The Arts in Psychotherapy 57 (2018) 50–58

Contents lists available at ScienceDirect

The Arts in Psychotherapy

Research Article

Do creative arts therapies reduce substance misuse? A systematic

review
Karen Megranahan ∗ , Michael Thomas Lynskey
The Institute of Psychiatry, Psychology & Neuroscience, Kings College London, Addictions Department, 4 Windsor Walk, Denmark Hill, London, SE5 8BB,
United Kingdom

a r t i c l e i n f o a b s t r a c t

Article history: The complexities of substance misuse treatment indicate a need to consider the efficacy of creative
Received 13 February 2017 arts therapies for those who find it difficult to verbalise their emotions and feelings. The focus of this
Received in revised form 22 May 2017 systematic review is to identify and critically evaluate studies on the effectiveness of creative arts ther-
Accepted 7 October 2017
apy interventions for reducing substance misuse, aiming at reaching some conclusions on the subject.
Available online 13 October 2017
Research studies employing randomised control trials (RCT’s) and controlled clinical trials were identified
across eight academic databases. A total of 3204 records were found out of which 381 were duplicates and
Keywords:
a further 2818 were excluded as not meeting the inclusion criteria. Five RCT’s met the inclusion criteria
Addiction
Substance misuse and related to music. The effect size (Cohen’s d) of reported outcomes showed a strong positive effect for
Creative arts therapies music therapy to enhance contemplation (0.9), treatment readiness (0.76), motivation (0.54) and reduc-
Music therapy tion of cravings (−0.54). The results of this review should be interpreted with caution because of the
Systematic review small number of studies found and the difference in the treatments employed. However music therapy
may be valuable in treatment plans for substance misuse. Further research is warranted to examine the
long-term effectiveness of music therapy.
© 2017 Elsevier Ltd. All rights reserved.

Background
The nature of addiction
Addiction is a major problem to society and infiltrates all com-
munities. The National Institute of Drug Abuse (NIDA) estimates
the annual cost of addiction to the United States of America to be
US$484 billion (National Institute on Drug Abuse, 2016a). NIDA fur-
ther explains the gravity addiction presents to society with over
60% of crime being related to addiction. The UK National Health
Service (NHS) reported that deaths from drug misuse have risen to
their highest level since comparable records have existed in 1993
(NHS Digital, 2016).
Treatment of addiction
Treatment of addiction is complex and often unsuccessful due
to the problems in engagement and availability of services (Appel,
Ellison, Jansky, & Oldak, 2004). This is intensified by the chronic
nature of addiction whereby the user is unable to stop despite
∗ Corresponding author.
E-mail address: karen.megranahan@kcl.ac.uk (K. Megranahan).
knowing the dangers and negative effects of their substance use.
Finding a process of recovery that can overcome both physical and
psychological dependence on substances (Laudet, 2005), can take
several cycles of treatment. This cyclical nature of seeking absti-
nence can be prolonged and is symptomatic of ineffectual processes
aimed at the addictive behaviour. Therefore, focussing on finding
ways of improving rates of treatment retention and reducing rates
of relapse is a priority for researchers. Getting to the root of the
problem requires a therapeutic process that allows safe exploration
of emotions and feelings for those who often find it difficult to ver-
balise their hidden or buried fears because of concurrent mental
health problems, often related to prior trauma.
Previous research has indicated that psychiatric comorbidity
is common amongst those seeking treatment for substance use
disorders and is reported to be as high as 75% (Weaver et al.,
2003). Most substance use intervention studies tend to overlook
the importance of psychological effects experienced through child-
hood abuse (Lopez-Patton et al., 2016). The prevalence of childhood
trauma and neglect amongst patients at drug and alcohol services
has led to recommendations that trauma screening be routinely
included in treatment interventions (Kelly, Harrison, & Palmer,
2016). When addiction is severely entrenched unemployment and
criminal activities become more prominent, leading the user into
a downward spiral of destructive activities and self-stigmatisation

