American Journal of Public Health Jeremy Nobel Arts Public Health

There are many more things, betwixt heaven and earth, than are dreamt of in your philosophy, Horatio.

—Shakespeare, Hamlet

The World Health Organization (WHO) defines holistic wellness as:

viewing human being in his totality within a wide ecological spectrum, and … emphasizing the view that ill health or disease is brought nigh by an imbalance, or disequilibrium, of man in his full ecological system and not just by the causative agent and pathogenic evolution.^{1 (p13)}

This of import perspective is echoed in the system's 1946 preamble, wherein health is defined as a state of complete concrete, mental, and social well-being rather than merely the absence of disease or infirmity.

Implied in this definition is the necktie to health outcomes or changes in wellness every bit a result of an activeness; in the nowadays case, the connectedness between artistic appointment and the psychosocial and biological manifestations of that connection. More specifically, there is evidence that engagement with artistic activities, either every bit an observer of the creative efforts of others or as an initiator of i'due south own artistic efforts, tin raise one's moods, emotions, and other psychological states equally well every bit have a salient bear on on important physiological parameters.²

Chronic diseases are a nationwide burden, with cardiovascular affliction existence the leading cause of death during the by century and the incidence of diabetes continuing to increase, now affecting more than 20 million Americans.^3,iv These diseases are associated with psychosocial difficulties such as low⁵ and chronic stress, contributing to negative cardiovascular outcomes.^6,7 Date with artistic activities has the potential to contribute toward reducing stress and depression and can serve every bit a vehicle for alleviating the burden of chronic illness.

Over the past decade, wellness psychologists take cautiously begun looking at how the arts might be used in a multifariousness of ways to heal emotional injuries, increase understanding of oneself and others, develop a capacity for self-reflection, reduce symptoms, and alter behaviors and thinking patterns.⁸ Given the ubiquity of artistic expression, equally well as the relative ease of engagement, the extent to which psychological and physiological effects are sustainably health enhancing is an important area for public wellness investigation.

Nosotros reviewed research in the area of art and healing in an try to decide the creative therapies nearly oft employed. Iv master therapies emerged: music engagement, visual arts therapy, movement-based creative expression, and expressive writing. In these forms of expression, arts modalities and creative processes are used during intentional interventions to foster health.⁹ By assessing the utilize of these processes in clinical and qualitative trials, i can determine how others accept found benefit in tying the intricacies of creative meaning to the complexities of wellness and wellness. Our hope is to aggrandize effective exploration of these concerns.

We farther believe that sure social and environmental factors are converging to thrust the central questions related to better understanding the human relationship between art and health into the spotlight of expanded and vigorous attention. Globalization, bringing with it the need to encompass the broad cultural diversity around how personal and societal philosophies interoperate, will put a premium on finding more than effective means to create and share meaning and meaningfulness. This need for meaning and relevance in daily experience has long been recognized as one of the fundamental driving forces in artistic creation and engagement.¹⁰

Similarly, expansion of individual and community wellness-enhancing efforts worldwide and an acceptance of the definition of health as being more than than the absence of affliction are spurring active investigation into the fundamentals of whole-person approaches to creating and sustaining health. Investigating the relationship between art and health offers some interesting means to bridge these ii of import areas of inquiry and perhaps provide timely and important insights into each.

Art and health have been at the heart of human involvement from the offset of recorded history. Despite that fact, and despite the invested endeavor and growth of noesis and understanding in each arena, information technology is interesting that we often still discover ourselves struggling with the "fundamentals" of fine art and wellness and their pregnant in society. We make no attempt to clarify or resolve these fundamental issues. Instead, our intent is to summarize current knowledge nigh the connection betwixt art and health, identify the most compelling next steps for investigation, and generate further involvement in researching the complexities of art and health. Legitimate enquiry questions include whether certain fine art-based therapies are more or less effective than others, whether the touch of therapy can be tied to other important variables and preconditions, and whether health benefits are sustained or short term. These issues deserve vigorous continued attention.

We conducted a review of current research to make up one's mind what is known virtually art and healing. The goals of our review, primarily roofing the menses 1995 through 2007, were to assess the state of peer-reviewed research on arts and healing, to provide a cursory summary of both qualitative and quantitative research methods and results, and to describe the principal categories of creative expression that have emerged as effective ways of enhancing health and wellness.

