A Hole in the Heart: confronting the drive for evidence-based impact research in arts and health

Promoting Health and Wellbeing Through Non-Clinical Arts Programming: Multi-Stakeholder Perspectives From the Veterans Health Administration

PURPOSE

While the value of art therapy is well-established and arts are increasingly leveraged to promote health and wellbeing more broadly, little is known about the impacts of non-clinical arts programs. In this preliminary investigation, we sought to fill this gap by exploring diverse stakeholders' perspectives on the impacts of non-clinical arts programming on Veterans receiving care at the Veterans Health Administration (VA).

DESIGN

Semi-structured qualitative interviews with Veterans, VA staff, and community partners.

SETTING

Interviewees were recruited from 7 VA medical centers that have recently implemented non-clinical arts programming to promote Veterans' health and wellbeing, some of them in partnership with community organizations.

PARTICIPANTS

33 individuals were interviewed, including 9 Veterans, 14 VA staff, and 10 community partners involved in non-clinical arts program implementation.

METHOD

Interview transcripts were analyzed using iterative rounds of qualitative content analysis.

RESULTS

The following impacts on Veterans were described: (1) mental health improvements, (2) renewed sense of purpose; (3) increased social connectedness, (4) improved self-esteem, and (5) self-driven engagement in art activities.

CONCLUSION

Non-clinical arts programming was perceived by diverse stakeholders to offer important benefits for Veterans' health and well-being. Offering non-clinical arts programming inside and outside healthcare facilities' walls is a promising direction for the field of public health undergoing a shift towards holistic approaches to improving individual and population health outcomes.

Defining "Arts Participation" for Public Health Research

Arts participation has been linked to positive health outcomes around the globe. As more research is taking place on this topic, there is heightened need for definitions for the complex concepts involved. While significant work to define "arts participation" has taken place in the arts sector, less work has been undertaken for the purpose of researching the arts in public health. This study developed a definition for "arts participation" to guide a national arts in public health research agenda and to advance and make more inclusive previous work to define the term. A convergent mixed-methods study design with sequential elements was used to iteratively develop a definition that integrated the perspectives of field experts as well as the general public. Literature review was followed by four iterative phases of data collection, analysis, and integration, and a proposed definition was iteratively revised at each stage. The final definition includes modes, or ways, in which people engage with the arts, and includes examples of various art forms intended to frame arts participation broadly and inclusively. This definition has the potential to help advance the quality and precision of research aimed at evaluating relationships between arts participation and health, as well as outcomes of arts-based health programs and interventions in communities. With its more inclusive framing than previous definitions, it can also help guide the development of more inclusive search strategies for evidence synthesis in this rapidly growing arena and assist researchers in developing more effective survey questions and instruments.

"To do and see what happens, instead of planning for something to happen", a qualitative study on how professional artists working in a palliative care setting shape their practice

BACKGROUND

Research has acknowledged the potential benefits of art programs in palliative care settings while also highlighting associated concerns due to the extreme vulnerability of clients. To add to existing research, which predominantly focuses on social and healthcare outcomes of art initiatives, this study examines how artists shape their practice in response to the unique challenges of palliative care and client vulnerability.

METHOD

We conducted ethnographic research, observing and conducting in-depth interviews with nine artists working in a Belgian supportive and palliative daycare centre.

RESULTS

The findings reveal that the artists prioritise providing meaningful artistic experiences and employ a responsive, improvisational approach, emphasising the principle of negotiation.

CONCLUSIONS

Working as an artist in palliative care presents both emotional and artistic challenges. Expectations regarding what art can mean in this context must be held in check, all while keeping the repercussions of interventions on clients firmly in focus.

Clothing the Clown: Creative Dressing in a Day-center for People with Dementia in the Netherlands

Creatief met clowns is a creative and art-based workshop for people living with dementia that invites participants to join in a collaborative process of creating an outfit and clothing a clown. In this article, I look at what happened in workshop sessions and how this mattered to those involved, including what participants with dementia valued about the activity - by listening to what they had to say, but also by attending to their performative, creative and affective ways of engaging in Creatief met Clowns. To further articulate values that came up in practice, I analyzed my findings in terms of the quality of psychosocial relations, the role of embodiment, material aspects, and playfulness in person-centered care. By combining an ethnographic study of art-based care-practice with a value-sensitive theoretical reflection on empirical findings, my approach offers an alternative to problematic efforts to quantify the value of art in person-centered dementia care.