https://doi.org/10.1016/j.aip.2017.10.005
0197-4556/© 2017 Elsevier Ltd. All rights reserved.
 K. Megranahan, M.T. Lynskey / The Arts in Psychotherapy 57 (2018) 50–58
(McLellan, Lewis, O’Brien, & Kleber, 2000). Strong associations with
mental health issues and increased risk of substance misuse is com-
mon for dependence (Swendsen et al., 2010). Where this is evident,
a psychiatrist may be part of the care team and as a result they
are likely to prescribe further medications such as antipsychotic
medication or antidepressants to manage symptoms (Kinderman,
2014).
The prevalence, burden and complexity of substance depen-
dence has led to the development of a range of services to treat
the problem of addiction and has resulted in many services being
offered. The services may differ depending on the type of addiction
and include community based programmes or residential rehabili-
tation, both of which offer some psychosocial interventions as well
as medication if required (National Institute on Drug Abuse, 2016b).
Some services are able to offer an enhanced range of opportuni-
ties to the service user including opportunities to engage in creative
activities. Residential rehabilitation centres such as the Phoenix
House group also offer access to performing and visual arts therapy
(Phoenix House, 2016), as part of their therapeutic programme.
Traits relating to substance misuse include loneliness, low self-
esteem, an inability to communicate and the loss of a sense of
control (Moore, 1983). These characteristics point towards the
appropriateness of creative arts therapies as a treatment method
for this group (Waller & Mahony, 2002), particularly because cre-
ative arts expression is effective when verbal expression is difficult
(Kaufman, 1981).
Creative arts therapies
Our experiences shape who we are and how we relate to oth-
ers (Bandura, 1977). Relationships are established as an infant
before verbal communication is developed by hearing the music
of communication through caregiver speech, looking and watching
(Bowlby, Bowlby, & Gaitling, 2005).
In a dual diagnosis homeless population, staff in a New York
modified therapeutic community, identified art therapy as a
positive and beneficial contribution to the services offered as
a treatment for substance misuse (Siddiqui, Astone-Twerell, &
Hernitche, 2009).
In the UK there is increasing interest in and recognition of the
therapeutic benefits of creative arts therapies. For example, the
Royal Society for Public Health Special Interest Group recently
hosted a conference exploring the contrasts and commonalities
between theoretical perspectives, research methods and profes-
sional practice in creative arts therapies, medical health humanities
and arts, health and wellbeing (London Arts in Health Foundation,
2016).
Additionally, the Paul Hamlyn Foundation (Paul Hamlyn
Foundation, n.d.) is working to promote the use of arts both in
the UK and internationally and supported through funding the Arts
Strategy for Addictions developed by the South London and Maud-
sley Trust (SLaM). The focus is to improve access and participation
to what is believed to be an opportunity to enrich the lives of those
that are socially marginalised or disadvantaged (SLaM AdArt, 2016).
The British Association of Art Therapists supports and promotes
the use of art therapy in rehabilitation (The British Association of Art
Therapists, 2016a) with localised schemes such as a Scottish Art-
full Strategy initiative, promoting creative arts and the role it plays
in providing improvement in the health and wellbeing of people
with mental illness (Scottish Arts Council, 2008). Another similar
initiative network exists in Leeds (Arts and Minds Network, 2003)
providing a range of creative arts in health to support recovery,
encourage creativity and mental health wellbeing. Finding social
inclusion in the stigmatised world of addiction leaves many unable
to recover and to find new ways of living (National Social Inclusion,
2016). The UK Department of Health has published a policy and
51
guidance on the review of creative arts and has concluded that there
are benefits to creative arts and health initiatives being delivered
across a wide range of priority areas (Department of Health, 2007).
The UK NICE guidelines in 2010 added art therapy to its list of
recommended therapeutic interventions which has enabled ser-
vices to justify the expansion of resources to enable provision
(National Institute for Health and Care Exellence, 2014). The South
London and Maudsley NHS Trust provides opportunities for addicts
to participate in art groups in recognition of the associated benefits
(SLaM AdArt, 2016).
The benefits are also being recognised within and beyond the
NHS, who are looking to embrace art as having a central role to play
in the wellbeing and health of individuals (London Arts in Health
Forum, 2016).
Types of creative arts therapies
Creative arts therapies are tools to bring about change, explor-
ing meaning and tapping into the unconscious processes. There are
three key types of creative arts therapies that are offered by profes-
sional therapists that, in the UK, are registered with the Health and
Care Professionals Council (HCPC, 2016); these are art, music, and
drama. In addition, dance and movement therapy is currently work-
ing towards professional status registration with the same body.
Creative arts therapies extend beyond these forms, including for
example, literature and creative writing. A 2014 study chose bel-
letrist literature as a therapeutic analysis tool for an aftercare group
with alcohol dependence which was found to be helpful for those
with higher education and an interest in literature (Rus-Makovec,
Furlan, & Smolej, 2015).
The creative art therapists in the USA are registered with the
Art Therapies Credential Board (Art Therapy Credentials Board Inc.,
n.d). The Australian and New Zealand Arts Therapy Association
(ANZATA) organisation is the professional organisation for arts
therapy in Australia, New Zealand and Singapore (The Australian
and New Zealand Arts Therapy Association, 2016). In order to work
as a creative arts therapist in the UK, a masters’ level qualification is
mandatory and similar levels of qualifications are required in those
countries where a system of registration is obligatory. There are
people working with service users that do not have these qualifica-
tions and the work that they are offering is described as the use of
‘arts in health’. If the service user is receptive to this activity, it can
