1. Introduction
1.1. Research Background and Significance
With the rapid development of society and the accelerated pace of life, people’s mental health problems have attracted more and more attention. Psychological disorders, stress, anxiety, and depression have become one of the main factors affecting people’s physical and mental health. Although the traditional psychotherapy is effective, it has some limitations, such as long treatment cycle, great side effects and unstable curative effect (Kong & Wang, 2013) .
As a new type of psychotherapy, expressive arts therapy (EXAT) and painting therapy can help patients better understand and express their feelings, relieve stress, and improve their mental health through the expression and creation of art forms. During the EXAT process, creative works become important because of the significance and meaning that the client gives to these works (Gong, 2022) . The treatment methods have the advantages of quick curative effect, small side effects and wide application range, and have been widely used in psychotherapy, rehabilitation nursing, education, and other fields (Lu, 2016) .
1.2. Research Purpose and Content
The purpose of this paper is to summarize the research results of EXAT and painting therapy, and deeply discuss their development history, theoretical basis, application fields and mechanism research, to provide more effective treatment methods for mental health. The details are as follows:
1) To summarize the development and theoretical basis of EXAT and painting therapy. This paper introduced the definition, classification, development, and theoretical basis of EXAT and painting therapy, including theoretical support from psychology, neuroscience, and sociology.
2) To explore the application fields of EXAT and painting therapy. This paper discussed the application of EXAT and painting therapy in psychotherapy, rehabilitation nursing, education, social work, and other fields, as well as the application characteristics and effects in different fields.
3) To explore the mechanism of EXAT and painting therapy. This paper introduced the mechanism research results of EXAT and painting therapy, including the research progress in neurobiology, psychology, and sociology.
2. The Development and Theoretical Basis of EXAT
2.1. Definition and Classification of EXAT
EXAT is a comprehensive treatment method that helps people express their feelings, relieve stress and improve their mental health by taking art form as the medium. According to different art forms and therapeutic purposes, it can be divided into many different categories.
Painting therapy is a kind of treatment method with painting as the main means. Through the process of painting, patients can relax, adjust their emotions, and improve their self-awareness. Painting therapy can be divided into two forms: free painting and theme painting. Free painting means that patients can draw the patterns they want at will without any subject restrictions. Theme painting refers to the patient’s painting according to the theme provided by the therapist to achieve a specific therapeutic purpose (Sun et al., 2016) . Symbolic tools enable clients to expand and enrich the therapeutic conversation, especially those who have limited verbal self-expression, show resistance, are reluctant to participate, or are less adept at expressing their feelings and emotions (Abdullah, 2021) .
Music therapy is a treatment method with music as the main means, which helps patients relax, relieve their emotions, and improve their mental health through the rhythm, melody and sound of music. Music therapy can be divided into two forms: listening to music therapy and playing music therapy Listening to music therapy means that patients can achieve therapeutic purposes by listening to music. Playing music therapy means that patients express their feelings and emotions by playing musical instruments.
Dance therapy is a kind of treatment method with dance as the main means, which helps patients relax, adjust their emotions, and improve their self-awareness through dance movements and rhythms. Dance therapy can be divided into two forms: free dance and theme dance. Free dancing refers to the patient dancing freely without any restrictions. Theme dance means that patients dance according to the theme provided by therapists to achieve specific therapeutic purposes.
Drama therapy is a kind of therapy with drama as the main means, which helps patients express their emotions, relieve stress, and improve their mental health through performances, role-playing and other forms. Drama therapy can be divided into two forms: free drama and theme drama. Free drama means that patients can perform freely without any restrictions. Thematic drama means that patients perform according to the theme provided by therapists to achieve specific therapeutic purposes.
2.2. The Development of EXAT
EXAT s a therapeutic method to help people express their feelings and relieve anxiety and stress through painting, music, dance, and other art forms. Its development can be traced back to the early 20th century.
In the early 20th century, artists began to use art as a treatment to help patients alleviate their psychological problems. In the 1920s, Florence Cane, an American artist, began to use art as a psychotherapy. She believed that art could help people express their feelings and relieve anxiety and stress. In 1950s, EXAT began to get more and more attention. At that time, Margaret Naumburg, an American psychologist, put forward the concept of “non-directional art therapy”. She believed that art could help people express their subconscious emotions and conflicts, thus alleviating psychological problems. In 1960s, EXAT began to enter clinical practice. At that time, Edith Kramer, an American psychologist, put forward the concept of “EXAT”. She believed that art could help people express their emotions, relieve anxiety and stress, and promote individual growth and development.
2.3. The Theoretical Basis of EXAT
The theoretical basis of EXAT includes psychology, art, philosophy, and other disciplines. Among them, psychology is one of the main theoretical foundations of EXAT, and its main theories include the following aspects (Hao, 2014) :
1) Psychodynamic theory: Psychodynamic theory holds that people’s psychological problems stem from conflicts and repression in the subconscious. EXAT can help patients explore and express subconscious emotions and conflicts through artistic expression, thus alleviating psychological pressure.