METHODS

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We focused on artistic arts or expressive activities that were conducted primarily in North American and European countries and primarily with adults. We excluded studies focusing on complementary medicine practices. Although the literature in this review targeted adults (aged eighteen years or older), many studies accept focused on use of the arts with children in various contexts (due east.g., sandplay,¹¹ dance-movement therapy,¹² dramatherapy,^thirteen,14 music,¹⁵ myth to facilitate storytelling and drawing activities,^sixteen wheelchair trip the light fantastic experiences,¹⁷ mandalas,¹⁸ art therapy during painful cancer procedures,¹⁹ drama therapy,²⁰ and drawing.²¹), and other reviews have focused on art therapy and children.^22,23 Also, nosotros excluded manufactures about art education or art in professional career development. Finally, we did not evaluate the relationship of creative expression with major mental disorders such as schizophrenia or dementia, astringent developmental disorders, end-of-life issues, the use of art with incarcerated populations, or the impact of faith on health outcomes.

We assessed how creative expression as a healing procedure has been used in both clinical and informal practice to promote wellness and healing. Nosotros searched the post-obit databases and Internet sites, roofing the recent period of 1995 through 2007: Medline (PubMed) for general health care literature; Proquest, specifically PsycINFO for psychology journals and CINAHL for nursing and allied wellness literature; the Cochrane Library for health care reviews; and the Web of Science database including the Scientific discipline Commendation Alphabetize, the Social Sciences Alphabetize, and the Arts and Humanities Index. Primary keywords included the arts and medical outcomes, the creative arts and healing or wellness, creative expression and healing or wellness, the arts and health care, creative expression and illness, music therapy, art therapy, and artistic expression and humanities.

In the Cochrane Library show-based literature, the merely studies that included references to art or creative expression were those associated with the treatment of schizophrenia or schizophrenia-similar illnesses^24,25; therefore, we did not include any Cochrane database studies in our review. In addition to the sources but mentioned, specific journals were also targeted considering of their connection to art and wellness: Wellness Teaching Enquiry, Health and Quality of Life Outcomes, Health Education and Behavior, The Arts in Psychotherapy, and the Journal of Music Therapy.

Nosotros too searched literature from 1970 to 1995 on PubMed (MeSH art therapy database) to determine whether there were further foundational enquiry manufactures, only we did not find any abstracts matching our criteria. However, we constitute 1 randomized controlled trial in PubMed, and we included that study.²⁶ Because music therapy was observed to exist a predominant source of research in the arts and healing, the Journal of Music Therapy was also reviewed for foundational articles. As mentioned, four major areas of arts and health care emerged from our review: music engagement, visual arts therapy, movement-based creative expression, and expressive writing. Therefore, we focused on the potential of these creative areas to promote healing.

RESULTS

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The idea that creative expression can make a powerful contribution to the healing procedure has been embraced in many dissimilar cultures. Throughout recorded history, people have used pictures, stories, dances, and chants as healing rituals.²⁷ there has been much philosophical and anecdotal discussion nearly the benefits of art and healing, but less empirical research exists in the literature. In fact, although arts therapy has been used clinically for more a century²⁸ and has been recognized as a profession since 1991,²⁹ much of the published work is theoretical in nature, with fiddling discussion of specific outcomes.^13,thirty Only in contempo years have systematic and controlled studies examined the therapeutic effects and benefits of the arts and healing.³¹

Nevertheless, we accept seen positive outcomes for the potential of using art to promote healing in our four primary areas of focus. This commodity is not meant to be a comprehensive review of all of the literature available (other authors have provided comprehensive overviews in areas such equally music therapy³² and expressive writing³³). Instead, it represents a sampling of the many potential benefits of art in enhancing health and health.

