Mandala Therapy

Mandalas in Tibetan Buddhist practice

A systematic review glosses the Sanskrit word mandala as circle or center and links the practice to Eastern traditions such as Buddhism. In Tibetan the corresponding term is dkyil 'khor, which Himalayan Art Resources says early Tibetan scholars translated as center and circumference: a deity at the center of a palace, surrounded by the palace and the universe. The same reference says the mandala serves as a meditation system in deity yoga and as the focus of initiation rituals.

The Philadelphia Museum of Art describes the Kalachakra sand mandala as a Vajrayana design that serves as a map for the meditator and a blueprint of a sacred palace-temple, drawn by monk-artists from memorized geometry. It says the practice began in India as chalk diagrams drawn on the ground during initiation rituals. Himalayan Art Resources adds that sand mandalas are generally taken apart after use. These sources describe ritual and meditative practice, not therapy.

Jung and the mandala in psychology

The Rubin Museum states that Carl Jung was fascinated by the mandala, describing it as an artistic representation of the inner and outer cosmos, and that his first known mandala-like work, Systema mundi totius, dates from 1916, within the 1914 to 1930 period of The Red Book. The museum links his interest to the use of mandalas in Tibetan Buddhism. A systematic review adds that Jung used the technique to work through problems and treated drawings as reflecting self-perception and mood.

A scoping review of mandala painting for people with cancer cites Jung's Mandala Symbolism and his theory of the self as its main theoretical source. It also names a separate Chinese framework, mandala painting psychotherapy, as the basis for several Chinese studies. That review does not discuss Buddhist origins.

Critiques of the Jungian reading

A 2014 undergraduate thesis in religious studies argues that popular writing on Tibetan Buddhism overstates its psychological side largely because of Jung's interpretations of mandala symbolism and the Tibetan Book of the Dead. The abstract reports that critics have called his approach Orientalist, and the author supports that critique. Only the abstract was open for this draft, and a single thesis is one scholarly view, not a settled consensus.

Structured and unstructured mandalas

Researchers separate unstructured mandala work, in which a person draws freely within a circle, from structured work, in which a person colors a set pattern. Of 11 studies in one review, seven used coloring, three used unstructured drawing and one was unclear. Other reviews use the labels mandala art, mandala painting therapy and mandala coloring for overlapping activities, so findings under one label should not be assumed to apply to another.

Mandala therapy and art therapy

The American Art Therapy Association describes art therapy as a mental health profession practiced by clinicians with master's-level or higher degrees, and states that recreational coloring must be distinguished from art therapy services provided by a credentialed art therapist. None of the sources reviewed defines a profession called mandala therapy. The phrase is best read as a descriptive label for an activity used inside or outside art therapy.

Mantzios and Giannou also distinguish mandala coloring from mindfulness training, noting that coloring books marketed as mindful lack the instruction found in formal mindfulness programs. The word mindful therefore describes a marketing claim in some uses and a tested intervention in others.

Settings and who delivers it

In the trials reviewed, mandala activities were most often offered in hospital or clinic settings as an added activity alongside routine care. In one review of 11 studies, the implementers were mandala therapists in two studies, art therapists in two, an occupational therapist in one and unspecified in six. Several of the individual trials identified in PubMed searches were nursing studies run in Turkey and Iran.

Formats used in studies

Formats vary widely and are reported here only as study descriptions, not as a protocol. One trial in children before surgery used a single 15 to 20 minute session in which each child chose one of five printed designs. A trial in hospitalized adults with COVID-19 used 30 minutes a day for six days, and a trial in male veterans used 15 minutes twice a week for three weeks. Some protocols added calming music or meditation.

A scoping review of 11 cancer-related studies found sessions ranging from a single 30 minute session to weekly sessions of two hours over eight weeks, and its authors cite the lack of standardized protocols as a limitation. A review of 11 studies likewise found no clear guidance on dose.

Reasons given for using mandala activities

Reviewers describe mandala-based activities as low-cost, non-pharmacological strategies for emotional regulation, and propose that attentional focus, non-verbal expression and a sense of mastery may account for any effect. These are proposed mechanisms and have not been shown to explain trial results. The original coloring-versus-free-drawing study that popularized the idea, by Curry and Kasser in 2005, linked coloring to mindfulness only in its introduction and did not test it, according to Mantzios and Giannou.

