The purpose of this study was to find out the effect of a picture book creation art therapy program on the career decision-making self-efficacy and career decision level of university students. The participants were chosen among the third- and fourth-year students of universities located in the metropolitan area who below-average career decision-making self-efficacy and career decision level scores on pre-tests. For the experimental group only, the program was conducted twice a week for 120 minutes for a total of 12 sessions. The measurement tools included a career decision-making self-efficacy scale, and a career decision scale. Quantitative changes were analyzed using the Wilcoxon Signed Ranks Test, and qualitative changes were analyzed through the completed career picture books. The results were as follows: First, the picture book creation art therapy program had statistically significant effects on university students career decision-making self-efficacy. Second, this program had statistically significant effects on university students career decision level. Third, the career expression picture book had qualitative changes on the career decision-making self-efficacy and career decision levels of university students. Thus, this program is clinically valuable to improve the career decision-making self-efficacy and career decision levels of university students. It is expected that this program will be widely applied to help university students career decisions.