Visual art represents a fundamental aspect of human behavior, with both cross-cultural prevalence and culture-specific variations in expression. This diversity, rooted in the organization and function of the human brain, aligns with its biological universality rather than eluding scientific inquiry (Nadal and Chatterjee, 2019). From prehistoric cave paintings to contemporary digital art, its capacity to evoke emotion, shape identity, and foster connection transcends time and geography. This duality has sparked interest in its therapeutic potential. While traditional medicine often focuses on symptom reduction, AT offers a complementary approach by addressing the psychological, social, and neural dimensions of mental health (Hu et al., 2021). Through creative processes (e.g., painting, sculpture, and music), AT aims to restore fragmented self-narratives, regulate emotions, and promote resilience (Douglas, 2017).

We define art therapy (AT) as a professional psychotherapeutic intervention involving three essential components: (1) a trained art therapist, (2) a client or patient, and (3) active engagement in art-making as the primary mode of communication and therapeutic change (American Art Therapy Association, AATA; British Association of Art Therapists, BAAT). This definition explicitly distinguishes AT from (a) general art-making activities without therapeutic intent, (b) passive art appreciation or aesthetic experiences, and (c) other creative art therapies (e.g., music and dance therapies). However, this distinction does not imply isolation. Insights from each of these three domains can meaningfully inform our understanding of AT's underlying mechanisms, as they share overlapping neurobiological, psychological, and relational processes that converge with AT's therapeutic action.

The therapeutic use of visual expression dates back to antiquity, with ancient practices, such as ancient Chinese texts and Stone Age cave art, providing historical precedents for modern art therapy's focus on emotional expression and psychological healing (Haslam, 2011; Bogen, 2016) (Figure 1). These early practices facilitated memory, emotional expression, and spiritual sustenance across cultures. Eastern traditions formally acknowledged the therapeutic value of art. For example, China's Qing Dynasty text “Theoretical Parallel Prose” (理论骈文) prescribed literature and music to alleviate emotional distress, considering these forms superior to medicinal treatments. The modern concept of AT emerged in the mid-20th century: Adrian Hill coined the term “art therapy” during his 1942 tuberculosis treatment, while Margaret Naumburg formalized the discipline through psychoanalytic integration, culminating in the establishment of the American Art Therapy Association in 1969 (Detre et al., 1983). McNiff (1981) characterized AT as one of the most ancient forms of healing. The British Association of Art Therapists later defined AT as “psychotherapy using art media as its primary communication mode.” In the late 20th century, AT underwent scientific transformation through Semir Zeki's neuroaesthetics, which established biological mechanisms that connect artistic experiences to brain reward systems, self-reflection, and empathy (Zeki, 1999; Kolodny, 2020; Magsamen and Ross, 2024). Contemporary frameworks now integrate neuroscience with anthropology and psychology, validating the efficacy of AT while expanding accessibility through cultural hybridization and social prescribing (Mughal et al., 2022; Magsamen and Ross, 2024).

This narrative review employed a purposive sampling strategy to identify seminal and contemporary literature relevant to our neuro-psycho-cultural framework, aiming to provide a comprehensive and interdisciplinary synthesis of the healing potential of AT. We conducted targeted searches in PubMed, Web of Science, and PsycINFO databases (search period: 1990–2025) using combinations of the following terms: “art therapy,” “neuroaesthetics,” “sense of self,” and related neural mechanisms (e.g., “default mode network,” “interpersonal neural synchrony”). The selection of literature was guided by its relevance in constructing the central thesis of a neuro-psycho-cultural triad in AT, prioritizing impactful empirical studies, foundational theoretical papers, and illustrative clinical cases across populations (trauma, schizophrenia, and neurodegenerative diseases). The following synthesis is structured to explore how AT nurtures the sense of self. It will delineate the supporting neurobiological and psychological mechanisms, examine its clinical applications and cultural dimensions, and conclude with a discussion of integrated findings and future perspectives.

