Abstract
This clinical practice guide traces the role of art and creativity in mental health and well-being. This is a difficult task since the evidence from research spans a wide variety of fine art forms and different aspects of creativity. Hence, we have tried to combine both evidence-based research as well as our clinical experience and practice in the field of arts in utilizing creative pursuits as a life skill and a well-being initiative. The focus of the guidelines is preventive and promotional with relevance to mental health. We also hope that this should be a beginning in encouraging psychiatrists in India to use art-based therapies in their clinical practice. This will further our knowledge of how arts can be a therapeutic intervention as well as a well-being tool. It will also build on the evidence base on how art impacts our mental health. Creativity is undeniably one of humanity's most valued traits; the capacity to produce new ideas, innovations, and art is perhaps the most striking characteristic of the human brain. “Art” has evolved, and what is art, has been redefined over human history. The domain of “art” refers to the diverse range of activities that often use imagination to express ideas and feelings. Whilst the boundaries of what constitutes art or creativity may sometimes appear esoteric, we still can identify a range of creative pursuits: visual, musical, verbal, literary, dance, or creative pursuits related to our body movements and a range of forms of newer integrated forms and those that use technology are recognized as art forms. As in most ancient traditions, in India, we have a plethora of fine art traditions many of which have a highly systematic practice around their learning. We believe this is an asset that we need to nurture and celebrate. We begin by tracing the footsteps of Indian fine arts being a mental health promotional tool in ancient India. We then proceed to describe the scope of creative pursuits for different populations and its relevance in school and child mental health. We offer suggestions as to how creative art forms can be utilized in a practical way in daily life, schools, and care of the elderly. It is to be noted that the entire focus here is the process of creativity and not the completed product or the achievement related to the same. Hence, it is relevant to each one of us and to anyone who wishes to be healthy.
Keywords: Creative pursuits, mental health, well being
INTRODUCTION
Creativity is the ability to discover innovative and original ideas. It is one of the 10 life skills advocated by the World Health Organization (WHO).[1] It is a part of our drive as humans — fostering resilience, sparking joy, and providing new insights for a feeling of self-actualization and, thus, a sense of well-being.
Fine art forms are the expressions of creativity in humans. But an idea need not be artistic or world-changing to count as creative. Life requires daily acts of novelty; in this sense, everyone of us possesses some amount of creativity. We realize that fine arts and craftsmanship activities like drawing, drumming, singing, innovative movements-dance, and drama permit people of all age groups and from different cultural backgrounds to communicate their musings, sentiments, and feelings in a way different from the typical methods of verbal expressions. Hence, creative pursuits in any form, how much ever trivial, have unique utility as mental health-promoting and protecting activities.
WHAT IS CREATIVITY?
Creativity is difficult to define due to its complex neuro-psycho-philosophical construct and probably that is the reason we find many definitions on literature search. In a divine sense, it is about creating out of nothing, but scientifically speaking, it is about creating something tangible or intangible by somebody with the help of something. Creativity is reflected not only in its products but also in the process and the person who never remains the same after the visible or invisible grind. The outcomes of creativity include from inner transformation to problem solving and the creation of insight and knowledge to innovative and aesthetic artifacts.
Creativity leads to the creation of something in the outside world, but simultaneously, it also has consequences every time on the inner self, leading to strengthening of self and inner resilience, validation and enhancement of esteem, relief from pain and distress, and restoration of order. The creative person, according to a humanistic perspective, has the consciousness and the ability to address crisis in transformative ways. Therefore, the creative person can be understood as being in a process to reach self-actualization and to develop characteristics that are related to mental health, such as subjective well-being, resilience, optimism, quality of life, and other aspects emphasized by positive psychology.[2]
CREATIVE PURSUITS
If we go by the classical approach, we may expect a domain-changing effect from creativity, but when we talk about creative pursuit, we mean a process or an endeavor. To understand this, let us have a look at the most democratic classification of creativity, which accepts the division of class (having high intelligence, divergent thinking, and creative personality) and mass [Table 1].
Table 1.
Definitions of creativity
Definitions of creativity
|
Newer definitions have made the boundaries of creativity more permeable and have allowed the majority to enter the zone that was philosophically reserved for minority elites [Table 2]. Earlier creativity was classified as little-c (everyday creativity) and Big-C (Breakthrough Creativity). However, Kaufman and Beghetto[3] [Table 3] introduced and inserted two more Cs in the picture and made a model that has an entry gate and scope for everybody and proposes that persistent effort helps in reaching a higher level.
Table 2.
Four-C model of creativity given by Kaufman and Beghetto
| Type of Creativity | What does it include | Learning process | Whom does it impact |
|---|---|---|---|
| Mini-c | Transformative learning, meaningful interpretations of daily experiences | Changes in understanding | Individual |
| Little-c | Creative actions and thoughts | Out-of-box thinking in anything we do | Individuals and their zone of influence |
| Pro-C | Creative acts of experts/experiences people | Learns within an organization, community, or domain | Organization, field system of practice.market |
| Big-C | Eminent creativity.Exceptional people | Autodidactic, unconventional thinking | Culture, society and the world |
Table 3.
Stages of creation as described by Wallas[2]
| Preparation Incubation Intimation Illumination Verification |
Creative pursuits include activities resulting in all the Cs of Kaufman and Beghetto. They can be classified as
Everyday creativity
Scientific experiments/innovations
Arts
Arts include:
Performing arts (music, dance, theatre, singing and film)
Visual arts (painting, photography, sculpture)), Design, Craft
Literature (writing, reading, and attending literary festivals)
Culture (going to museums, galleries, art exhibitions, concerts, theatre, community events, cultural festivals and fairs)
Online, Digital, and Electronic Arts (animations, film-making and computer graphics)
This range is very accommodating, and anybody can indulge in one or other creative pursuits. It is noteworthy that both the practice and research in creativity appear to be undertaken by mental health professionals other than psychiatrists. One reason for this, perhaps, is that the realm of creativity is thought to be restricted only to high achievers/eminent people. Clinically, creativity has always been considered an area that requires special expertise from the service providers as well as service users. By having an overinclusive, all-accommodative definition and a wide range of activities, it is possible to overcome this barrier.
The research evidence for creative pursuits to promote mental health and well-being
Creative art forms are generally believed to be having an entertainment value. We enjoy reading poetry, viewing dance and drama, listening to music, or taking part in all these as social activities. While we wholeheartedly enjoy these, we are not sure about their usefulness. But the very purpose of creating the dance (which can be seen as an amalgamation of several art forms including literature, poetry, sculpture/painting, music, and drama), as stated in Natyashastra Bharat Muni is credited as the author of Natya Shastra, which covers ancient Indian dance, dramaturgy, poetics, and music.[4] The exact time of the text is unknown but estimated to be between 200 BC and 200 AD. In the first chapter of Natyashastra, Bharata describes that Brahma created a dance to alleviate stress and negative feelings like fear, anger, lust, and jealousy and to calm the mind. This new creation of dance by Brahma was in response to the plea made by Indra (the king of heaven according to Indian mythology) and his associates when the whole universe was engulfed in negative feelings and people were suffering. Mythology aside, Bharat Muni's narrative demonstrates a profound understanding of how art form can help deal with our emotions. He then goes on to systematically code the various art forms.
Thus, in India, the original purpose of creative art forms was not just to provide entertainment as it is often practiced today. Its main purpose was therapeutic, which was to alleviate the suffering of the mind; an art form with the body as a medium was chosen [Table 4].
Table 4.
Responses to creative ursuits
Responses to creative pursuits
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Verbal language often involves a degree of cognitive processing, as it does not offer a direct avenue for our sensory experiences. It serves only to share labels or names for what we have seen, heard, or thought. Perceptual experience may be far more subtle, subjective, and contextual.[5] Body movement or visual language offers an opportunity to tap into such sensory experiences and allow suitable expression. One may hypothesize that such an avenue allows the “processing” or shaping of fears and trauma, through agreed goals in art therapy.
