The World Health Organization (WHO) has identified 10 diseases as leading causes of major disabilities, among which four psychological disorders, including obsessive–compulsive disorder (OCD), are notable (Steketee, 2011). Obsessive–compulsive disorder can significantly disrupt various aspects of life such as work and social relationships, with a prevalence rate of 1–3% (Markarian et al., 2010).

Difficulty in emotion regulation is strongly associated with mental disorders, including OCD (Bischof et al., 2024). Emotion regulation refers to the capacity to effectively control and manage emotional responses, enabling individuals to navigate challenging and emotional situations with flexibility while regulating the intensity of their emotions. Mastery of this skill empowers individuals to consciously or unconsciously regulate their emotions, and their lives are improved across emotional, cognitive, and behavioral domains (Pruessner et al., 2020). The inability to regulate emotions contributes to 49% of OCD symptoms (Goldberg et al., 2016). The urge to avoid feelings and emotions through suppression serves as the underlying factor of obsession. Compulsive behaviors in obsession arise as a means to alleviate emotional disturbance caused by uncontrollable thoughts (Bischof et al., 2024).

Another issue observed among individuals with OCD is low mindfulness (Moroń & Kocur, 2023). Mindfulness is characterized by full awareness of one’s emotions and both internal and external changes in the present moment, while maintaining a non-judgmental focus on them. This practice heightens attention and awareness in the present moment, enabling individuals to become more attuned to their inner world, emotions, and feelings (Schuman-Olivier et al., 2020). Mindfulness, as an internal quality, can enhance flexibility and improve the mind’s capacity to accept challenges. Individuals experiencing symptoms of OCD often exhibit reduced attention to both internal and external states in the present moment. By cultivating mindfulness, they can learn to accept their conditions and emotions without judgment or self-blame. This practice can be highly effective in reducing anxiety and obsession (Çek et al., 2022).

Various pharmacological and psychotherapeutic approaches have been proposed for treating obsessions. Mindfulness-based therapy is one such psychotherapeutic approach that appears to be effective in managing obsessions and their associated consequences (Borgohain, 2024). People could avoid living in the past and future world through mindfulness and being aware of their thoughts, emotions, and physical conditions at any moment (Khoury et al., 2015). Mindfulness therapy was first introduced by Jon Kabat-Zinn for mindfulness-based stress reduction. A person observes their thoughts, emotions, and feelings in the present moment without judgment and reaction using mindfulness-based therapy and their self-monitoring improves. In this way, their negative reactions, obsession symptoms, and anxiety disorders decrease (Chien et al., 2022).

Practicing mindfulness involves yoga and meditation as well as breathing exercises and those related to body senses, mood, and emotions, which alters cognitive and emotional responses, leading to a reduction in obsessive–compulsive symptoms (Borgohain, 2024). Using mindfulness for obsession treatment is considered a biological-cognitive-behavioral method that is different from exposure and response prevention in behavioral therapy. Teaching mindfulness to obsessive patients enables them to observe changes in their mind and change their behavior. Changes in the mind cause functional changes. Unlike behavioral therapy techniques that control the output, mindfulness-based therapy influences the output, input, and biological processes causing obsessive behavior (Chien et al., 2022; Schwartz et al., 2005).

Mindfulness-based therapy could be performed in different ways, one of which is mindfulness-based art therapy (MBAT). In this intervention, a mindfulness-based reduction approach and art therapy are integrated, which involves practicing mindfulness, focusing on breathing, using mindfulness meditations, and employing artistic creativity and creative non-verbal expression (Peterson, 2015). In MBAT, direct intervention, i.e., mindfulness exercises, is performed, and creative expression of thoughts and feelings is taught through art (Demir et al., 2024).