In constructing this neuro-psycho-cultural framework, we consciously integrate findings from adjacent fields to enrich our mechanistic explanations. To ensure conceptual clarity, we define the scope of the evidence as follows:

The primary foundation is direct AT evidence. This comprises clinical studies in which visual art-making is the core therapeutic modality within a defined psychotherapeutic relationship. To elucidate specific therapeutic mechanisms, we also draw upon parallel evidence from related creative art therapies, such as music and dance/movement therapies. These studies are cited when they provide robust paradigmatic examples of a therapeutic mechanism that is theoretically transferable to AT. We explicitly note when cited evidence originates from these analogous modalities. Furthermore, we incorporate foundational insights from neuroaesthetics—the study of the brain's response to art in non-clinical settings. Neuroaesthetics, pioneered by Semir Zeki in the late 20th century (Zeki, 1999), investigates the neural mechanisms underlying aesthetic experiences, artistic creation, and appreciation. This interdisciplinary field merges neuroscience, psychology, and art studies to explore how the brain processes beauty, emotion, and meaning in both natural and artistic contexts (Nalbantian, 2008). These studies are cited to bridge basic science with clinical applications. This integrative approach allows us to present a more comprehensive and mechanistic synthesis while maintaining scientific specificity by transparently acknowledging the source and the inferential distance of evidence.

Contemporary research has provided preliminary neurobiological evidence supporting AT as a potentially effective therapeutic intervention, although the underlying mechanisms remain to be definitively established. To ensure conceptual clarity, we establish a hierarchical evidence framework:

Thus, the core findings include (a) neurobiological reorganization associated with AT; (b) clinically significant symptom reduction in populations with trauma, schizophrenia, stroke, and cancer; and (c) culturally embedded frameworks that facilitate cross-cultural healing. Table 1 summarizes the key studies supporting these findings, with detailed information on sample sizes, methods, and limitations. Notably, the majority of neuroimaging studies on AT are small-scale proof-of-concept designs, and causal links between specific AT techniques and neural changes remain unconfirmed because of methodological heterogeneity and the absence of large-scale randomized controlled trials.

A sense of self or personal identity can be defined by a unique set of psychological, interpersonal, and physical attributes constituting an individual's identity, which also serves as the foundation for daily experiences (Moe and Docherty, 2014). Disturbances in the sense of self are central to schizophrenia, depersonalization disorders, anosognosia, Capgras syndrome, bipolar disorder, and other disorders (Inder et al., 2008; Johnstone et al., 2020; Kirberg and Chadha, 2024). Creative freedom in AT allows patients to externalize and process emotions and experiences that may be ineffable through verbal means, fostering self-sufficiency and integrating the self into therapy (de Witte et al., 2021). The concept that art can serve psychological functions has historical roots. Philosophers such as Aristotle theorized about art's cathartic potential. Similarly, personal accounts of artists, such as Vincent Van Gogh, illustrate the relationship between creative expression and psychological states (Figure 2: The Starry Night). Although the personal significance of art has been illustrated, the practice of modern AT to facilitate psychological transformation through symbolic representation and emotional processing requires proper facilitation.

While long-term pharmacotherapy ameliorates the positive symptoms of psychosis, residual negative symptoms persist, affecting behavioral repertoires. Adjunctive AT promotes holistic identity development and enhances social communication (Hanson et al., 2010). Studies confirm that AT reduces schizophrenia psychopathology by reinforcing self-concept (Teglbjaerg, 2011), providing a safe space for emotional embodiment and cognitive integration (Samaritter, 2018; Vaisvaser, 2021; Vaisvaser et al., 2024). Notably, marginalized groups (e.g., individuals with learning disabilities) use art to reclaim agency and reshape societal perceptions (Hall, 2013). Similarly, military personnel with post-traumatic stress disorder (PTSD) and traumatic brain injury benefit from the trauma-processing capacity of AT, which helps alleviate guilt and restores self-continuity (Kaimal et al., 2019). Furthermore, evidence from structured art-making contexts, including some therapeutic art programs, suggests potential benefits for empathy and self-esteem in various populations (Won, 2016). Separately, research on arts education has linked artistic engagement to the growth of critical thinking and self-concept (Hinds, 2017). While these findings from adjacent fields are suggestive, the highlighted mechanism may be operationalized systematically within a formal AT context. These outcomes align with AT's role in facilitating externalization-concretization and symbolization, which are core mechanisms for affective-cognitive processing (de Witte et al., 2021; Vaisvaser et al., 2024). In summary, the synthesized literature suggests that the cultivation of the sense of self is a central proposed mechanism through which AT may address disturbances in self-experience across different mental health conditions.