divert their attention from their usual substance finding focus to a
more useful and healthy activity. Concern about the use of creative
arts therapy without adequate professional training is an ongoing
area for investigation (Springham, 2008).
Art therapy
Art therapy is a protected term that can only be used by a reg-
istered art therapist. It can be defined in a clinical way as a form
of psychotherapy and is considered to be psychodynamic using
the art form as its primary method of communication (The British
Association of Art Therapists, 2016a). The skill of art is not impor-
tant but the ability to self-express what maybe cannot be put into
words is the essence of the therapeutic relationship. The three way
process between the therapist, the client and the art form offers
the client an alternative way of communicating feelings that might
be difficult to verbalise (The British Association of Art Therapists,
2016a).
Music therapy
Music therapy builds a therapeutic relationship between the
therapist and client in a goal based process which addresses rela-
tional and social needs (American Music Therapy Association,
52 K. Megranahan, M.T. Lynskey / The Arts in Psychotherapy 57 (2018) 50–58
2015). Music therapy can be implemented in a number of different
ways including participating in music creation through improvi-
sation or composition, or through using known music in a music
psychotherapeutic approach. The music therapist is able to select
the methods that most suit the environment and the participants.
However, Ross et al. (2008) identified that it was unclear which part
of the music therapy was the key most beneficial part, although
it was evident that previously unmotivated patients had become
more enlivened in their treatment when participating in music
therapy (Ross et al., 2008). Very early research suggested that music
therapy may be most beneficial when used with those who have
always had an interest in music (Glatt & Zanker, 1956). As early
as 1935, art and music therapy was used to treat addicts as part
of the Narcotic Farm project and the ‘Narco’s Big Band’ performed
at extravaganza music events (Campbell, Olsen, & Walden, 2008).
More recently the New Note Orchestra has been formed which is a
deliberately inclusive assembly group for people recovering from
alcohol and substance misuse (New Note Projects, 2016) and boasts
that every member has maintained their recovery.
Drama therapy
Drama therapy aims to achieve therapeutic goals through the
use of active and experiential dramatic processes, such as sto-
rytelling, improvisation and role play (North American Drama
Therapy Association, 2016) by creating a safe environment where
emotions can be explored and new skills associated with being
drug free practised. The North American Drama Therapy Associ-
ation identifies inherent characteristics of people diagnosed with
substance misuse as tending to be sensitive and creative people
who take quickly to the creative arts and thrive on being able
to express themselves through movement, art, words, music, and
drama (North American Drama Therapy Association, 2016).
Dance and movement therapy
Dance and movement therapy (DMT) allows the exploration of
the inter dependent connection between mind and body (Schore,
2012) and looks introspectively at the present moment where there
is an opportunity to reshape the past (Stern, 2004). DMT offers
improved self-awareness of fears and anxieties, and makes a path-
way for clarity (Scarth, 2013). DMT is defined by the European
Association Dance Movement Therapy (EADMT) as ‘the therapeu-
tic use of movement to further the emotional, cognitive, physical,
spiritual and social integration of the individual. Dance as body move-
ment, creative expression and communication, is the core component
of Dance Movement Therapy. Based on the fact that the mind, the
body, the emotional state and relationships are interrelated, body
movement simultaneously provides the means of assessment and the
mode of intervention for dance movement therapy.’ (The European
Association of Dance Movement Therapy, 2010).
Arts in health
Arts in health can be summarised as the outreach of opportu-
nity of creative arts engagement to those who would otherwise be
excluded. A standard definition continues to be a challenge due in
part to the wide variety in this field (Fancourt, 2017). The provision
of arts in health is not restricted in the way that creative arts thera-
pies are according to the qualification of the provider. The benefits
are being recognised within and beyond the NHS, who are look-
ing to embrace creative arts as having a central role to play in the
wellbeing and health of individuals (London Arts in Health Forum,
2016).
Evaluating creative arts therapies
Measuring success in the field of addiction is usually defined
as a reduction in substance use or abstinence of the service user.
For example the Drug Abuse Treatment Outcome Study (DATOS)
found drug abuse fell by 50% after outpatient treatment (Hubbard,
Craddock, Flynn, Anderson, & Etheridge, 1997). In the absence of a
clearly defined measured reduction, there are also more interme-
diate outcomes that can be measured such as levels of motivation
to change and treatment retention rates. Examining the efficacy of
creative arts therapies in reducing substance misuse as an adjunct
to treatment or as a stand-alone service will contribute to the devel-
opment of optimal treatments for substance use disorders.
Purpose of this review
A systematic review of existing literature to examine whether
there is evidence that participation in creative arts therapies
increases treatment efficacy with those affected by substance use
disorders.
Objectives
To evaluate the effectiveness of creative arts therapy inter-
ventions for reducing substance misuse. In addition, a range of
secondary outcomes, including motivation for treatment readiness,
will also be examined.
Research approach and methodology
The Preferred Reporting Items for Systematic review and Meta-
Analysis Protocols (PRISMA-P) (Moher et al., 2015) was used as the
framework for this review.
Eligibility criteria
Studies were selected according to the criteria outlined below:
Study design
Randomised control trials (RCT’s) and controlled clinical trials
were included. All other study designs were not included in this
review.
Participants
People with a diagnosis of substance use disorder. Data reported
for all ages and nationalities.
Interventions
All interventions that could be defined as expressive arts
(Malchiodi, 2013), and contained a form of creative arts therapy