2) Humanism theory: Humanism theory holds that everyone is unique and valuable and should be respected and concerned. EXAT emphasizes the uniqueness and value of individuals by paying attention to their inner experience and expression.
3) Behaviorism theory: Behaviorism theory holds that human behavior is the response of the environment. EXAT can adjust the mood and behavior of patients by changing the environment and stimulation.
4) Cognitive behavior theory: Cognitive behavior theory holds that people’s emotions and behaviors are influenced by cognition and beliefs. EXAT can adjust patients’ emotions and behaviors by changing their cognition and beliefs.
In addition, art and philosophy also provide theoretical support for EXAT. Art believes that art is a language, and emotions, thoughts and values can be conveyed through the expression of artistic forms. EXAT can also convey patients’ emotions and values through the expression of artistic forms. Philosophy holds that art is an essential activity of human beings, and it is human’s understanding and expression of themselves and the world. EXAT can also help patients to know and express themselves and the world through the expression of artistic forms.
3. The Development and Theoretical Basis of Painting Therapy
3.1. Definition and Classification of Painting Therapy
Painting therapy is a kind of psychotherapy with painting as the main means. Through the process of painting, it helps patients to express their emotions, relieve pressure, adjust their emotions, and improve their self-awareness, to achieve the purpose of treatment and rehabilitation. Painting therapy originated from psychotherapy practice in the early 20th century. With the development of psychology and art, it gradually formed a complete theoretical system and application methods.
Art therapy is a kind of treatment method with painting, sculpture, handicrafts, and other art forms as the main means. Through the process of artistic creation, it helps patients to express their feelings, relieve their pressure, improve their self-awareness and self-worth, and promote their personal growth and development. Color therapy is a treatment method with color as the main means. It helps patients to adjust their mood, relieve stress and improve their mental health through the use and feeling of color. Color therapy is often combined with art therapy to play a therapeutic role together. Symbol therapy is a treatment method with symbols as the main means. Through symbols, symbols, and metaphors in painting, it helps patients express their feelings, relieve psychological pressure, adjust their emotional state, and promote personal growth and development. Image therapy is a treatment method with images as the main means. Through painting, collage, creative painting and other forms, it helps patients express their feelings, relieve psychological pressure, adjust their emotional state, and promote personal growth and development (Zhang, 2015) .
3.2. The Development of Painting Therapy
Painting therapy is a kind of therapy with painting as the main means, and its development can be traced back to ancient civilization. As early as ancient Egypt, ancient Greece and Rome, painting was used as a treatment. For example, Hippocrates, an ancient Greek doctor, used painting to treat mental illness.
At the beginning of the 20th century, painting therapy began to become a formal treatment. In 1914, the American psychiatrist Leo Kanner first used painting as a means to treat children’s autism. In 1930s, Margaret Naumburg, an American artist, began to use painting to treat mental disorders of children and adults, and founded the American Painting Therapy Association in 1947. Since then, painting therapy has been widely developed and applied in the United States.
In 1950s, European artists and psychologists began to study and apply painting therapy. In the late 1950s, British psychologists George Stikkel and Elizabeth Kandel founded the British Painting Therapy Association and began to use painting therapy to treat mental diseases and psychological disorders. In 1980s, painting therapy began to be widely developed and applied in Asian countries. Hirofumi Ogihara, a Japanese artist, founded the Japanese Painting Therapy Society in 1984 and introduced painting therapy into Japan’s medical system and education system. China also started the research and application of painting therapy in 1980s, and established China Painting Therapy Society in 1995.
The development of painting therapy shows that it has become a widely accepted and applied treatment method. In different countries and regions, the application fields and methods of painting therapy are different, but its core idea and goal are to help patients relieve stress, adjust their emotions, and improve their self-awareness through painting, thus improving their physical and mental health.
3.3. The Theoretical Basis of Painting Therapy
Painting therapy is a kind of therapy with painting as the main means, and its theoretical basis mainly includes the following aspects:
3.3.1. Theoretical Basis of Psychology
One of the theoretical foundations of painting therapy is psychological theory, including human development psychology, cognitive psychology, emotional psychology, psychotherapy and so on. Painting therapy helps patients express their emotions, relieve stress, adjust their emotions, and improve their self-awareness through the process of painting. The theory of human developmental psychology can help to understand the growth process and psychological development stage of patients, so as to better treat them. The theory of cognitive psychology can help patients understand their own cognitive patterns and ways of thinking, to better understand and solve their own problems. The theory of emotional psychology can help patients understand their emotional state, to better control their emotions. The theory of psychotherapy can help painting therapists to treat better and improve the therapeutic effect.