When someone has not managed to distill their feelings or thoughts either due to cognitive or emotional challenges, verbal communication may not be easy and may lack clarity.[6] In such situations, body movement or visual language offers an alternative avenue that is not restricted by vocabulary, verbal syntax, or semantics. Such non-mimetic forms of expression, such as dance and body movement, and visual art rely on visual or physical idioms to mediate our psychological pain, anxieties, cognitive dissonance, and confusion.
Well-being Connections
Many studies also tell us about the transformational and positive mental effects of creative pursuits. Based on two meta-analyses, Zhao et al.[7] has revealed a negative association between creativity and negative well-being and a positive association between creativity and positive well-being.
When creativity is pursued, three psychological mechanisms play a role in promoting/maintaining positive mental health – Authentic Self, Positive Focus, and Flow.
The Authentic Self – All creative pursuits give a purpose and avenue for expressing the self. This process makes life meaningful. A way to express the self and a meaning.
Positive Focus – All creative pursuits orient the mind for positive focus. Purposeful creative involvement promotes well-being. Mihalai Czikszentmiha,l[8] in his book titled CREATIVITY, beautifully explains the difference between entertainment and creativity. “Entertainment keeps chaos temporarily at bay, but the attention it absorbs gets wasted. However, when we learn to enjoy using our latent creative energy so that it generates its own internal force to keep concentration focused, we not only avoid depression but also increase the complexity of our capacities to relate to the world.”
Flow – When challenges closely match a person's abilities, one can enter a state of flow. In flow, there is a complete merger of action and awareness and loss of sense of time. This is experienced by individuals across a range of activities, from creative pursuits to sports.
According to positive psychologists, the experience of flow enriches life, does away with boredom, and imparts meaning. It is important to note that one can reach the state of flow by continuous engagement.
Sadly, the research till very recent times focused only on studying creative people or people who are proficient in Big “C” and their mental illnesses. So much so that the value of creative thinking as a life skill was kept aside. In India, we have often, explicitly or implicitly through societal values, discouraged our children from choosing creative professions in our pursuit of material success and security. However, the recent research appears to have taken a better course by inspecting many realms of creativity and appears more useful to clinical practice. Now, the research has been looking at Creativity as an important way of enhancing and maintaining a sense of well-being. Feeling happy while dancing, singing, painting, or doing some activity that “creates” something, however small/productive, is known to all of us. But beyond feeling happy the research shows that it also can be useful for our overall health. A recent large scoping review.[9] showed how the arts can have a lasting impact on several components of health. They are summarised in the following tables. The WHO also advocates a cross-sectoral and multi-disciplinary approach for popularising the art interventions as a cost-effective tool to promote health.
Prevention and promotion through arts
Affect the social determinants of health
Support child development
Encourage health-promoting behaviors
Help to prevent ill health
Support caregiving
Management and treatment through arts
Help people experiencing mental illness;
Support care for people with acute conditions;
Help to support people with neurodevelopmental and neurological disorders
Assist with the management of non-communicable diseases
Support end-of-life care
Recognize the added health value of engagement with the arts by:
Ensuring that culturally diverse forms of art are available and accessible to a range of different groups across the life course, especially those from disadvantaged minorities;
Encouraging arts and cultural organizations to make health and well-being an integral and strategic part of their work;
Actively promoting public awareness of the potential benefits of arts engagement for health
Developing interventions that encourage arts engagement to support healthy lifestyles
Cross-sectoral nature of the arts and health field by:
Strengthening structures and mechanisms for collaboration between the culture, social care, and health sectors, such as introducing programs that are cofinanced by different budgets;
Considering the introduction or strengthening of lines of referral from health and social care to arts programs, for example, through the use of social prescribing schemes; and
Supporting the inclusion of arts and humanities education within the training of healthcare professionals to improve their clinical, personal, and communication skills
Research has recognized that the practice of creative pursuits can be beneficial in influencing positively psychological, physical and social components.
Psychological components
Aesthetic engagement
Involvement of the imagination
Sensory activation
Evocation of emotion
Cognitive stimulation
Physical and social components
Physical activity
Social interaction
Engagement with themes of health
Interaction with healthcare settings
Responses to creative pursuits
Psychological – enhanced self-efficacy, coping, and emotional regulation
Physiological – lower stress hormone response, enhanced immune function, and higher
Cardiovascular reactivity
Social – reduced loneliness and isolation, enhanced social support, and improved social
Behaviors
Behavioral – increased exercise, adoption of healthier behaviors, skills development
Creative Pursuits and Child Well-being
Art can enhance a child through improved mother-infant bonding, support the child across several domains ranging from speech and language to motor skills, and extend to neuro-cognitive development, educational attainment, and emotional well-being [Table 5].
Table 5.
Benefits for child development from arts engagement
From Activities at Home
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“Motherese,” or baby talk, has musical components. Lullabies have been part of every culture. These songs sung by the mother to the infants have been thought to enhance maternal nurturing behaviors. It is found to reduce stress hormones both in mothers and their infants. It can increase perceived emotional closeness and strengthen the mother-infant bond.[10]
Music plays an important role in reading, language, and auditory skill development. Studies have shown structural differences in grey matter and white matter in children who engage in music (especially during early childhood) compared with those who do not.[11,12]
Engaging in arts early in life facilitates autonomy, competence, and relatedness and lowers the risk of developing social and behavioral maladjustment issues in adolescence.[13]
Arts engagement, including music therapy and dance, can reduce internalizing symptoms such as anxiety and depression in children and adolescents. In adults with a mental illness, activities such as choir singing, art-making, expressive writing, and group drumming reduce mental distress, depression, and anxiety while simultaneously enhancing individual and social well-being with similar results for older adults. According to neurobiological theories and research, these benefits may reflect the modulation of serotonin and other neurotransmitters, a decrease in cortisol and other stress hormones, and a reduction in inflammatory immune responses. Music has been found to improve sleep quality, sleep efficiency, and time to sleep onset, with greater effectiveness than meditation.[14]
Another interesting study is worth mentioning. This study examined the effectiveness of hip-hop dancing on participants' cognitive skills.[15] Some of these abilities, like working memory and critical thinking, are connected to a better performance in STEM disciplines, that is, science, technology, engineering, and math subjects. Participants were challenged with a set of digital tasks, which assessed key areas like working memory, speed of mental rotation, problem-solving skills, and the process of “theory of mind'. The authors controlled confounding factors like demographics and dance style experience other than hip-hop dancing. The hip-hop dancers had much faster mentally rotating images of hands at greater angle disparities. They also displayed greater accuracy in identifying human facial images with positive emotions.
Non-pharmacological interventions like music-visual arts therapy have promising potential to complement traditional medical treatment in child healthcare. They facilitate recovery and promote resilience and well-being. Music therapy and other music-based interventions have been widely used in the clinical treatment of children and adolescents globally.[16] Another review, which was presented as a conference paper and available online by Paušić et al.[17] assessed the benefits of dance and movement therapy in children's mental health. It is understandable that a performing art form like dance helps the active expression of emotions. In addition to this, dance as a therapy was found to be useful in improving body image and perception of self and others. An increase in tolerance towards others and improved ability towards others were the other advantages. It was also seen to be effective in reducing problematic behaviors. Dance led to better parent-child bonding and made parenting much easier in the case of children with special needs. It helped children in perceiving both their as well as “others” competency. As commonly seen by the dance trainers, through dance, a gradual welcome transition takes place in body stance, balance, and movement control [Table 6]. This was reported by the authors even in children with disabilities. It acted as a remedy for initiating and maintaining motivation for physical exercise especially in adolescents avoiding physical exercises and having increased weight.
Table 6.
Engagement in Arts through formal training
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Creative Pursuits and Art Activities in Schools
Schools around the world are now incorporating art concepts and activities into their curriculum. Earlier known as extra-curricular activities, they are now appropriately called “Co-curricular education” – CCE. Various art-based projects have been utilized with a particular focus on enhancing child mental health in schools. In fact, there is a move to include arts as a part of the core curriculum as opposed to being seen as an add-on [Table 7]. These programs have produced positive results. It was reported that the inclusion of these artistic activities (theatre/dance/music/newspaper) improved students' verbal and nonverbal expression and increased their confidence, concentration, engagement, cooperation, and collaboration with peers and adults. Some schools even see a decrease in behavior problems and improvements in attendance, grades, and test scores[18]
Table 7.
