No - Relevance and scope of review: Given the long history of creative arts therapies with service members, veterans, and their family members, this is an important topic. Music therapy, in particular, traces its origins as a profession in service to veterans (Clair, Else, Tan, 2018) which forms an important historical context to the profession.
The title, “Evidence Map of Art Therapy” is not clear. Was the scope of the evidence synthesis review intended to focus only on art therapy interventions or broader to all creative arts therapies (CATs), including music therapy, dance movement therapy, etc.? The terminology and the title do not accurately reflect the very large scope of the review as presented. The “arts” and “art therapy” are distinct and different terms.
The scope of the review and evidence map includes all CATs and appears highly ambitious. It is suggested that the search strategy may be more effective – if/when revisited - using an alternate search plan, expanded terms, and undertaken in phases or stages. Perhaps a search by individual CAT practice area and guided - or narrowed - by specific questions would be more effective/useful. This may prove to be valuable for clinical decision making, future research, and practice policy.
Creative arts therapies include and refer to distinct professions, each utilizing multiple possible evidence-informed interventions in practice. The term art therapy or music therapy is the term applied to the profession as a whole and it is not specific to a particular theoretical framework or model that underpins an intervention or protocol. Appendix B refers to the profession (art therapy, music therapy) as an intervention which is nonspecific and technically imprecise. (For a related discussion on interventions in music therapy see www.sciencedirect.com/science/article/pii/S096522991730938X) Music therapy, in particular, consists of areas of subspecialty given its scope of practice spans a broad range of populations, conditions, and settings. I would, therefore, suggest citing the definition of each profession directly from the respective professional associations if the scope of the review includes research across all creative arts therapies and not just art therapy. Explicit statement of the research review question(s) of interest would be useful for the reader to understand the scope.
While the overall approach to the review appears sound, there is the possible bias due to overlooked literature and scope. The draft evidence map document is clearly a good fit with emerging definitions regarding the aims and purposes of evidence synthesis reviews and evidence synthesis mapping (Miake-Lye, Hempel, Shanman, & Shekelle, 2016). It is, however, a bit unusual to prepare an evidence map on a broad topic including multiple creative arts therapies and absent specific attention to the intersection of a) conditions most commonly affecting veteran (and adult) populations and b) presenting conditions most commonly seen by CATs in practice. A focused set of questions may permit a more sensitive and specific evidence map (or evidence map series).
Search strategy: It appears many peer reviewed studies were missed due to a search strategy that overlooked search terms for peer reviewed studies specific to the various creative arts therapy. The search strategy noted in Appendix A appears to assume the term [art therapy] encompasses CAT studies in addition to art therapy. For example, “music therapy” is a specific term in the NLM MeSH (//www.ncbi.nlm.nih.gov/mesh/) and subcategories do not include art therapy. A PubMed search using MeSH term [music therapy] and publication type [clinical trial] yielded 737 hits and 630 hits if publication type was further refined to RCTs or 186 hits if publication type was limited to comparative studies.
Cochrane reviews specifically in music therapy (and this reviewer’s specific area of practice expertise) appear to be overlooked from the search. Topics include, but are not limited to, acquired brain injury, outcomes with cancer patients, schizophrenia, depression, and dementia. Similarly, SRs in the Journal of Music Therapy on topics such as pain are well cited and indexed with the NLM/PubMed but were not captured in the search strategy.
Page 4, line 16: There is a limited body of work in meta-syntheses of qualitative studies in music therapy. Data generated from rigorous qualitative research methods and combined on a topic may represent an missed opportunity in understanding the gaps in research and knowledge. Many of these questions arise and build upon the conclusions found in a meta-synthesis, inform future trials, and often touch on lines of inquiry and question types not found in RCTs seeking evidence of efficacy or effectiveness (pragmatic trials), but important to patient care, treatment, practice policy, and future research (e.g. Meadows & Wimpenny, 2017; Medcalf & McFerran, 2016).
