Drama and Theatre for Health and Well-Being
Drama and theatre for health and well-being is a constellation of ideas, practices, and approaches which are intentionally engaged for health and well-being benefits, ranging from explicitly therapeutic interventions to group-based activity more resonant of cultural activity.
The rock art of indigenous communities from 20,000 years ago has been interpreted as early indications of how humans have connected performance, in a broad sense, with the health and well-being of their communities (Fleischer and Grehan 2016). Now, at a global level, there is increasing recognition that drama and theatre can facilitate a variety of health and well-being outcomes for an extensive range of groups, not predetermined by affluence or socioeconomic status (APPG 2017). In a broad sense, drama and theatre are a constellation of arts-based practices, processes, and spaces, which intentionally work with more or less fictive characters, roles, relationships, and plots, in order to generate a wide range of experiences or outcomes (Wall et al. 2018b, forthcoming). Indeed, theatre and drama have been described as “the most integrative of all the arts: they include singing, dancing, painting, sculpture, storytelling, music, puppetry, poetry and the art of acting” (British Medical Association 2011, p. 10), which can help people to understand and then change how they relate to and then live out their own world.
In practice, as drama and theatre more or less share conceptual and theoretical underpinnings and practices, the boundaries which separate drama and theatre are fluid. One very brief definition is that “(a) [applied] drama is based on improvised interaction in a fictional context without given lines or external audience, and (b) applied theatre is usually created and devised by the participants and performed to an audience” (Wall et al. 2018b, forthcoming). Within this categorization, applied theatre is often used to raise awareness or stimulate change and often engages formally trained performers alongside other people and extends beyond formal theatre spaces to facilitate self-reflection and self-transformation (Maeve and Pentergast 2014). Examples of process and practices within this genre include Theatre of the Oppressed (Boal 1979), Forum Theatre, and Forum Play (Räthzel and Uzzell 2009; Österlind 2011; Arveklev et al. 2015). In addition, some conceptualizations or genres of drama and theatre are more explicitly therapeutic than others and in some countries, such as the UK, are recognized as such through official healthcare systems. For example, drama therapy and psychodrama draw on medical or psychoanalytical and arts training and deliver an integrated approach to therapy, potentially tackling social, emotional, and physical aspects of health and well-being (Fleischer and Grehan 2016).
Such outcomes reflect the World Health Organization’s (WHO) broader and holistic notions of health and well-being which reject the medical model of health which focuses on “the history of illness, investigation into the physiological basis of symptoms, and remedies to return those to normal, followed by measurement of outcomes” (British Medical Association 2011, p. 1). A more contemporary global movement conceptualizes health and wellness in more holistic and integrated ways which understands “the patient first as a person, within their family, community and workplace… [which] merges readily into modern views of patient-centred care, and of patients as partners in their care” (ibid). This “social” model is sensitive to the person in a wider and complex social life and includes aspects of the psyche, economics, environment, and a closer orientation toward preventative measures (Cann 2017).
Public health policies around the globe reflect such shifts, for example, the expansive network of Health Action Zones and Healthy Living Centers in the UK in the 1990s, which attempted to tackle social exclusion from health and social care. More recently, the UK government has recognized the role of the arts in health in a public health white paper (Department of Health 2004), established the National Alliance for Arts, Health and Wellbeing in 2012, established an evaluation framework to guide the use of arts interventions for health and well-being (Public Health England 2016), and developed policy recommendations through the All-Party Parliamentary Group on Arts, Health and Wellbeing (2017). In a broader sense, arts-based practices such as drama and theatre have also been positioned as offering “an antidote to the mental and emotional pollution of commercialism, which eventually lead to the toxification of air, land, water, and the excessive consumption of carbon” (Shrivastava et al. 2012, pp. 32–33). However, such holistic and integrated approaches are not limited to the directly therapeutic forms of drama and theatre, and performance practices have been described as having a “distinctive” capacity (Wall et al. 2018b, forthcoming) to help a vast range of people “break with what is supposedly fixed and finished… so a person may become freed to glimpse what might be” (Greene 1995, p. 19). Indeed, drama has been recognized as being linked to the socio-emotional development of children and young people (Menzer 2015).