School programs related to creative pursuits
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Do's and don'ts while pursuing art activities
Suggestions for parents/teachers
Do's
Focus on the enjoyment of the activity
Keep the choice for the child to change activity
Keep the regularity
Guide the child
Allow the child to experiment within the framework
Encourage the child to focus on the process
Permit the child to express his/her views
Motivate the child to share their work with (significant) others
Don'ts
Do not compare with others
Do not aim for perfection
Do not continue the activity if a child shows signs of resistance even after a few weeks of classes. Try switching over to a different activity
Do not keep long-term goals
The website of Scotland's national curriculum authority, Learning and Teaching Scotland (LTS), contains a section entitled “What is creativity?” It recognizes that “students who are encouraged to think creatively are more interested in discovering things for themselves; more open to new ideas and challenges; more able to solve problems; more able to work well with others; and more effective students. Creativity has long been a popular term in education, but well-being is a relatively new addition to the educational lexicon and suggests that it is about young people's well-being in the broadest sense and not just their physical health. The connection between the two concepts is usually not explicitly stated, although it is often implicitly assumed that students' motivation increases when a “creative” approach to teaching and learning is taken, which in turn increases their personal well-being.[24,26]
Methods to incorporate art forms in teaching school subjects
Use of storytelling technique
Description through daily experiences
Ask students to narrate their own experiences
Short skits based on that particular section
Poster making
Making a song/poem out of the text content/main components
Sample list of activities for parents and teachers to involve children in creative activities
Keep a “Busy Box” with new and recycled play materials such as string, scraps of paper, pancake pans, paddle sticks, stickers, and straws. Your child can make anything from these materials
Empty cardboard box for decoration. They can build a house, a robot, a truck, an animal, whatever interests them
Empty kitchen towels, small plastic juice bottles, or old gloves or socks for making dolls
Take a nature walk and look for natural materials to create works of art. Your child can use it to draw, create a collage or a nature doll, or paint
Use software applications or computer programs to create digital art. For example, there are apps that let you draw or organize photos into collages for free
Children enjoy stories; for example, when we read a story to a child, we may notice that they move their arms, legs, or face, imitating what is happening in the story. The activities of reciting nursery rhymes usually involve the children first imitating the activities and then actually learning the songs. Theatre and storytelling also provide children with the opportunity to develop and practice vocabulary and learn the structure of stories. When children take on the roles of a caring nurse, a teacher, a police officer, a father, and a mother, they see the world from someone else's perspective. This helps them develop empathy.
Some theatre activities to stimulate children's interest and imagination:
Carry a disguise box or bag. Use old clothes or find cheap and fancy clothes
Help your child make masks and supplies from home/school waste
Organize a puppet show or other puppet show. You can also use a cardboard box to make a puppet theatre
Set up a tent in your backyard/school and pretend you are going on a camping adventure
Staging daily events. It could be going shopping, having a pet, going to the zoo, riding the bus, etc.
As the story progresses, encourage children to act out the story using movements or sounds
Help them create a special video with a video creation app and share it with others
Interventions used in drama therapy for healing and positive change,
(Whipple, 2012)[26]
Create visualizations
Create spontaneous fill-in-the-blank stories.
Role-playing game with role cards
Creating poetry
Recitation, enactment, or interpretation of literature
Retelling or reenacting familiar stories
Stories told through figurines, puppets, or objects
Story summation and titling
Art activities for intellectual disability and children with special needs.
Intellectual disabilities pose a great challenge to children and their carers – parents and teachers. Though research strongly suggests that art activities can be a good source of educating these children, the general art classes stigma becomes a barrier, and seldom do these children get to attend these classes. Again, most of the parents strive hard to make their children with intellectual disabilities somehow try academics taught in school. And consider the time spent on art activities as a waste of energy and time.
A recent study has shed light on the usefulness of play and playfulness of children with intellectual disability. It has shown that there might be a role for activities like clowning play intervention to aid their development.[27]
In art therapy, digital art therapy is a new method in which clients use digital media to express themselves creatively. Art therapy with digital media has become an important experience that offers young people with intellectual disabilities, who have difficulties with expression and communication and a feeling of lethargy, the opportunity to awaken curiosity, enjoy creative activities, and bring positive emotions to life to express. Therefore, it is believed that a deep understanding of the characteristics of and the differences between traditional and digital media is required and that their complementary use in creating therapeutic goals and art therapy is important.[28]
An interesting study examined aspects of implicit relationships in mothers and adolescents with intellectual disability using an arts-based nonverbal tool, the Joint Painting Procedure (JPP).[29] The results contribute to uncovering and better understanding the relationship dynamics that develop between mothers and adolescents with intellectual disabilities. The JPP has been shown to provide a meaningful, arts-based assessment of the implicit and explicit aspects of relationships developed during interactions. Because of the verbal barrier, it is challenging to know the inner world of adolescents with intellectual disabilities in general and their experiences related to their relationship with their mothers. This study used an arts-based method to learn more about the relationship between adolescents and their mothers. The engagement and accessibility of arts activities for this population is a key strength of the JPP, as other arts-based research with adolescents and young people with intellectual disabilities has found. It offers direct access to the life experiences of these young people in the context of the relationship dynamics with their mothers. The results suggest the presence of a number of emotional characteristics in the relationships of adolescents with intellectual disability with their mothers that are similar to those of typically developing adolescents. This also shows that these hidden expressions can be changed and transformed during the painting process.
The influence of artistic activities on the parent-child relationship in cases of intellectual disability,
From dependence to autonomy
Painting together as a means of verbal communication
A sense of playfulness and joy
In 2015, Hui, Chow, Chan, Chui, and Sam in China conducted two studies on classrooms and creativity in Hong Kong. The study directly addresses the issue of well-being, as the authors note that academic success in an Asian school leaves no room for happiness; Rather, learning is “serious work.” They consider that the most effective creative wellness courses are based on active participation in artistic activities such as visual art or theatre. The final observation one can make is that most training programs analyzed report that positive emotions are the central outcome of their programs.[30]
Music, sound, movement, and dance: creative activities for young children. Young children generally enjoy singing. They like repetitive songs and simple melodies. They can make up their own lyrics to famous songs, and the lyrics often come from events and people around them. Singing helps children understand the difference between fast and slow, long and short, high and low, loud and quiet. Children will be able to invent activities and dance steps to the sounds of music. Movement with music is also useful for releasing energy and emotions. For example, we often see children jumping for joy or stamping their feet in anger.
These are some ideas that can encourage children to sing, dance, and move creatively:
Fly like a butterfly, crawl like a caterpillar, or jump like a frog
Build homemade instruments. For example, a drum set can consist of a pot, a lid, and a wooden spoon
Reports noises in a regular rhythm, for example, the ticking of a clock or a leaking faucet
Encourage the child to clap, tap, march, or beat to the beat
Watch short videos of animals making sounds and moving in nature. A child can make the drum sound like a stomping elephant and the shaker like a slithering snake. Or if he likes to dance like a monkey
Listen to the musical pieces Peter and the Wolf or The Carnival of the Animals, or similar songs in any Indian languages in which the sounds of different instruments represent different animals. Guess which animal the music represents and try to imitate their sounds
Sing songs, chants, and nursery rhymes such as “Incy Wincy Spider,” “Head and Shoulders,” “Frère Jacques,” or “The Wanky Donkey”
Thus, it can be said that arts education has a positive and significant impact on the psychological well-being of children. In addition, research also suggests that creativity and self-esteem positively and significantly influence the relationship between arts education and psychological well-being.[31]
Creative activities for preschool goers with diverse abilities.