Art therapy has been formally recognized and studied as a therapeutic approach (Springham, 2016). In this method, artistic materials and methods are integrated with counseling approaches (Pesso-Aviv et al., 2014). Art allows one to experience life’s moments at any time and place and improve internal and external conflicts. A bridge is established between internal and external experiences by means of art and it moves toward healing (Torgerson, 2018). People could project their inner world through art and deepen their connection with themselves and surrounding world (Isis et al., 2024). When mindfulness is taught through art therapy, educational concepts are better transferred and people creatively express their emotions non-verbally. Thus, its effectiveness is significantly greater than applying mindfulness alone as direct training (Cheshure et al., 2023; Rappaport & Kalmanowitz, 2014). Painting therapy is a widely used and effective method for the indirect expression of thoughts and feelings, based on which one becomes aware of their inner world through painting. People express their feelings and emotions by projecting their inner life through painting and manifest it as painting. Watercolor is a unique painting technique that also serves as a peaceful and calming form of meditation. Beyond the pleasure of painting, it fosters a sense of mindfulness due to its distinctive characteristics (Haines, 2016).

A comprehensive examination of the literature reveals ample evidence regarding the influence of mindfulness interventions on emotion regulation among individuals with OCD (Azizi et al., 2023; Borgohain, 2024; Chien et al., 2022; Pseftogianni et al., 2023; Riquelme-Marín et al., 2022). However, despite recent investigations into mindfulness-based art therapy (Demir et al., 2024; Isis et al., 2024; Jang et al., 2018), there remains a scarcity of studies specifically focusing on individuals with OCD or delving into the intricacies of emotion regulation within this population. The results of a study have shown that mindfulness-based art therapy significantly reduces anxiety and negative emotions in a sample of college students (Beerse et al., 2020). The findings of another study showed that MBAT was effective in reducing the symptoms of depression and stress in patients with migraine and increasing their happiness (Demir et al., 2024). The effectiveness of MBAT has also been assessed as a single-session intervention. Evidence indicates that this single session can enhance mindfulness, mindful creativity, and positive emotions, while also reducing negative emotions in individuals (Isis et al., 2024).

Studies have shown that 20–40% of individuals experience symptom relief from medication. However, recurrence of symptoms has been observed in 70–90% of cases after medication discontinuation (Rector, 2001). Thus, pharmacotherapy alone does not have a lasting effect and psychotherapy along with taking medication is required. Some patients refuse to take or continue taking medication due to its side effects (Sadock et al., 2014). Exposure therapy is performed in psychotherapies commonly used for obsession treatment such as behavior therapy and cognitive-behavioral interventions. Although this is useful, it is highly stressful. Most of the patients do not continue treatment due to increased anxiety resulting from these methods. There is a need for innovative and integrative approaches that address the limitations of current treatments for OCD. Mindfulness-based stress reduction and art therapy are integrated in MBAT, and this approach could be a more effective method than mindfulness alone due to its attractiveness and non-verbal expression as well as using one’s artistic creativity in exploring oneself and the environment.

However, our review of previous studies revealed that none of these mindfulness-based art therapy studies had been conducted using watercolor painting in individuals with OCD, despite the potential of art to assist such individuals in alleviating their negative and repetitive thoughts. Given that limited research has been conducted in this field, it is of particular importance to conduct studies on the effectiveness of MBAT among patients with OCD. MBAT could be widely and easily used at medical and counseling centers for OCD patients if its effectiveness is confirmed. Therefore, the present study was conducted to determine the effectiveness of mindfulness-based art therapy on improving emotion regulation, enhancing mindfulness, and reducing obsessive symptoms using watercolor painting.

