1.1. Background of Study

Depression affects approximately 2.3% of the Malaysian population, which is characterized by determined sadness and a loss of interest (Global Health Data Exchange, 2019). It can distort cognition and behaviour, leading to emotional distress, self-injury, and an increased risk of suicide (Remes et al., 2021). The Beck Depression Inventory (BDI; Beck et al., 1961) assesses the severity of depression across three domains: somatic, affective, and cognitive. The somatic domain involves physical symptoms such as fatigue and changes in sleep or appetite (Tylee & Gandhi, 2005). The affective dimension includes emotional symptoms such as anhedonia and irritability (Beck et al., 1961). Lastly, the cognitive domain focuses on negative beliefs, such as pessimism and worthlessness (Conradi et al., 2011).

Depression is a significant concern for young Malaysian adults. Research indicates that 27.5% and 9.7% of university students experience moderate and severe depression, respectively (Shamsuddin et al., 2013). A systematic review further highlights prevalence rates ranging from 14.3% to 81.7% across various Malaysian populations, with students reporting high levels of stress and anxiety (Mud Shukri et al., 2023).

In many Asian cultures, experiences of depression are deeply influenced by collectivist values and the concept of “saving face.” Mental illness is often viewed as a source of deep shame that reflects negatively on the family (Lian et al., 2025). This stigma discourages open discussion and leads individuals to suppress symptoms in order to protect their family’s reputation.

Furthermore, mental health literacy remains low among many Malaysians. This lack of awareness, combined with cultural stigma and the belief that depression is shameful (Park et al., 2018), results in reluctance to seek professional help. Therefore, only a minority of young adults with depression pursue clinical support (Aalto-Setälä et al., 2001).

The situation is worsened by a shortage of mental health resources. Malaysia has only 1.27 psychiatrists per 100,000 people, significantly below the WHO’s recommended ratio of 10 (Midin et al., 2018). In addition, local interventions rely heavily on traditional methods such as Cognitive Behavioural Therapy (CBT), introduced decades ago (Ward, 2019), highlights the delay in adopting modern psychotherapies. Because most current interventions focus on verbal expression primarily, as there is an urgent need to explore alternative therapeutic methods.

1.2. Expressive Art Therapy

Expressive art therapy acts as a non-verbal psychotherapeutic model, which serves as an important alternative to improve the current circumstances. It involves creative expression of the arts, which helps individuals express feelings and thoughts that are difficult to communicate verbally, thereby improving their psychological, physical, and emotional well-being. (Case & Dalley, 2014). Expressive art therapy has become popular in mental health settings, and given its human-centred and recovery-oriented approaches that consider individuals’ emotions and needs (Case & Dalley, 2014).

1.3. Expressive Therapies Continuum

The Expressive Therapies Continuum (ETC) model represents a significant theoretical foundation for expressive art therapy (Hinz, 2019). It presents that different art media and activities can elicit various levels of visual information processing (Hinz, 2019). The ETC divides this processing into a hierarchy of three levels, each of which comprises two components: (1) kinaesthetic/sensory, (2) perceptual/affective, and (3) cognitive/symbolic. These levels state their progress from simple to sophisticated processing.

People usually prefer a dominant component at each level. For example, one may be familiar with the sensory component but not the kinaesthetic. Therapists, therefore, intentionally challenge these unfamiliar areas to foster balance. Mastering each level allows progression towards “Creativity”—the final stage characterized by flexible, integrated information processing and psychological resolution. By the end of an ETC-based intervention, the individual will be equipped with all six different modes of understanding, expressing, and processing their depressive experiences in a creative and holistic manner. Thus, the expressive arts intervention aims to assess non-dominant components and moderate overused functions, ensuring a balanced and holistic therapeutic process.

1.4. ETC and Depressive Symptoms

The ETC aligns closely with the depressive symptom classifications in BDI. The BDI’s somatic, affective, and cognitive domains (Beck et al., 1961) correspond respectively with the ETC’s sensory, affective, and cognitive levels. Both frameworks are theoretically grounded in Triune Brain theory (MacLean, 1990), which organizes human experience across three evolutionary layers: the survival-based brainstem (somatic), the emotion-centred limbic system (affective), and the logic-oriented neocortex (cognitive).

Combining both models to this hierarchy explains that depression is a synchronized experience across body, emotions, and thoughts, rather than a purely “mental” construct. Consequently, this study hypothesizes that ETC-based interventions may alleviate depressive symptoms by addressing these three interconnected aspects of human functioning.