conducted in an individual or a group setting were included. Com-
plex multifaceted creative art interventions were also included.
Comparators
The comparator selected was treatment as usual which may vary
from study to study. There was no exclusion on the type of control.
Duration
Included studies were not limited by the length of the interven-
tion.
Setting
There was no restriction by type of situation or venue in which
the intervention was provided.
 K. Megranahan, M.T. Lynskey / The Arts in Psychotherapy 57 (2018) 50–58
Language
There was no limitation on language and all studies that met the
criteria are reported.
Information sources
The databases searched were Cochrane CENTRAL Register of
Controlled Trials, CINAHL, EMBASE [OVID 1980 onwards], MED-
LINE [OVID 1948 onwards], PsycINFO, PubMed, Scopus, and Web
of Science. The electronic database searches were supplemented
by searching for trial protocols on the World Health Organisa-
tion International Clinical Trials Registry Platform (World Health
Organisation, 2016) and ClinicalTrials.gov (U.S. Department of
Health and Human Services, 2016). PROSPERO (Centre for Reviews
and Dissemination University of York, 2016) was also searched for
on-going or recently completed systematic reviews. To ensure lit-
erature saturation, the reference lists of the included studies were
screened. Lastly a checklist of the included articles was circulated
to the review advisers and experts who were identified by the team
in order to add any seminal texts that may have been missed.
Search strategy
Literature search strategies were developed using medical sub-
ject headings (MeSH) and text words relating to addiction and
creative arts therapies. When the search strategy was completed,
the syntax and subject headings were adapted for the other
databases. The RCT study filter published in the Cochrane Handbook
for Systematic Reviews of Interventions (Lefebvre, Manheimer, &
Glanville, 2011) was used.
Study records
The search strategy was implemented to identify the study
records.
Data management
Literature searches were run separately for each database and
the results exported and amalgamated into Eppi Reviewer 4 (ER).
The full references and abstracts were uploaded to ER. Duplicates
were located within ER and individually screened and excluded.
The test screening questions were developed for the assessments
based on the criteria for inclusion and exclusion. Subsequently full
text articles were uploaded to ER and the screening questions were
applied again to the remaining studies.
The data obtained from ER was used to formulate a PRISMA flow
diagram once the screening process was completed, as shown in
Fig. 1.
Selection process
The titles and abstracts were screened by the first author. Full
text reports for all studies that met the inclusion criteria on the first
screen were obtained and also for where there was any uncertainty.
A further screen based on the full text identified any further stud-
ies for exclusion. Double screening of records on title and abstract
was not possible due to limitation of resources. In the event of any
uncertainty another member of the team was consulted. At the sec-
ond screening stage the reasons for excluding trials were recorded.
The review authors were not blind to the journal titles nor the
study authors and institutions. The included studies were jointly
reviewed with a member of the study team to ensure the inclusion
criteria were met.
53
Data collection process
Data from included studies were extracted for analysis. The data
extracted contained participant information, methodologies, inter-
vention details and all reported outcomes. A joint review of all the
identified data extracted was performed to determine whether any
other studies needed to be excluded.
Outcomes and prioritisation
The primary outcome of interest was the number of partici-
pants who showed a recorded reduction in amount of substance
misuse. This may include abstinence or a reduction in the amount
used as measured either by urinalysis or other method such as
a breathalyser for alcohol dependents. The inclusion criteria did
not specify a minimum duration of abstinence. The secondary
outcomes reported were also of interest, such as motivation for
treatment, and data were extracted on all secondary outcomes
reported in each individual paper.
Alternative analysis
Due to the nature of creative arts therapy and its inherent
diversity, studies included were not comparable and therefore a
meta-analysis was not possible. As a result, a calculation of effect
size for each of the different study outcomes was calculated, iden-
tifying similarities in the types of intervention and outcomes. A
narrative synthesis was conducted to describe key characteristics
and findings of the included studies.
Results
The findings of this review were used to examine whether cre-
ative arts therapies can reduce substance misuse. Additionally, the
potential impact of creative arts therapies on secondary outcomes
was investigated.
Identification of relevant literature
The search strategy across eight databases was not date
restricted and took place on the 13th and 14th July 2016. Further
searches were conducted in an attempt to find unpublished work
or work in progress. A total of 3204 records were initially identified
which included 381 duplicates. This was further reduced by screen-
ing on title and abstract after which a total of 19 studies remained.
The Prisma diagram (Fig. 1) highlights the exclusion process at each
point of the selection. The full text screen was conducted on the 19
studies and 14 were excluded either due to study design (N = 8),
type of participants (N = 3) or full text not being available (N = 3).
This process resulted in the identification of a total of five studies
that met the inclusion criteria.
The included studies
The five studies listed in Table 1 met the inclusion criteria. They
matched the criteria for a randomised control study (RCT) and the
participants had been diagnosed with a substance use disorder. The
total number of participants across all five studies was 619. Due
to the nature of the measured outcomes a meta-analysis was not
feasible because there was no opportunity to measure the same
outcome across three or more studies.
Each study in Table 1 has been given a code (ID) of A, B, C, D or
E in the first column for identification in further tables. The char-
acteristics of the 619 participants of the five included studies are
displayed in Table 2, divided by each study.
54 K. Megranahan, M.T. Lynskey / The Arts in Psychotherapy 57 (2018) 50–58