Creative arts therapies have been proven to improve the behavior, mental well-being, and functioning of people with intellectual disabilities. Playing an instrument, acting a role, creating an image, moving freely, or combining creative media can offer a person a different way of being. This can stimulate new behaviors, skills, expressions, and emotions, which can then be transferred into everyday life. The multisensory nature of creative art therapy can promote sensory regulation and support psychomotor development. For children and adults with severe and multiple learning difficulties or complex needs, creative art therapies can work on the sensory level, connecting to the body and stimulating the senses. Self-image arises through exploration and creativity. Mothers of children with intellectual disabilities are heavily burdened with care work, and the children themselves have difficulty dealing with their emotions. Creativity can then become a tool to express their concealed emotions.[32]
Some examples of activity modifications for children with disabilities
Needs help developing creative play skills. The parent/teacher can model simple activities, such as – Showing the child how to growl like a monster, playing the drum, breaking the activity down into simpler steps, or using written or illustrated instructions to help the child understand what to do
Sensory sensitivity, give the child tools for touching objects like play dough, playing music more gently, or slowly introducing different textures and colors
Visual impairment or motor problems, use larger materials and tools – for example, create collages with large leaves instead of flower petals, or use thick pens instead of pencils
Having a lot of energy encourages larger movements such as jumping, swinging, grabbing, squatting, or shaking
Has limited mobility. Gather play materials for the child and place them within easy reach
Examples of art activities to improve bonding in mother-child with special needs dyads
► Mirror each other's movement
► Create costumes using art materials for a party
► Relieve stress through drumming, moving and drawing
► Play movement charades
► Draw on the same paper or move together
► Create a gift box for each other
► Create a “Thank you” card
► Create artwork and movement together and share
Instructions that can be shared with the child before starting the activity
There is no right or wrong way to make art in art activity
Child has permission to “screw it up”
He or she does not need to make art pretty, precise, or even understand (In fact, more interesting things sometimes arise from the strangest or ugliest pieces!)
The goal of using the arts and visual materials is not necessarily to create something you would display (although you might)
The purpose of art is to tap into different parts of the brain using imagination, metaphor, and images to gain new perspectives and solve problems in new ways.
We can certainly also create something beautiful as part of an art activity, but it is not the only way to work.
The study, as part of the nationally-representative National Study of Child Development, examined whether creativity, like participating in activities such as free writing, storytelling, crafts, painting, drawing, or acting at age 7, is associated with a lower risk of social maladjustment and behavior in children in early adolescence. Data from 7,558 7-year-olds who were socially and behaviorally “stable” at baseline were analyzed. Associations have been found between moderate and high creativity and a lower risk of symptoms of internalizing behavior (including depression and withdrawal), externalizing behavior (such as fidgetiness and anxiety), as well as a lower risk of social and behavioral instability. The associations were independent of social, demographic, educational, parental, academic, and personality covariates and robust to a range of sensitivity analyses.[33]
Thus, it can be agreed that encouraging creativity through various ways in children and adolescents can have a multitude of benefits for mental health and well-being in childhood, which can further be of preventive value in future life.
Training in creative modalities – Mental health issues.
All over India, we come across children attending training for various art forms. The benefits of these classes have not been studied through systematic research. However, our experience says that these classes do serve some useful purposes from a developmental viewpoint.
Benefits from arts training classes for children
Child has exposure to a different peer group at times of different age groups, other than his/her usual peer group, for example, schoolmates
Group singing, dancing, and drama slowly make children more confident and or comfortable in expressing themselves
A variety of cognitive skills – sequential memory, multitasking, attention and concentration etc., improve
Through drawing and painting, drama, and dance, child gain a medium to express negative emotions like aggression, anger, etc., expressions of which are usually not always socially accepted or encouraged
The process of engaging in an art form also allows in coping and managing negative emotions
We suggest the following strategies to cross these hurdles:
The school curriculum itself needs to have stronger and more focused art-based programs.
The children who show a good orientation, enjoyment, and interest can be referred for specialized training outside school hours.
The parents, wherever possible, need to join art-based training classes themselves which will lessen the pressure on the child.
Psychiatrists should conduct art teacher education sessions in schools and art institutes drawing their attention towards the positive learning experiences in the training environment in art classes.
The parents need to be educated through schools about the benefits of arts as a tool for resilience and mental health promotion in children.
They should be made aware of the fact that despite not achieving to be an expert artist, children can still have a multitude of health benefits from learning any of the art forms. It should not be thought of as a waste of time, money, and energy.
The role of creative pursuits in the mental health and well-being of young adults:
Participation in creative activities that are deemed enjoyable can create opportunities for young people to be exposed to positive role models and peers. Developing positive social and personal skills such as confidence, a sense of belonging, coping skills, and self-regulation is pivotal for a young person's well-being. Young people may be able to develop these skills in spaces where they feel physically safe and emotionally supported. This, coupled with consistent structure and boundaries, supportive adult relationships, and opportunities for mastery, can contribute to their enhanced well-being.
A gang, is loosely defined as a group of persons, usually youths, who share a common sense of identity and who generally engage in criminal behavior. With a lack of positive role models and social instability, children and youths from socially deprived backgrounds are vulnerable to seeking a sense of belonging and or identification through gangs. However, even children who come from homes that enforce positive values and norms can be at risk of joining gangs as they encounter different standards of behavior in their friends' homes or other community settings. While parents are the main socializing agents of children when they are young, as they grow older, their peers become increasingly influential.
Difficulties in art training classes that might pose a threat to the mental health of a child
Parental expectations (explicit or perceived) for the child to be proficient in the art form, excel in exams, or generally perform on stage can put psychological pressure on the child. This focus on the “product” does not offer the psychological benefits offered by focusing on the “process” of creating art.
Similarly, comparison within a learning group of an art form, from teachers or parents, has a similar disadvantage where the focus shifts to the art product rather than the process.
Training in art should be an opportunity not only to learn a new skill, but an opportunity to offer some joy and enrichment to the child. If the process of learning art involves undue pressure on the child's time, leaves the child tired and not adequately rested, or leaves the family in financial stress, it defeats the purpose.
The arts training in any art form usually involves lessons in basics, and this can be quite a tedious process. Children and parents can both perceive this as boring, contrary to their expectations of art form. Thus, children and parents might get discouraged early. It is important to be mindful and sensitive around the child's strengths and aptitudes and make the initiative worthwhile.
While we hope the process of training in art offers an alternative peer group that might broaden the social horizon for the child, it can come with the challenges of another learning microsystem, involving the risk of favoritism from art teacher or negative peer relationships or bullying which would have a negative effect on the child's psyche.
Young people may be less likely to become involved in gangs if they have good relationships with their parents and family members and are able to openly discuss their problems with them. Further, as friends play a critical role at this stage of development, spending time with a prosocial peer group may also protect against joining a gang. Cultural activities like group music, dance, and drama can provide an opportunity for positive and prosocial peer groups.