Historically, art has been studied primarily within the humanities but has not been seriously considered in the sciences (Bromberger et al., 2011). A growing number of scientific studies on neuroaesthetics have elucidated the neural mechanisms underlying art perception and evaluation. With its detected biological foundations, AT has been proposed as a treatment for post-traumatic conditions (Gerge et al., 2025). AT enhances self-understanding, agency, and the capacity to overcome challenges (King, 2016). Neuroscience can be used to support scientific research and the theoretical foundation of AT. The aesthetic engagement in art might induce plasticity of body and peripersonal space representations, especially in an interpersonal context (Drummond, 2024). Recent studies are beginning to quantify the associations between art-making and visual representation with measures of stress, anxiety, and depression (Kaimal et al., 2016; Walker et al., 2017; Kaimal et al., 2018; Berberian et al., 2019). Current research in AT has examined neurobiological changes, including salivary markers of immune function (Futterman Collier et al., 2016), heart rate variability (Haiblum-Itskovitch et al., 2018), EEG (Belkofer et al., 2014; Kruk et al., 2014), fMRI (Walker et al., 2018; Payano Sosa et al., 2023), functional near infrared spectroscopy (fNIRS) (Kaimal et al., 2017), and cortisol levels (Kaimal et al., 2016), which is a key glucocorticoid hormone and widely studied stress marker. Preliminary evidence has suggested an association between AT and reductions in stress and anxiety biomarkers, which is potentially mediated through mechanisms such as cognitive distraction and emotional expression (Reynolds and Prior, 2003; Reynolds and Lim, 2007; Stuckey and Nobel, 2010). However, the causal pathways and specificity of art therapy require further investigation. In addition, blood pressure could also be recognized as a biomarker since it was significantly decreased after art-making, which served as an effective stress reliever. Furthermore, Futterman et al. found that textile art has mood-enhancing effects, as indicated by altered levels of IL-β, a pro-inflammatory cytokine, which reflects changes in inflammatory immune responses (Futterman Collier et al., 2016). Neuroimaging studies show physiological changes during art-making. A preliminary qEEG study found that both clay sculpting and drawing increased gamma power in the right medial parietal lobe compared to general movement (Kruk et al., 2014). Another study also differences in the left posterior temporal, parietal, and occipital regions of artists when comparing pre- and post-drawing EEG recordings within the alpha frequency band (Belkofer et al., 2014). The use of AT for promoting emotional expression, wellbeing, and resilience is well-documented, as art-making can be a basis to consider experiences differently, reorganize thoughts, gain personal insights, and enhance therapeutic relationships (Konopka, 2014; Tavormina et al., 2014; Vaisvaser et al., 2024). These findings contribute to an emerging body of research exploring the biological foundations of AT. Although promising, the current evidence is characterized by methodological limitations, including small sample sizes and inaccurate measurements.