Evidence of the effects of such approaches across a variety of settings suggests that “in all sectors it was found that there are beneficial effects, especially for relieving stress and improving socialization” (Fleischer and Grehan 2016, p. 93). Specific impacts can include “positive physiological and psychological changes in clinical outcomes; reducing drug consumption; shortening length of hospital stay; promoting better doctor-patient relationships; improving mental healthcare” (British Medical Association 2011, p. 9). Similarly, attendance at theatres has been found to enhance a variety of physical and emotional well-being outcomes linked to dealing with stress, as well as drama- or theatre-based interventions in the workplace to address stress and resilience at work (APPG 2017). In a broader sense, drama and theatre have been used in settings including developing the personal and social well-being of young people (Barnes 2012, 2015); building the resilience of children, young people, and youth (Zarobe and Bungay 2017); enhancing the health and well-being of children in hospitals (Sextou 2016); the health and well-being of young prisoners, prisoners with disabilities, female prisoners, and the homeless (APPG 2017); chronic mental health recovery and social isolation (Makin and Gask 2012; Mann et al. 2017); the health and well-being of older people (Wilkinson et al. 2013; Bernard et al. 2015; Organ 2016); the health and well-being of people with dementia and their carers (Harries et al. 2013); the health and well-being of people living with HIV and AIDS (Barnes 2014); and the well-being implications of urbanization and climate change (Wang 2017), postnatal depression (APPG 2017), and those fleeing war (Arts Education Partnership 2011). As was identified in the national consultation process of the All-Party Parliamentary Group on Arts, Health and Wellbeing, it was recognized that:
There’s a lazy way of looking at the arts as a soft option or something fluffy. They’re actually really hard. If anybody […] has ever done theatre or has ever prepared for an exhibition or has ever prepared for a concert, it’s severely nerve wracking. It tests your nerves’ capacity. It tests your stamina. It absolutely tests your determination. (APPG 2017, p. 110)
The orientation of drama and theatre to create explicitly fictive spaces and processes have been linked to developing capacities to deal with and tackle complex, emotionally charged, and difficult challenges in relation to holistic thinking, integration of multiple perspectives, and the development of attitudes and values (Svanström et al. 2008; Österlind 2012; Pässilä et al. 2017). As such, “people are enabled to explore the perspectives and their respective consequences, tensions, and dilemmas in fictive situations… an authentic but safe space to embody perspectives and explore them” (Wall et al. 2017, 2018a forthcoming, 2018b, forthcoming). Such processes of intentionally working with, playing with, and experimenting with roles, characters, and metaphors in the context of storytelling are also recognized in other arts practices (Bolton and Ihanus 2011; Wall 2016a, b; Stokes et al. 2018 forthcoming; Rossetti and Wall 2017; Tran and Wall 2018 forthcoming) (also see the chapter on “Creative Writing for Health and Wellbeing”), and as Etherton and Prentki (2006, p. 146) explain it, “the cornerstone of theatrical communication is empathy.”
This entry illustrates four key areas of discussion related to how theatre and drama are applied in various settings for the purpose of generating health and well-being outcomes: the first considers one of the most dramatic “characters,” the clown, and its therapeutic applications in a variety of contexts; the second examines the use of drama and theatre processes, specifically Imaginary Theatre, to create dementia-friendly spaces which enhance recall and other quality of life indicators; the third explores theatre collaborations in the community to create spaces for people experiencing mental health challenges for collective learning and health benefits; and, finally, the relatively new field of “performance on prescription” is examined, where theatre and drama activities become part of the wider health and social care systems to deliver health and well-being outcomes.
Clown as the Dramatic Healer
A particular form, or genre, of drama and theatre is clown work. Clown has a long history going back to the trickster found in the mythology and stories of many traditions. Shamans and clowns have many features in common, and in several Native American tribes, clown figures have been part of healing rituals (Van Blerkom 1995). There is documentation that humor and theatre have been used in the treatment of patients since the thirteenth century (Sridharan and Sivaramakrishnan 2016), and it is said that Hippocrates used clowns and other performers in the hospital (Koller and Gryski 2008). Since the late twentieth century, a movement of clowning in work with traumatized and vulnerable people has spread around the world, with Moshe Cohen, the founder of Clowns Without Borders, as a pioneer. Today there are several clown organizations, both international and local, performing and giving workshops for people suffering in humanitarian crises. In 2016, Clowns Without Borders, the biggest of the organizations, had a total of 400 performers visiting 48 countries and reaching over 300,000 children (CWB 2016). Clowns are performing and doing pedagogical work in refugee camps, with children living on the streets, areas stricken by natural disasters, and other socially and economically vulnerable places (Peacock 2016).