Fig. 1. Prisma Diagram.

Table 1
Summary of Included Studies.

ID Author and year Title Location Number of participants Intervention delivered by Length of
intervention

A Silverman (2011)
B Silverman (2012)
C Silverman (2014)
D Silverman (2015)
E Silverman (2016)
Effects of music therapy on change USA 141 Art Therapies Credential Single session
readiness and craving in patients Board Certified Music
on a detoxification unit Therapist
Effects of group songwriting on USA 99 Art Therapies Credential Single session
motivation and readiness for Board Certified Music
treatment on patients in Therapist
detoxification: A randomized
wait-list effectiveness study
Effects of music therapy on drug USA 131 Art Therapies Credential Single session
avoidance self-efficacy in patients Board Certified Music
on a detoxification unit: a Therapist
three-group randomized
effectiveness study
Effects of lyric analysis USA 104 Art Therapies Credential Single session
interventions on treatment Board Certified Music
motivation in patients on a Therapist
detoxification unit: a randomized
effectiveness study
Effects of a Single Lyric Analysis USA 144 Art Therapies Credential Single session
Intervention on Withdrawal and Board Certified Music
Craving With Inpatients on a Therapist
Detoxification Unit: A
Cluster-Randomized Effectiveness
Study

Analysis of the included studies study was conducted there was an assumption that there was no
use of substances in these premises. Therefore, it was not possible
A meta-analysis was not feasible due to the limitations of the to verify the primary objective of interest in relation to a reduction
data and differences in outcome measures. of substance use.