Trauma Aware and Anti-Oppressive Arts-Health and Community Arts Practice: Guiding Principles for Facilitating Healing, Health and Wellbeing

There is a growing call for arts-health and community arts professionals to work in 'trauma informed ways' to prevent re-traumatisation and promote healing. This paper reports on a scoping review of existing literature that deal with trauma aware and informed practice and its applications in arts-health and community arts. Trauma informed practice does not seek to target or treat trauma but, rather, seeks to provide a safer and more informed space for people who experience post-traumatic stress conditions and symptoms to engage in facilitated arts activities. We particularly examine the extent to which existing literature acknowledges the presence of oppression-related collective trauma - such as racial trauma - and offers appropriate creative, anti-oppressive and trauma aware practice approaches. A total of 19 articles were included following librarian input and team checking. Included articles were written in English, published in peer reviewed academic journals, included a creative arts component, and adopted an intentional trauma informed or aware approach to practice. An additional three sources were included as part of descriptive synthesis to foreground leading First Nations resources for practice. Although no specific guidelines for trauma aware practice in arts-health or community arts were found, findings are consolidated at the end of the paper to offer interim principles, values and activities for trauma aware and informed practice in arts-health and community arts. Findings can also inform general trauma related research and therapy by highlighting the growing role of arts and creativity in responding to diverse experiences of trauma and its effects.

Help is on its Way: Exploring the Mental Health and Wellbeing Outcomes of a Massed Community Choir Program

BACKGROUND

This paper explores the mental health and wellbeing outcomes of a massed community choir program in Australia.

METHODS

This study employed a mixed methods approach. Data were collected via a survey of choir participants (N = 305), four qualitative interviews and focus groups with facilitators and participants (N = 22), and two workshops with organising staff (N = 5). Questions were derived from a co-designed program logic, and data were triangulated and analysed thematically.

RESULTS

Participants reported feeling a sense of connectedness (psychological), but also experiencing connection (social) with their fellow singers. Psychological outcomes included the sensations of affect, arousal, and affirmation. Social outcomes included experiencing belonging, inclusion, and sharing. These positive psycho-social experiences promoted positive mental health and wellbeing outcomes in the large group of participating singers.

CONCLUSIONS

This paper addresses gaps in our understanding about the mental health and wellbeing outcomes fostered by community choirs at scale.

Enstranglements: Performing Within, and Exiting From, the Arts-in-Health "Setting"

The following text explores performative art works commissioned within a specific "arts and health" cultural setting, namely that of a medical school within a British university. It examines the degree to which the professional autonomy of the artists (and curator) was "instrumentalized" and diminished as a result of having to fit into normative frames set by institutional agendas (in this case, that of "the neoliberal university"). We ask to what extent do such "entanglements," feel more like "enstranglements," suffocating the artist's capacity to envision the world afresh or any differently? What kinds of pressures allow for certain kinds of "evidence" to be read and made visible, (and not others)? Are You Feeling Better? was a 2016 programme curated by Frances Williams, challenging simplistic expectations that the arts hold any automatic power of their own to make "things better" in healthcare. It included two performative projects - The Secret Society of Imperfect Nurses, by Anthony Schrag with student nurses at Kings College London, and Hiding in Plain Sight by Becky Shaw (plus film with Rose Butler) with doctoral researchers in nursing and midwifery. These projects were situated in a climate of United Kingdom National Health Service cuts and austerity measures where the advancement of social prescribing looks dangerously like the government abnegating responsibility and offering art as amelioration. The text therefore examines the critical "stage" on which these arts-health projects were performed and the extent to which critical reflection is welcomed within institutional contexts, how learning is framed, expressed aesthetically, as well as understood as art practice (as much as "education" or "learning"). It further examines how artistic projects might offer sites of resistance, rejection and mechanisms of support against constricting institutional norms and practices that seek to instrumentalise artistic works to their own ends.