3.3.2. Theoretical Basis of Art Therapy
The second theoretical basis of painting therapy is art therapy theory, including the philosophical basis, theoretical model, and practical experience of art therapy. The philosophical basis of art therapy mainly includes humanism, existentialism, psychodynamics, and other theories, which emphasize people’s self-realization and self-cognition, and are in line with the goal of painting therapy. The theoretical models of art therapy include art creation model, art experience model and art therapy model, which provide theoretical guidance and practical experience for painting therapy.
3.3.3. Theoretical Basis of Neurobiology
The third theoretical basis of painting therapy is neurobiological theory, including neuroscience, neuropsychology, and neuroimaging. Neurobiological theory can help to understand the therapeutic mechanism of painting therapy and the influence of painting on the brain and nervous system. Neuroimaging studies have found that painting can activate many areas of the brain, including temporal lobe, frontal lobe, and parietal lobe, which are related to emotion, cognition and vision, indicating that painting has many effects on the brain.
4. Application Fields of EXAT and Painting Therapy
4.1. The Field of Psychotherapy
Psychotherapy is one of the most common application fields of EXAT and painting therapy. In psychotherapy, EXAT and painting therapy are widely used to treat psychological problems such as depression, anxiety, post-traumatic stress disorder and personality disorder.
EXAT and painting therapy can help patients express their inner feelings and experiences, relieve stress and anxiety, and enhance their self-awareness and self-control ability. Research shows that EXAT and painting therapy have significant effects on improving patients’ mental health.
In addition, EXAT and painting therapy are also widely used in the psychotherapy of children and adolescents. Studies have shown that EXAT and painting therapy can help children and adolescents express their emotions, enhance their self-confidence and self-esteem, relieve stress and anxiety, and improve their learning and social skills (Malchiodi, 2011) .
4.2. Rehabilitation Nursing Field
The application of EXAT and painting therapy in the field of rehabilitation nursing is mainly aimed at patients with physical disorders or chronic diseases, helping them recover their physical functions and improve their quality of life and mental health.
EXAT and painting therapy can be used as auxiliary means of rehabilitation training to help patients recover their physical functions. For example, through painting training, patients can exercise the flexibility of hand muscles and the coordination of fine movements and improve the functional use of hands. EXAT and painting therapy can help patients relieve pain and anxiety. For example, through painting, patients can divert their attention and relieve the feeling of pain. By expressing emotions, patients can alleviate the negative emotions caused by pain. EXAT and painting therapy can help patients adjust their mentality and ease their emotions. For example, through painting, patients can express their feelings and relieve anxiety and depression; through dancing, patients can relax and improve their self-confidence and self-awareness (Zhou, 2019) .
EXAT and painting therapy can be used as a means of social skills training to help patients improve their social skills and self-expression skills. For example, through dancing, patients can exercise their physical coordination and sense of rhythm and improve their social expression. Through painting, patients can express themselves and enhance their self-confidence and self-awareness.
4.3. Education Field
The application of EXAT and painting therapy in the field of education has also attracted more and more attention. The application in the field of education mainly includes the following aspects (Yang et al., 2013) .
4.3.1. Students’ Mental Health Education
The application of EXAT and painting therapy in school mental health education has been widely recognized. Through the expression of artistic forms, students can better understand their emotions and hearts, and at the same time, they can better understand others. This method can help students better adapt to school and social life and improve their emotional intelligence and social skills (Yang et al., 2015) .
4.3.2. Special Education
The application of EXAT and painting therapy in special education is becoming more and more common. This method can help special children express their feelings and hearts better, to better adapt to school and social life. At the same time, painting therapy can also help special children improve their hand-eye coordination and creativity and promote their physical and mental development.
4.3.3. Teachers’ Professional Development
EXAT and painting therapy can also help teachers to better develop their professional ability. By participating in relevant training and courses, teachers can better understand students’ emotions and hearts, to better guide students' learning and growth.
4.3.4. Subject Teaching
EXAT and painting therapy can also be applied in subject teaching. For example, in Chinese teaching, students can better understand the plot and characters in the text through painting. In mathematics teaching, students can better understand geometric figures and so on through painting.
4.4. Social Work Field
Social work is a profession aimed at promoting social justice and human welfare. Social workers need to help the disadvantaged groups in society solve their life problems and improve their quality of life. EXAT and painting therapy are also widely used in the field of social work.
On the one hand, EXAT and painting therapy can help social workers better understand the inner experience and emotional needs of vulnerable groups. Social workers can understand patients’ inner feelings by observing their artistic works, so as to make better help plans and improve work efficiency (Guo, 2011) .
On the other hand, EXAT and painting therapy can also be used as a means of social work to help the disadvantaged groups relieve their pressure, reduce their psychological burden, and enhance their self-confidence. For example, in the community service center, social workers can organize EXAT and painting therapy activities to help community residents reduce stress, ease their emotions, and enhance community cohesion and centripetal force (Chen, 2010) .