Patch Adams, starting his work in the 1970s, is known to be the first hospital clown in modern time, but professional clowning in hospitals started in 1986, when Michael Christensen introduced the program The Big Apple Circus Clown Care Unit in the USA. Here, clown doctors parodied the medical doctors in order to make the hospital procedures and props less frightening and bring laughter and play into the hospital environment. In the same year in Canada, Karen Ridd started working as a therapeutic clown in Child Life Programs aimed at severely ill children, work that has spread around the world, just as that of the clown doctors from the Clown Care Unit (Koller and Gryski 2008). The approach of the Clown Care Unit using parody is somewhat different from the therapeutic clown who is the “child’s friend, the encourager of play, imagination and creativity” (ibid., p. 19). While the clown doctors always work in pairs in order to not put pressure on the patient to interact with the clown, the therapeutic clown works alone to build an intimate relationship with the child. Today there are clowns working in hospitals around the world, using a variety of approaches with heritage from the Clown Care Unit as well as from the therapeutic clowns in Child Life Programs. Since then there is a growing evidence base which demonstrates how the use of clown reduces the level of anxiety both in the children and their parents (Sridharan and Sivaramakrishnan 2016), reduces the need for medical sedation (Viggiano et al. 2015; Dvory et al. 2016), calms and improves cooperation in the process of gathering forensic evidence from children who have been sexually abused (Tener et al. 2010), reduces fear and pain in children who have been abused (Tener et al. 2012), and reduces pain compared to different medical interventions (Bertini et al. 2011; Wolyniez et al. 2013; Weintraub et al. 2014).
Although clowning in healthcare is mostly associated with children, its use among adult and elderly patients is growing in various settings (Dionigi and Canestrari 2016). In elderly care, clowns are shown to support social interaction (Rämgård et al. 2016) and lower agitation and aggressive behavior in patients with dementia (Low et al. 2013; Kontos et al. 2016). Clown work seems to not only support individual well-being but also contribute to a better environment around the patients and enhance the well-being of staff and family (Rämgård et al. 2016). Women who in IVF treatment had a clown encounter just after the embryo transfer had better odds of getting pregnant (Friedler et al. 2011), and Gruber et al. (2015) argue that clowns can be useful in psychiatric wards and point to the clown’s ability to open up for communication. Through its way of playing, clowns “present the possibility of embodying a role without being consumed by it” (Gruber et al. 2015, p. 22), thus being particularly valuable for psychotic patients. Similarly, Linge (2013) found that the benefits of clown in a hospital setting are linked to a “magical safe space” between the clown and the patient, a transitional area between fantasy and reality where joy can be experienced through a form of relationship which does not place any demands on the patient. Others emphasize the biological aspects of humor and laughter reducing stress and releasing beneficial hormones in the body (e.g., Friedler et al. 2011).
Clowns are not only recognized for enhancing the health and well-being of the person meeting the clown but are also known as a healing practice for those doing the clown work themselves. Peacock describes clowning as “an intensely personal experience which generates play from within the performer” (Peacock 2014, p. 13). In an interview Bowen White, a medical doctor and clown, claims that the clowning supports his own playfulness and well-being. He says, “there is a residual effect that remains in the psyche [after clowning] when I’m Bowen White” (American Journal of Play 2009, p. 2). In a clown therapy program for drug addicts, the clients themselves worked in a process to bring to life their inner clown. The results showed that participants improved their relationships and experienced an enhanced sense of balance in their lives with less conflicts, increased emotional flexibility, better ability cope with life changes, and an increased level of creativity and ability to laugh at themselves (Gordon et al. 2017). Similarly, Cilliers (2009) writes about clown from a theological perspective and claims that “the clown embodies the good news that human beings can retain their humanness, even if they are stripped of everything, and when all else fails” (p 191). In this way, the clown can be an interrupter of the status quo, especially in relation to oppressive regimes, but this aspect has so far received relatively little attention (Peacock 2016).
Imaginary Theatre and Dementia
As of December 2017, the World Health Organization (WHO) predicts that “worldwide, around 50 million people have dementia, and there are nearly 10 million new cases every year” (WHO 2018), a number predicted to grow as the population ages, making the diagnosis, treatment, and – ultimately – prevention of dementia a governmental priority. Responses to dementia are primarily pharmacotherapeutical, as “there is no treatment currently available to cure dementia or to alter its progressive course” (ibid). At the same time, the treatment of dementia “is an expensive, complex and multi-faceted policy problem” which requires multiple stakeholders working together (Baker and Irving 2016, p. 379). Theatre and drama, as particular forms of arts for health interventions, encompass plastic, embodied, aural, and visual forms. In applied practice, they offer alternative approaches, with positive impact on the well-being of people living with dementia, caring environments, and social perceptions of the condition (APPG 2017).