Well-being Benefits Adolescents and Young Adults Participating in Arts-based Activities:
Opportunity to develop and master new skills
Improvements in one's confidence, self-esteem, and self-efficacy
A platform for creative expression
An avenue to express emotions
Creates a space for social interaction
A chance to develop positive relationships with others
Engage with peers from different backgrounds and potentially broaden their social circle
Challenge existing thoughts and ideas and make new friends
It can lead to a sense of purpose and belonging
Can provide a safe space for young people to participate in constructive activity with their peers while being supervised by positive role models
Provide an alternative way to engage in a healthier lifestyle
Better acceptance of their body image
Research conducted at a variety of performing arts programs yielded similar findings with regard to the benefits of participation in creative arts. Adolescent girls participating in a performing arts program in New Zealand reported high levels of positive emotions, enthusiasm, pride, and being able to “be themselves.”[34] Another study aimed to explore the lived experiences of four young people engaging in a dance community project. Engaging in dance appears to contribute to the overall emotional well-being of these participants. Having a safe space to engage in a prosocial activity offers an alternative to the negative behaviors, including drugs, violence, and gangsterism, that they are confronted within their community. Researchers opined that dance programs and other recreational facilities have a potentially important role to play in the promotion of well-being, particularly in places that have limited access to resources.[35]
Art interventions have been shown to have a positive impact on children and adolescent's ability to cope with and recover from anxiety related to environmental change. Applied theatre, in particular, has been proven to help young people develop “creative resilience” and “ hope” and encourages young people to take social and political action in response to the changes around them. The original intent of this project was to work with grassroots professionals and established youth theatres to explore how drama can strengthen the well-being and empowerment of children and young people, both through direct approaches to disaster recovery and through coping with environmental anxiety and ecological pain experienced at a social level. The study conducted during the pandemic drew its data from online interviews with 12 youth theatre professionals. They found that there is a trend towards “resilience and survival” among young people in response to disasters and the climate crisis, for which the fine arts can act as a vehicle of change. Authors argued that youth art and performance are fighting for their survival and that the potential of professionals to support young people in this work is increasingly threatened.[36]
Caution needs to be exercised while advocating art activities for adolescents and young adults. It is advisable that the art activities involve proper guidance or supervision by a guide who is nonjudgemental but at the same time is firm and facilitates creativity in the right channel. A review found evidence that arts interventions can have negative outcomes; lower anxiety was found in a control group than those in a drama workshop intervention group. In a study of the effect of listening to rap music on college students, among other findings, a higher likelihood of thinking about engaging in sexual activity, drinking alcohol, and marijuana use when listening to rap music than when listening to most other types of music.[37]
Some of the benefits of engaging in creative pursuits lie in the creative act, while others lie in the social milieu of the creative activity. It is difficult to argue that creative pursuit can be harmful. However, the environment and peer relationship needs to be appropriate for maximum benefit. Hence, while advocating creative pursuits as a health modality for young adults, one needs to be mindful of the environment and setting of such creative pursuits.
Creative Pursuits and Adults
Maintaining mental well-being can be challenging in today's world. Therefore, there is a constant search for effective tools to maintain mental health. A recent study identified and examined the ways in which the arts have been used to improve the well-being of communities in the United States.[38] The review examined 44 publications with combined study populations, representing a total of 5,080 studies and participants, including marginalized populations. It highlights positive associations found across a wide range of psychological, physical, and social outcomes, including improved self-esteem and formation of identity, cognitive function, physical balance, and fitness. This overview shows that art comes in a variety of forms (e.g. music, dance, and theater), and forms of participation (e.g. active, open, or both) can contribute positively to the individual as well as communal or group well-being. It has been seen for many years that participatory arts projects make a significant contribution to the health and well-being of local communities, only for the positive results to diminish as funding for short-term projects dries up. At the same time, there is growing evidence on behalf of arts and health organizations that creativity and art have a significant impact on people's health and well-being, their emotions, and their interactions within themselves and their neighbors.[39] The research shows how arts and health professionals can learn from each other and work more effectively with local communities. The findings based on qualitative research evaluating the innovative and large-scale ‘Be Creative Be Well’ initiative (part of the wider Well London programme), which has produced around 100 different small-scale participatory arts projects across 20 of London's most disadvantaged people, confirms this.
Public places where clinicians can advise arts to be used
Primary and High schools
Medical and psychiatric wards
Outpatient units
Prisons
Rehabilitation settings
Private clinics
Public transport hubs such as railway or bus stations, airports, subways etc.
Key features in the advocacy of community arts initiatives
A belief in providing opportunities for individuals and communities
Inclusiveness
Forging links with community settings
Promoting innovation and participation
Facilitating access to creativity for people with disabilities
Potentially providing the means for the resulting creative products to reach a wider audience
Clinicians can highlight the results of this research by encouraging people to engage in creative activities in daily life or in specific circumstances
Participate in art therapy. No artistic skills or special talent are required to participate in art therapy.
People of all ages can benefit, including children, teenagers and adults.
Research suggests that the mere presence of art can play a role in improving mental health.
Research has shown that artwork displayed in hospitals helps create an environment in which patients feel safe.
Art plays a role in promoting socialization and maintaining identity outside of the hospital.
This is not the same as art/dance/music classes.
While art classes focus on teaching a technique or creating a specific finished product, art therapy focuses more on allowing clients to focus on their own inner experiences and the process of creating art.
When creating art, people can focus on their own observations, ideas, and feelings.
Participants in art therapy are encouraged to create works of art/dance/music/theatre that express their inner world rather than creating something that is an expression of the outside world.
Receptive Music/dance/drama activities – Here participants listen to music/watch dance, drama, and paintings, rather than producing it. Distinctions between these differences between active and receptive interventions vary and comparative studies that isolated specific components of musical engagement have yet to be conducted.
The distinction between active and receptive interventions varies, and no comparative studies have been conducted to isolate specific components of musical engagement. An interesting study examined the connections between musical behavior, lifestyle, and mental states while staying in a shelter during the COVID-19 pandemic. An online survey examined music experiences, lifestyle changes, stress levels, music behavior, media use, and perception of noise in the environment. Responses were collected from 620 people in 24 countries, with a large percentage of responses coming coming from United states (55%) and India (21.4%). Structural equation modeling (SEM) analysis revealed a causal relationship between lifestyle, stress, and music behavior. Things like changes in stress levels, occupational hazards, and staying at home contribute to changes in the music experience, e.g., relieving emotions through music, feeling emotions through music, and tuning in more. Changes in stress levels were related to changes in occupational risks and income, and people who began living with other people, especially children, due to the epidemic showed fewer changes in their stress levels. People whose stress levels varied more were more likely to use music more specifically to support their mental well-being, such as calming emotions, influencing mood, and relaxing.[40]
Suggested list of receptive art activities
Listening alone to pre-recorded music
Watching live dance with pre-recorded music
Watching drama/movie
Watching dance videos/live movements of a dancer
Viewing visual art such as paintings, sculptures, or art installations
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Museum visits
Reflection and discussion on what was viewed/heard would bring larger benefits.
Suggested list of active Art activities
Music activities that involve interactive engagement, playing, and creation of music with an instructor
Dance activities are where the person mirrors the movements of the instructor, leads the group with his/her movements, and communicates through his/her movements.
Drama based on theme/role play/answering questions such as “What if?”, “I like”/“I dislike”
Engaging in the creation of visual or structural art ranging from doodling, drawing, painting, sculpturing, or other expression of art forms.
Craft activities, e.g., knitting, pottery, etc.
Receptive art activities
Advantages
Any art form can be chosen
Participants can be easily engaged
Multiple forms can be tried
Participants can participate despite physical/psychological disability
More suitable for the geriatric age group
Disadvantages
Efficacy lower than active forms
Sustained engagement is difficult
Participants may grow bored easily
For instance, if one is battling a significant conflict, like a hateful relationship with wife, the instructor might draw upon a sequence where the husband needs to be in the shoes of his wife and say things from her perspective. Drama can be used at its best in groups, where each member is assigned a particular role. As one rehearses ways to express oneself, either by letting out one's emotions through effective storytelling or using tools to depict things, one gradually picks up the art of looking at one's own problems as well as any problem using a new pair of eyes.
Art instructor training programs focusing on mental health.
There are several arts or creative pursuit-based therapeutic interventions recognized and researched across the world, ranging from art therapists, dance and movement therapists, music therapists, and drama therapists. The list is not exhaustive. Across the world, these have evolved and continue to develop. In India, we are still in the infancy. These therapeutic interventions are not routinely incorporated within our mainstream mental health treatment facilities. The professions themselves do not have large-scale training or accreditation programs. While work continues to embed learning and up-skilling for the future, we might need to think creatively for the more immediate future, where we do not have these therapies embedded or professionals available. We might need to think of the skill set in the room to facilitate the delivery of the benefit of creating art. The art teaching schools are numerous and often can be found in the smallest of the cities and even rural areas. However, many a time, the art teaching is performed in a traditional way of perfecting the art form. Hence, it might be far from the goal of “feeling happy.” The sole goal can be focused on “achieving.” Though this might be desirable from the learning point of view and for naturally talented people who want to pursue art as a career, for the larger group, this may not be necessary.
It would be useful to conduct regular, for example, once-in-a-year workshops from professional bodies of psychiatrists, clinical psychologists, or mental health professionals to conduct training programs for art teachers with particular relevance to the role of arts in mental health and well-being. These programs can bring forth a careful discussion on how traditional art teaching can be modified, albeit partially to encourage people to attend classes, performances, or training for more modern or innovative art forms that can be delivered with the goal of nurturing mental well-being and or healing.