Method

Participants

This randomized controlled trial used a pre-test-post-test-follow-up design to compare experimental and control groups. The research population included patients with OCD living in Isfahan Province, Iran. OCD was diagnosed using the cutoff score of greater than 91 in Vancouver Obsessive–Compulsive Inventory (VOCI) and based on the diagnostic and statistical manual criteria of mental disorders by a psychiatrist. For this purpose, 40 patients with OCD were selected among those referring to a counseling center in Isfahan, 2022, using the convenience sampling method and randomly assigned to experimental and control groups (n = 20 per group). The research methodology and objectives were first explained to the participants. Participants provided informed consent before participating in the study. In the pre-test phase, the participants of both groups filled out VOCI, Gratz and Roemer’s Difficulties in Emotion Regulation Scale (DERS), and Five Facet Mindfulness Questionnaire (FFMQ). The experimental group received MBAT intervention using watercolor painting in eight sessions, each lasting 2 hr (one session per week). The control group received no intervention. To control for the placebo effect, the control group participated in three sessions of discussions about obsession. These discussions were designed to provide the participants with an experience of therapeutic attention without incorporating the specific components of MBAT. This ensured that the control group received a comparable level of interaction and attention from facilitators, similar to the experimental group, without directly engaging in mindfulness-based techniques or art therapy. We chose to focus on discussions about obsession to maintain relevance to the study’s primary outcome (obsessive symptoms) while avoiding any therapeutic intervention. These discussions were strictly limited to informational content and did not include any guidance, coping strategies, or therapeutic elements. By doing so, we aimed to ensure that the control group received attention similar to that of the MBAT group, minimizing attention bias while avoiding direct intervention. However, we acknowledge that this placebo approach may have limitations, such as increasing the participants’ awareness of their obsession-related symptoms without offering a therapeutic resolution. Despite this, it allowed us to control for the placebo effect and isolate the specific impact of the MBAT intervention.

The pre-test was performed immediately before the intervention, the post-test was conducted immediately after the intervention, and the follow-up was carried out 2 months after the intervention in both groups. The inclusion criteria were being diagnosed as an OCD patient by a psychiatrist, getting the cutoff point in the compulsive obsession symptom scale in the Iranian norm (Imandoust et al., 2020), being physically able to do tasks and being 20–60 years old. Exclusion criteria were suffering from other psychological disorders, participating in other psychotherapeutic interventions and having a physical disability. The flowchart is present in Fig. 1.

Fig. 1
figure 1

Flowchart

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Procedure

Despite an extensive search, no widely recognized and specific intervention program for MBAT using watercolor painting was found. The protocol design primarily drew inspiration from protocols outlined by Monti et al. (2006), Peterson (2013), and Jang et al. (2018). Monti et al. (2006) incorporated mindfulness exercises, such as body scan and sitting meditation, within an MBSR curriculum, similar to the protocol outlined by Santorelli et al. (2017). Given the capabilities of watercolor painting, the researcher, specializing in watercolor and art therapy, designed methods for both the methodology and content of the sessions. The primary researcher conducting the intervention sessions has a master’s degree in psychology and works as a teacher and judge in international watercolor competitions. With several years of experience in mindfulness and art therapy research, the researcher has a strong foundation in these fields. Following the development of the protocol, its content validity was meticulously evaluated and approved by five experts in the field of MBAT. They are certified psychotherapists with specialized training and extensive experience in mindfulness-based interventions and art therapy.

The MBAT program consisted of eight sessions incorporating watercolor painting, featuring a range of activities. These included practicing attentive and mindful use of painting tools. Engaging in body scan meditation to heighten bodily awareness for all participants; participating in seated meditation sessions; practicing mindfulness by being attentive to the mind–body connection. Engaging in non-judgmental observation of sensory experiences and mindful brush movements; focusing on breathing rhythm and depicting various emotions and bodily sensations in real time. Creating a color spectrum by diluting paints with water; drawing the inner state and body using different color intensities while maintaining focus on breathing rhythm. Painting based on inner feelings and emotions without utilizing white color; mindfully depicting inner states, emotions, thoughts, and bodily sensations with watercolors while focusing on breathing rhythm and accepting the outcome; concluding sessions with a reevaluation of the comprehensive self-image. Furthermore, weekly assignments were tailored to each session’s content. Participants received instructional voice recordings from the researcher to assist with completing these assignments.

