Active elements, effects, and working mechanisms of creative arts therapies in forensic psychiatric care: a realist review

Introduction: Mental disorders are highly prevalent among forensic detainees, complicating treatment and increasing recidivism risk. Due to limited insight and communication difficulties, experiential approaches, such as creative arts therapies are needed. Creative arts therapies - including art therapy, music therapy, drama therapy, and dance/movement therapy - use psychotherapeutic engagement with art modalities to achieve therapeutic goals. As empirical studies demonstrate their effectiveness, questions shift from whether these interventions work to how and why they work. Methods: In this review, we applied principles of realist review approach to analyze how and why CATs work by identifying active elements and working mechanisms, aiming to clarify causal pathways and inform targeted clinical application. Results: Twenty-seven studies were included with 1437 participants in total. Based on realist review standards, four studies were excluded for relevance and six for rigor, leaving 17 studies included in the review. The analyses resulted in twelve models identifying active elements of arts therapies in forensic care, and explaining how these contribute to observed outcomes. Overall, a hierarchical structure can be observed, in which the identified active elements range from those grounded in fundamental physical and bodily experiences, to those facilitating emotional expression and recognition, progressing further to elements that engage higher-order cognitive processes -such as attention regulation and executive or inhibitory functioning- and culminating in elements that foster social interaction and prosocial behavior. Discussion: These models offer a conceptual framework for understanding creative arts therapies in forensic contexts and guide further empirical research and refinement of clinical practice.