The most widely practiced form of intervention within applied theatre is Reminiscence Theatre, which stimulates persons living with dementia toward recall of events, emotional states, and people. In line with WHO’s (2018) framing of dementia as an irreversible degradation of capacities for narrative coherence on which memory – and identity – is seen to rely, Reminiscence Theatre is a strategy for memory regeneration, supporting participation in a social world and thereby aiming to “improve quality of life for residents through verbal and nonverbal communication” (APPG 2017, p. 136). Such interventions can include “non-linear narratives from long-term memories, communicated through speech, drama, literature, song/utterances, art/craft, listening to/making music, handling objects/sensory materials/props, dancing to music or embodied through movement” (APPG 2017, p. 132). There is now a body of evidence which demonstrates a variety of impacts including measures relating to quality of life and well-being (ibid).
Paradoxically, however, Reminiscence Theatre – a function of social model practice – operates on the underlying assumptions derived from medical model thinking (in contrast to the social model of health and illness). Braidotti (2013) challenges the determination of identity by ability to recall an autobiographical, linear narrative, suggesting that intense moments of living manifest in “glitches” in memory recall, that is, “dis-identifications” with authorized narrative modes. This has implications for the valorization of memory recall as a therapeutic process for people living with dementia, and in Imaginary Theatre, Malone and Redgrave (2016) offer a future-focused alternative to Reminiscence Theatre, influenced by Braidotti’s advocacy of the creative power of random and spontaneous thought processes. Imaginary Theatre is central to two multisensory projects facilitated in care homes (and schools): Forgotten Futures and The City (by Niamh Malone, Hope Graduate Theatre Company) and Never Ending Story (by Donna Miles, the RMD Memory Matters Creative Arts Company). Both projects place equal emphasis on enhancing the well-being of persons living with dementia and engagement with care staff and families. Each is now discussed.
Forgotten Futures and the City was an applied theatre project conducted in seven nursing homes in and around the city of Liverpool (England) in 2017/2018, culminating in an interactive exhibition of its findings at Tate Liverpool (March 2018). The project aimed to (1) apply in practice Mayo’s (2014) argument that older people need to be engaged in “future-orientated” discussions, rather than reminiscence, and (2) to counteract the isolation experienced by many care home residents, by providing opportunities to engage with the living city. Facilitators used images of Liverpool’s cityscapes and, with complementary music, props, and dialogue, invited residents to imagine futures for Liverpool. Privileging the “here and now,” the interventions fostered a sense of wonder and delight, such that the imperative to reminisce, with its pressures toward accuracy of recall, was displaced by an approach to storytelling that released residents’ imaginations, uncensored and unrestricted. Thus, Imaginary Theatre treats memory as a site of shifting imbalances between real and fictional events; in other words, remembering is understood as a creative act, associated more with becoming than with being, embracing the now of “joyful discontinuity” (Braidotti 2013, p. 167).
Never Ending Story is an intergenerational project which started in Flintshire (Wales) in 2016, involving care homes and schools. It used Imaginary Theatre to help people living with dementia to articulate not only a remembered biography but also perspectives on the now – the lived present – as active authors of their own, ongoing life story. Never Ending Story worked explicitly in line with established national initiatives and specifically toward creating a dementia-friendly community, that is:
A city, town or village where people with dementia are understood, respected and supported, and confident they can contribute to community life. In a dementia-friendly community people will be aware of and understand dementia, and people with dementia will feel included and involved, and have choice and control over their day-to-day lives. (Alzheimer’s Society 2013, p. 2)
In this way, the approach was designed to privilege strategies for a diverse range of people to come together with mutual support and respect. By early 2018, 997 staff and pupils involved in Never Ending Story had gained Dementia Friend status, that is, people who have turned their understanding of dementia into action (Dementia Friends 2018). Indeed, both Forgotten Futures and Never Ending Story anticipate emerging scholarly concerns on “the limitations of art and dementia research which focuses exclusively on wellbeing, or which relies solely on quantitative measures to interpret the value of the work” (Hatton 2018, forthcoming, p. 11). Similarly, other evidence suggests that engaging in theatre work of this kind impacted the quality of care given, for example, by friends, family, and helping professionals (Schneider 2017). Problematically, however, when interactive arts projects are subjected to “accountability” where value is associated with impact measurement, very often Reminiscence Theatre outcomes are easier to quantify. Nonetheless, the two projects discussed here employ Imaginary Theatre deliberately to engage and celebrate the limitless possibilities the imagination presents for people living with dementia and their ability to create exciting narratives, which may not always abide by established conventions.
