Art for Health and Well-Being
Many descriptions are used to describe the therapeutic relationship between art therapist and client. “The term creative arts therapy refers to an arts-based therapy performed by a creative arts therapist who is credentialed under the auspices of the national organization representing that treatment modality. A creative arts therapist demonstrates aesthetic competencies in his or her respective arts modality and has received education and training in that art form before entering into the study and clinical training in one of the creative arts therapies.” These can include arts therapies, expressive arts therapies, therapeutic arts, creative arts therapy (or in therapy), expressive therapies, and art psychotherapy (Micozzi 2011: 177–178). Art therapy is a form of psychotherapy that uses art media as its primary mode of communication. Clients who are referred to an art therapist need not have experience or skill in art. The art therapist is not primarily concerned with making an aesthetic or diagnostic assessment of the client’s image. The overall aim of its practitioners is to enable a client to change and grow on a personal level through the use of art materials in a safe and facilitating environment (The British Association of Art therapists 2017).
Art can be used as a complementary tool in healing and medicine. This entry seeks to increase recognition of the use of expressive arts as powerful tools for social, psychosocial, physical, and spiritual health and wellness. The role of expressive arts as highlighted in this paper explores the current collaboration between health professionals and art therapists, both within the hospital setting and larger community. It also provides a future perspective of the role of arts as an integral part of a sustainable healing and wellness model of the future. As proposed in this entry, there exist many opportunities for greater incorporation of the healing arts in the mainstream medical model. This is shown to be of benefit for patients, family members, and healthcare staff.
Art and art making has been part of most ancient healing practices. Through images, shapes, colors, and lines, art is a symbolic language that can be used in the clinical setting for personal growth, transformation, greater self-awareness, and healing. The collaboration between health professionals, hospital settings, and trained expressive art therapists provides an opportunity for the arts to be incorporated into the mainstream medical approach. This collaboration between health professionals and art therapists can take place both within the hospital setting and outside in the wider community. Art therapy is a diverse field that utilizes the creative process existing in every individual to achieve an increased sense of well-being. Art therapy has a wide application and can be used for a variety of people from children, adolescents, adults, and the elderly; people with addictions and disabilities; prisoners, veterans, and families experiencing difficulties; and people with mental and emotional problems as well as physical disease and illness. As proposed in this entry, there exist many opportunities for greater incorporation of the healing arts in the mainstream medical model to provide a broader scope of integral solutions for sustainable health and wellness models in the future.
The Role of Art in Healing
Since the beginning of time, art and art making was intimately woven into the human experience. Art in its essence is as old as humankind, evident in the earliest cave paintings discovered in the Lascaux Cave in southwestern France to the first depictions of the human figure sculpted from the ivory of a mammoth tusk (Curry 2012). Throughout history, the arts in one form or the other have been used by many cultures for healing, celebration, and expression of the human condition. In the modern context, art is mostly associated with art museums, art galleries, and concert halls or similar places that provide opportunities for engagement with works of art. Apart from the aesthetic and educational purpose of art, it also holds the potential to act as a powerful tool for healing and transformation. The relationship between the therapist and the client is of central importance, but art therapy differs from other psychological therapies in that it is a three-way process between the client, the therapist, and the image or artifact. It offers the opportunity for expression and communication and can be particularly helpful to people who find it hard to express their thoughts and feelings verbally (The British Association of Art therapists 2017).
The true healer neither knows nor seeks boundaries between art and medicine. For this reason, one might view art and medicine as one. (Richard Lippin)
There are various ways to interact with art. Art forms, like music, dance, drama, painting, sculpture, and poetry, provide passive exposure to its possible healing effects. The art observed by the viewer is an invitation to appreciate the art piece as a finished object of beauty and artistic expertise and craftsmanship. Art can also invite the viewer to become a participant into the multilayered expression of the piece and find personal resonance and meaning. The third possible interaction is where the person steps out of the role of the viewer and observer into being an active participant in the creative process. In the third example, art becomes a therapeutic medium that “can guide, exhort, and console its viewers, enabling them to become better versions of themselves” (De Botton and Armstrong 2015: 5). The utilization of art in this way can act as a powerful tool for social, psychosocial, physical, emotional, and spiritual wellness.