Active art activities
Advantages
More efficacious as compared to receptive art activities
Better communication through active participation of the client
A person can express his feelings through the active means of arts
Better emotional regulation through artwork (dance/music/painting/drama)
Disadvantages
Participants may be hesitant to try a new activity in which they are not trained
Participants may be bothered about making mistakes/awkward movements/their voice quality
May pose high resistance
Usually, a combination of art forms in an active way is difficult to practice.
Sample 1. Art sessions based on facial expressions
(Can be shared with a dance/drama artist for any group of interested individuals)
Phase 1 – viewing eight basic emotions- Rasas in Indian aesthetics.
The instructor brings out Sringara (love), Veera (Valour), Karuna (Sadness/mercy), Adbhuta (Wonder), Hasya (Humour), Bhayanaka (fear), Bheebatsya (Disgust), Roudra (Anger) through her expertise.
Phase 2 – group members are asked to identify the type of emotion. Each member is asked to remember any story related to that particular type of emotion. Slowly, they can be asked to narrate any incident where they felt a particular type of emotion
Phase 3 – Group members are invited to remember the incident and asked to enact the emotion.
Phase 4 – Members can verbally share their feedback. The instructor speaks about the importance of expressing emotions in managing mental health.
Co-delivered workshops run in collaboration between mental health professionals and the teacher of art might be another alternative approach to ensure there is the right skill set in the room to deliver the mental health benefits of creating artwork.
Activity sessions based on mudras – gestures in Indian classical dance
Instructors can work in a variety of ways with gestures.
To begin with, recite and show 28 single-handed gestures – Asamyutha hasthas and 24 double-handed gestures. The group needs to watch.
Idea is to create an interest and curiosity.
Then hold the first-hand pataka – with the palm extending all fingers and holding straight.
Ask the group to imitate.
Ask, “What all can be communicated through this gesture?”
Generate answers. Extend it to a movement. Connect it to meaningful communication.
Similarly, for other gestures.
Do remember throughout that the idea is to achieve a better expression and communication of feelings and body movement and not to learn all gestures according to text like in traditional artistic teaching.
Drama techniques that can help emotional regulation
Situational enactments
Role-playing
Improvisations
Puppetry
Storytelling
Theatre games
Tools to measure creative aptitude, creative attitudes, and benefits from creative experience.
Measuring creativity, as agreed by global research till now is a difficult task. Nonetheless, it is important in many aspects. An extensive discussion on measuring creativity at different instruments available is outside the scope of this guideline. However, the following are noteworthy from the focus of this paper.
Though children and adults need to be encouraged to learn any art form they like and engage in any form of creative activity, assessment of creative aptitude can help one be persistent with a particular activity and can have increased benefits.
The assessment can happen over a range of different domains related to creativity, such as divergent thinking, humor, aesthetic experience, imagination, innovation, type of activity, and creative achievement.
Structured instruments cannot only aid the researcher in assessing how beneficial the activity can be for the user but also help one understand whether the user is enjoying the creative activity.
As mentioned, art or creativity can be used for a range of purposes but are broadly grouped as when used for health promotion or psychosocial well-being or when more specifically used for the management or treatment of mental health or physical health conditions. Art-based therapies offer benefits for a wide variety of settings, including both physical ailments and mental illnesses alike. It is important to bear in mind, especially when assessing the impact of art and creativity as a treatment intervention, that if one takes a narrow disease or symptom-focused approach, we might not be able to capture some of the benefits art and creativity offer. Art-based therapies can be used for the enhancement of mental well-being and are not limited to the treatment of specific diseases. We recommend self-reported quality of life or recovery-based scales instead. There are scales and self-reported questionnaires standardized in more than one language, which are freely available for public and academic use on the web.[41,42,43,44] When using a clinician-rated scale, global impression scales would be an alternative, for example, the Clinical Global Impressionn (CGI).[45,46] Interested readers can refer to these websites. To the best of our knowledge no scales to assess creativity developed in Indian languages are available currently.
Art activities keep in focus women's mental health and well-being.
Women's mental health in India has many social dimensions, such as domestic violence, teenage pregnancy, gender discrimination, and legal barriers to abortion, which may pose serious challenges to mental health. Gender is considered an important factor in mental health and mental illness. Modern women may have conflicting views about the patriarchal belief system, orthodox code of conduct for women, marriage deemed as necessary, especially for women, practice of dowry, submissive attitude of daughter-in-law in the house, and preference for a male child. Women's main occupations include motherhood, raising children, cooking, and housework. These factors have a significant impact on the prevalence, symptoms, treatment, and outcomes of mental disorders among Indian women. Therefore, women's mental health needs to be understood from the perspective of reproductive health, psychopharmacology, psychosocial determinants of mental health, and legal issues.
Creative tasks can have a particularly positive impact on women's quality of life. Numerous studies confirm this power of creative art forms. One such study examined the effects of drama-focused therapy on improving self-esteem, quality of life, communication skills, and meaning in life while reducing symptoms of post-traumatic stress disorder (PTSD), depression and anxiety, and gender stereotypes in women who have faced Intimate partner violence.[47] The program combined elements of theatre, psychodrama, and theatre of the oppressed. The authors found a statistically significant reduction in depressive symptoms and gender stereotypes. They also observed an increase in these women's meaning in life, reporting that they value their lives more and find more reasons to live. They were also more likely to see positive meaning in some aspects of their daily lives. As part of another project, the Australia Council commissioned the study Australians and the Arts: “What do the Arts mean to Australians?” More than 1,200 participants took part in the study. Women, girls, and people from non-English speaking backgrounds were found to have significantly more positive attitudes towards art than men and boys. About 80% of respondents said they “feel good when I express myself creatively,” 66% agreed that “art is good for my inner self,” and 66% love being an artist. Art was also valued for its contribution to national identity and for other intellectual, social, and emotional benefits.[48,49]
Ways to find time to include a hobby in working women
➢ Remember to include some creative activity in your routine
➢ Organize a club in the office and try small programs for different occasions
➢ Maintain your stability in other's comment
➢ Utilize travel time to listen to songs/watch short dramas and try to reflect on how you felt and spent that time meaningfully.
Use of art activities to promote well-being in the elderly and people with dementia
Current research shows promising results in using artistic interventions to promote well-being and extended lifespan with improved quality of life in the geriatric population. Nowadays, it is common for older people reaching retirement age to return to pursuing interests that they were previously unable to do due to their commitments/work/lack of time. In this section, we will review some of the evidence and practical aspects of using arts interventions with older adults.
The elderly population often complain of decreased sleep. There has been a study that looked at the effect of music in intensive care unit (ICU)-admitted elderly patients. The causes of sleep disorders can be an underlying illness, unpleasant treatment, psychological stress, or the intensive care environment itself. Non-pharmacological interventions such as noise reduction, music therapy, alternative and complementary therapies, and social support were studied and recommended to improve sleep in seriously ill elderly people.[50] The geriatric population thus can be asked to utilize art activities to aid them with improved sleep.
In dementia, art therapy has been used successfully to increase a sense of well-being. Dementia is described as a decline in the ability to remember, think, and perform other cognitive functions. More than 55 million people worldwide suffer from dementia, and approximately 10 million new cases of the disease are diagnosed each year. Art therapy, dance or movement therapy, music therapy, and reminiscence therapy have been studied as non-pharmacologic treatments for Alzheimer's disease. Studies have shown multidisciplinary cognitive rehabilitation in patients with mild Alzheimer's disease to be useful.[51,52]
Components of positive mindset changes seen in women who attend art activities
Set firm goals in life
Feel way less isolated
Self analyze
Relate and respond positively to relationships
Manage aggression
Harness their creativity
Address the root cause of their issues faster
Can distract themselves during stressful situations
Rediscover their self-esteem
Psychological barriers for women wanting to participate in artistic activities
I am not good enough
I was never good at art at school
I cannot do anything with my hands
I was not an artistic child
I am not an artistic person
I have no artistic expression within me
I do not think I am creative because I use a plan
I have not attended art classes earlier
Ways to overcome barriers to pursue art activities in homemakers
Keep a fixed time for the activity
Focus on enjoying the activity rather than fixing a goal
Short-term goals like learning a few lines of a song in 1 week can be rewarding at the same time enjoyable too
Select a time of the day when you are not disturbed
Share the importance of your activity to your quality of life, in keeping you happy with your family members.