Theatre Collaborations for Mental Health in the Community
The WHO’s (2013) Mental Health Action Plan 2013–2020 recognized the global significance and impacts that mental health has on communities and the need for coordinated action at the country level. Although this may not have been achieved at the country level as yet, drama and theatre work has actively been tackling this for some time. Anyone who initiates work with people who have mental health problems does so, consciously or unconsciously, with some sort of theory about the nature of mental ill-health and the possible benefits that engaging in theatre might bring. In its long history, a range of theoretical assumptions in the field have included theatre as a means of uncovering unconscious motivations, resolving conflict, exploring personal trauma, changing behavior, or quite simply providing entertainment and distraction (Rowe 2015).
As mentioned earlier, there are various approaches to working through theatre in mental health (such as dramatherapy and psychodrama), and although each proceeds from a particular understanding of mental health and difference in emphasis, all these approaches draw on the immediacy, sociability, and potential for insights into the human condition that are key characteristics of all good theatre. As a current example, Converge is a project based in England (initially York, then followed by Leeds and Newcastle), which offers, as part of a wider educational program, courses in theatre to local people who are experiencing mental ill-health and which support a theatre company, Out of Character, constituted of people trained through Converge’s courses. Converge began in 2008 with a simple idea: that real benefit would come from inviting local people who experience mental ill-health to take part in a theatre course involving theatre students (undertaking a theatre degree) in its delivery (Asghar and Rowe 2018). These people who participate in the courses would be regarded as students not as patients, clients, or service users; they would take part in a course, not some form of therapy, and the course would take place in a properly appointed theatre space.
Lose confidence and hope for the future – the “diagnosis” can overshadow and over-define a person’s sense of identity. Converge’s response to the corrosive nature of the mental health identity has been to invite people to be students and performers within a university environment. The focus is on theatre, not on the problem. It may be conceptualized as an “oblique approach” (see Kay 2010).
Become more socially isolated, losing contact with wider social networks. Theatre is by its nature a profoundly interactive and social form and can facilitate intergroup awareness and empathy (Rowe et al. 2013). Many involved in teaching the courses know, from their own experience, the pleasures of being part of a theatre troupe, and this is crucial to the benefits the work can bring (Asghar and Rowe 2018).
Experience the stigma that remains pervasive in mental health. Converge recognizes that many of the people it works with tend to fill roles and attend places that are not valued by society (Foucault 2001). As a place valued by society and focusing on aspiration, the university plays a crucial role in the Converge theatre model. Converge considers it essential to work with professional theatre teachers and practitioners in properly resourced spaces.
Become more passive, believing that they do not have a contribution to make or a purpose to be part of. Beyond the challenges and pleasures of working together, most of Converge’s work concludes with a performance, sometimes just to friends and family, but for Out of Character, to a wider public in a mainstream theatre. In these performances Out of Character engages with current issues and debates in mental health. For example, “In/Hospitable” is a planned performance which explores the real tensions and challenges of mental health provision in 2018, using interview material from medical professionals, administrators, academics, and the lived experience of the actors themselves. Out of Character is employing a professional playwright to produce the final script, and the advanced publicity runs as follows:
At Carrel Psychiatric Hospital something has changed. The impossible has happened and keeps happening. Different versions of care alternate and compete with each other. Every hour the facility completely changes; only the patients remain the same. Hope, horror, health and hilarity all combine in the debut of this new science fiction play by Out of Character.
Evidence suggests that each of these aspects is challenged through the Converge theatre model, and the following brief examples illustrate and evidence the practice. Christie became part of Converge and later became a trustee of Out of Character Theatre Company:
When I first arrived at Converge I was anorexic, nervous, extremely timid and devoid of the ability to play and have fun. I didn’t have many friends at that time either as my social anxiety wouldn’t permit it. For a long time, I felt that my body took up too much space. The great thing about going through Converge, Out of Character, and latterly, voluntary, community and professional work in theatre and dance, is not only the skill and level of professionalism I have attained; but the ability to own the space my body is in. I’ve learnt where the ends of my body start, and the rest of the world begins. I’m okay now that I “use up” space, I’m also confident in how to utilise it for theatre and dance. I’m still learning.