The collaboration between health professionals, hospital settings, and trained expressive art therapists provides an opportunity for the arts to be incorporated into the mainstream medical approach. This collaboration between health professionals and art therapists can take place both within the hospital setting and outside in the wider community. Existing “arts in health programs” offer multiple benefits to patients, including improvements in overall health outcomes, treatment compliance, and quality of life (The National Alliance for Arts, Health and Wellbeing Online). Economic benefits are equally compelling, including an overall reduction in healthcare costs, shorter hospital stays, less medication, and fewer complications (State of the Field Committee 2009: 1). The integration of the arts into healthcare environments also has the potential to create a less stressful environment for staff, resulting in higher job satisfaction and a better service for patients (Center for Humanities in Medicine). To improve and increase the availability of arts programs, a partnership approach between the arts, the community, and health sectors, are not only desirable but necessary.
Medical art therapy is defined as “the use of art, expression, and imagery with individuals who are physically ill, experiencing trauma to the body, or undergoing aggressive medical treatment such as surgery or chemotherapy” (Micozzi 2011: 173). The integration of expressive art therapies with conventional medical treatment can address patient’s health issues on a broad scale, inside and outside of the hospital setting. Expressive arts began in the 1970s at Lesley College Graduate School (now Lesley University) in Cambridge, MA, when Shaun McNiff brought together some artists and therapists whose interests focused on the role of the arts in human development. At the time, the field was oriented primarily toward therapeutic work and was given the name “expressive therapy.” Over the years it became clear that the arts played a central role in the therapeutic orientation of these practitioners, and ultimately the name became crystallized as “expressive arts therapy” (Eberhart and Atkins 2014).
Creative arts therapy has also been classified as a mind-body intervention, and its role can, therefore, be explored as relevant to the prevention, health promotion, and management of difficult symptoms. Many descriptions are used to describe the therapeutic relationship between therapist and client. “The term creative arts therapy refers to an arts-based therapy performed by a creative arts therapist who is credentialed under the auspices of the national organization representing that treatment modality. A creative arts therapist demonstrates aesthetic competencies in his or her respective arts modality and has received education and training in that art form before entering into the study and clinical training in one of the creative arts therapies.” These can include arts therapies, expressive arts therapies, therapeutic arts, creative arts therapy (or in therapy), expressive therapies, and art psychotherapy (Micozzi 2011: 177–178).
The International Expressive Arts Therapy Association (IEATA) seeks to increase recognition of the use of expressive arts as powerful tools for social, psychosocial, physical, and spiritual wellness. The role of the art therapist is fundamental in the long-term healing effect of the creative activity (The International Expressive Arts Therapy Association). The National Center for Complementary and Integrative Health (NCCIH) also began looking at research on music and other arts-based therapies. According to Emmeline Edwards, Director of the Extramural Research National Center for the NCCIH, arts-based therapies fit with their mission and the strategic plan formulated in 2016 to “define, through rigorous scientific investigation, the usefulness and safety of complementary and integrative health interventions and their roles in improving health and healthcare” (The National Center for Complementary and Integrative Health).
Art therapists are employed in many different settings. These include child, adolescent, adult, and older aged psychiatry; secure hospitals departments dealing with head injuries and stroke victims; departments dealing with disabilities which include learning, deafness, physical and mental impairment, autism, and speech difficulties; palliative care and bereavement projects; forensic services; psychotherapy departments; drug and alcohol projects; trauma units; and education and mental health projects including drop-in centers (The British Association of Art Therapists 2017).Working side-by-side to improve the patient’s overall experience during illness and treatment, inside or outside the hospital setting, is a more holistic and inclusive approach that can benefit both patient and healthcare provider while providing a positive and uplifting environment in an otherwise stressful setting.
Art Programs in the Hospital Setting
“Humanities in Medicine” programs at major teaching hospitals and clinics offer a wide range of experiences for both patients and medical students. The terms “Humanities in Medicine” and “Medical Humanities” are used interchangeably in some contexts with applied arts in health. All these phrases refer to “a diverse, multidisciplinary field dedicated to transforming the healthcare experience by connecting people with the power of the arts at key moments in their lives” (State of the Field Committee 2009: 1). An example of successful integration and utilization of the arts in the medical setting is the Center for Humanities in Medicine at the Mayo Clinic. Here the primary value is the needs of the patient that must come first, by integrating the arts and other expressions of human culture into the healing environment. The Center acts as a gathering place for communities of patients, families, staff, learners, and the public to promote the artful and compassionate delivery of healthcare (Center for Humanities in Medicine).