Water is recognized as an invigorating element in meditation, and its role in enhancing mindfulness has been emphasized. Therefore, hearing the sound created by moving the brush in water during watercolor painting as well as looking at paints flowing in water, akin to an anchor, grounds a person in the present moment, and as a result, could improve awareness and reduce stress. Observing the flow and movement of colors on wet cardboard, beyond one’s control, as they create intricate patterns and occasionally blend to form new hues, serves as a valuable exercise in fostering acceptance without judgment. Throughout the drawing exercises, the researcher provided verbal cues to ensure that participants approached their drawings mindfully. This involved ensuring that participants were fully present in the moment and receptive to the creative process without judgment, focusing on their emotions and thoughts. At times, specific prompts were given to direct their focus toward particular aspects. For instance, in one exercise, participants were encouraged to depict their emotions and inner state while concentrating on their breathing, heartbeat, and sensations in their hands and engaging their five senses, including hearing. While watercolor painting was incorporated as a central element of the intervention, it is important to note that it was not equated with formal meditation practices. Instead, watercolor painting was used to enhance mindfulness by encouraging participants to focus on sensory experiences, such as observing the flow of colors, engaging with the texture of the painting tools, and practicing non-judgmental awareness of the creative process. These activities were designed to cultivate mindfulness and present-moment awareness, aligning with the broader goals of the intervention. Unlike structured meditation techniques, watercolor painting in this context allowed participants to explore their emotions and inner states in a mindful, creative manner, complementing the more formal mindfulness exercises like body scan and seated meditation. The details of the intervention sessions are outlined in Table 1.

Table 1 Content of interventional sessions
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Measures

Difficulties in Emotion Regulation Scale

This 36-item scale measured defects and difficulties in emotion regulation on a 5-point Likert scale, ranging from 1 (almost never) to 5 (almost always) (Gratz & Roemer, 2004). This scale consisted of six dimensions: not accepting negative emotions, difficulty in performing targeted behaviors in times of helplessness, difficulty controlling impulsive behaviors, limited access to effective emotion regulation strategies, lack of emotional awareness, and lack of emotional clarity. The scores of the six subscales were added and the total score was calculated for difficulty in emotion regulation. A higher score indicated more difficulty in emotion regulation. The psychometric properties of difficulty in emotion regulation, including internal consistency, test–retest reliability, and construct validity, were confirmed in clinical and non-clinical research (Gratz & Roemer, 2004). Cronbach’s alpha of the Persian version of this scale was reported as 0.79–0.92 (Besharat & Bazzazian, 2015). The test–retest reliability of the whole scale was obtained twice within 4 and 6 weeks as 0.71–0.87 (Besharat & Bazzazian, 2015).

Five Facet Mindfulness Questionnaire

This 39-item questionnaire measured five factors of mindfulness: view, description, action to awareness, non-judgment of inner experiences, and lack of reaction to inner experiences. The items were scored on a 5-point Likert scale, ranging from 1 (never) to 5 (always) (Baer et al., 2006). Higher scores indicated greater mindfulness. Cronbach’s alpha of the Persian version of FFMQ was obtained as 0.90 (Tamannaeifar et al., 2016). The test–retest reliability showed the correlation coefficient of the subscales of FFMQ was 0.76–0.86 and the test–retest reliability of the total score was 0.89 (Heydarinasab, 2013).

Vancouver Obsessional-Compulsive Inventory

This self-report tool measured a wide range of obsessive symptoms. This 55-item questionnaire included six subscales of pollution, verification, obsessive thoughts, hoarding, perfectionism, and doubt, scored based on a 5-point Likert scale, ranging from 0 (not at all) to 4 (extremely). Higher scores indicated more obsessive symptoms. The internal consistency, test–retest reliability, and appropriate concurrent, diagnostic, and construct validity of the questionnaire were confirmed (Thordarson et al., 2004). The test–retest reliability of the Persian version of Vancouver’s inventory was obtained as 0.91–0.96, and the test–retest reliability of the whole scale was 0.94. Cronbach’s alpha of the whole scale was reported as 0.85, and its validity was confirmed (Izadi et al., 2012).

Data Analyses

Data were analyzed by repeated-measures mixed ANOVA (groups × times) and the independent samples t-test with change scores. The normality of the distribution of scores was evaluated using the Shapiro–Wilk test and the homogeneity of variances was evaluated using Levene’s test. Effect sizes (Cohen’s d) were estimated by dividing mean of change scores by standard deviation of the change scores (Feingold, 2009).