In addition, EXAT and painting therapy can also be used as self-care means for social workers. Social work is a highly stressful profession, and social workers often have to deal with various complicated social problems and bear greater psychological pressure. EXAT and painting therapy can help social workers to relieve stress, adjust their emotions and improve their mental health, to better complete their work tasks.
5. Study on Mechanism of EXAT and Painting Therapy
5.1. Emotional Expression and Emotional Adjustment
EXAT and painting therapy help patients express their inner feelings and reduce emotional pressure through artistic expression. In painting therapy, patients can express their emotions through the process of painting, and turn negative emotions into works of art, thus alleviating emotional pressure. In EXAT, besides painting, it also includes music, dance, and other forms. These forms of expression can better stimulate patients’ emotional expression and emotional adjustment ability and help patients better understand their emotional state (Yan & Chen, 2011) .
5.2. Self-Awareness and Self-Exploration
EXAT and painting therapy can help patients better understand themselves and explore themselves. In painting therapy, patients reflect their inner world through paintings, so as to better understand their emotional state and needs. In EXAT, patients can better explore themselves and discover their potential abilities and values through music, dance, and other forms.
5.3. Enhance Emotional Connection and Social Support
EXAT and painting therapy can help patients strengthen emotional connection and social support. In painting therapy, patients can establish emotional connection and trust relationship through interaction with therapists, to better receive treatment. In EXAT, patients can participate in art activities, establish contact with other patients, share their feelings and experiences, and gain social support and comfort.
5.4. Reduce Anxiety and Depression
EXAT and painting therapy can help patients reduce anxiety and depression. In painting therapy, patients can relax their body and mind and relieve anxiety and depression through the process of painting. In EXAT, patients can relieve emotional stress and reduce anxiety and depression through music, dance, and other forms of activities (Gong, 2008) .
6. Discussion and Conclusion
EXAT is a holistic approach for therapy which helps patients express their emotions, relieve stress, and improve their mental health through art forms such as painting, music, and dance. Painting therapy is a therapeutic method that uses painting as the main tool. Through the process of painting, patients can relax, adjust their moods, and improve their self-awareness. EXAT includes psychodrama or drama therapy, poetry therapy, theatre therapy, music therapy, and movement/dance therapy, which have formalized creative interventions, and painting therapy, which can also be viewed as a technique of EXAT (Malchiodi, 2014) , which can be used either as a stand-alone technique or as a primary therapeutic approach (Jiang, 2021) .
This paper summarizes the development, theoretical basis, application fields and effect evaluation of EXAT and painting therapy. Through combing and analyzing the related literature, it summarizes the wide application of EXAT and painting therapy in the fields of psychotherapy, rehabilitation nursing, education and other fields, as well as EXAT and painting therapy achieves significant therapeutic effects. For instance, in psychotherapy, EXAT or painting therapy has been shown to be useful in improving mental health, relieving stress and anxiety (Malchiodi, 2011) , and improving self-acceptance (Moula et al., 2022) . In the field of rehabilitative care, EXAT and painting therapy can help patients with pain and anxiety relief and distraction (Zhou, 2019) . In education, they apply to student mental health, special education, and teacher professional development (Yang et al., 2015) . Meanwhile, in the field of social work, EXAT and painting therapy can help social workers better understand the inner experience and emotional needs of the disadvantaged groups (Guo, 2011) , and help the disadvantaged groups to alleviate pressure, reduce psychological burden, and enhance self-confidence (Chen, 2010) .
It can thus be seen that EXAT, and painting therapy currently have a wide range of application areas and have beneficial effects. Creative interventions are more beneficial than traditional talk therapy among many intervention methods (Gambrel et al., 2020) . It provides a safe therapeutic space for the development of creativity (Karkou & Sanderson, 2006) , and is immensely useful for reconciling emotional conflicts, exploring avenues of self-expression, and coping with symptoms and traumatic experiences (Miholić & Martinec, 2013) . They enhance empowerment of self-help by reconstructing the primary meaning of the self through nonverbal artistic expression (Li & Peng, 2022) .
Nevertheless, there are some shortcomings and limitations in the application and research aspects of EXAT and painting therapy. First, the current research mainly focuses on the application field and effect evaluation of EXAT and painting therapy, but the mechanism research needs to be further deepened. More experimental and clinical studies are needed in the future to explore the mechanism of EXAT and painting therapy. Second, the treatment protocols of expressive art therapy and painting therapy need to be further optimized. According to Erikson’s eight-stage theory, people at different periods of time have different psychological evolutions with different contradictions and conflicts (Erikson, 2018) . In the future, a more personalized and effective treatment plan needs to be designed based on the patient’s specific condition and treatment goals.