1.5. Cultural Consideration

Due to the stigma and emotional restriction prevalent in Asian cultures, traditional verbal therapies can be ineffective and often produce overwhelming emotions (Mao et al., 2022). Many individuals feel uncomfortable discussing emotions openly, fearing they may be perceived as weak or threatening (Lian & Bono, 2023). Consequently, non-verbal expressive art therapy is more suitable; its metaphorical approach is less confrontational and can provide a “safe space” that keeps the patients in their window of tolerance (Schoonover, 2021).

While the systematic review by Abdul Rahman et al. (2024) highlights the effectiveness of expressive arts therapy in Malaysia, it also underscores a significant lack of standardized formats or fixed theoretical models within the existing literature, which limits replicability. The ETC addresses this gap as a relatively modern and highly structured framework that provides a clear, hierarchical framework for intervention. Therefore, the current study applies this modality to establish a more standardized and replicable expressive arts therapeutic approach within the Malaysian context.

In addition, depression is an individualised experience; the Asian collective environment and culture must be taken into account. Object Relations Theory emphasizes the intersubjectivity between the self (mental representation of oneself) and object (mental representation of significant figures) (Lian & Bono, 2024). In collectivist cultures that prioritise social cohesion, this bi-directional relationship of nature of is particularly notable. Accordingly, the present study posits that effective interventions for depression should address both the individual’s internal experience and their perceptions of how the “world” interacts with depression.

To combine these gaps, the present study developed a comprehensive ETC-based art intervention manual (Lian et al., 2025). The intervention is organised with three core themes: (a) The Self/Individual Experience, (b) The Object/World Experience, and (c) Summary. Each theme adopts a progressive approach, moving from sensory-kinaesthetic to affective-perceptual and cognitive-symbolic modalities, ensuring a structured progress throughout the ETC levels. The intervention manual was developed by an experienced expressive arts therapist holding a Level 7 postgraduate diploma in Transpersonal Arts in Therapy Training.

2. RESEARCH OBJECTIVES

This study aims to evaluate the feasibility, acceptability, and preliminary efficacy of the developed ETC-based art intervention in mitigating depressive symptoms in Malaysian young adults. The specific research objectives are as follows:

Objective 1: To assess the effectiveness of the ETC-based art intervention in reducing depressive symptoms from three perspectives, which are overall, cognitive-affective, and somatic.

Objective 2: To evaluate participants’ changes and progression throughout the ETC-based art intervention.

Objective 3: To explicit participants’ views on the effectiveness of the ETC-based art intervention.

3.1. Research Design

This study employed a one-group pre-test and post-test study design combined with quantitative analysis (survey), unstructured observation, and a focused group discussion. This method was used to examine participants’ changes in depressive symptoms, non-verbal observational changes, and their opinions after engaging in the ETC-based art intervention. The effectiveness of the intervention in reducing depressed symptoms was measured using the BDI (Beck et al., 1961). In addition, unstructured observations were conducted to record participants’ behaviours, expressions, or interactions throughout the intervention without predefined categories or guidelines. Furthermore, a focus group discussion was carried out to explore the opinions of the people on the effectiveness of the intervention. This study has been adapted from the semi-structured in-depth interviewing questions developed by Ghani et al. (2015); the similarity in research objectives regarding the effectiveness of psychological treatments in Malaysia is considered.

3.2. Participants

In research, convenience sampling is used to recruit participants from Raffles University who met the eligibility criterion of scoring 21 or above on the BDI, indicating the presence of depressive symptoms. Eligibility was further restricted to individuals who were free from other ongoing treatments. Individuals with severe mental disorders, psychotic conditions, or intellectual disabilities were excluded to minimize potential risk and reduce confounding effects. From a clinical perspective, such individuals require intensive, multidisciplinary psychiatric care and specialized stabilization beyond the scope of the research intervention. Moreover, this exclusion helped control for confounding variables, such as fluctuating medication regimens or acute psychiatric episodes, which could obscure the specific therapeutic effects of the ETC-based intervention. The proposed sample size was 10 participants, based on a similar art therapy and depression study by Blomdahl & Goulias (2024). Given this intervention in the early phase, a small sample size was adopted to examine its feasibility and preliminary efficacy.

3.3. Intervention

The intervention was built to begin with the dominant components at each ETC level and progressively transition towards the less dominant components, with the aim to balance the ETC components, that allows participants to process and understand depressive experiences differently. Based on the BDI, individuals with depression are dominant in the Cognitive, Affective, and Sensory domains, aligning with depressive symptoms (Beck et al., 1961). Therefore, the treatment plan aimed to balance dominant with non-dominant domains. For instance, at the kinaesthetic/sensory level, the intervention starts with the sensory and moves to the kinaesthetic component. Similarly, it transitions from affective to perceptual and from cognitive to symbolic, with the former in each pair representing the assumed dominant component.