Results

There were 14 women and 6 men in the experimental group and 16 women and 4 men in the control group. The mean ages of the participants were approximately similar in both groups (32.7 ± 9.25 in experimental and 36.8 ± 11.79 in control group, respectively). T-tests showed there was no significant difference between groups regarding age (t(28) =  − 1.22, p = 0.23). Eleven participants of the experimental group were single, 6 were married, and 3 were divorced. There were 9 single, 7 married, and 4 divorced participants in the control group. Three participants in the experimental group had formal school education and 17 participants had graduate education. In the control group, 5 participants had formal school education and 15 had graduate education. The mean and standard deviation of the participants in mindfulness, difficulties in emotion regulation, and obsessive symptoms are shown in Table 1, separately for the experimental and control groups.

The normality of score distribution for both the experimental and control groups was supported by the Shapiro–Wilk test (e.g., for mindfulness pre-test: W = 0.96, p = 0.58 for the experimental group and W = 0.97, p = 0.74 for the control group. Similar results were found for the other variables). Levene’s test for equality of variances was not significant (e.g., for mindfulness pre-test: F(1, 38) = 0.18, p = 0.68. Similar results were found for the other variables), indicating that the assumption of equality of variances was not violated. Finally, there were no differences between two groups regarding pre-tests (p < 0.05).

As seen in Table 2, repeated-measures mixed ANOVAs 2 (group, experimental vs. control) × 3 (time, pre vs. post vs. follow-up) with score of obsessive symptoms as the outcome variable revealed a significant main effect of time (F(1, 38) = 114.03; p > 0.01) and a significant interaction effect of group and time (F(1, 38) = 129.88; p < 0.01). The results of repeated-measures mixed ANOVA for difficulties in emotion regulation revealed a similar pattern; the results show a significant main effect of time (F(1, 38) = 134.82; p > 0.01) and a significant interaction effect of group and time (F(1, 38) = 161.76; p < 0.01). The decrease in mean scores of obsessive symptoms and difficulties in emotion regulation in the experimental group indicates that participants improved on these measures, whereas the mean scores of control group participants were almost stable at all times of measurement (Table 1). On the contrary, the change of scores in mindfulness in the post-test was incremental in the control group; there were a significant main effect of time (F(1, 38) = 366.17; p > 0.01) and a significant interaction effect of group and time (F(1, 38) = 382.19; p < 0.01). Compared to the control group, the increase in the post-test scores of mindfulness in the experimental group shows that the intervention of art therapy with watercolor painting had a significant effect on improving the mindfulness of the participants (Table 3).

Table 2 Means and standard deviations of dependent variables
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Table 3 Tests of between subject effect in repeated-measures mixed ANOVAs group (2) × time (3)
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The results of the independent t-test were also consistent with repeated-measures mixed ANOVA. The independent samples t-test with change scores of obsessive symptoms (post-test minus pre-test) as the dependent variable was significant (t(38) =  − 11.01, p < 0.01; with mean change scores of − 35.65 and 1.65 for experimental and control group, respectively). In a similar pattern, change scores of difficulties in emotion regulation (post-test minus pre-test) as the dependent variable were significant (t(38) =  − 10.88, p < 0.01; with mean change scores of − 30.80 and 2.55 for experimental and control group, respectively). Finally, the independent samples t-test with change scores of mindfulness (post-test minus pre-test) as the dependent variable was significant (t(38) = 18.76, p < 0.01; with mean change scores of 40.30 and − 0.30 for experimental and control group, respectively).

In order to evaluate the stability of the intervention effect in the follow-up phase, the independent t-test was used. The independent samples t-test with change scores of obsessive symptoms (follow-up test minus post-test) showed that improvement of criminal thinking in the follow-up phase has also been continued (t(38) =  − 0.83, p = 0.41; with mean change scores of − 1.25 and − 0.45 for experimental and control group, respectively). Similarly, change scores (follow-up test minus post-test) of difficulties in emotion regulation (t(38) =  − 0.41, p = 0.68; with mean change scores of − 2.15 and − 1.05 for experimental and control group, respectively) and mindfulness (t(38) = 1.53, p = 0.13; with mean change scores of 1.75 and − 0.15 for experimental and control group, respectively) were nonsignificant. These results indicate that decreases in obsessive symptoms and difficulties in emotion regulation and increase in mindfulness observed in the experimental group were sustained during the follow-up phase.