The title is misleading. “Art Therapy” implies a single discipline, i.e. visual arts therapy. This report provides evidence in multiple creative arts therapies disciplines. A truer title would be Evidence Map of Creative Arts Therapies - Visual Art, Music, Dance/Movement Therapy. The introduction (beginning line 16) misstates the definitions of creative arts therapies, expressive arts therapies, and arts in health as provided in the NOAH white paper Arts, Health and Well-being in America (pg 7) by inaccurately condensing the content and removing “creative arts therapies” from the definition. The actual definition provided in the report is “Creative Arts Therapies (CATs) include the distinct regulated health professions of art therapy, dance/movement, therapy, drama therapy, music therapy, poetry therapy, and psychodrama therapy.” At line 22, the definition of Expressive Arts Therapy becomes muddled from excessive reduction of the definition provided in the White Paper (pg 7). Line 24 the definition of “arts in health” is not clear as written. Throughout this paragraph art therapy is used interchangeably with creative arts therapies, creating confusion. When referring to multiple arts disciplines, Creative Arts Therapies should be used. In a single discipline, Art Therapy, Music Therapy, Dance/Movement Therapy, etc is correct. This needs a thorough copy edit to correct these unfortunate mistakes to lend clarity to what is being examined here.
Yes - It’s not a bias necessarily, but in numerous places the report continues to incorrectly use Art Therapy when referring to more than one discipline including the description of the Evidence Map (line 48). Though referring to “Art Therapy Modality” in reality the evidence is showing five distinct Creative Arts Therapies modalities, including visual art therapy, dance/movement therapy, drama/psychodrama therapy, music therapy and poetry therapy. Taken together these are defined as the Creative Arts Therapies.
I am concerned that the failure to be precise in the terminology may have negatively impacted the Search Strategy, and skewed the study selections for the interventions. Line 46 again incorrectly quotes the NOAH white paper as including the six “distinct regulated health professions of art therapy” disciplines, when these are clearly outlined in the NOAH paper as belonging to the overarching category of creative arts therapies. By using the term ‘art therapy’ instead of creative arts therapies, it’s little wonder the report indicates a preponderance of art therapy studies. It seems the music therapy category is underrepresented given the longer length of time that music therapy has been undergoing research.
//www.sciencedirect.com/science/article/pii/S0197455618301916
Vaudreuil, R., Avila, L., Bradt, J., & Pasquina, P. (2018). Music therapy applied to complex blast injury in an interdisciplinary model: A case report. The Journal of Disability and Rehabilitation. doi: 10.1080/09638288.2018.1462412 (Impact factor = 1.8)
//www.tandfonline.com/doi/full/10.1080/09638288.2018.1462412
Page 8 Line 13-27 “Art Therapy” - My understanding the study/evidence mapping would be on all the disciplines that make up the Creative Arts Therapies. There are four distinct and separate Clinical Professionals who are governed by their respective accreditation bodies – Art Therapy; Music Therapy; Drama Therapy and Dance/Movement Therapy. The term “Art Therapy” does not encompass professional work of the other professions i.e. Music therapy, Dance Therapy and Drama Therapy. Page 8 line 17 – professions of “art therapy” is inaccurate. Art Therapy is it’s own specific profession and does not encompass the other professional disciplines.
Page 8 line 26/27 - considered a distinct from art therapy. I believe art therapy in this context you are referring to the Creative Arts Therapies and should not be grouped into the term Art Therapy. You could reference National Coalition of Creative Arts Therapies Associations, Inc. This is made up of the professional organization for each of the distinct Therapies that make up creative arts therapy professionals i.e. Art Therapy – American Art Therapy Association; Music Therapy – American Music Therapy Association; Dance Therapy - American Dance Therapy Association; Drama Therapy - North American Drama Therapy Association.
General Comments
The scope of the intended scope – it appears the scope of project is attempting to look at literature and evidence across the four distinct professional groups of art therapy; music therapy; dance/movement therapy and drama therapy across all clinical topics. However, the literature search to appears to have only utilized primary term Art therapy which does not provide or excludes data related to the other terms/professions such as Music Therapy (MT); Dance/Movement Therapy (DMT); Art Therapy (AT), etc. The text appears to treat the term “art therapy” as a Intervention rather than the name of each of the professions. Each of the professions have unique credentials for the associated profession.