Primary objective Secondary objective

The primary objective was to measure the number of partic-
ipants who showed a reduction in amount of substance misuse,
however, no studies examined a reduction or abstinence of sub-
stance use. Since all studies took place in detoxification units and
all participants were currently resident in the location where the
Table 3 highlights the different interventions that were used
within each study. Two studies (A and C) used more than one inter-
vention as well as a control. Intervention types were rockumentary,
recreational music therapy, song writing and lyric analysis. All stud-
ies had a control group and four of the studies (B, C, D and E) used
 K. Megranahan, M.T. Lynskey / The Arts in Psychotherapy 57 (2018) 50–58 55

Table 2
Sample characteristics across each of the five identified studies

Study ID A B C D E All studies

Mean age Mean Age of Participants Average Age

Intervention 1 39.34 44.6 40.88 42.35 36.58 40.75
Intervention 2 39.32 – 34.93 – – 37.13 39.44
Control 36.19 43.26 39.78 40.87 36.98 39.42
Gender % of Participants Total %
Male 58 48 53 55 55 336 54
Female 42 52 45 44 44 279 45
No response – – 2 1 1 4 1
Drug of choice % of Participants Total %
Alcohol 55 64 57 62 44 342 55
Heroin 23 17 17 14 42 146 24
Prescription 9 14 24 21 10 94 15
Crack/Cocaine & Marijuana – 3 1.5 2 0.5 9 1.5
Unspecified & No Response 13 2 0.5 1 3.5 28 4.5

Table 3
Outcomes measured and Effect size Cohen’s d Calculation.

ID Author and year Intervention Type of Control Outcome Cohen’s D

A Silverman (2011) Rockumentary (N = 42) (NB: Verbal Therapy (N = 43) (Verbal Helpful 0.24
Rockumentary is a detailed journey therapy here is the same questions Enjoy 0.42
through the bands history and the without any elements of the music Motivation 0.22
lyrics of the chosen song and the or verbal accounts of the band and Precontemplation −0.03
participants relate it to their own its history) Contemplation 0.9
experience within the group) Action 0.51
Craving 1 −0.45
Craving 2 −0.31
Recreational Music Therapy Verbal Therapy (N = 43) (Verbal Helpful 0.53
(N = 56) (NB: Recreational Music therapy here is the same questions Enjoy 0.49
Therapy here is a Rock and Roll without any elements of the music Motivation 0.03
Bingo Game) or verbal accounts of the band and Precontemplation −0.1
its history) Contemplation 0.59
Action 0.46
Craving 1 −0.54
Craving 2 −0.5
B Silverman (2012) Group Songwriting (N = 45) (NB: Wait List Control (N = 51) Circumstances (external) 0.04
Group song writing of two verses Circumstances (internal) 0.18
accompanied by a guitar) Motivation 0.54
Readiness for treatment 0.76
C Silverman (2014) Group Lyric Analysis (N = 34) Wait list control (N = 47) Motivation for sobriety −0.01
Eagerness for treatment 0.41
Self-efficacy 0.41
Verbal Therapy (N = 41) Wait list control (N = 47) Motivation for sobriety −0.05
Eagerness for treatment 0.32
Self-efficacy 0.09
D Silverman (2015) Scripted group music therapy Wait list control (N = 53) Problem recognition 0.47
(N = 51) Desire for help 0.42
Treatment readiness 0.62
Pressures for treatment 0.09
Total motivation 0.56
E Silverman (2016) Lyric Analysis (N = 60) Wait list control (N = 83) Withdrawal −0.33
Craving −0.31