Mayo Clinic’s world-class art collection, including the Chihuly glass chandelier in Gonda, and various works of Miro, Warhol, Calder, and others contribute to an enhanced patient experience from the moment they enter the door. Several programs are offered to visitors, employees, and more than 8000 patients per year. Music ensembles performed by professional musicians offer 24 concerts each year. The Cancer Education Center offers the “Creative Renewal Workshops for Wellness” or weekly seminars that inform oncology patients on alternative methods of healing with an emphasis on the arts, including creative writing, guided meditation, and journaling. “Arts at the Bedside” is a one-on-one service provided by professional artists and authors that visit patients at their bedside and include visual arts, music, and creative writing exercises. This happens at least once a week in the various departments of the Clinic, like oncology, pediatrics, and transplant units. Both the patient and the family are supported in this way. At Mayo Clinic, care staff also benefit vicariously, enjoying the hospital unit music concerts during their work hours (Rian 2013: 281–286).
The University College London Hospitals (UCLH) is another example of a well-established institution that has successfully incorporated an arts program benefiting patients, staff, and visitors alike. The arts program includes regular music, permanent exhibitions, and work produced by patient groups. A 3-year evaluation of the UCLH rolling arts program demonstrated that the intrinsic value of art lies in its ability to affect the individual by its specific aesthetic quality and meaning. The study showed that art in the hospital setting could awaken sensory faculties, give pleasure, unsettle, soothe, pose existential questions, arouse a critical consciousness, stimulate curiosity, and give form to feeling. Whether these effects are short or long term will be influenced by personal, cultural, and social factors (Froggett and Little 2012).
Researchers have shown that arts in health programs offer multiple benefits to patients, including improvements in overall health outcomes, treatment compliance, and quality of life (State of the Field Committee 2009: 1). Economic benefits are equally compelling, including an overall reduction in healthcare costs, shorter hospital stays, less medication, and fewer complications (State of the Field Committee 2009: 1).Various research studies conducted in Ireland, the UK, Canada, and Australia, dating from 1999 to 2014, explored the beneficial effects of the arts on health, healthcare, and well-being. The research studies point to the fact that in the majority of cases, the arts not only provide enjoyment and a sense of achievement for people using healthcare services but also have a profound positive impact on their health. The integration of the arts into healthcare environments has the potential to create a less stressful environment for staff, resulting in higher job satisfaction and a better service for patients. The inclusion of the arts into a hospital/healthcare environment can also have favorable clinical outcomes, which in turn can result in savings in public expenditure.
Music, in particular, was found to be very effective in reducing levels of anxiety and stress in the hospital setting. Used in conjunction with medical treatment, music helped to speed up recovery and reduce hospital stay. Studies report that music as art in medical intervention can generate positive reactions on a wide scale within the clinical setting. Examples include the use of harp music to support patients and family during the final stages of death (Ganzini et al. 2013); decrease pain in severe neuropathic pain (Korhan et al. 2014); and reduce anxiety before, during, and after surgical interventions (Kim et al. 2011). Relaxing music was successfully applied to patients before surgery to calm them down which reduced the number of induction agents during anesthetics. It significantly reduces anxiety and stress and helps to normalize vital signs. Of great importance are the findings on the significant reduction of anesthetics, medication for sedation, and analgesics (Patil et al. 2015). These results also implicate that music interventions can contribute to reducing costs within the hospital setting.
Another department of a hospital, which can be a hugely stressful experience for patients, is a visit to the emergency department. “Designing Sound for Health and Wellbeing” was a 3-year interdisciplinary project, from 2008 to 2010, where a team of researchers including composers, art producers and art historians, emergency medicine practitioners, and health psychology researchers from the School of Art, RMIT University and St Vincent’s Hospital, Melbourne, investigated whether sound compositions of audio field recordings and electroacoustic music could make a difference in the levels of stress and anxiety patients experienced in the hospital emergency department. They found a significant reduction in the stress and anxiety levels of the patients taking part in the project. This study demonstrates that patient stress and anxiety levels can be significantly reduced through listening to specifically designed music and sound compositions (Macarow et al. 2012).