Examining the Range and Scope of Artists' Professional Practices With Individuals With Palliative Care Needs: An International, Cross-Sectional Online Survey

Background: Internationally, it is recognized that artists facilitate arts engagement with individuals with palliative care needs. There is a gap in the literature describing the range and scope of artists' professional practices in palliative care. The aim of this study was to examine an international range of professional practices among artists who work in palliative care including key professionals' perceptions of these practices. Methods: An international, cross-sectional, online survey was conducted with health professionals, artists, and program coordinators with experience with artists working in palliative care. This survey was part of a larger mixed methods study. An instrument was systematically developed to examine artists' professional practices. Descriptive statistics were reported for the total sample including frequencies, means and standard deviations and open-ended items were analyzed thematically. Results: 101 valid surveys were analyzed. Findings outlined: (1) who delivers the arts; (2) where and with whom; (3) practice descriptors; and (4) perceptions of practice. Themes identified from open-ended items on benefits and risks of practice revealed impacts on patients and artists alike, including: (1) enhanced well-being; (2) vulnerabilities; and (3) facilitators and barriers. Conclusion: Findings demonstrated a wide range of artists' practices in palliative and end-of-life care, featuring notable consistencies in international practice worth further exploration. Ongoing and international efforts examining artists' practices in palliative care contribute to the development of future research, policy and practice.

Arts engagement facilitated by artists with individuals with life-limiting illness: A systematic integrative review of the literature

BACKGROUND

Living with life-limiting illness significantly impacts quality of life. A growing body of evidence suggests that arts engagement facilitated by artists promotes well-being. However, no synthesis of the literature exists to describe arts engagement delivered by artists with individuals receiving palliative care.

AIM

To systematically review and synthesize evidence to identify outcomes and key knowledge gaps to inform future research and practice.

DESIGN

A systematic integrative literature review was conducted using a pre-defined search strategy and reported using PRISMA guidelines. Analysis was conducted iteratively and synthesis achieved using constant comparison to generate themes.

DATA SOURCES

PubMed/MEDLINE, CINAHL, PsycINFO, Scopus, Web of Science, and Embase were searched for studies published between database inception and August 2020. Search terms included variations on arts/artists; patients/service users; and palliative or end-of-life care. Eligibility criteria was applied and study quality assessed.

RESULTS

Seven reviewed studies explored literary, performing, and visual arts engagement in hospitals, hospice and community settings in England, the United States, France, and Canada. Study designs, interventions and findings were discussed. Themes identified across studies associated arts engagement with (1) a sense of well-being, (2) a newly discovered, or re-framed, sense of self, (3) connection with others, and (4) challenges associated with practice.

CONCLUSION

Recommendations for future research were offered in order to maximize benefits, minimize risks and address complexity of artists' engagement in palliative care including: (1) consistency in methods and reporting; (2) inclusion of wider perspectives; and (3) key considerations for adapting the arts by health condition and art form.

'To more than I can be': A phenomenological meta-ethnography of singing groups for people with chronic obstructive pulmonary disease

Anecdotal experience and qualitative accounts suggest that singing groups, classes or choirs specifically for people with COPD (henceforth referred to as COPD-SGs) are effective in improving health. However, this is not reflected in the quantitative evidence. This meta-ethnography deployed phenomenological methods to explore this discrepancy. Analysis identified the phenomena of being together, being uplifted and being involved as central benefits of COPD-SGs. When viewed through the phenomenological lens of body-social as distinct from body-subject and body-object, findings demonstrated that the qualitative effectiveness of COPD-SGs is greatest on a collective basis. Qualitative research into the effectiveness of COPD-SGs offers more favourable results because phenomenological approaches can identify collective benefits that quantitative methods cannot. COPD-SGs should seek to maximise these collective benefits by rediscovering their cultural and artistic heritage within the national and global Arts in Health (AiH) movement, which has long emphasised the radical creative and healing power of group activity.

Exploring the impact of a clinical dance therapy program on the mobility of adults with a neurological condition using a single-case experimental design

BACKGROUND

This study built upon previous quasi-experimental design research studying the effectiveness of a 12-week dance therapy program for persons with a physical disability (DTPD) aiming to improve mobility.

METHODS

We conducted a single-case experimental design (SCED), including pre- and post-interventions measures, with seven participants with repeated measures during pre-dance (A1), dance program (B) and post-dance phases (A2).

RESULTS

Five participants completed the study and significantly (p < 0.05) improved their scores on the MiniBESTest; 2/5 and 4/5 improved scores for the 4 Square Step Test and the Multidirectional Reach Test-Behind, respectively, with very large effect size (ES). Aggregated ES (A1-A2) went from moderate to very large.