Music Engagement

Music is the nearly accessible and near researched medium of art and healing, and there has been a principal emphasis on the soothing capacity of music and its ability to offset overly technological approaches to care.³⁴ In detail, music therapy has been shown to decrease anxiety.^35–37 The pleasure shared by participants in the healing process through a music therapy program can help to restore emotional residuum as well.³⁸ In that location is also bear witness of the effectiveness of auditory stimulation, together with a strong proposition that such stimulation abolishes pain, as a strategy for achieving control over pain.³⁹

In add-on, it has been shown that music can calm neural activity in the encephalon,⁴⁰ which may lead to reductions in anxiety, and that information technology may aid to restore effective functioning in the allowed arrangement partly via the actions of the amygdala and hypothalamus. As the action levels of neurons in the central nucleus of the amygdala subtract in response to calming effects of music, there may be corresponding reductions in the signals existence sent to other parts of the encephalon. Table one outlines the results of key studies we reviewed that focused on music engagement.^26,41,42

Tabular array 1 Details of the Music Engagement Studies Reviewed

In a lengthy review of the music therapy literature from 1983 to 1990, Aldridge noted that most of the research was concerned with passive music therapy and the playing of prerecorded music to patients to reduce stress and enhance well-beingness.³² Overall, he ended that although there is a broad literature covering applications of music therapy, at that place is a general absence of valid clinical research from which noun conclusions can be drawn. In a later review, Gregory examined the Periodical of Music Therapy from 1964 through 1999 to decide whether report methodologies included behavioral inquiry designs (e.yard., reversal, multiple baseline).⁴³ Of the 607 articles published in that journal during the written report fourth dimension menstruum, 96 (fifteen.eight%) included a behavioral research design.

A widely researched phenomenon is the utilise of music in the command of chronic cancer hurting.³² Five benefits of using music therapy with cancer patients have been reported in the literature: increases in hospital patients' sense of control, promotion of health and the healthy aspects of patients' lives, reductions in pain⁴⁴ and increases in amnesty, decreases in anxiety, and reductions in psychological and physical symptoms.⁴⁵ In several clinical studies examining the furnishings of music and music therapy on healing and wellness, music has been found to be a form of relaxation and anxiety reduction.^{41,42,46–50}

In a study of patients admitted to a coronary intendance unit with acute myocardial infarction, Guzzetta institute that relaxation and music therapy were effective in reducing stress.²⁶ In that investigation, lxxx patients were randomly assigned to a relaxation, music therapy, or command group. The relaxation and music therapy groups participated in three sessions over a two-day menstruum. Stress was evaluated via apical heart rates, peripheral temperatures, cardiac complications, and qualitative patient evaluative information. Results demonstrated that apical heart rates were lower and peripheral temperatures were higher in the relaxation and music therapy groups than in the control group.

Another area of research is the relationship between coronary heart illness and reductions in anxiety states.^51–53 In one study, music was introduced into the private hospital rooms of 45 patients with myocardial infarction.⁴¹ A Holter monitor was attached to each participant, baseline physiological values were obtained, and participants were asked to consummate the State Trait Feet Inventory. After listening to relaxing music for 20 minutes, participants exhibited pregnant reductions in heart rate, respiratory rate, myocardial oxygen demand, and, in item, anxiety, both immediately after and 1 60 minutes later on the intervention.

In their written report, Burns et al.⁴² investigated the human relationship of music therapy with positive emotions and immune system responses. They assessed the therapeutic effects on patients of listening to music, both live and recorded, while in a relaxed state, likewise equally the effects of active involvement in music improvisation. Xx-nine patients participating in a residential 1-calendar week class completed the University of Wales Institute of Scientific discipline and Technology (UWIST) Mood Adjective Checklist, and data were collected on cortisol levels. Results showed increases in well-being and relaxation and decreases in tension during the listening experience, increases in well-beingness and decreases in tension during the improvisation feel, and decreases in serum cortisol levels during both experiences.

An additional anxiety report⁵⁴ sought to investigate the effects of group music therapy combined with other artistic fine art methods on cocky-reported levels of anxiety, depression, and self-esteem among women who had experienced intimate partner violence. The group met for 6 sessions, each 1 to 1.5 hours in duration, over a menstruation of 3 months. Visual analog scales were used to appraise anxiety, depression, and cocky-esteem; the goals of the grouping were to increase self-esteem and self-expression, decrease anxiety and depression, and increase social back up. Significant decreases in depression and marginally meaning decreases in anxiety were observed among the report's 7 participants. No pregnant effects were plant for cocky-esteem. Most participants reported that all of interventions were helpful and rated the group therapy as a positive experience. These findings suggest that active music therapy in a group context may be effective in improving mood among women recovering from intimate partner violence.

