
For participants who attended the creative activity
group as a therapy option (n = 403), the mean DASS-21
scores on admission were 29.68 for Depression (SD =

330 © 2011 Blackwell Publishing


13.12), 24.29 for Anxiety (SD = 11.52) and 24.85 for Stress
(SD = 9.80). These admission scores of the average patient
in the creative activity group fall in the extremely severe
range on the DASS-21 for Depression and Anxiety and the
moderately severe range for Stress. Severity labels on the
DASS-21 refer to the broad non-clinical population.
Statistically significant improvements from admission to
discharge were seen across all subscales of the DASS-21 for
the cohort of creative activity group participants: Depres-
sion, t(158) = 12.35, P < 0.001; Anxiety, t(165) = 11.34, P
< 0.001; Stress, t(165) = 8.52, P < 0.001. Large effect sizes
were observed in the statistical analyses comparing partici-
pant scores from admission to discharge on the DASS-21
Depression and Anxiety subscales (Depression ES = 0.98;
Anxiety ES = 0.88). The Stress subscale showed a moderate
effect size of 0.66. Large improvements from admission to
discharge were also seen on the Q-LES-Q: t(156) = 12.25,
P < 0.001 (ES = 0.98) and the mental health subscale of the
SF-14: t(176) = -11.39, P < 0.001 (ES = 0.85). A moder-
ately sized change was observed in the vitality subscale of
the SF-14: t(176) = -8.502, P < 0.001 (ES = 0.63).
Discussion
This research study found statistically significant improve-
ments in mental health outcomes for the participants in the
creative activity group over a 5-year period. Reductions
from pre- to post-treatment in both self-reported and
clinician-rated symptoms were clearly demonstrated for the
creative activity group participant sample. The degree of
clinical change from admission to discharge across four
different psychometric measures was large and statistically
significant. The creative activity group sample improved
across all the psychometric measures from admission to
discharge with moderate to strong mean effect sizes.
These positive outcomes need to be considered in the
context of their limitations. One of the key limitations is
the non-experimental nature of the research. This limits the
ability to draw strong conclusions regarding causality.
There are many complex variables that occur when a
patient is admitted to hospital:
• concurrent nursing care;
• differing treating psychiatrists;
• differing treatment plans;
• differing psycho-pharmacological medication
regimes.
It was not possible to account for the above mentioned
variables in the research design of this study. Improvement
in outcomes for the participants in the creative activity
group could be due to any number of unmeasured factors
or variables. Although a randomized controlled trial could
potentially resolve some of these issues, this was beyond
© 2011 Blackwell Publishing
Painting a path to wellness
the scope of the present study. It is argued that the com-
plexity of variables involved in creative activity and mental
health limits the viability of randomized controlled trials in
this area (White 2004, Staricoff 2006, Biley & Galvin
2007).
Another limitation stems from the dependent variables
utilized in the research studies, which were patient scores in
the DASS-21, HoNOS, Q-LES-Q and SF-14. Each of the
measures used in the study has different psychometric
properties. These routine outcome assessment measures
determined illness severity on admission for the average
creative activity group participant and provided a measure-
ment of treatment effectiveness by discharge. However,
reliance on such measures in a research study also creates
limitations. Participants in the creative activity group may
have benefited in ways not captured by the DASS-21,
HoNOS, Q-LES-Q or SF-14. Certainly, a limitation of this
study was that the psychometric measures utilized were not
specifically ‘arts-based’ assessment tools.
Overall, however, the DASS-21, HoNOS, Q-LES-Q and
SF-14 were viewed as valid and reliable measures that were
responsive to change and suitable for use in an inpatient
psychiatric facility and in mental health outcome research.
No significant limitations associated with the measures
used (e.g. test–retest reliability, inter-rater reliability) were
observed to impact on the results of this study.
Although the longer length of stay and greater chance of
readmission for the creative activity group sample may be
explained by the acuity and severity of cases referred to the
group, from the data available it was not possible to cor-
relate length of stay with greater improvement in outcomes.
Patients with long hospital admissions, for example, did
not necessarily have better outcomes than patients dis-
charged earlier. Patients in the creative activity group
sample were also twice as likely to have had a previous
admission to the hospital, suggesting that patients in this
group are more chronically unwell with mental health
problems. The question of how to address relapse preven-
tion in the creative activity group warrants significant
consideration.
Research results in this study have been based on mean
outcomes of the creative activity group sample population.
The degree of improvement experienced by individual
patients in the creative activity group was not examined.
The variability of individual responses to the creative
therapy experience remains unknown.
It is important to acknowledge that involvement in a
creative activity group will not be meaningful or beneficial
for everyone. Participation in creative activity should
not be ‘predetermined as “good for” people with mental
health needs’ (Spandler et al. 2007, p. 797), and group allo-
cation in the hospital should reflect individual patient needs
331
L. Caddy et al.

and preferences. Research findings form ‘only part of the impact on patients’ day-to-day life following discharge
toolkit of clinical decision making’ (Nolan & Bradley from hospital. It would be interesting to establish if people
2008). are still involving themselves in creative activity at home.

Recommendations for future research Conclusion

It is recommended that future research should compare
outcomes between subsets of patients within the creative
activity group. Such subsets could be based on gender,
diagnostic differences, patients receiving ECT treatment
and patients who attended a combination of creative
therapy and discussion-based groups. The degree of clinical
improvement for de-identified individuals within the par-
ticipant sample could also be determined, allowing for a
better understanding of the individual client profiles asso-
ciated with good or poor outcomes following participation
in the creative activity therapy group.
Recently, in an informal discussion around the craft
table, the current group of participants were talking
about their experiences of being involved in the creative
activity process. One participant stated ‘through my art
work I am painting a path to wellness’ and this seemed
to resonate for many people in the group. A return to
qualitative research to capture such stories of indivi-
dual meaning making and experience within the creative
activity group might further support the findings of this
quantitative research study.
Follow-up studies could be designed to ascertain if par-
ticipation in the creative therapy group had meaningful
The present research study provides encouraging empirical
data establishing correlations between participation in a
creative activity group and improvement in measured
mental health outcomes for patients of a private hospital
over a 5-year period. This study contributes to the call for
more quantitative outcome data in the field of creative
activity and mental health. Research findings suggest that
participation in creative activity has potential benefits for
people experiencing mental health problems including
reductions in self-reported and clinician-rated symptoms.
The demonstration of positive correlations between partici-
pating in a creative activity group and measured mental
health outcomes gives both clinicians and consumers
greater confidence in the therapeutic benefits available
through participation in creative activity.
Acknowledgments
Participants past and present of the creative activity group.
Moira Munro (CEO), Geoff Hooke (Director of Informa-
tion Technology) Dr. Catherine Bishop and the Quality
Improvement and Therapy Teams of Perth Clinic, Western
Australia.

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