CONCLUSIONS

Results support the effectiveness of the DTPD program for adults with neurological conditions, and for the use of SCED to explore effectiveness of dance interventions for heterogeneous cohorts.

Interdisciplinary arts and health practice with an institutional logics perspective

Background: Investigating the interdisciplinary relationships between stakeholders engaged in arts and health practice in the UK and Denmark, specifically with regard to institutional logics theory. The identified stakeholders: health professionals, museum educators and mental health service users. Method: Semi-structured interviews were conducted with 30 participants: health professionals, museum educators and service users. Data were collected in Denmark and the UK. A thematic approach was used to analyse the data and theoretical lenses of sociological theories, and institutional logics explored the findings. Results: The interdisciplinary work in arts and health is complex, given the different disciplines and institutions involved. Findings illustrate that institutional logics play a vital and ambiguous part in arts and health practice and that this presents a challenge for interdisciplinary working in the field. Conclusions: Awareness of the complexity of multiple logics in the arts and health field; recognising the differences between disciplines and institutions could benefit from research and practice.

Medical Students' Efforts to Integrate and/or Reclaim Authentic Identity: Insights from a Mask-Making Exercise

Medical students' mask-making can provide valuable insights into personal and professional identity formation and wellness. A subset of first- and second-year medical students attending a medical school wellness retreat participated in a mask-making workshop. Faculty-student teams examined student masks and explanatory narratives using visual and textual analysis techniques. A quantitative survey assessed student perceptions of the experience. We identified an overarching theme: "Reconciliation/reclamation of authentic identity." The combination of nonverbal mask-making and narrative offers rich insights into medical students' experience and thinking. This activity promoted reflection and self-care, while providing insight regarding personal and professional development.

Clown's view as respiciō: looking respectfully to and after people with dementia

Clowns seem suspect when it comes to respect. The combination of clowning and people with dementia may seem especially suspicious. In this argument, I take potential concerns about clowning in dementia care as an opportunity to explore the meaning of a respectful approach of people with dementia. Our word 'respect' is derived from the Latin respiciō, meaning 'looking back' or 'seeing again', as well as 'looking after' or 'having regard' for someone or something. I build upon this double meaning of respiciō by examining how simultaneously we look to and after people with dementia. I do so empirically by studying how miMakkus clowns in their practice learn to look with new eyes to people and things around them. I call this clown's view and differentiate it from the predominant way of observing people in dementia care. I argue that respiciō comes in two guises, each of which merges specific forms of looking to and looking after the other. By making conventional, solidified ways of seeing the other fluid again, clowns remind us of the value that comes with a veiled way of paying respect to people with dementia.

Looking and listening for learning in arts- and humanities-based creations

CONTEXT

The arts and humanities are gradually gaining a foothold in health professions education as a means of supporting the development of future clinicians who are compassionate, critical and reflexive thinkers, while also strengthening clinical skills and practices that emphasise patient-centredness, collaboration and interprofessional practices. Assignments that tap into trainee creativity are increasingly used both to prepare learners for the demands of clinical work and to understand the personal and professional challenges learners face in these contexts. Health professions educators need methods for interpreting these creations in order to understand each learner's expressions. This paper describes two theoretical frameworks that can be used to understand trainees' unique learning experiences as they are expressed in arts- and humanities-based creations.

METHODS

The authors introduce the philosophical underpinnings and interpretation procedures of two theoretical frameworks that enable educators to 'hear' and 'see' the multilayered expressions embedded within arts- and humanities-based student creations: Gilligan's Listening Guide and Kress and van Leeuwen's approach to visual rhetoric. To illustrate how these frameworks can be used, the authors apply them to two creative summaries that learners made as part of a humanities-informed, interprofessional education intervention that took place in a non-acute-care teaching hospital. The interpretations of two creative summaries, a poem and a pair of paintings, highlight how applying these theoretical frameworks can offer important insights into learners' experiences.

CONCLUSIONS

This cross-cutting edge paper describes how the Listening Guide and visual rhetoric can help health professions educators listen to and read the arts- and humanities-based creative expressions made by learners. Insights gained from these interpretations can advance the understanding of students' personal experiences in different learning environments and can inform curriculum development.