Join a class which can become a social activity too.
Try to take part in small performances/shows which can boost your self-esteem
Be persistent in pursuing this activity. Use diplomacy while convincing family members to allow you to take up the activity regularly
You can change the type of activity to see which suits you the best
Find an activity that is easy to pursue, less expensive, and one that you enjoy
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Wherever possible, when you take children for their art classes, try joining the same class, which can have multiple benefits
Saving time,
What difficulties your child can face,
How you can help her/him
Reduced cost of travel,
Less pressure on child,
Increased motivation for the child
A sense of feeling young by learning with your child
One form of cognitive rehabilitation was art therapy. People used memory training, computer-assisted mental stimulation, expressive activities (drawing, verbal expression, writing), physiotherapy, and physical training. Improvement was recorded. Participation in arts interventions, including dance, expressive writing, music, theatre, and visual arts, has been studied for its therapeutic and psychological effects. In their study, Richards et al.[53] presented the intervention group with art therapy exercises for one and a half hours. Activities included hat decorating, collage, embossing, painting, ceramics, photography, and printmaking. Each week, participants developed an art product based on the instructions. Art therapy has been shown to increase self-esteem by strengthening emotions related to self-esteem or competence. Finally, after the two-month course, participants continued to create artwork themselves, resulting in a greater sense of accomplishment and self-esteem.
Caregiving and Creative Pursuits
Caregiving is an inevitable challenge faced across the world with a large aging population. In India, we have moved away from a joint family system where caregiving would have been easier to a nuclear family system wherein caregiving is perceived by both the caregiver and the person who is suffering as a huge burden. The caregiver issues are seriously neglected by society, and this neglect, in turn, can hamper the process of caregiving.[54] There is a recent wealth of data on the usage of art interventions in caregivers, dyads of caregivers, and elderly people with mental health issues. Let us look at some of them.
The review by Irons JY et al. looked at 516 studies and came to some notable conclusions.[52] The qualitative synthesis revealed that the interventions provided nurses with the opportunity to understand, accept, and adapt to their identity as carers. Caregivers viewed personal development, such as learning new skills, positively, valued the opportunity to learn cognitive and behavioral skills, and the opportunity to express their feelings in a safe space was important to them. Creative Group interventions were particularly helpful in building social connections with caregivers and other caregivers. The current review identified all creative interventions focused on dementia carers. This, in turn, identified evidence gaps regarding creative interventions for informal caregivers with other neurological conditions. There are encouraging preliminary data on music and art interventions but little data on other art forms, such as theatre and dance. Creative interventions can be useful to many caregivers and provide a range of psychosocial benefits. The results can be encouraging to pave the way for future research aimed at developing appropriate and creative arts programs and testing their effectiveness using robust tools.
The study by Pienaar et al. used interpretive phenomenological analysis to examine the importance of participating in a 5-week arts and crafts program for caregivers of people with dementia. Eight caregivers participated in the study, and four who met the eligibility criteria agreed to be interviewed. Participants felt that the arts group provided a sense of freedom and calm, strengthened identity by promoting success, provided social support through a collective focus on arts and crafts, and increased resilience to caregiving. Some found the 5-week program to be too short. The benefits were related to the security of knowing that loved ones with dementia are close to them and well cared for.[54]
Identified benefits for elders and caregivers
Creative arts are unique, fun and encourage expression
A feeling of accomplishment
Meaningful connection and support between informal carers
Find common ground and overcome isolation
Positive impact on dyadic relationships
The carer is seen in a new light as the person to be cared for
Roles are forgotten, and the feeling of equality is rediscovered
Caregiver respite
Take a walk.
Work in the garden.
Find a class, in-person or online
Break the exercise up into manageable time frames. Seek and accept the support of others
Practice pleasant and nurturing activities that bring you joy (Reading a good book/Playing an instrument/Pursuing an old hobby)
Important considerations on the benefits of art participation for older adults
Art contributes to the communication
Develop a sense of identity preservation
Strengthen social networks in communities
Art helps create age-friendly communities in which older people can thrive and function
Improved quality of life for both the carer and the elder
Family members seeing older relatives perform also often inspired to do something they have not performed before, such as attending more arts performances or taking up an artistic discipline of their own. Creative arts programs create a bond between older adults and caregivers in long-term care facilities. Staff may then see their jobs as a mission to take care of people, not just as employment. The intent of arts and aging programs is to accomplish one or more outcome goals for older adults—all aimed at enhancing quality of life. Community involvement and a support network—are particularly important for older adults, and they are two areas in which the arts have a significant impact. Mastery is less important for people with dementia, for whom learning a new technique or topic may be difficult. Concentric circles of influence spread out from the participants to affect family members, professional caregivers, staff, and members of the public. Adult learning, which builds instruction around the experiences, interests, and goals of adults — is the educational philosophy that underlies effective arts and aging programs for cognitively fit older adults.
Time Slips—a one-session program—uses storytelling to invite contributions from all participants.
(Adapted from art and aging tool kit[55])
Facilitators greet participants individually and then show the assembled “storytellers” whimsical, dramatic, provocative photographs.
Using open-ended questions, they elicit responses to the images that create a story, which is re-read after every four or five answers to establish momentum and remind the storytellers of what they have created.
The telling format involves crediting individuals for their contributions as the tale builds. Non-narrative logic may be necessary to express the participants' humor, desires, and sometimes sadness.
Facilitators record the story to share with staff and families.
Activity sample for caregivers and elderly people
Movement warm-up
Group storytelling
Sharing selected stories with the broader community
Start with the familiar and move into the unknown
Place music or singing first and progress to activities that feature writing or dance. When selecting topics for storytelling, writing, or movement, build trust by guiding newly formed groups in exploring less personal
A trust-building exercise might be designed like this
Each elder presents the person to his or her right with an imaginary gift that the giver thinks the recipient would like to receive — an object, an idea, or an emotion
The giver should know exactly what the gift is and try to present it as if it were real, not imaginary
After presenting the gift, the giver explains what it is. The recipient feels accepted, confident, and happy
Yamaha's Clavinova Connection sequence of activities for each session[55]:
Arrival song — Played while the facilitator welcomes participants
Warm-up — Music, movement, imagery, and awareness
Drum circle — Each keyboard simulates a drum kit
Improvisation — Pentatonicbased exercises performed with dynamic soundscapes
Music insight — A discussion of musical concepts
Song of the day — Group and individual playing of a designated song to condition a sense of fulfillment, enthusiasm, and personal accomplishment
Mind-body wellness — A Clavinova cool-down that repeats the initial exercise
Reflection — A group discussion focused on awareness and progress
Farewell song — To inspire a light-hearted spirit in anticipation of the next class or join in on the chorus
Reminiscence – Reminiscence helps older adults make sense of and reconcile life experiences. Maintaining self-esteem; reinforcing personal and collective identity; resolving grief. Helping to assuage the anxiety of physical and mental decline. It is known to stimulate memory function and socialization.[56] It can be just plain fun for older adults as they recall pleasurable experiences and perhaps even find solace in sharing painful ones. Reminiscence is pertinent to older adults with dementia, even if they cannot always connect their words or images to the past.
Visual art is a communication tool with which they can tell facilitators, family, and staff about who they are and what they have experienced in life. While reminiscence works well for people in the early stages of dementia who are trying to hang on to memories, it may be too frustrating for those in the middle to late stages of the disease.[57]
Themes that may stimulate participants' memory include:
Work we have loved,
Places these feet have walked
Games these hands played
Your favorite vacation,
Unexpected moments of surprise,
Moments of love, moments of support.
Senses—sight, touch, hearing, taste, and smell—may invoke memory
Using fabrics, herbs, photographs, or music.