When Tom arrived for the first ‘Introduction to Theatre’ course in 2008 he seemed distracted. He clutched sheaves of paper, which he told me were plays and poems he was writing. To begin the course, I asked people to say their name and one thing about themselves. Tom said, “My name’s Tom, I’m a schizophrenic.” At first, he attended irregularly but it became clear that he had a passion for theatre. He joined the newly formed Out of Character Theatre Company performing with them in the university and at conferences. In 2010 he enrolled part-time on the B.A. Theatre programme, got a job and in 2013 got married. Despite occasional relapses his mental health remained good and in his fifth year, he led a theatre course entitled ‘Give it a Go, Jo’ designed to integrate local people from the community with those who use mental health services. A project which is now flourishing in York. Tom has come a long way since 2008 and now he says, “When I introduce myself I don’t necessarily see the need to mention my mental health problems and I might say, My name is Tom, I’m a recent theatre graduate, I work in sales to pay the bills and I’m married”.
Performance on Prescription
The previous sections illustrate some of the ways in which drama and theatre can be engaged, either outside of the formal healthcare system or as a part of it. The latter of these, where drama and theatre processes or spaces form part of the wider state-funded provision of health and social care, perhaps to compliment or replace medical treatment, have emerged as policies and practices variably described as arts on prescription, social prescribing, or cultural commissioning. Although this trend has emerged across the globe, it has seen particular growth in Western Europe (Jensen et al. 2017). Such a trend recognizes the larger-scale health and well-being benefits of creative and cultural activity as part of the healthcare system, and indeed, evidence has suggested a €3 return on every €1 invested (Health Education England 2016) or a social return on investment of €11.55 for every €1 invested (Whelan 2016).
Although such measurements and calculations value drama and theatre activity in the extremely narrow terms of economic utility, such narrative continues to provide an avenue for the promotion of drama and theatre for health and well-being benefits across cultures. Wider narratives of benefit echo those examined earlier in this paper, including self-confidence, self-esteem, sense of empowerment, reduction in anxiety and depression, a reduction in risk factors related to long-term care, reduction in medicine, enhanced cognitive skills, sense of achievement, and reduced use of healthcare (Stickley and Hui 2012a; Stickley and Eades 2013; Thomson et al. 2015; Maughan et al. 2016). Additionally, such benefits also seem to influence a wider network beyond those being referred to such programs, including the health and social care staff (such as nurses) and the wider family and friends network (Stickley and Hui 2012b; Fleischer and Grehan 2016). In contrast, there is also evidence that there is a small minority that does not immediately benefit from these services (Goulding 2014) and there is mixed evidence as to the longer-term engagement and impacts of engaging in prescribing services (Carnes et al. 2017).
There are various approaches to performance on prescription, but there is a common principle that they are typically delivered across a wide range of community settings including “homes or through community organisations, hospitals, hospices, day centres or nursing homes” and typically involve wide range of organizations (APPG 2017, p. 125). For example, Goulding (2014) describes the work of an expressive arts organization that crosses “visual arts… creative writing and storytelling, theatre and movement” (p. 94) and that incorporates “visits to exhibitions, performances and festivals… into the programme…[facilitated by professionals] qualified within the fields of psychology, psychotherapy, counselling, art therapy, applied music, drama and the visual arts” (ibid, p. 94). Similarly, in Norway, Oslo’s Teater Vildenvei has been commissioned to support the mental health of various populations for over 20 years. Here, participants are referred by Oslo University Hospital and regional psychiatric centers across Oslo (Torrissen 2015). And in Scotland, charity Hearts and Minds operates Edinburgh’s Elderflowers program which is based on drama and theatre processes, partially funded by the Scottish Government (APPG 2017). Other schemes have governmental support, such as the Bosnian Government’s establishment of youth musical theatre originally in Srebrenica, and then to Kosovo, Chechnya, Palestine, and East Africa, to alleviate and address posttraumatic stress (Arts Education Partnership 2011).
Create a shared mission and vision together.
Plan for the longer term.
Engage local community talent, skills, knowledge, and enthusiasm.