a wait list control group. Study A used a verbal therapy group as
the control group. A list of all the measured outcomes is shown in
Table 3. The most commonly measured outcome was motivation
for abstinence which was included in four of the five studies. Two
studies assessed craving and in the Silverman (2011) study there
were two cravings recorded. This was where the participants could
record their craving for more than one substance using the brief
substance craving scale (Somoza et al., 1999). The studies reported
sufficient data to be extracted in order to perform a Cohen’s d cal-
culation of effect size using The Hong Kong Polytechnic University
Effect Size Calculator (PolyU, 2016) and the results are included
in Table 3 and are graphically displayed in Fig. 2. The effect size
(Cohen’s d) was calculated for all the dependent measures within
the five included studies. Contemplation, action, helpfulness, treat-
ment readiness and total motivation were recorded as having an
effect size (Cohen’s d) greater than 0.5. Contemplation was mea-
sured in two different studies and the recorded Cohen’s d effect
size was 0.59 and 0.9.
Discussion
The five studies included in this review all related to music ther-
apy. There was no opportunity to perform a meta-analysis due to
variations in the approaches employed and the outcomes mea-
sured. No study was identified in which the primary outcome of
interest, a reduction in substance use, had been explored. The indi-
vidual outcome effect size results show some evidence to support
music therapy as having a favourable efficacy on the treatment for
substance misuse. This outcome is endorsed by a study that exam-
ines the influence of music and emotions where the majority of
participants acknowledge the importance of music to their recov-
ery (Dingle, Kelly, Flynn, & Baker, 2015). This is further supported
56 K. Megranahan, M.T. Lynskey / The Arts in Psychotherapy 57 (2018) 50–58
Fig. 2. Graphical illustration of the measured outcomes effect size, Cohen’s d.
by the results of a pilot study which looked at the reduction of crav-
ing through music assisted systematic desensitisation, the results
showed ninety-four percent of participants reported a positive ben-
efit (Stamou, Chatzoudi, Stamou, Romo, & Graziani, 2016). The
effect size calculations revealed a strong positive effect on a num-
ber of outcomes including contemplation, treatment readiness, and
strong negative results to suggest a reduction in cravings.
Amount of literature
The UK All Party Parliamentary Group on Arts in Health
and Wellbeing (APPGAHW) reported that the amount of related
research evidence in relation to arts and health varies in quality
and is sometimes inaccessible. As a result the APPGAHW inquiry
report highlights the need for further quality research, in partic-
ular longitudinal studies exploring the relationship between arts
engagement, health and wellbeing (All-Party Parliamentary Group
on Arts, 2017).
The amount of literature that met the inclusion criteria for this
review, in relation to the number of randomised control trials and
clinical control trials identified, was disappointingly low and only
connected to one of the creative arts therapies, music. No stud-
ies were found meeting the inclusion criteria relating to visual art,
drama, dance and movement therapy, or arts in health. In partic-
ular, there is a lack of studies that have examined the longer term
patterns of drug use as an outcome.
Quality of the research and reporting found
Although the RCT is favoured in the hierarchy of research, the
arts may be more appropriately measured through a combination
of methods such as good observation data. Since this review has
only sought to include RCT evidence the author recognises the lim-
itations and further advocates a review of other types of research
evidence to supplement the results of this review. Whilst it is not
possible to identify the number of creative arts therapists working
specifically with those with substance abuse, the APPGAHW has
reported that ‘research is sometimes hampered by poor coopera-
tion from health professionals’ which could be due to workloads
and patient prioritisation above the need for research evidence
(All-Party Parliamentary Group on Arts, 2017).
The five included studies were designed and conducted by an
experienced certified music therapist and therefore provided a pro-
fessional level of intervention. However, the study design, in all
cases, did not collect any long term follow up data to investigate
whether the resulting effect was lasting, or to examine whether
participation in music therapy was associated with a subsequent
reduction in substance use. Across all studies included, the inter-
vention was limited to a single session. The professional guidelines
for creative arts therapists do not stipulate the number of sessions
that a client should receive, it does discuss the building of a ther-
apeutic relationship which is not possible over one session (The
British Association of Art Therapists, 2016b). Whilst there is follow
up on the same day as the intervention, and this has been ana-
lysed for the immediate effect, it would be good to know if it was
a lasting effect and if so how long. Despite the single session study
design there was nevertheless a strong effect size, which suggests
that music therapy can have a positive impact on the effective-
ness of substance abuse treatment. Further research would benefit
from stronger study design employing longer periods of both treat-
ment and follow up, where the effect can be measured after the
treatment.
Limitations of the results
Despite the small number of randomised control studies that
have examined the efficacy of creative arts therapies for people in
addiction treatment, initial evidence suggests that such activities
may have beneficial effects across a range of measures. Notably,
the single session music interventions examined in this review