Populations and outcomes studied

Researchers have studied mandala activities for anxiety, depressive symptoms, pain, nausea, mindfulness, posttraumatic stress symptoms and caregiver burden. Populations include children before surgery, hospitalized adolescents with cancer, hospitalized adults with COVID-19, veterans diagnosed with posttraumatic stress disorder, and adults aged 55 and older. Each use is a separate question, and a result in one group does not carry over to another.

Systematic and scoping reviews

A 2023 systematic review searched six databases to April 2023 and included 11 studies with 405 participants: six randomized trials, four quasi-experimental studies and one qualitative study. Anxiety was the most consistent outcome, but the authors concluded that therapeutic benefits for psychological well-being are uncertain. Randomization was clearly described in two of the six trials, and participants and providers were not blinded in any of them.

A scoping review of mandala painting in cancer care (11 studies, searches to December 2023) reported improved quality of life, satisfaction with care and negative emotions, but no significant effect on pain or fear of recurrence. Its authors did not assess study quality.

Meta-analysis in adults aged 55 and older

A 2026 meta-analysis pooled nine randomized trials with 648 participants aged 55 or older. Mandala-based activity was associated with lower anxiety (seven trials, 531 participants; standardized mean difference -0.95, 95% confidence interval -1.43 to -0.48) and lower depressive symptoms (four trials, 283 participants; -1.21, -1.86 to -0.56). Heterogeneity was about 85% for both outcomes, certainty was rated very low, and outcomes were measured immediately after the intervention. The authors describe the estimates as preliminary and likely overestimated.

Individual trials with different results

A trial of 64 children before surgery in Iran found anxiety fell within the mandala group, but post-session state anxiety did not differ from the control group (44.34 and 44.75, P = 0.879); the authors concluded coloring was likely not effective for that use. A trial of 84 male veterans with posttraumatic stress disorder compared mandala coloring with free coloring and reported lower symptom scores in the mandala group after three weeks (47.21 compared with 52.38); both groups improved, and only the abstract was reviewed.

A trial of 70 hospitalized adults with COVID-19 reported lower anxiety scores after six days of coloring than in the control group (44.05 and 67.85). The size of that difference, and the lack of an active comparator, argue for cautious reading.

Mandala coloring compared with other coloring

As summarized by Mantzios and Giannou, Curry and Kasser found that students who colored a mandala or a plaid pattern had greater anxiety reduction than students who colored freely, and a later replication found a mandala advantage over both. In Mantzios and Giannou's own two experiments with 88 and 72 students, unguided mandala coloring did not improve mindfulness or anxiety more than free drawing. The authors conclude that coloring books are not supported as mindfulness tools.

Design limits of the evidence

Reviewers repeatedly cite small samples, short sessions, immediate outcome measurement and self-reported outcomes. Blinding is difficult because participants know they are coloring, and the authors of one review note possible publication bias. Comparators were usually routine care or no activity, so an effect of attention or distraction cannot be separated from an effect of the mandala form. The 2026 meta-analysis did not search trial registries or grey literature.

Interpretive limits

Mantzios and Giannou argue that Jungian mandala work, which centers on drawing and active imagination, differs from coloring printed designs, so trial results for coloring do not test the Jungian theory. Terrana's thesis separately questions the psychologized reading of Tibetan mandalas. The sources reviewed did not identify long-term follow-up studies of mandala activities.

Adverse effects and their reporting

The 2023 systematic review did not assess adverse effects systematically, and the 2025 scoping review and 2026 meta-analysis report no adverse event data from the included trials. The only harm-related signal in one review was a small uncontrolled study in 12 people who had had breast cancer, in which anxiety fell but distress scores rose after an eight-week program. Absence of reports does not show that none occurred.

Suitability and care boundaries

A qualitative systematic review of art therapy for non-psychotic mental health disorders found that most service users and providers found it acceptable, while a small number reported negative effects, including evoking feelings that could not be resolved. That review concerns art therapy delivered by therapists, not mandala activity specifically, and is cited only to show that art-based work can bring up distress.

In the trials summarized here, mandala activities were added to routine care and not used in place of it. People with anxiety, depression, posttraumatic stress or a serious illness should not delay or replace assessment and treatment with a coloring activity, and worsening distress is a reason to contact a health professional.

Training and oversight

The American Art Therapy Association says art therapy requires graduate-level training and credentials that can be checked through the Art Therapy Credentials Board. No mandala-specific training standard or professional register was found in the sources reviewed, and the review literature shows delivery by many types of staff. A reader can ask any facilitator about their professional qualifications, supervision and how they respond if a session becomes distressing.