Visual Arts

Art helps people express experiences that are too difficult to put into words, such as a diagnosis of cancer. Some people with cancer explore the meanings of past, present, and time to come during art therapy, thereby integrating cancer into their life story and giving it meaning.⁵⁵ Case studies are a typical methodology focusing on the use of the arts in meaning making. For example, McMurray and Schwartz-Mirman⁵⁶ and Reynolds and Prior⁵⁷ conducted case studies in an attempt to understand why some people turn to making visual art afterwards a cancer diagnosis and how artistic self-expression might contribute to maintenance or reconstruction of a positive identity. Table two summarizes the use of art therapies in the healing process.^57–63

TABLE 2 Details of the Visual Arts Studies Reviewed

Guillemin, one of the kickoff to utilize drawings in an effort to understand experiences of health and disease, examined how 32 middle-anile women with eye disease understood their condition.⁶⁴ Afterwards an individual interview, each participant was asked to "describe" her heart disease. The drawings were grouped into 3 themes: the heart at the center, the middle in the lived body, and eye affliction equally a social disease. Use of color, spatial organization, and composition were explored. The drawings were considered as both visual products of the women's knowledge about heart disease and processes of embodied knowledge production. It was ended that having individuals draw how they visualized their condition was an insightful method with which to explore understandings of illness.

Fine art can be a refuge from the intense emotions associated with illness.⁶⁵ At that place are no limits to the imagination in finding artistic ways of expressing grief. In detail, molding clay can be a powerful fashion to assistance people express these feelings through tactile involvement at a somatic level, besides as to facilitate exact communication and cathartic release and reveal unconscious materials and symbols that cannot be expressed through words.⁶⁶

Women taking part in a qualitative study focusing on cancer described ongoing cancer-related difficulties such every bit fear for the futurity, hurting, sleeplessness, part loss, activity restriction, reduced self-conviction, and altered social relationships.⁶³ Engaging in different types of visual art (textiles, bill of fare making, collage, pottery, watercolor, acrylics) helped these women in 4 major ways. Offset, it helped them focus on positive life experiences, relieving their ongoing preoccupation with cancer. Second, it enhanced their self-worth and identity by providing them with opportunities to demonstrate continuity, challenge, and accomplishment. 3rd, it enabled them to maintain a social identity that resisted being defined by cancer. Finally, it allowed them to express their feelings in a symbolic manner, specially during chemotherapy.

In another study, supportive intendance providers responding to a survey described the healing benefits of music and art therapy in hospital settings, and these benefits seemed to exist clustered around notions of exploration, expression, release, and the healing process.⁶⁷ In an additional written report conducted at the Chelsea and Westminster Hospital, Staricoff compared the utilize and nonuse of an art intervention in dissimilar units of the hospital.⁶⁸ The groups that received the intervention were significantly more than probable than were those that did non to have improved clinical outcomes, including improve vital signs, diminished cortisol related to stress, and less medication needed to induce sleep.

There is also evidence that use of art and music reduces hospital stays, with studies showing before discharges among patients taking part in visual and performing arts interventions than among those non doing so.^69,70 In 1 study, surgery or disquisitional care patients who participated in guided imagery or had a pic of a landscape on their wall had a decreased demand of narcotic pain medication relative to their counterparts and left the hospital earlier.^71,72 Evaluations of fine art projects can link the benefits of creative expression to healing and greater wellness.

Two other visual arts studies accept focused on the experience of women with cancer.^58,73 In a quantitative trial of mindfulness fine art therapy targeted toward women with cancer, Monti et al.⁷³ found that those who engaged in fine art making demonstrated statistically significant decreases in symptoms of concrete and emotional distress during handling. In addition to the introduction of self-care through guided imagery, the art-making therapy involved the women cartoon complete pictures of themselves and engaging in yoga and meditation. The relaxation and symptom reduction produced past creative expression opened pathways to emotional healing.