Although AT has been used clinically for more than a century and has been recognized as a profession since 1991, the majority of published works remain theoretical, with limited discussion regarding specific mechanistic outcomes (Devlin, 2006; Junge, 2010). In recent years, systematic and controlled studies have examined the therapeutic effects and benefits of AT (Frisch et al., 2006). For instance, randomized trials in breast cancer patients showed significant reductions in pain, emesis, and anxiety, along with improved quality of life, following marbling art interventions with music accompaniment (Mollaoğlu et al., 2024). Research examining potential biomarkers represents an initial step toward addressing the methodological challenges in AT outcome assessment. Advanced neuroimaging tools (fMRI, fNIRS) and interdisciplinary collaboration are critical for linking biological changes with psychological outcomes (Beans, 2019). Art therapists' clinical expertise could generate testable biopsychosocial hypotheses; however, further research is needed to clarify the unique mechanisms of AT, including (a) therapist–client dynamics: INS during joint art-making, which enhances coordination and relational safety in clinical settings; (b) art effects: differential neural activation patterns; and (c) session structure/duration: optimal duration/frequency, as evidenced by studies showing sustained anxiety reduction in children with asthma after seven weekly sessions (Beans, 2019). Comparative studies should distinguish art therapist-led interventions from artist-led programs (e.g., teaching artists), exploring contextual mediators such as biophilic environments (nature-integrated spaces that lower cortisol) (Miola et al., 2025), traditional studios, and virtual reality spaces (Neill et al., 2019). Theoretical models that propose individualized, neuroscience-informed approaches in AT are conceptually consistent with personalized mental health, as well as culturally adaptive frameworks such as China's Transforming Symptom's Symbol into Emptiness (TSSE), which integrates Qigong and embodied metaphors to resolve psychosomatic symptoms (Niu et al., 2025).

This narrative review has several limitations inherent to its design. The qualitative synthesis and selective inclusion of literature, while suitable for building a theoretical framework, preclude quantitative conclusions and may be subject to selection bias. The field of AT also faces methodological challenges: The majority of included studies have small sizes n < 50) and are dominated by Western samples, leading to potential ethnic and cultural bias; positive outcomes are overrepresented in the published literature, suggesting possible publication bias; and few clinical trials use blinded assessors, increasing the risk of detection bias. These biases may overestimate AT's efficacy and limit the generalizability of neurobiological findings (e.g., DMN reconfiguration), highlighting the need for future studies to adopt rigorous designs (e.g., multicenter trials and mixed-methods quality assessment) to mitigate these limitations. Furthermore, standardizing outcome measures and distinguishing AT-specific mechanisms from contextual (e.g., placebo) effects (Abbing et al., 2018) is an important question. Thus, future studies need to prioritize the following: First, employing active control conditions (e.g., structured social activities) to isolate the specific effects of AT from non-specific factors such as therapeutic attention and expectation. Second, establishing a core outcome set that integrates subjective self-report measures (e.g., self-concept scales), objective physiological biomarkers (e.g., cortisol and HRV), and standardized neuroimaging metrics (e.g., DMN connectivity and INS) to facilitate cross-study comparisons. Third, investigating the “active ingredients” and optimal “dosing” of AT, including session frequency, duration, and the differential effects of various art media.

Despite these challenges, the proposed neuro-psycho-cultural framework offers a valuable heuristic model. This framework attempts to integrate subjective healing experiences with objective biological measurements in a cultural context. AT shows promise across diverse populations, with emerging evidence from controlled studies suggesting potential clinical benefits, although larger-scale randomized trials are needed to establish its efficacy. Randomized controlled trials (RCTs) reveal that AT significantly reduces depression in post-stroke patients (Yaqing Yuan and Chen, 2024), alleviates pain, emesis, and anxiety in breast cancer survivors (Mollaoğlu et al., 2024), and enhances spiritual wellbeing and social connectivity in elderly populations with mild-to-moderate depression. Concurrently, interdisciplinary studies, particularly neuroaesthetic investigations of DMN activation, INS synchrony, and stress physiology, further validate the biological and cultural dimensions of AT. For clinicians, this neuro-psycho-cultural framework provides a rationale for using AT to target core self-disturbances in conditions such as PTSD and schizophrenia and justifies the use of culturally adapted practices to enhance engagement and efficacy.

Ultimately, AT represents an integrative intervention paradigm in which creative expression modulates emotional responses, reconstructs self-identity, and enhances communal bonds. This has been increasingly elucidated through scientific research (Banerjee and Roy, 2024). As Semir Zeki posited, the therapeutic value of art is rooted in its congruence with the brain's inherent functional organization. Continued interdisciplinary collaboration will not only validate the clinical efficacy of AT but also clarify the fundamental role of artistic engagement in regulating health, cognition, and interpersonal relationships. With continued development, the gap between the sciences and the humanities has diminished.