The effect size (post-test minus pre-test) of experimental, as compared to control group, was Cohen’s d = 11.03 for scores of obsessive symptoms. Cohen’s d for difficulties in emotion regulation and mindfulness were 10.9 and 18.79, respectively. According to Cohen’s d criteria, a d-value of 0.8 or greater is a large effect.

Discussion

The results showed MBAT using watercolor painting was effective in improving emotion regulation among OCD patients, which was in line with the findings of previous research (Beerse et al., 2020; Burns & Waite, 2019; Gambrel et al., 2020; Jang et al., 2018; Peterson, 2015). However, there were some inconsistencies, e.g., some studies applied either art therapy or mindfulness intervention and did not address the integrated art therapy and mindfulness. Moreover, they focused on art therapy using watercolor painting. The participants in these studies differed from those in the present study, as they did not focus specifically on individuals with obsessive tendencies. Finally, some of the studies were not interventional and examined the relationship between mindfulness and obsession as structural equations.

To explain this finding, it could be stated that in mindfulness-based intervention, the clients are taught how to overcome their irrational emotions, in such a way that they observe their thoughts and emotions non-judgmentally and focus on them to be able to control and change them (Zoogman et al., 2015). Attention is among the effective factors in emotion regulation (Berking & Wupperman, 2012). Mindfulness-based therapy increases attention and acceptance of emotions and understanding their true meaning (Lindsay & Creswell, 2019). Therefore, mindfulness is effective for people to communicate with their emotions and not to suppress them and be aware of their flexibility against emotions and, as a result, be able to moderate them (Peterson, 2015). Being aware of emotions and feelings and accepting them are among the main factors for improving emotion regulation (Berking & Wupperman, 2012). Greater mindfulness reduces emotional reactivity; enables a person to gain more control over their feelings, emotions, and body; and, thus, facilitates emotion regulation; it is possible to create positive emotions and make them stable by focusing on them (Lindsay & Creswell, 2019). Art therapy moderates emotions because art enables one to express their feelings and emotions, resolves conflicts, and reduces patients’ emotional disorders (Shalani & Azadimanesh, 2016). MBAT causes people to be deeply connected with their feelings and emotions and develop an empathetic relationship with themselves and others. In this way, one’s control over their emotions and all they feel inside increases (Lindsay & Creswell, 2019). A person indirectly expresses their feelings and emotions in a projective manner using painting therapy and dominates their emotions by being aware of them. Mindfulness-based painting creates balance between different parts of the brain. The person becomes aware of their responses and emotional and behavioral changes and manages them (Shalani & Azadimanesh, 2016). Compared to other techniques, it is possible to express emotions and feelings along with mindfulness in watercolor painting. The person could mindfully go on a journey through water and color, get rid of their confusion with soft strokes of the brush on the cardboard, and become aware of their emotions by focusing on the created roles and accept them non-judgmentally (Haines, 2016). To regulate emotions and reduce negative emotions, there is no need to instill and add positive emotions to one’s psyche because this approach could cause anxiety. It is better to express and accept emotions. Mindful watercolor painting is one of the ways to express emotions. Therefore, MBAT using watercolor painting could play an effective role in improving the emotional regulation of obsessive people.

The results revealed MBAT using watercolor painting was effective in enhancing mindfulness among OCD patients, which was in line with the findings of previous research (Gambrel et al., 2020; Peterson, 2015). However, there were some inconsistencies in the research method and intervention content. To explain this finding, it could be stated that mindfulness-based therapy fosters mental development by encouraging individuals to live in the present moment, preventing deviation of thoughts, which in turn increases mindfulness and concentration (Habibi & Hanasabzadeh, 2014; Khoury et al., 2015).