The psychological effects of breast cancer, in item, may include adjustment disorders, low, and feet, and these symptoms in turn may generate feelings of fearfulness, anger, guilt, and emotional repression. In their report, Puig et al.⁵⁸ explored the efficacy of a complementary creative arts therapy intervention with respect to enhancing emotional expression, spirituality, and psychological well-being amongst newly diagnosed breast cancer patients. This pretest–posttest report included 4 individual therapy sessions conducted over a four-week period, with each 60 minutes-long session comprising guided, semistructured, artistic arts therapy exercises involving drawing implements. 30-nine women with stage 1 or phase 2 breast cancer were randomly assigned to an experimental grouping that took part in an individual creative arts therapy intervention or to a delayed treatment control group.

Analyses of covariance were used to analyze the results, which indicated that the creative arts therapy intervention was not effective in enhancing the expression of emotions or the participants' level of spirituality.⁵⁸ Nevertheless, participation in the intervention enhanced experimental group participants' psychological well-being by decreasing their negative emotions and enhancing their positive emotions.

Medical professionals are beginning to recognize the role that artistic arts play in the healing procedure; increasingly, arts in medicine programs are emerging throughout the United States and worldwide.⁷⁴ With the success of the University of Florida's general arts in medicine program, a similar set of activities was launched in the long-term dialysis unit with the goal of assessing their effects.⁵⁹ Long-term hemodialysis is associated with impaired quality of life and low, which are thought to worsen compliance with handling regimens. At baseline and 6 months, the study authors administered the Medical Outcomes Study 36-Detail Short Form Wellness Survey (SF-36) and Beck Anxiety Inventory to 46 patients and assessed dialysis times, interdialytic weight proceeds, and predialysis laboratory results.⁷⁵

They also examined relationships between these variables and participation in the arts in medicine plan. The intervention, led by artists, included artwork, crocheting, crafts, seasonal displays, poetry, and playing of musical instruments. At 6 months, the participating patients, nurses, technicians, and physicians reported that the program had a positive touch on the unit. Paired comparisons with baseline data showed significant improvements in SF-36 symptom scores (e.yard., weight gain, serum carbon dioxide content, phosphate levels) and a trend toward reduced levels of depression.

In improver, regression analyses showed that high levels of program participation correlated with improved SF-36 social functioning, bodily pain, and physical part functioning scores, likewise as a tendency toward greater albumin levels, but also higher phosphate and lower calcium levels. In conclusion, participation in an arts-in-medicine program was related to improved quality-of-life measures, and at that place were encouraging trends in terms of improvements in depression and sure laboratory and hemodialysis parameters.

Walsh et al. conducted a pretest–posttest quasi-experimental written report to test the efficacy of a creative arts intervention with forty family caregivers of patients with cancer.⁶⁰ Participation in the creative arts intervention was the independent variable, and stress, anxiety, and emotions were the dependent variables. The 6-calendar month written report was implemented at a regional cancer handling heart. The creative arts intervention consisted of several artistic arts activities designed for bedside delivery. Participants completed the Mini-Profile of Mood States (Mini-POMS), the Beck Anxiety Inventory, and the Derogatis Affects Balance Calibration (equally a measure of negative and positive affect). The creative arts intervention promoted short-term well-existence in this sample of family unit caregivers. Caregivers reported significantly reduced stress, decreased feet, and increased positive emotions after taking function in the intervention. They also reported increases in positive communications with cancer patients and wellness intendance providers.

In another study,⁶¹ the specific aim was to decide the furnishings of a i-60 minutes fine art therapy session on pain and other symptoms mutual to developed cancer inpatients. The Edmonton Symptom Cess Scale and the Spielberger State-Trait Anxiety Alphabetize were used to quantify symptoms, and the fifty patients taking part were asked open up-concluded questions to evaluate their perceptions of the experience. There were statistically significant reductions in 8 of the nine symptoms measured by the Edmonton scale, including the global distress score, as well as significant improvements in most of the domains measured by the Spielberger State-Trait Anxiety Index. Patients overwhelmingly expressed comfort with the process and a desire to go on with therapy. This study provides initial evidence of the efficacy of art therapy in reducing a broad spectrum of symptoms among cancer inpatients.