Terminology – appears the term art therapy is attempting to encompass all therapies. This is misunderstood term and not inclusive of the other creative arts therapy professionals – music therapy, drama therapy, dance/movement therapy. In addition, the term art therapy seems to represent an intervention when that actually is term used for the profession itself and not the intervention specifically.
The term art therapy within the literature search is missing a considerable amount of research from the other professions such as music therapy, dance/movement therapy and drama therapy. That is a gap in the use of the term “art therapy” to try to encompass all of the other professions. There is missing literature on varying subtopics such as Traumatic Brain Injury; Post Traumatic Stress Disorder and music therapy interventions.
Research questions for the evidence review were not all explicitly stated for high priority topics that are pertinent to Veterans and active service members such as evidence mapping on suicide prevention; depression; post-traumatic stress disorder; traumatic brain injuries; pain; opioid/substance abuse; sleep; trauma or complex trauma as examples.
It would be good to add a credentialed academic scholar for each of the professions represented (Board Certified Music Therapist; Board Certified Art Therapists; Board Certified Dance Therapist; etc. to the Technical Expert Panel (TEP) section of the study. There was peer reviewers with credential however they would have limited scope whereas if added to TEP that could help provide improved Guide topic refinement and ensure proper terminology usage is used to capture full scope of the work and literature.
In general it appears - term art therapy was misunderstood and utilized to capture full extent of the project but was missing literature that impacts the overall creative arts therapy professionals work related to the professions of art therapy, music therapy, dance/movement therapy etc.
Topics for interventions utilized by the credentialed therapist in the professions of music therapy, dance/movement therapy and drama therapy were missed which resulted in potential lost information on outcomes related to the delivery of interventions used by the professionals.
Would request to re-run literature search using alternative searching strategies to include terms that impact creative arts therapist in music therapy, dance/movement therapy etc. Execution of updating terms and also adding in a few more individuals from the professional associations would improve the result of the study and provide more meaningful data to the Program offices for decision making and strategic planning.
Yes - See above comments
Yes - The search criteria, which focuses on the term “art therapy,” has weighted the review toward the (visual) art therapy. Suggestions for improved search criteria are included in my attachment.
Yes - I am concerned that many studies focused on music therapy have been overlooked. Note, for example, Music interventions for improving psychological and physical outcomes in cancer patients by J Bradt, C Dileo, L Magill, A Teague (2016), which is included in the Cochrane Database of Systematic Reviews.
Yes - Distressingly, this report’s search criteria (and the very title of the synthesis) betray an unwitting bias toward “art therapy” (that is, visual art therapy) over music therapy, dance and/or movement therapy, drama and/or theater therapy, and expressive or creative writing therapy. For a report of this type, it is crucial to use search terms that don’t lock one into a particular arts modality. Appendix A explains that “art therapy” was indeed a pivotal search term, possibly at the expense of these other types of creative arts therapies. In short, the search terms are terrifically biased, if I read the appendix correctly.
Yes - I’m sure there are, due to the unfortunate search criteria (see above).
Yes - Perhaps not bias so much as lack of clarity in the conflation of “art therapy” and “creative arts therapies,” as well as lack of comprehensive inclusion of literature in the synthesis.
Yes - See my comments below.