Again, further research and funding can be valuable to ensure that sound and music interventions are implemented as part of a safe, low-risk intervention within the hospital setting, requiring minimal financial cost, while being aligned with the sustainable goals for greater well-being for both staff and patients – inside and outside of hospital settings (Macarow et al. 2012). Preti and Welch (2012) demonstrated that the choice of music is important in the positive impact it can have on the hospital staff. A helpful suggestion by Robb et al. (2011) was to implement the delivery of music in a more systematic way in the hospital environment to the benefit of both patients and staff. Standardization of arts in medical practices would strengthen the acceptance of sessions in clinical settings by establishing expectations of how the two disciplines of medicine and music integrate into hospitals (Raab 2016).
The American Cancer Society has found that music therapy and art therapy as part of complementary and alternative therapies may increase patient satisfaction, well-being, and health outcomes and may be beneficial during extended stays. The role of photography providing various images and viewed by cancer patients resulted in the feedback of 96% of participants who enjoyed looking at the photographs. The photographs they preferred most often were images of nature, including a lake sunset (76%), rocky river (66%), and autumn waterfall (66%). Because many cancer patients are in the hospital setting for prolonged stay and treatment and often prevented from interacting with nature, the role of art and specifically photographic images of nature displayed throughout the hospital might play a role in the healing experience with the hospital setting (Hanson et al. 2013).
Art Programs Outside the Hospital Setting
The arts have the potential to alleviate anxiety in a world that is becoming increasingly stressful. Activities, such as the arts in social prescribing programs that can reduce GP visits and shorten hospital stays, increase one’s sense of well-being, as well as increase socialization within the community need to be embraced. To improve and increase the availability of arts programs, a partnership approach between the arts, the community, and health sectors, are not only desirable but necessary (Fleischer and Grehan 2016).The availability of arts programs outside of the hospital setting has proved of value in the aging population through the integration of the arts into all long-stay units as a core activity. These activities can have a profound positive impact on managing an aging population and promoting healthy aging. Healthy aging is promoted through evidence from numerous arts on prescription programs in the United Kingdom that such programs help older participants to socialize, gain confidence, and be a part of the community (Arts Council of England). A study by Kara (2016) also calls for further investigation of the value of music interventions to be included in palliative care settings.
Art is used as a form of therapy as well as a sense of communitas that brings people together with a common goal to achieve greater self- awareness and healing through making art in a group setting. The sharing of creative work brings forth an empathetic understanding of each other, “easy mutual help,” and shared pleasure in working together (Turner 2012: 2–3). There are basically two types of art therapy groups. The first is art psychotherapy groups that help people to express feelings, problems, or conflicts; achieve insight; or resolve painful emotions and experiences. The art therapist takes an active role in determining themes and directives, for example, women with breast cancer taking part in an 8-week support group to explore and communicate common issues and experiences regarding medical treatments and the effects on their bodies or personal fears they might have (Malchiodi, 2017: 196). In a similar fashion, art psychotherapy groups are formed around specific populations, like recovering alcoholics, teenagers with behavioral problems and HIV or AIDS, parents whose children are seriously ill, and many more. On the other hand, art studio or open studio groups provide a different experience. People going to art studios are less seen as patients and more as artists who are seeking a process for self-expression, exploration, and healing. Many groups are a mixture of the philosophies depending on the needs of the group members.
The Role of Art in Medical Training
At the Mayo Clinic Center for Humanities in Medicine, a course was offered for the first time in 2013, “Humanities for the Physician in Training,” introducing first- and second-year medical students to various disciplines within the field of humanities. Sections on theater, reflective writing, and visual thinking strategies were taught by professional artists and writers. For the final course assignment, students created projects in a discipline of their choice. Another course, “The Practice of Narrative Medicine,” was designed to introduce first- and second-year medical students to techniques and applications of written narratives in medical practice, providing them with the opportunity to be mentored by published authors, and offer them the opportunity to build their own creative writing skills with peers and mentors. The Center for Humanities in Medicine also provides a mentoring series for first- and second-year medical students. “Fireside chats” allow students the opportunity to interact with senior physicians in leadership positions, hearing their personal stories of challenges in medical training and early medical practice (Rian 2013).