Motion-Based Creative Expression

A growing involvement in dance and motility has accompanied recognition of the mind and body benefits of motor activity.⁷⁶ Movement-based creative expression focuses on nonverbal, primarily physical, forms of expression as psychotherapeutic or healing tools. Through the movement of mind and body in a creative style, stress and anxiety can be relieved, and other health benefits can be achieved equally well. Table 3 highlights some of the enquiry conducted in the surface area of movement-based creative expression and dance therapy to promote well-being.^77–80

TABLE three Details of the Motion-Based Creative Expression Studies Reviewed

Picard expanded Newman's theory of expanding consciousness to include creative motility as a mode of expression.⁸⁰ She conducted two in-depth interviews and a single artistic movement grouping experience with each of 17 midlife women. The results demonstrated expanding consciousness at midlife, with patterns of meaning identified in relationships with others, the cocky, and spirit besides equally challenges associated with loss, affliction, and threats to relationships. The consciousness activities identified were choosing, balancing, accepting, and letting go, and creative motility was shown to support cocky-awareness.

Sandel et al. conducted pilot enquiry at two cancer centers in Connecticut to determine the effects of a trip the light fantastic toe and movement plan on quality of life, shoulder function, and body image among breast cancer survivors treated inside the preceding five years.⁷⁹ Xxx-5 women completed this randomized controlled trial, which included a 12-week intervention focusing on healing through motion and dance. Results showed significant quality of life improvements in the intervention group. Shoulder range of motion increased, as did body paradigm, at 13 weeks. By addressing posttreatment patients' concrete and emotional needs, this program essentially enhanced their quality of life.

A unique study involving the use of theater investigated the benefits of a short-term intervention for adults aged 60 to 86 years (n = 124) that targeted cognitive functioning and quality of life issues of import for independent living.⁷⁸ The theater component consisted of enervating exercises designed to have participants feel the essence of acting (i.e., to become engrossed in the drama). In the visual arts component, participants speculated on the intention of the art or commented on an ambiguous image. Participants were grouped into 1 of three study weather condition: theater arts (primary intervention), visual arts (not-content-specific comparing group), or a no-treatment control group.

After 4 weeks of pedagogy, those given theater preparation exhibited significantly greater gains than members of the no-treatment control group on both cerebral and psychological well-being measures, specifically word and listening recall, problem solving, cocky-esteem, and psychological well-being. A comparison of theater and visual arts training showed fewer benefits in fewer areas for visual arts.

In a different type of movement expression, tai chi, a semimeditative practise derived from martial arts, has been gaining popularity as an intervention for reducing falls in older adults and improving health condition. Ane study,⁷⁷ conducted amidst older adults who were becoming frail, attempted to determine whether intense tai chi practice could improve perceived health status and cocky-rated health more than than wellness education. The participants were 269 women aged seventy years or older who were recruited from twenty congregate contained senior living facilities.

In this 48-calendar week randomized controlled trial, participants were randomly assigned to receive either tai chi or wellness educational activity. Participants were interviewed regarding their perceived health status and self-rated health earlier randomization and at 1 yr. Perceived wellness condition was measured with the Sickness Touch on Contour. Relative to the health didactics group, the tai chi group exhibited significant improvements in physical performance and airing and borderline significant improvements in the Sickness Impact Contour body care and movement category. Cocky-rated wellness status did not modify in either group. These findings propose that older women who are becoming frail demonstrate perceived wellness status benefits, virtually notably in airing, after taking function in intensive tai chi exercises.

Expressive Writing

Studies have shown that, relative to control group participants, individuals who have written about their own traumatic experiences showroom statistically significant improvements in various measures of concrete health, reductions in visits to physicians,⁸¹ and better immune system operation.⁸² Writing increases health and wellness in varied ways, as shown in the expressive writing studies outlined in Tabular array 4.^83–87

TABLE 4 Details of the Expressive Writing Studies Reviewed

Pennebaker^88–90 is the leading researcher on the power of writing and journaling for healing purposes.²⁷ According to Pennebaker, although the expressive writing paradigm has generally produced positive results, no unmarried theory or theoretical perspective adequately explains how or why.⁸⁸ This situation can be attributed to the fact that "expressive writing occurs on multiple levels—cognitive, emotional, social and biological—making a unmarried explanatory theory unlikely."^88(p138) Yet, there is footling doubt that writing has positive consequences, and self-report studies suggest that writing about upsetting experiences produces long-term improvements in mood and health.⁸⁹