Since predetermined treatment plans can sometimes overlook individual needs (Hinz, 2019), therapists can individualise treatment within structured groups by varying art therapy directives. This includes allowing participants the autonomy to change or alter tasks based on preference and the freedom to choose their preferred media and materials. Participants were oriented on the materials’ which is unique in characteristics, before the first session.

The intervention comprised 16 sessions, covering all six components and three levels in the ETC over two cycles. The order progresses from the bottom to the top level (i.e., sensory-kinaesthetic to affective-perceptual to cognitive- symbolic). This arrangement accounts for the vulnerability of depressive patients and the limitations of emotional expression among Asians (Mao et al., 2022). Beginning with the less emotionally demanding sensory-kinaesthetic level allowed for a gradual progress towards the more emotional and advanced cognitive-symbolic level (Hinz, 2019).

The first ETC cycle focuses on the individual experience of depression, whereas the second cycle focuses on the world-related experience of depression (i.e., the experience of their environment). The expressive art therapy is constructed as group therapy, which enhances collectivistic support in the form of community (Chung & Bemak, 2004). The manual was evaluated by two registered art therapists who work extensively in Asia, and their feedback was systematically incorporated. An overview of the manual is given in Table 1, while the full version is available upon request. For further details regarding its development, can be found in Lian et al. (2025).

3.4. Outcome Measures

3.5. Procedures

Participants completed a form, which included the BDI, to determine eligibility and pre-test depressive symptoms. Eligible participants were provided with an information sheet detailing the study objectives, procedures, confidentiality, and right to withdraw. Only those who signed the informed consent form were enrolled.

This study used an expressive art therapy manual integrating ETC and BDI concepts. The intervention involved 16 one-hour sessions conducted over three months, and was delivered by an experienced expressive art therapist. An experienced supervisor ensured adherence to the treatment protocol and provided feedback. Observations were conducted with participants’ approval. Upon completion of treatment (i.e., post-test), participants completed a feedback form to share their experiences. Information on helplines and support services was provided. A focus group discussion and the final BDI assessment were conducted after the intervention to measure changes in depressive symptoms.

3.6. Analyses Strategy

Quantitative data were analysed using IBM SPSS version 26. Participants’ sociodemographic characteristics were analysed descriptively. Normality tests were conducted. The data violated the assumptions of normal distribution due to the small sample size. Thus, the Wilcoxon signed-rank test was performed to examine differences in depressive symptoms from pre-test to post-test, with a p-value of ≤ 0.05 considered statistically significant. Qualitative data collected through observation and focus group interviews were analysed thematically.

4.1. Participants’ Characteristics

A total of 10 participants aged 18 to 26 years (M = 22 years old) participated in this study. Chinese and Indian participants were equally represented, with five individuals from each group. Six females comprised the majority of the participants. For eight participants, this was their first experience with psychotherapy and while the remaining had received some sort of psychotherapy treatment previously.

4.2. ETC and Depressive Symptoms

The somatic, cognitive affective symptoms, and overall depressive symptoms showed a decrease after the intervention. Participants’ cognitive-affective symptoms decreased from (M = 20.10, SD = 4.51) to (M = 6.70, SD = 6.24). Similarly, overall depressive symptoms declined from (M = 29.0, SD = 6.81) to (M = 10.90, SD = 9.26), followed by a reduction in somatic symptoms from (M = 8.90, SD = 3.07) to (M = 4.20, SD = 3.36).

The results of the Wilcoxon signed-rank test indicate a reduction in participants’ depressive symptoms from cognitive-affective, somatic and overall aspects after the intervention. For cognitive-affective symptoms, the median score decreases from 18.50 to 4.50, z = –2.803, p = 0.005, for the somatic symptoms, the median score decreases from 9.50 to 3.00, z = –2.809, p = 0.005. In total, overall depressive symptoms, the median score reduces from 28.00 to 9.00, z = –2.807, p = 0.005.

4.3. Observed Changes

The emotional, cognitive, behavioural and social changes were derived from the observation. Each theme was further categorised into one or two subthemes.

4.3.1. Emotional

The majority of the participants exhibited signs of anxiety during the first four sessions. They appeared uncomfortable and often displayed a nervous gesture such as fidgeting or covering their mouths. One participant showed frustration through her facial expressions (e.g., frowning) when asked to colour with both hands, suggesting confusion or mistrust. Even by the fourth session, several participants continued to display closed body postures (e.g., crossing arms, turning the body away), indicating persistent anxiety. However, a positive shift occurred starting in the fifth session with most participants appearing noticeably calmer, displaying more open body language and relaxed facial expressions.