Art therapy is very effective in improving mindfulness by encouraging the person to be in the present moment and have creative expression (Zahedzadeh & Joohari Fard, 2018). Being in the present moment is among the important factors of mindfulness. Art is like an anchor that keeps the person in the present moment and increases mindfulness (Blomdahl et al., 2013). Art makes a person accept and enjoy the experience of the present moment. Accordingly, art therapy facilitates mindfulness. In painting therapy, the person accepts their conflicts using colors and painting tools, instead of running away from them, thus leading to greater self-acceptance (Malchiodi, 2011). Unlike other techniques, the colors do not cover each other in watercolor painting (Haines, 2016), i.e., the underlying layers could be observed and the light goes through them if the paint is diluted properly. Therefore, paint layers on the cardboard are transparent. Thus, one could see the underlying layers of the painting and communicate with them. In this way, the desire to focus and pay attention increases. As mentioned before, paying attention and focusing are among the major factors in increasing mindfulness.

In watercolor, the cardboard whiteness should be maintained for parts of the painting that must be in white color (Blake & Croney, 1998). In this technique, white color is not used, but the cardboard whiteness replaces the white color. Thus, it requires great attention and concentration. Due to its special features, this technique of watercolor is a good exercise for increasing attention and concentration. Watercolor painting and flowing of color and water increase one’s enthusiasm to be present in every moment, observe watercolor events, and experience and accept them. Thus, it strengthens other elements of mindfulness. Watercolor painting is an effective meditation (Haines, 2016). In watercolor painting, the person should decide in the moment about how to color and use different methods (Blake & Croney, 1998). Therefore, it is a good exercise to be present in the moment and focus on what is happening at that moment, which could increase mindfulness.

One of the unique and challenging features of wet-on-wet technique is that the paint moves ahead of the brush on the wet cardboard, making it impossible even for skilled people to predict the result with certainty. As a result, the person’s acceptance increases. Integrating mindfulness exercises and watercolor painting results in acceptance and creative self-expression, so that the person accepts their presence at every moment as it is. Hence, MBAT using watercolor painting could play an effective role in enhancing the mindfulness of obsessive people.

The results indicated MBAT using watercolor painting was effective in reducing obsessive symptoms among OCD patients, which was consistent with findings of previous research (Çek et al., 2022; Fairfax, 2008; Külz et al., 2014; Riquelme-Marín et al., 2022). To explain this finding, it could be stated that patients with OCD mostly have a strong feeling of disgust toward themselves and life, and this feeling increases their anxiety and obsession. Mindfulness reduces self-blame. Thus, mindfulness-based therapeutic approaches reduce disgust and the resulting anxiety and, as a result, obsession (Riquelme-Marín et al., 2022). People who suppress their thoughts more have more obsessive thoughts (Rassin et al., 2000). Considering that mindfulness-based therapy is based on accepting thoughts without judgment, thoughts are suppressed less and, as a result, obsession decreases. Mindfulness and obsession symptoms are inversely correlated because mindfulness affects biological processes of obsession and increases self-monitoring (Ahmadi Bejagh et al., 2015). Mindfulness reduces unhealthy and negative thoughts and has positive effects on regulating behavior derived from thoughts (Klussman et al., 2020). Mindfulness-based therapeutic approaches make a person observe their thoughts and feelings in the present moment without judgment and reaction; thus, negative reactions, obsession symptoms, and anxiety disorders decrease (Mennin et al., 2007). Mindfulness exercises make people aware that they are capable of making changes in themselves and empower them in this regard. Therefore, it is very useful for OCD patients who believe that they could not change themselves. Mindfulness ensures a person that they are not influenced by forced and controlled patterns (Riquelme-Marín et al., 2022). Mindfulness exercises make the obsessive person aware that they could control their obsessive behavior. They realize that thoughts are just thoughts and often may not be the truth. In this way, they could get rid of them. A person should be aware of the messages they hear from the reasoning mind while thinking and let them go without struggling and conflicting with them (Garland et al., 2014).