In one exercise, Pennebaker⁸⁹ had students write about their deepest thoughts and feelings on an of import emotional issue, with the only rule beingness that "once y'all begin writing, go along to practise so until your [fifteen- to 30-minute] time is up."^89(p162) Dozens of replications of these types of studies accept demonstrated that emotional writing tin can influence frequency of dr. visits, immune role, stress hormones, claret pressure, and a number of social, academic, and cognitive variables. These effects take been shown to concur beyond cultures, age groups, and diverse samples.^91,92

Expressive writing can better control over pain, depressed mood, and hurting severity, equally can be seen in Table 4. For case, in a pair of randomized controlled trials,^83,84 patients were assigned to write most either emotional or nonemotional topics. In their ix-calendar week study, Graham et al.⁸⁴ divided 102 chronic hurting middle outpatients into an anger-expression group (n = 51) and a control grouping (northward = 51). Results showed greater improvements in command over pain and depressed mood, and marginally greater improvements in pain severity, in the acrimony-expression group than in the control group. These findings suggest that expressing anger may be helpful for individuals suffering from chronic pain, especially if it leads to pregnant making.

In their study, Petrie et al.⁸³ had 37 HIV-infected patients write 30 minutes per 24-hour interval for 4 days. CD4+ lymphocyte counts and HIV viral loads were measured at baseline and at 2 weeks, three months, and 6 months later the writing exercise. Participants who engaged in emotional writing rated their essays equally more personal, valuable, and emotional than did control group participants. HIV viral loads dropped immediately after the intervention in the experimental grouping and increased slightly in the control group. The CD4+ lymphocyte counts of the emotional writing group gradually and continuously increased during the 6-month follow-up, whereas the CD4+ lymphocyte counts of the command writing group increased slightly from baseline levels and then remained stable. On the basis of the participants' reports of the value of writing and the study's preliminary laboratory findings, the results propose that emotional writing may exist beneficial for patients with HIV. There is show, however, that the benefits of writing may not be maintained over time.^86,87

Another form of expressive writing, poetry, has long played a role in the art of healing.⁹³ Several authors^94–96 have described the use of poesy to assist people detect their voice and gain access to the wisdom they already have but cannot experience because they cannot find the words in ordinary language. According to Carroll:

Our voices are saturated with who we are, embodied in the rhythms, tonal variations, associations, images and other somato-sensory metaphors in improver to the content pregnant of the words. Our voices are embodiments of ourselves, whether written or spoken. Information technology is in times of extremity that nosotros long to detect words or hear another human vocalisation letting united states know nosotros are not lone.^{94 (p164)}

Finding 1'southward vocalization via poetic means can be a healing procedure because it opens up the opportunity for self-expression not otherwise felt through everyday words. One British infirmary introduced poetry into the culture of the hospital and then that patients could experience other forms of literary work⁹⁷ and perhaps feel healing through the short snippets of expressive words and emotions to which they could relate.

Expressive writing through journaling is another mode to access the unconscious self. Journal writing has been linked to creativity, spiritual awareness, and expansion of the self.^98,99 In 2 qualitative studies,^100,101 journal writing helped participants place and work though feelings, improve relationships, and learn new things about themselves.

In an in-depth qualitative study conducted at Boston Academy, Grossman et al.¹⁰¹ explored how sixteen resilient male survivors of serious babyhood sexual corruption, representing a range of racial, ethnic, and socioeconomic backgrounds, fabricated meaning from their corruption experiences. Three master types of meaning-making styles were identified in the narratives: meaning making through action, use of cerebral strategies, and spirituality. Meaning making through action included helping others and using artistic expression to describe and procedure the abuse. Although not all of the men used creativity to detect healing, 1 of the participants reflected on how he used writing, which was crucial to his survival. He reported that he would write both fiction and nonfiction to "go inside" and "be characters. Create characters. Daydream. That was the safe infinite."^{101 (p438)}

In a peculiarly unique study combining several visual, music, motility, and expressive writing modalities, Garland et al.¹⁰² examined the positive outcomes of a pair of psychosocial interventions aimed at cancer patients, mindfulness and healing arts, with respect to posttraumatic growth, spiritual well-being, stress, and mood.¹⁰² Garland et al. focused on 2 groups of cancer patients: those involved in mindfulness-based stress reduction (xv hours of class word, meditation, and yoga sessions) and those involved with motility to music, journaling, artistic writing, and drawing (12 hours of self-exploration and healing activities) hours. Participants in both groups improved significantly over time in terms of overall posttraumatic growth, but participants in the mindfulness therapy grouping, in item, showed improvement on measures of anxiety, anger, overall stress symptoms, mood disturbance, and spirituality. Benefit finding was the best predictor of long-term adjustment to chronic illness.