The role of art activities in psychoeducation.
Another important area that needs to be explored is the role of creative art forms in mental health awareness and psychoeducation. We also need to create awareness of promoting mental health through fine arts and creativity. The attention of our clientele/general public needs to be drawn to the role of creativity in fostering a sense of well-being and in lifestyle modification.
According to WHO, mental health promotion involves creating an environment that promotes healthy living and encourages people to adopt a healthy lifestyle.[56] Enabling national mental health policies and legal frameworks is essential to effectively manage mental health disorders and provide comprehensive guidance to ensure mental health promotion. This requires a multi-sectoral commitment and a life course approach.[58]
A study in Kerala[59] demonstrated how theatre, storytelling, and film-based platforms can be used as tools to improve mental health literacy. The project showed that theoretically, existing knowledge of theatre has the potential to help both the actors and audience by providing information about mental illness, challenging stereotypes, reducing stigma, decreasing the sense of isolation, providing role models, and instilling hope can be implemented practically. As in the Kerala study, we have found that classical dance, music, and poetry could be used effectively for mental health literacy.
On the Edge is a mental health education program designed to support early intervention by increasing knowledge and understanding of early psychosis, reducing the stigma associated with mental health issues, and improving awareness of avenues of help.[60] The target audience was young people aged 14–22 years in schools and colleges. An interactive drama program was developed through collaborative working across psychiatry, applied drama, and those with direct experience of psychosis. The project engaged 2500 students in 71 performances that took place in 51 schools and colleges. The quantitative and qualitative evaluations found significant gains. Thirty-one schools developed supportive links with local mental health services. This program shows the value and effectiveness of delivering health education on early psychosis through the medium of applied drama, and offers a model for a program that can be incorporated into early intervention services. Qualitative data showed that students believed mental health was an important subject that, despite their personal experience, was rarely dealt within schools.
These programs stand out as different awareness programs compared to routine speeches, talks, or other health programs. It might be seen that General public/schools/colleges are initially hesitant to organize this program for two important reasons. One, they want a straightforward mental health issue – most likely stress management/academic issues/parenting skills; Two, they are scared about the cost of the program. This barrier can be overcome by a careful discussion using advocacy skills, cost reduction techniques, and partnering with key stakeholders. It has been said that given the failure of most previous strategies to improve mental health in developing countries over the past 60 years, it is time to take a new approach with renewed vigor. It is important while designing any community awareness programmes with special relevance to mental health issues. The role of fine arts with an entertainment value offers an important advantage since entertainment is often viewed as universally enjoyable.
Try this approach to reminiscence:
Ask each participant to shake hands with a partner whom they do not know well, and take the time to notice each other's hand:
Are there any rings? Is the hand smooth or rough?
Ask questions about your partner's hand:
What kind of work have these hands done? Where did that ring come from?
Bring the group back together and ask each person to describe how his or her hand feels and any difference in sensation before and after the exercise.
Ask each person to share one story about his or her partner
Review the stories for familiar themes and record them for future use
Instructions for facilitators
Minimize distractions, especially if the participants have dementia.
Allow for ample spacing between chairs.
Ensure that participants feel connected to the group and not cramped.
Make metal folding chairs more comfortable by supplying inexpensive foam cushions.
Monitor the room temperature, watch for signs of discomfort, and learn how to control the thermostat.
If participants are too hot or cold, they will not focus.
Monitor the acoustics and minimize unnecessary noise, but do not limit conversation.
Participants, particularly those with hearing aids that often amplify background noise, are distracted by sounds that echo around a space without any fabric, padding, or carpet.
Position participants who have difficulty hearing and seeing at the front of the group or in a place with a good sight line to the conductor, director, or teaching artist.
Use a portable public address (PA) system.
Use as many printed instructions as you can to minimize misunderstanding due to hearing problems.
Practice your best projection and diction when speaking to a group.
Repeat directions. Verbal repetition not only helps with memory but also can make the words clearer.
Enlarge music scripts
Language tips while conducting art activities for senior citizens
Never use the word handicapped; the word is disability.
Never use a disability as an adjective: a writer who is blind, not a blind writer.
Focus on the person, not the disability.
Never use special because this term separates the individual from the group. For example, information is not required regarding the special needs of the group but the needs of the group.
Never use euphemisms, such as physically challenged or handicapable. These terms are condescending.
Never use labels: the disabled, the blind, the deaf, A.B.s (able-bodied), T.A.B.s (temporarily able-bodied), or normal.
When communicating with frail older adults or those with dementia:
Face the person when you speak.
Establish eye contact.
Use hand gestures (point).
Speak distinctly, calmly, and softly.
Use simple sentences.
Allow ample time for answers.
Minimize background noises.
Do not overuse the word no; yes or may be might be adequate.
Sudden, quick, unexpected movements can be frightening.
Let the person know the time of day and where they are, and reiterate what is going on every now and then.
In theatre studies, it was found that theatre can also spark discussion and personal reflection about mental illness, and decrease stigma. At the same time, it can build empathy for people living with mental illness and even encourage activism in others. Sensitization about mental health issues appears possible through the medium of fine arts. Such designs can open dialogues about mental health issues.
Art activities for psychoeducation and mental health awareness
Helpful in demonstrating the symptoms of mental illnesses
Can depict how mental health issues might happen to anyone
Can give information on what to do and where to turn when it happens more effectively
Reduce stigma
Enhance awareness of help and support
Important components of the art activities for psychoeducation programs
The realism of the creative play/activity
The quality of the acting/portrayal
The emotional power of the performance
The sense of safety that the production gave to talking about the issues
The use of different forms of learning to engage students with the message of the program
Creative art forms in psychoeducation
For specific mental health disorders as a group activity, 10 min skits – street plays
Short songs that are tuned in popular filmy tunes
Dance drama based on specific mental health issues
Lecture demonstrations by artists-psychiatrists on different art media about various mental health issues
Key points about public awareness
Push your message about the benefits of art programs through public speaking opportunities.
Understand that everyone can and should advocate.
Develop public awareness goals.
While advocating, ensure that the audience, message, messenger, and method all fit together.
Identify and think strategically about audiences.
Turn existing rationales and arguments into messages.
Enlist participants whenever possible to be your messengers.
Anticipate that your public awareness efforts will be ongoing and that you must be persistent.
Be imaginative and strategic in developing methods.
Sensitize the media.
CONCLUSION
We believe there are advantages to using nonverbal communication in addition to conventional methods of psychotherapy, which is especially important in a multi-linguistic country like India. We often have social workers who have been widely and effectively using art-making in their rehabilitation program for mentally challenged children and in marginalized populations, such as the destitute, people incarcerated in prisons, and underprivileged groups of society. At the same time, we have relatively rich resources comprising trained artists, psychologists, psychiatrists, psychotherapists, and educationists, especially in urban settings. Unfortunately, in spite of having a sizeable skilled workforce, our mental hospitals, Institutes, and clinics do not incorporate art therapy in their model of care. There is a need to form partnerships between this workforce and the institutions to create multi-disciplinary teams. Teams can take an innovative skill-based approach as opposed to a profession-based structure and may consist of partnerships between arts and psychotherapists or social workers. Recourse allocation is critical, and this would involve physical space and material to create artwork along with employing professionals. There is little in the form of formal art therapy training in India. Therefore, unlike other methods of psychotherapy, art therapy is sometimes conducted jointly by a trained artist and a competent psychologist or psychotherapist to ensure there is the right “skill mix” in the room[61]
Thus, our “Take home messages” can be summarized as follows:
Creativity is a unique human attribute that has played a very important role not only in advancing the journey of civilization but also in taking care of the health and mental health needs of people.
Newer technologies are extending great help to humanity but at the same time posing a threat to mental musculatures involved in the creative process by abundance of ease. So, there is a need to engage people, especially younger ones in creative pursuits religiously.
We have substantial evidence for the role of creative pursuits not only in the prevention of mental illness and promotion of mental health but also in therapy and stigma reduction.
We must develop a strategy for the implementation of creative interventions at schools, families, social centers, and health and mental health establishments.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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