At the beginning of therapy, participants seem reserved in their artworks, using simple colours and spending shorter durations painting. Initially, their emotional expression and the storytelling elements in their paintings were limited. However, as they become more comfortable in the therapy environment, their artistic style evolved. They began using a wider range of colours and tones, and their artwork became more dynamic, expressive, and featured more in-depth stories (Figure 1). One participant created a new shade by mixing colours, demonstrating increased emotional depth in their seventh session (Figure 2). Participants also explored various drawing techniques, including using their fingers and splashing materials.

Figure 1. - Comparison of participant 3’s paintings from Sessions 1 and 6.

Figure 2. -   Comparison of participant 7’s paintings from Sessions 3 and 7.

4.3.2. Cognitive

Several participants were confused and struggled to generate ideas for their artwork at the beginning of the therapy, which was manifested in their quick and simple creations. Throughout the therapy, participants gradually became more engaged, able to think deeply and express emotions through art. For instance, they developed a better understanding of interpreting their drawings symbolically. One participant who initially painted a simple shape later created a complex tree figure representing herself, demonstrating growth in artistic expression (Figure 3).

Figure 3. -  Comparison of participant 2’s paintings from Sessions 1 and 7.

4.4. Feedback on the Interventions

Participants’ perspectives on the intervention were recorded across four domains: emotional, cognitive, social, and behavioural. Each theme was further categorised into one to three sub-themes.

5.1. Emotional

Firstly, participants shifted from anxious to relaxed states during expressive art therapy sessions. Their artwork showed increased complexity and a wider range of color usage. Participants reported greater emotional awareness, improved expression, and a sense of relaxation.

These positive impacts align with Nan et al. (2021), who suggested art therapy fosters emotional balance and self-awareness. They also highlight art’s soothing capacity, which facilitates emotion regulation and promotes calmness. As a powerful tool for expression, art allows individuals to externalize hidden feelings and impulses. This creative process brings unconscious emotions to awareness, facilitating the understanding and resolution of negative experiences. Vick (2003) regarded art as a potent medium for exploring suppressed feelings—such as trauma or grief—that are often difficult to articulate verbally. Furthermore, Larsen et al. (2010) noted art’s symbolic capacity to express self-concept, which offers a valuable alternative for communication when verbal expression is inadequate.

5.2. Cognitive

Secondly, participants demonstrated increased cognitive engagement and depth of interpretation in their artwork. They also reported improved mental clarity and focus after expressive art therapy sessions.

Expressive art therapy positively impacts cognitive abilities. Engaging in creative art activities enhances cognitive functions, including memory, attention, and problem-solving (Pike, 2013). Art creation requires individuals to process thoughts, strengthening cognitive abilities. In addition, art therapy stimulates divergent thinking and creativity, letting individuals explore new ideas and perspectives (Pike, 2013). Lee et al. (2019) examined art therapy’s effects on older adults’ cognitive performance; the art therapy group mainly improved memory, visuospatial abilities, attention, working memory, and executive function compared to the musical and control groups. These findings suggested that art therapy positively affected on cognitive flexibility, problem-solving skills, and overall cognitive function.

5.3. Social

Thirdly, observations indicated that participants more socially engaged by sharing and forming connections with peers. In the focus group, participants expressed gratitude for the social interaction and support provided by the expressive art therapy group.

Wang et al. (2019) investigated immigrant youths in a group art therapy setting and found their social functioning and adaptability were enhanced. This suggested art is a powerful medium for connection, facilitating discussion, sharing, and the discovery of commonalities. Kong & Han (2024) conducted a meta-analysis of 20 studies, which validating the effectiveness of group art therapy for adolescents and highlighted its potential to promote self-awareness, empathy, and social skills. Group settings allow individuals to recognize both their unique individuality and shared experiences, ultimately improving social functioning. Therefore, the authors intentionally incorporated designed activities fostering social interaction through art in the current manual.

5.4. Behavioural

Lastly, observational studies showed that participants who exhibited increased activity levels during expressive art therapy sessions. They demonstrated greater engagement, actively seeking out materials, contrasting with previous passive behavior. Focus group participants reported that the structured routine and active nature of art-making activities were motivating factors.

Shukla et al. (2022) has suggested art, which enhances self-reliance and self-motivation by requiring individuals to rely on their own abilities to create. The non-judgmental and supportive nature of art therapy promoted self-esteem and confidence. This aligns with humanistic theory, which posits that individuals achieve self-actualization and personal growth through opportunities for self-expression, empathy, and unconditional positive regard (Herron, 2022). Art therapy offers such an environment, supporting artistic processes and creations without judgment, fostering motivation. In addition, behavioural activation theory posits that consistent engagement in enjoyable activities leads to positive reinforcement, which boosted positive emotions and motivation (Ekers et al., 2014). Participants’ consistent involvement in art activities over multiple weeks in expressive art therapy facilitated behavioural activation.