Making music, making friends: Long-term music therapy with young adults with severe learning disabilities

This collaborative practitioner research study emerged from music therapists' concerns about the value of improvisational, music-centred music therapy for young adults with severe learning disabilities (SLDs), given the long-term nature of such work. Concerns included the relevance, in this context, of formulating, and reporting on, therapeutic aims, development, change; and working in 'goal-oriented' way. Focus groups with the young adults' families and a range of professionals suggest that, rather than leading to developmental change, long-term shared therapeutic musicking provides young adults with ongoing opportunities for experiencing confidence and self-esteem, with feelings of shared acceptance and success, and also provides young adults and their families with opportunities for developing and sustaining friendships. In addition, families experienced meeting other parents and carers in the communal reception area as supportive and countering their isolation. Focus groups assigned intrapersonal, relational and social values to long-term music therapy for young adults with SLDs.

Ethnographic Evidence of an Emerging Transnational Arts Practice?: Perspectives on U.K. and Mexican Participatory Artists' Processes for Catalysing Change, and Facilitating Health and Flourishing

This article reports new ethnographic research exploring community-based, participatory arts practice in Northern England and Mexico City. Noting the value of an ethnographic approach, the study investigated whether commonalities discovered in practitioners' approaches are significant enough to constitute a generalisable participatory arts methodology, transcending significant contextual differences, and recognisable across national boundaries. Shared characteristics emerged in practitioners' modes of engagement with groups, and strategies for catalysing change; clear convergences from which a core methodology in community-based participatory arts for change is distilled. It suggests the opening of liminal spaces in which participants can reflect, rehearsing fresh ways of engaging in transformative dialogues in relation to the world in which they live. This article presents the study findings as a grounded characterisation of 'participatory arts practice': a complex but potentially powerful mechanism, in use within numerous community health projects, and evident in diverse settings, despite little or no exchange of ideas between practitioners.

The ‘ripple effect’: Towards researching improvisational music therapy in dementia care homes

Increased interest in, and demand for, music therapy provision for persons with dementia prompted this study’s exploration of music therapists’ strategies for creating musical communities in dementia care settings, considering the needs and resources of people affected by dementia. Focus group discussions and detailed iterative study of improvisational music therapy work by six experienced practitioners clarify the contextual immediacy and socio-musical complexities of music therapy in dementia care homes. Music therapy’s ‘ripple effect’, with resonances from micro (person-to-person musicking), to meso (musicking beyond ‘session time’) and macro level (within the care home and beyond), implies that all who are part of the dementia care ecology need opportunities for flourishing, shared participation, and for expanded self-identities; beyond ‘staff’, ‘residents’, or ‘being in distress’. On such basis, managers and funders might consider an extended brief for music therapists’ roles, to include generating and maintaining musical wellbeing throughout residential care settings.

Evidence of a transnational arts and health practice methodology? A contextual framing for comparative community-based participatory arts practice in the UK and Mexico

BACKGROUND

This paper draws on new research exploring community-based, participatory arts practice in Northern England and Mexico City to discuss contextual influences on artists' practice, and whether a common practice model can be identified. The international comparison is used to interrogate whether such a practice model is transnational, displaying shared characteristics that transcend contextual differences.

METHODS

The study used multi-site ethnography to investigate the participatory practice of more than 40 artists. Participant observation and extended individual and group dialogues provided data on practice in a diverse range of art forms and settings, analysed using open coding and grounded theory principles.

RESULTS

Findings locate differences in practitioners' motivations, and perceptions of the work's function; however, key similarities emerge across both sites, in practitioners' workshop methodologies and crucially in their creative strategies for catalysing change. A model is presented distilling the key elements of a common practice methodology, found across the study and across art forms.

CONCLUSIONS

The discussion notes where divergences echo nationalities of contributors, drawing inferences about the level of influence of national context in this work, and concludes with the implications of these findings for potential international collaboration, to face challenges within the community arts and health sector globally.

Creativity and health: an anti-humanist reflection

Many studies suggest that health benefits from engaging with the creative arts, but explanations of the association remain tenuous. This article explores both creativity and health from an anti-humanist perspective and develops a Deleuze-inspired analysis to supply the theoretical framework for creativity and health. In this view, creativity is an active, experimenting flow within a network or assemblage of bodies, things, ideas and institutions, while health is understood as the capacity of a body to affect and be affected by this assemblage. It is consequently unsurprising that there is a relationship between creative activity and health. This analysis is used to explore how creative production and reception can affect health, and to assess the implications for sociology and for arts in health-care practice.