DISCUSSION

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In all four areas of creative creative expression reviewed here, there are clear indications that artistic appointment has significantly positive effects on health. At that place are, even so, limitations to many of the studies included in our review, and sweeping generalizations as to what they may hateful in amass cannot exist made. We also recognize that our sample of studies is not exhaustive, and other research has been added to the literature since our review was conducted.

In addition, as a event of the wide range of studies examining the relationship between multiple varieties of art-related interventions and a similarly large group of physiological and behavioral outcomes, comparisons both between intervention types and within sure illness states or conditions are challenging. Moreover, many of the studies were observational in nature and at best were limited to a preintervention and postintervention comparison within the treated groups, with limited or no command groups bachelor for comparison. Also, many of the interventions were both minor in size and launched in groups that were "convenience samples" of bachelor participants, introducing a number of potential confounding factors such as responder bias equally well as limiting the generalizability of the findings to other populations.

More than randomized controlled trials involving consistency in terms of the measurements used would increase the likelihood that patterns of health improvement associated with art can be demonstrated. In the studies reviewed here solitary, stress and psychological outcomes were assessed with the Spielberger Country-Trait Anxiety Alphabetize, the UWIST Mood Adjective Checklist, the Mini-POMS, and the Beck Low Inventory, among other instruments. Also, many of these studies were short term, and thus longitudinal follow-ups are needed to secure additional information.⁵⁸

With respect to inquiry methodology, the qualitative information focused on the meaning-making process of the arts and healing, and examples were provided of how art-based programs can contribute to wellness. Qualitative studies that written report private and unique results through rich descriptions and data could complement the use of quantitative methods. Both are needed to empathize creative appointment and health effects among generalized populations with unique individual differences.

Several issues should be considered in time to come studies seeking to add together to the insights available from the investigations reviewed here. For example, researchers should make better attempts to plant meaningful command groups, should attempt to quantify interventions and outcome variables at college levels of standardization and precision to allow for more cross-report comparison, should expand report populations to allow exploration of the effects of interventions in groups with diverse cultural and socioeconomic backgrounds, and should plan for longer term follow-ups to assess the sustainability of outcomes over time.

Finally, the majority of the research was conducted within hospital rather than customs settings. Given our nation'southward platonic of individuality, the social back up that can exist derived from one's community is an important but much ignored area of enquiry. Community leaders can partner with researchers to create a wellness intendance agenda that can have an affect on not only those who are ill in hospitals but those in the customs who desire to experience greater wellness. Traditionally, scientists involved with statistics have not partnered with those in the arts community, only in futurity studies, teams with solid research methodology experts (i.e., biostatisticians), clinical experts, and those with artistic expertise in the community should exist created to grade an effective triad of experts.

Despite methodological and other limitations, the studies included in our review appear to point that creative appointment can decrease anxiety, stress, and mood disturbances. It is not unreasonable to assume that time to come studies involving improve methodology and more consistent assessment of outcomes will demonstrate the power of artistic engagement to better psychological and physical well-being and quality of life. As tin can exist seen from our assay, it is likely that creative appointment contributes to many aspects of physiological and psychological atmospheric condition typically associated with improved wellness condition.

Use of the arts in healing does not contradict the medical view in bringing emotional, somatic, artistic, and spiritual dimensions to learning. Rather, it complements the biomedical view by focusing on non only sickness and symptoms themselves but the holistic nature of the person.¹⁰³ When people are invited to piece of work with creative and artistic processes that bear on more than their identity with illness, they are more able to "create congruence between their affective states and their conceptual sense making."^{104 (p53)} Through inventiveness and imagination, nosotros detect our identity and our reservoir of healing. The more we understand the relationship between artistic expression and healing, the more we will find the healing power of the arts.

Acknowledgments

We recognize the Foundation for Art and Healing for its financial support and potent commitment to improving research on the utilise of creative expression and wellness for the do good of individuals and communities.

Human Participant Protection

No protocol approval was needed for this study.

References

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