The use of artwork as a vehicle to enhance reflection on personal, professional values and experiences have been used in the training of third-year medical students to improve their observational skills, such as medical interviewing and physical diagnosis (Byars et al. 2015). It echoes findings by Perry et al. (2011) that, studying art-based approaches alongside clinical observation skills, students were able to see a complete picture of the patient and were aware of more than one perspective. Students stated that they had developed skills of observation and analysis through using the visual arts and applied these in their practice. The link between art and medicine is present in the use of language, the communication of ideas, and recognition of shared levels of understanding. Individuals wanted to take this understanding back to their clinical practice. The aim was to encourage an understanding of the patient’s story or narrative by the medical practitioner, in order “to diversify and deepen the kind of meanings people know how to construct and to provide them with the appetite and ability to shift frames” (Edmonds and Hammond 2012).
The use of creative arts has also been effective in improving the mental health and well-being of physicians, clinicians, and mental health workers by reducing professional burnout and improving their skills and rapport with patients (Brooks et al. 2010). These findings, however, are independent of each other. In other words, research in the United States has been exclusively unilateral. While studies have shown efficacy for artistic and humanities-based programs for clients and clinicians separately, there is almost no literature addressing the mutual benefits when clients and clinicians are co-participants. This process, known as mutual recovery, looks beyond the standard direction of “clinician treating patient,” and encompasses the well-being of all parties present and participating in the recovery experience.
Mutual recovery is a formal term that describes the potential for creative art therapies to positively contribute to the well-being of not only the client but also the mental health caregiver. This pilot specifically investigates the use of creative arts therapy – in this case, music – as a medium for mutual recovery. This study found that nonverbal communication in the form of drumming appeared “fundamental as a mechanism for creating a form of expression and connectedness” (2016: 13). The positive effect put forth by the caregivers may enhance feelings of compassion and connection between both parties present in treatment and may also contribute to both personal and professional growth for that caregiver (Callahan et al. 2017).
Health Benefits of Art
The health and well-being benefits from art interventions are well researched and have demonstrated positive clinical outcomes on many levels, whether physical and mental-emotional well-being. These include clinical improvement in diseases like anxiety and stress, depression, autoimmune disease, HIV and AIDS, hypertension, childbirth, surgical interventions, and mental health (Fleischer and Grehan 2016). Creative arts such as music, dance, poetry, narrative, and cinema have been studied regarding their effects on clients and community organizations and show improvement in coping skills, group bonding, and increased self-esteem. A simple example of the effects of written emotional disclosure as an adjunct to physiotherapy in outpatients with musculoskeletal pain supports the hypothesis that the cognitive and emotional processing afforded by written emotional disclosure strengthens the effects of physiotherapy, while promoting greater psychophysical improvement in individuals affected by low back pain and neck pain (Pepe et al. 2013).
The creation of art has many psychological benefits for people with mental illness, including improved self-esteem, self-discovery, empowerment, self-expression, the rebuilding of identity, self-validation, motivation, and a sense of purpose and focus and cognition. Additionally, it was found that individuals with mental illnesses viewed art production as an activity that held the power to change or transform their lives in some way and gave them a sense of belonging in the community (Van Lith 2015). Art and creative art projects can play an important role in the recovery process of mental illness, as well as providing ongoing support for both the patient and their families as part of a greater understanding for mental illness in the society. This can result in social inclusion in the community, rather than social exclusion, which comes at a high cost to their sense of well-being and their families. Creating and viewing art can prove to be of value to engage in healing dialogues surrounding the topic of mental health.
