The role of art education in improving therapeutic relationships in mental health nursing

Abstract Background The quality of therapeutic relationships plays a decisive role in treatment engagement, adherence, and recovery among individuals with severe mental illness. However, communication barriers, emotional withdrawal, and illness-related cognitive disturbances often restrict effective nurse–patient interaction. Preliminary clinical observations indicate that art-education activities may provide a nonverbal, low-threat channel that facilitates emotional expression and improves interpersonal rapport, yet rigorous empirical evidence remains sparse. Therefore, this study implemented a structured art-education intervention, which aimed to determine whether it could significantly enhance therapeutic relationship quality in mental health nursing and to further examine its effects on emotional regulation and treatment engagement. Methods A total of 172 psychiatric inpatients diagnosed with schizophrenia or affective disorders were included, all meeting the diagnostic criteria of the Tenth Revision of the International Classification of Diseases and Related Health Problems. After obtaining informed consent from family members and approval from the hospital ethics committee, participants were randomly assigned to an intervention group (n = 86) or a control group (n = 86) using a random-number table method. Both groups received standard psychiatric nursing care, including medication management, psychological support, and daily behavioral guidance. In addition, the intervention group participated in an 8-week structured art-education program, conducted twice per week for 60 minutes per session. The sessions were delivered by nurses with training in art therapy and included thematic drawing tasks, emotional color-recognition and expression exercises, and artwork presentation and group-sharing activities. The primary outcome was the Working Alliance Inventory (WAI), which evaluates patients’ trust in nurses, willingness to cooperate, and agreement on therapeutic goals. Secondary outcomes included the Difficulties in Emotion Regulation Scale (DERS) and a treatment-engagement behavioral rating, used to assess the intervention’s effects on emotional regulation and treatment involvement. All measures were collected at baseline and after the 8-week intervention. Statistical analyses included paired t-tests for within-group changes, independent-samples t-tests for between-group comparisons, and multiple linear regression to examine the independent predictive effect of the intervention on therapeutic-relationship improvement while controlling for age, illness duration, and baseline symptom severity. The significance level was set at p.05. Results After 8 weeks, the intervention group showed a substantial improvement in WAI total scores from 47.3 ± 6.1 to 58.9 ± 5.8 (t = 14.42, p.001), significantly exceeding the change in the control group, which improved by only 2.8 points (effect size d = 0.86). DERS scores decreased by 12.4 ± 4.9 points in the intervention group, compared with 3.1 ± 2.8 in the control group (t = 11.07, p.001). Treatment engagement increased by 21.7% in the intervention group (p=.004), whereas the control group showed no significant change (p=.231). Multivariate regression demonstrated that the art-education intervention independently predicted improvement in therapeutic relationship scores (β = 0.41, p.001) after controlling for age, illness duration, and baseline symptom severity. Discussion The findings indicate that structured art education significantly enhances therapeutic relationships, emotional regulation, and engagement in psychiatric care. These improvements may result from the intervention’s capacity to facilitate nonverbal communication, reduce interpersonal tension, and strengthen mutual trust. The results support incorporating art-based educational activities as an auxiliary intervention in mental health nursing to optimize therapeutic relationships. Future studies should explore long-term effects, mechanisms of change, and applicability across diagnostic subgroups.