Take a bottom-up approach rather than a prescribed approach.
Be prepared to negotiate and let the community take ownership.
Let the arts and health evolve and grow together.
Focus on participation rather than what counts as art and what does not.
Aim for a balance between engagement and artistic success.
Ensure networking/communication to avoid duplication and promote good practice.
However, although there are many exemplar programs globally, and indicators that there are some contexts where prescribing is becoming “normalized” into daily practice (Whitelaw et al. 2017), there are still a number of key barriers or issues that need development (Jensen et al. 2017; Pescheny et al. 2018). These barriers include (1) a lack of awareness and buy-in from those professionals within the health and social care system who refer/prescribe services, especially local doctors who are the main actors in prescribing (Baker and Irving 2016; Bertotti et al. 2017); (2) the complexity of navigating the referral process, especially when people are also navigating their own lives (Goulding 2014; Pescheny et al. 2018); and (3) the recommissioning process that requires partners to reapply for funds which can increase overall costs and damage the consistency of the service provision as well as the relationships of collaborators (APPG 2017). Rather, commissioners should consider “embedding arts approaches into the mainstream care landscape, subject to regular review rather than re-commissioning” (APPG 2017, p. 57).
Although the evidence for arts on prescription, and similar arrangements in relation to performance on prescription, is generally positive, there are also stark criticisms about such evidence. In relation to social prescribing, for example, over 60% of “schemes lack formal evaluation, with those funding the activity tending to be reluctant also to fund evaluation” (APPG 2017, p. 75). When schemes are evaluated, the methodological approaches adopted are criticized in relation to the notions of rigor expected from medical research (Goulding 2014), that is, the approaches fail to generate an “evidence base of sufficient range and robustness upon which public policy and funding can securely depend” (Cann 2017, p. 90). The most common criticism relates to small sample sizes which cannot demonstrate statistical significance (Fleischer and Grehan 2016; APPG 2017; Bickerdike et al. 2017), but other criticisms relate to the use of solely quantitative or qualitative approaches (Goulding 2014), the lack of comparative controls and standardized measurement instruments (Bickerdike et al. 2017), the difficulty in being able to establish cause and effect in practice settings and lack of resources (Bickerdike et al. 2017), the extent to which some empirical work is advocacy rather than empirically oriented research (Beard 2012; Goulding 2014; Bickerdike et al. 2017), and the lack of longitudinal empirical work to examine the effects of the interventions beyond the implementation period (i.e., the “perishability” of the effects) (Fleischer and Grehan 2016).
Conclusions and Future Directions
The ways in which theatre and drama (alone but more likely with other art forms) are combined or integrated into formal health and social care spaces will continue to develop, in relation to (1) understanding and reformulating person, space, and place but also in terms of (2) how drama/theatre is integrated and/or combined with research and development in science, technology, and engineering (Wall et al. 2018b, forthcoming). There is increasing pressure in the UK, for example, to formally recognize and more systematically integrate the therapeutic value of the arts into the state-approved and state-funded provision. This will include formal arrangements for arts on prescription, social prescribing, and/or cultural commissioning arrangements. In one way, the narrative of theatre and drama on prescription is laden with economic utility (i.e., return on investment) which may undermine the broader cultural benefits and impacts of art forms; however, in another way, such a narrative is attractive in contexts where the state is reducing the budgets for health and social care. In this context, the narrative of therapeutic value is poignant and will seemingly continue to develop, and new arrangements are likely to emerge which tackle some of the ongoing issues related to the damaging effects of recommissioning on a cyclical basis and which make relationship building challenging (APPG 2017).
How this develops and emerges will inevitably prompt research, but given the ongoing critical debate about the empirical evidence of the health and well-being impacts of arts-based interventions (including but not exclusively relating to drama and theatre), it is also likely that there will be further empirical work akin to medical evidence for other treatments. Such research is likely to echo if not mimic medical research methodologies and methods but will, itself, receive similar criticism from other stances which value the lived experience of the individual. It is also likely that as more arts-based practices become readily used for therapeutic purposes, perhaps beyond the scope of dramatherapy and psychodrama, there will be increasing pressure for greater governance of those activities and the practitioners that deliver such activity. This is indeed developing in other allied arts fields such as creative writing for therapeutic purposes (see the paper on “Creative Writing for Health and Wellbeing”), and this trend is set to expand as a means to ensuring but also raising standards of health and well-being across nations.
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