An arts health intervention research project titled “Artmaking, visual narrative and wellbeing” explores the benefits of visual narrative art making to support the long-term emotional and physical well-being of people living with chronic autoimmune illness. Art making and the visual narrative of the participant’s well-being involved interlinked intervention methods of directed art-making workshops and self-directed activities exploring self-reflection of feelings and perceived impacts on well-being from making art. This was explored from the participant’s perspectives and also from the perspective of a participant nominated by a relative or significant other. The art-making activities resulted in positive emotional outcomes, reduced stress levels, and general well-being, often described as “feeling good” when working. The visual narratives were able to build resilience through the expressive and transformative power of imaginative reworking of personal family stories and the exploration of the impact of other (The Art Visual Narrative and Wellbeing Project).
If this aspect of art making can be seen as a strategy to make sense of individuals’ past narratives and demonstrate how these narratives collide with present events in specific medical and sociocultural contexts, it may have the potential for long-term emotional and physical well-being for participants living with chronic illness. It may also provide them with the possibility of flourishing within the limitations of their illness (Grushka et al. 2014).
In general, most arts-based interventions are carried out in clinical settings and evaluated regarding clinical outcomes. Recently, however, more attention has been paid to the contribution of community arts to primary care and preventive care. On the public health side, the conversation between music, the arts, and health has been moving from the clinic to the community and from clinical medicine with its focus on individual therapeutic interventions to public health with its focus on community development and community capacity building. Art itself is experienced mainly in concert halls, art galleries, and museums and on stage, while there is also a movement toward art-based community projects. If the boundaries between medicine and art, as two distinct professions operating from different conceptual frameworks, can find areas of commonality, there will be a huge mutual benefit toward society.
In spite of the reinvention of public health, the arts as a tool for mobilizing communities, communicating health-related messages, and generating community well-being and healing are still underestimated and underutilized by some sectors of the health professions. Health and well-being are public goods and assets for human development and of vital concern to the lives of every person, their family, and community. Good health for the individual is a dynamic state of physical, mental, and social well-being. It is much more than just the absence of illness or infirmity. Good health for communities is a resource and capacity that can contribute to achieving strong, dynamic, and creative societies. Health and well-being include physical, cognitive, emotional, and social dimensions. They are influenced by a range of biomedical, psychological, social, economic, and environmental factors that interconnect across people in differing ways and at different times across the life course (WHO Commission on Social Determinants of Health – final report).
De Quadros (2017) suggests a preference for the use of the term global health as “an area for study, research, and practice that places a priority on improving health and achieving equity in health for all people worldwide.” A global health focus will use all the resources, knowledge, and experience of diverse disciplines to address health challenges and promote interdisciplinary collaboration to the advantage of the health and well-being of communities throughout the world. This review of research projects shows clearly that there are positive benefits of the arts on health and well-being. Not only do the arts show clinical benefits, but they also increase socialization with others and impact on the economics of the healthcare system by reducing drug consumption (and possible side effects) and hospital stays, as well as providing increased job satisfaction and better service delivery as healthcare providers.
Today’s society is being increasingly medicalized. Increasing visits to GPs and an ever-increasing consumption of drugs are not economically sustainable for the future. Research has shown that the arts can assist in improving the quality of life of both individuals and the wider community in general. Further research and evaluations are necessary to validate results with statistical significance and to prove that the arts have a role to play in healthcare. While no one is suggesting that the arts replace robust healthcare, research to date indicates that their inclusion in healthcare can promote all dimensions of well-being and thus move beyond traditional medicine (Fleischer and Grehan 2016).
Thus, the role of the arts in aiding people to achieve a sense of well-being goes beyond the medical model and the traditional delivery of healthcare. Art is a necessity and a human right if it can assist health and well-being. The therapeutic value of art can be explored and extended in more conscious and deliberate ways to be part of a sustainable health policy to enhance health and well-being. The benefit of art inclusion in medical education can be extended to the training of medical students and other health professionals. The ideal scenario to promote sustainability from an integrative perspective is to acknowledge that the patient and his or her environment are not separate, but always function as a whole. With greater sensitivity of the impact of the aesthetics of the environment, the influence of sound and color and the use of art therapies using a wide range of modalities can impact the approach to healthcare in subtle and bigger ways. Incorporating art and art therapy can create patient-friendly in-hospital settings, benefiting both patient and caregiver, while enhancing the quality and outcomes of medical interventions.
The value of art and art making can extend into the future to create new symbols of hope, interaction, universality, catharsis, and altruism.
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