produced moderate to strong effect sizes including 0.9 for contem-
plation, 0.76 for treatment readiness and 0.54 for motivation. Given
the promising initial results it is important that more types of cre-
ative arts therapies and more high quality research be conducted
to study the longer term outcomes.
 K. Megranahan, M.T. Lynskey / The Arts in Psychotherapy 57 (2018) 50–58
Generalisability
Since all of the research found emanates from the USA, it is
unknown whether these results would generalise to other coun-
tries. Also the setting in which the research took place is confined
to participants within a detoxification unit and therefore the results
cannot be generalised to other settings such as within community
service centres or longer term residential rehabilitation centres.
Implications for future research
Future research investigating the efficacy of creative arts thera-
pies would benefit by using an enhanced study design and longer
periods of treatment so results can be acknowledged as quality
assessment of outcomes. Important considerations should also be
given to the length of follow up required which should be consis-
tent with the expectations of treatment as usual, to see if there are
any advantages to this additional treatment. Ensuring that there
is an appropriate minimum number of participants in each group
for future research will also add to the quality of the research in
this area. In order to detect a medium size effect, defined as 0.5 by
Cohen’s d, requires 64 participants in each group (Cohen, 1992). Sil-
verman’s studies have between 34 and 83 in each group, as shown
in Table 3. Ideally the intervention providers would be separated
from the research design and authorship. These results should be
interpreted with caution due to the low number of studies. The
studies found are not comparable due to differences in the type
of music therapy intervention and outcome measures reported,
and the short time period over which the interventions took place
(Egger, Smith, & Altman, 2008).
Way forward
Music is interesting to almost everybody (Altenmüller, Finger,
& Boller, 2015) and is a useful medium for self-expression. The
authors’ concern about how effective treatment for substance mis-
use currently relies on prescribing medication, potentially creating
a self-perpetuating problem, promotes a need to look at alterna-
tives. In the short term offers of medication to prevent severe
reactions, relieve withdrawal, and aid the provision of service
engagement through voucher schemes, can entice people to regis-
ter with services. However, more focus is required on methods that
promote lasting engagement, that may be challenging to realise but
are nonetheless potential solutions to end the difficulties faced as
to why someone might turn to drugs in the first place. A review in
2000 found that positive effects of art therapy were found in rela-
tion to self esteem (Reynolds, Laura Nabors, & Anne Quinlan, 2000).
If the future research seeks to resolve the hurt and pain that is felt
deep inside by those suffering with substance dependence, we can
begin to release an emotional burden. Creative arts therapies are
one component in a series of tools that may be supportive to seek-
ing recovery, especially for those struggling to express themselves
through words.
Evidence is emerging for the use of music therapy as a treatment
for severe mental illness (Carr, Odell-Miller, & Priebe, 2013). A num-
ber of systematic reviews that have looked at the role music therapy
can have on people with mental disorders have found a posi-
tive effect, highlighting the need for longer follow up (Argstatter,
Hillecke, Bradt, & Dileo, 2007; Chen, Leith, Aaro, Manger, & Gold,
2016). A meta-analysis of the dose response relationship of music
therapy in relation to people with serious mental disorders showed
that when music therapy was additional to treatment as usual then
strong positive effects were shown (Gold, Solli, Krüger, & Lie, 2009).
It was determined that the effect increased with the number of ses-
sions of music therapy and that at least 16 were required to see a
strong effect size. The implications for this review are that with an
57
increase in the duration of the intervention a stronger effect could
be found.
The United Nations Office on Drugs and Crime is committed to
removing the barriers to cost effective treatment services. An esti-
mation of over 250 million people use illicit drugs in the world and
38 million people are assessed to be drug dependant, so finding
lower cost effective interventions is vital (United Nations Office on
Drugs and Crime, 2016). An opportunity to evaluate the cost of cre-
ative arts therapies compared to current treatment as usual would
be useful.
In 2008 a systematic review of music therapy and addiction
found that there was no consensus regarding the efficacy of music
therapy for treating patients with substance misuse (Mays, Clark, &
Gordon, 2008). Clearly Silverman’s studies are post this review and
therefore can add to the evidence that with further studies includ-
ing quality follow up, a positive argument for music therapy as a
treatment for substance misuse could be supported.
Conclusions and implications
Professionals in the field of treatment for substance use disor-
der are utilising creative arts therapies and anecdotally are finding
beneficial outcomes. This review has found a disappointingly low
level of quality evidence for the use of creative arts therapies as
a treatment to reduce substance misuse. As a consequence, this
review is unable to reach conclusive results due to the low num-
ber of included studies and the methodological issues employed.
However, the results herein show strong positive effects of music
therapy as a treatment to improve contemplation and treatment
readiness for those diagnosed with substance use.
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