It appears that the title and the terms used in the manuscript do not accurately reflect the review. The “arts” and “art therapy” are distinct and different terms. Further, it is unclear as to whether the scope of the synthesis review was intended to target art therapy interventions, or all creative arts therapies. Furthermore, some of the contents of the NOAH White Paper are misquoted. For example, please refer to my comments (related to content on page 8 of the PDF file - in ALL CAPS):
“The National Organization for Arts in Health (NOAH) identifies six “distinct regulated health professions of art therapy” (SIX DISTINCT REGULATED PROFESSIONS) which have “a definition of the profession, a legally defensible scope of practice, educational competencies, standards of practice, code of ethics, and evidence-based research.”1 These include art therapy, dance/movement therapy, drama therapy, psychodrama therapy (STRIKE “THERAPY,” PSYCHODRAMA IS KNOWN SOLELY AS PSYCHODRAMA), music therapy, and poetry therapy. Therapists within these disciplines are board certified (THEY SHOULD BE BOARD CERTIFIED, BUT THAT’S NOT ALWAYS THE CASE. SOME STOP AT NATIONAL REGISTRATION CREDENTIALS. OTHERS GO BEYOND BOARD CERTIFICATION AND OBTAIN LICENSURE SPECIFIC TO THEIR DISCIPLINE (OR OTHER, DEPENDING ON THE SITUATION IN A GIVEN STATE, SUCH AS COUNSELING LICENSURE). When these different modalities or disciplines are blended or combined by trained professionals this is referred to as expressive art therapy (THIS IS AN IMPORTANT DISTINCTION: I HAVE EDITED THIS SENTENCE SO AS TO CLARIFY, AND AVOID MISLEADING, THAT EXPRESSIVE ARTS THERAPY IS NOT REGULATED IN THE WAY THAT THE DISTINCT CATS PROFESSIONS ARE: “CONVERSELY, WHEN THESE DIFFERENT ARTS MODALITIES ARE COMBINED BY TRAINED PROFESSIONALS, THIS IS REFERRED TO AS EXPRESSIVE ARTS THERAPY.). While arts can be used in other ways within health care and public health, these arts in health programs are not led by trained therapists, but rather artists or other types of coordinators, and are considered distinct from CLINICAL CREATIVE ARTS THERAPIES.
THE CREATIVE ARTS THERAPIES ARE used in the treatment of a variety of conditions, including schizophrenia,2 depression,3 and stroke rehabilitation.4 Given the breadth of conditions to which CREATIVE artS therapIES haVE been applied (STRIKE: “and the variety of disciplines under the umbrella of creative art therapy” - REDUNDANT), we conducted an evidence mapping …”
I would encourage the authors to carefully consult the NOAH White Paper, //thenoah.net/wp-content/uploads/2019/01/NOAH-2017-White-Paper-Online-Edition.pdf, which includes definitions of the distinct CATs professions, as sanctioned by each profession’s national organization. On page 26 of the White Paper/PDF, Table 1, Creative Arts Therapies Professions Overview, includes an overview of the CATs professions. This information was provided by the national CATs organizations, therefore it is an accurate and trustworthy source.
Yes - Referring to the modalities as defined by Noah as “Art Therapy” is a concern to me. Practicing creative arts therapist may not being lumped into an “Art Therapy” category. Suggest replacing art therapy with ‘Creative Arts Therapy’, ‘Creative Arts Therapies’ or the plural “Arts Therapy”. Using the term, “Art Therapy” to refer to the larger spectrum of modalities may imply the authors did not fully grasp an understanding of the topic as Art Therapy in itself is a singular modality/profession.
Yes - I note that your search strategy included the key words “Art Therapy” and wondering if the individual modalities “Music therapy, Dance Therapy, etc. might have yielded more eligible studies. I am disappointed at the limited number of references that met your criteria for rigor – only 102 out of the original 1132 identified (only 10%). Is this solely an indicator of the lack of Randomized Controlled Trial, quantitative impact evaluations with health outcome data, or systematic reviews out there or the poor quality of the research in this field or could the search have been expanded?
Yes - See my comment above. I think that there are probably a number of quantitative impact or RCT studies missed in this review. One example is for dance movement therapy. Meekums et al (2015) did a Cochrane Review and identified 3 RCTs. I don’t see this included, or the articles (Jeong, 2005; Xiong, 2009; Rohrict, 2013). I wrote out some additional ones in my narrative comments.
If the articles want to be inclusive, I would recommend reviewing the systematic reviews to identify articles that the search strategy missed. Not all of the systematic reviews included articles that would be included in the current review, but I think there are a number that the authors will find.
Missing articles: I have some concerns about the search process and am not confident that the results reported reflect the literature that is out there about art therapy. I think reliance on just the terms “art therapy” (or parts thereof) may underlie some of the missing data from this review. The authors noted in the summary that using terms specific to different disciplines was outside of the scope of the review. But I think that at least adding the different types of art therapies would be helpful. I would suggest adding to the search with those additional key terms in order to be more inclusive.
There were few qualified studies from several of the NOAH defined Creative Arts Therapy professions. a search specific to each of the defined areas may add value. Music Therapy, Art Therapy, Dance Therapy, Drama Therapy, Poetry Therapy, Psychodrama.