COVID-19 is both a global health emergency and a major psychological crisis event, and its negative effects on college students' mental health continue to persist after more than three years. Previous studies[1, 2] suggest that the overall mental health status of college students has been poor during the COVID-19 pandemic, especially among those vulnerable to emotional problems. Results from a meta-analysis[3] showed that the prevalence of depression was 34% among college students, while that of anxiety was 31%. In addition, a subgroup analysis showed that the pooled depressive symptom prevalence of women was higher than that of men. Another meta-analysis[4], which included 27 studies and a total of 706,415 participants, found similar results. It indicated that during the COVID-19 pandemic, pooled anxiety symptom prevalence (36%) and pooled depressive symptom prevalence (39%) rose dramatically. Factors associated with psychological symptoms ranged from the fear of infection to family relationships, extensive economic changes, and social stress caused by the pandemic.
The huge number of college students in Chinese universities, the dramatic growth in the number of psychological problems, and the continued stress of the pandemic and its related negative effects have greatly increased the burden on the college counseling system. It is necessary to take action to screen for psychological symptoms efficiently and consistently address the mental health problems of college students. Not only is psychoeducation on both risk factors and self-help skills to improve emotional health important in coping with a psychological crisis, but it is also essential in the pandemic era. In addition, such strategies must take the financial burdens and time limitations that college students experience into account, as well as social distancing and other outbreak prevention and control requirements. One of the possible modalities to tackle all these requirements is online art brut therapy.
Art brut therapy, one of many art therapies, is an innovative form of psychotherapy that combines the creation of art brut with psychotherapy. "Art Brut," also known as grass-roots art or outsider art, was a term first coined in the 1940s by the renowned French artist Jean Dubuffet (1901–1985) after he viewed artworks created spontaneously by patients in psychiatric hospitals. It usually refers to artworks done by ordinary people who are obscure and have no connection with the professional art scene. The word "brut" implies that the work is unprocessed, unadorned, natural, raw, and innocent, to distinguish it from the elaborate works of the academy. The impulses, colors, lines and composition of the art brut creations all stem from the creator’s subjective imagination, and they are not bound by any traditional artistic rules. The bold colors and unique styles of the works often reveal the original innocence of the subject matter, a freedom of imagination, and peculiar composition.
As a therapy, art brut is a planned process of art creation with the goal of promoting mental health and spiritual healing under the catalytic guidance of an art therapist, with the dual functions of psychological assessment and psychotherapy. The creation process helps to release negative emotions such as repression, anger, sadness, and pain. The works also project the strong emotions and unforgettable psychological shadows of the artist, which provide a key with which psychologists can unlock the artist’s subconscious during psychotherapy. The use of perceptual, imaginative, and intuitive cognitive approaches allows mental images to be more concrete, visualized, and externalized than in traditional cognitive and behavioral psychotherapy. These artistic works are self-portraits and projections of individuals’ inner activities, which enable therapists to understand their cognitive, emotional and life stories; enhance both self-expression and communication with the therapist as well as with their families, and allow access to the subconscious for psychotherapy. The psychological goal of art brut therapy is hidden, the action is gentle and elegant, and the participants are highly motivated. In addition, participants are less defensive to psychotherapy and less psychologically impeded. Therefore, this method is suitable for all those who are not professional artists, and it allows for expressing emotions and feelings that are difficult to put into words, and for revealing the expression of inner shadows.
Previous practice and research have demonstrated that art brut therapy has distinct advantages when compared with other special education and rehabilitation tools, high operability, large participation, significant effects, ease of replication, and widespread application. It can significantly improve the creator's self-concept and self-efficacy, reduce negative emotions, promote social functions such as interpersonal interaction, and enhance both sleep quality and quality of life. In special populations, art brut therapy has been well documented to reduce negative emotions and increase self-esteem. We hypothesized that art brut therapy would also positively affect college students’ emotions. The temporal progression of changes occurring in emotional processing during such therapy has not been examined in depth, but qualitative research suggests that although 16 weeks of therapy could result in a larger effect size of improvement in emotional variables (e.g., depression, anger and anxiety), 8 weeks of therapy might be the most cost-effective duration to also lead to a large effect size of improvement in symptoms.
Several research groups have explored the pathophysiological mechanisms of anxiety and depression from a neuroendocrine–immune perspective and have found associations between these conditions and levels of cortisol and interleukin 6 (IL-6). The two main physiological pathways associated with the stress response have been extensively studied; these pathways comprise the hypothalamic–pituitary–adrenal (HPA) axis and the sympathetic–adrenal–medullary (SAM) axis[5]. The release of biochemical mediators such as cortisol and adrenaline via these pathways increases the release of certain signaling molecules, particularly inflammatory cytokines, from the immune system. Interleukin 1 (IL-1) and IL-6, for example, are the main typical inflammatory cytokines in the immune system. Continuous exposure to elevated levels of stress mediators leads to reduced expression of glucocorticoid receptors, resulting in cortisol resistance and ultimately inhibiting the downregulation of the HPA axis by cortisol. Normal cortisol regulation of the immune system response is lost, resulting in a pro-inflammatory state and immune system dysregulation.[6, 7] Conversely, lowering salivary cortisol and IL-6 levels reduces psychological stress in patients.[8]
Additional studies have theoretically explored the mechanisms by which art therapy improves mental health based on psychoanalytic theories. Others have used experimental results, such as the cleft brains by Sperry, to explain the cognitive functions of figurative thinking and emotional changes during artistic creation. Studies have also demonstrated that art therapy can enhance the mental health of oncology patients, including by the appearance of positive changes in indicators such as salivary cortisol and IL-6.
Art therapy has been used with cancer patients to both treat psychological symptoms and relieve physical discomfort. Although the literature suggests that art therapy can relieve anxiety and improve depression, respectively, and that both anxiety and depression are associated with the HPA axis, either few studies have yet combined these two mechanisms in university student populations, or no quantitative studies have yet been conducted to investigate the effect of art brut therapy on the mental health of university students. Therefore, there is a need to implement art brut therapy with university students both to observe related changes in psychological indicators and to analyze the mechanisms involved in art therapy at a more subtle level.
This study was designed to figure out the potential role of art brut therapy as a positive psychological approach for college students. The following research objectives and hypotheses will guide our proposed study.