Art therapy stimulates various aspects of the mind such as feeling, intuition, and thinking and integrates feeling and mind. Contrary to the belief of many people, art therapy is not only an emotional and recreational method, but it also activates the mind, promotes creativity, and uses the mind stagnant aspects, and, thus, provides opportunities to find solutions to problems (Farokhi, 2011). Painting therapy could help a person express their suppressed feelings and alleviate their inner tension and anxiety (Jangi et al., 2015). Painting activates the visual cortex of the brain and reduces fear and anxiety by creating a feeling of pleasure (Zadeh Mohammadi, 2018). Painting therapy helps a person become aware of their psychological state and control their anxious thoughts safely, which improves their psychological conditions (Khadar et al., 2013). Watercolor painting reduces anxiety and provides more freedom of action due to its characteristics (Haines, 2016). Anxiety increases obsessive thoughts and, consequently, obsessive actions. Watercolor could decrease obsessive thoughts and actions by reducing anxiety. Doubting thoughts and acting on them make the watercolor painting blurred (Blake & Croney, 1998). An obsessive person performs an action due to their obsessive thoughts, which apparently reduces the anxiety to some extent, but repeating this action institutionalizes the behavior and strengthens the obsession. Given that acting on obsessive thoughts, doubts, and hesitations during watercolor painting and manipulating and modifying them frequently blur the painting and, in most cases, it could not be corrected, a person who is working with watercolor experimentally realizes this issue and, thus, their desire to act on obsessive thoughts decreases while painting. This issue could be an exercise to reduce obsessive actions in other matters of a person’s life. As mentioned earlier, perfectionism is one of the characteristics of obsessive people. Watercolor is considered an exercise to reduce perfectionism because details are not much addressed in watercolor, but generality is more focused and borders are not much observed, e.g., usually the subject is not completely separated from the background, but streaks of the subject’s colors could penetrate into the background and merge together. Thus, dos and don’ts and mental barriers are broken to some extent. Therefore, MBAT using watercolor painting could play an effective role in reducing obsessive symptoms.

It can be inferred that MBAT through watercolor painting may effectively contribute to enhancing emotion regulation and mindfulness while reducing obsessive symptoms. This study specifically focused on the combined intervention of mindfulness and art therapy using watercolor, an approach that has been explored in only a limited number of studies. Furthermore, this method has received minimal attention among individuals with obsessive tendencies. The engaging nature of the exercises motivated participants to adhere to the treatment and complete assigned tasks. Art therapy through watercolor painting offered participants an alternative to traditional, symptom-focused treatments for obsession, fostering greater receptiveness to therapy. Consequently, MBAT using watercolor painting could serve as an appealing intervention alongside other psychotherapeutic and medical approaches to alleviate obsessive symptoms in patients with OCD. It is recommended that medical and counseling centers prioritize this method for individuals with OCD. Given that watercolor training can be provided virtually through video formats, multimedia and video training packages could be developed to facilitate at-home participation in exercises.

Limitations and Future Directions

In the present study, the severity of obsession was not controlled for due to limitations in the researcher’s sampling process. This may have influenced the outcomes, as varying obsession severity could affect the participants’ responsiveness to the intervention. Additionally, because there is no widely adopted and specific intervention approach in this field, some methods were designed by the researchers themselves. This limits the replicability and comparability of the findings across other studies and contexts. The implementation of the intervention program required the psychotherapist to have expertise in both art therapy and painting, which may restrict the generalizability of the approach, as not all therapists may possess such dual expertise.

To address the limited research background, we conducted an extensive literature review to incorporate relevant insights from related fields, which may have reduced some methodological constraints. Furthermore, to manage the expertise requirement for therapists, we implemented a rigorous training program, including comprehensive sessions on mindfulness-based art therapy and practical workshops on watercolor painting techniques, followed by ongoing supervision and support. Nevertheless, this training requirement could be a barrier to broader implementation.

Another limitation is that some participants experienced frustration when comparing their paintings with others, which might have impacted their engagement and emotional response during the intervention. To address this, we emphasized a non-judgmental, process-oriented approach and fostered a supportive, non-competitive environment. However, this frustration still represents a potential bias in the participants’ overall experience.

Given these limitations, future research should compare the effectiveness of this method with mindfulness and art therapy conducted separately to isolate the unique contributions of each component. It is also recommended to compare MBAT using watercolor with other painting methods to examine the impact of different mediums. Additionally, future studies should explore the use of this intervention across various severities of OCD to understand how symptom intensity influences outcomes, and consider refining interventions to minimize participant frustration.