CHAPTER 38

The Contribution of the Arts to Flourishing and Health

Rebecca Gordon-Nesbitt and Alan Howarth

Abstract

Between 2015 and 2017 in the United Kingdom, the All-Party Parliamentary Group on Arts, Health and Wellbeing explored the health and well-being impact of participating in creative activity and attending cultural events. This yielded a substantial report, Creative Health: The Arts for Health and Wellbeing, which was launched in the UK Parliament in July 2017. Acknowledging a reciprocal relationship between health and well-being, Creative Health makes the case that engagement with the arts aids human flourishing and relieves pressure on health services. This chapter revisits some of the evidence referenced in Creative Health to consider more closely the relationship between arts engagement, flourishing, and health. It takes as its starting point a conceptual model of the role of the arts in flourishing, proposed by the editors of this volume, which prompts consideration of immersion, embeddedness, socialization, and reflectiveness. This enables the relationship between arts engagement, flourishing, and health to be better elucidated.

Key Words: Parliament, health, well-being, arts, inequalities, flourishing

Background

In 2015 in the United Kingdom, the All-Party Parliamentary Group on Arts, Health and Wellbeing (APPGAHW) initiated an inquiry which comprised a series of expert meetings and sixteen round-table discussions in the Palace of Westminster that brought parliamentarians together with health and social care commissioners, clinicians, people with lived experience of physical and mental health conditions, artists, researchers, and activity providers.¹ These wide-ranging discussions addressed the health and well-being benefits of engaging with the arts (in the broadest sense) at different life stages.

In partnership with King’s College London (KCL), meetings and round-table discussions were combined with reviews of the literature on pertinent policy and evidence, alongside a call for examples of practice. This iterative process gave rise to a substantial report, Creative Health: The Arts for Health and Wellbeing, which was drafted by KCL Research Fellow Rebecca Gordon-Nesbitt (coauthor of this article) and launched in Parliament in July 2017 (All-Party Parliamentary Group on Arts, Health and Wellbeing [APPGAHW], 2017).

Flourishing in Creative Health: Policy and Research

Foresight project teams work with UK government departments to inform policy. In 2008, the Foresight Mental Capital and Wellbeing Project positioned mental well-being on a continuum between flourishing and disorder, noting that many of the people who occupy a position on this continuum and use primary care or other frontline services, “could benefit greatly from having access to interventions to improve their wellbeing” (The Government Office for Science, 2008, p. 61). In 2016, the final report for the Arts and Humanities Research Council Cultural Value Project noted, “The recognition that wellbeing has irreducible dimensions which can be measured [ … ] presented an opportunity for the contribution that arts and culture make to human flourishing to be acknowledged” (Crossick & Kaszynska, 2016, p. 37). Taken together, these two reports posit flourishing as the highest state of well-being and confer a role on the arts and culture in achieving it. Creative Health makes the case that the “arts have a significant part to play in improving wellbeing, thereby relieving pressure on front-line public services” (APPGAHW, 2017, p. 18). However, this is complicated by persistent inequalities in well-being, health, and access to the arts.

Creative Health explores the relationship between arts engagement, health and well-being through the prism of factors identified by the World Health Organization (WHO) as the social determinants of health:

The poor health of the poor, the social gradient in health within countries, and the marked health inequities between countries are caused by the unequal distribution of power, income, goods, and services, globally and nationally, the consequent unfairness in the immediate, visible circumstances of people’s lives—their access to healthcare, schools, and education, their conditions of work and leisure, their homes, communities, towns, or cities—and their chances of leading a flourishing life.

(Commission on the Social Determinants of Health, 2008, p. 1)

Expanding on this, the chair of the WHO Commission on the Social Determinants of Health, Professor Sir Michael Marmot, prefaced a review of health inequalities in England with the observation that “[p]eople with higher socioeconomic position in society have a greater array of life chances and more opportunities to lead a flourishing life. They also have better health. The two are linked: the more favoured people are, socially and economically, the better their health” (Marmot et al., 2010, p. 3). In a similar vein, the Taking Part survey—conducted by the Department for Culture, Media and Sport in partnership with Arts Council England, English Heritage, and Sport England since 2005—has consistently shown that both attendance at cultural events and participation in creative activity are disproportionately undertaken by prosperous, well-educated people (Inglis & Williams, 2010).

By controlling for socioeconomic factors, studies show that the health benefits of arts engagement are not confined to affluent audiences (Sundquist, Lindström, Malmström, Johansson, & Sundquist, 2004; Hyyppä, Mäki, Impivaara, & Aromaa, 2006). In direct contrast to the normal demographics of publicly funded arts, people accessing arts activities through health routes tend to be experiencing poor health. In a reciprocal relationship, the arts provide a route to better health and well-being, while health provides a route to the arts that can help to overcome persistent inequalities of access.

A section of Creative Health dedicated to environmental adversity examines ways in which the negative stress (distress) that accompanies chronic deprivation “debilitates and hampers human flourishing” (APPGAHW, 2017, p. 28). Specifically, the report describes how, “[a]t a molecular level, socio-economic disadvantage—and the chronic distress it causes for both children and adults—has negative effects on biological pathways and cellular functions” (APPGAHW, 2017, p. 28). By contrast, Creative Health argues that environmental enrichment can mitigate distress at molecular and cognitive levels. Drawing on the work of Swedish epidemiologist Lars Olov Bygren (2013), the report frames arts engagement as a form of environmental enrichment that can lead to better health and enhanced well-being.

In “The Role of the Arts and Humanities in Human Flourishing: A Conceptual Model,” Tay, Pawelski, and Keith (2018) take account of various “modes of engagement” (what we refer to in Creative Health as “creative participation”) and “activities of involvement” (what we call “cultural attendance”) to suggest that human flourishing may be enhanced through immersion, embeddedness, socialization, and reflectiveness (p. 217). By expanding on evidence referenced in Creative Health, these four mechanisms will be explored to elaborate a discussion of ways in which arts engagement can aid human flourishing and contribute to improved health.

Immersion

Tay, Pawelski, and Keith (2018) draw upon a body of research which suggests that absorption in creative activity—and the sense of “flow” that attends this—“may enhance human flourishing directly, through positive physiological and psychological reactions and increased hedonic well-being” (p. 217). In his 2004 TED Talk, Flow: The Secret to Happiness, Mihaly Csikszentmihalyi suggested that immersion in creative activity engages most of our capacity to process information. The UK-based political commentator Andrew Marr (2016), who rediscovered a love of painting while recovering from a stroke, described how “[t]he mind is completely engaged in something that is both difficult and absorbing—‘pure’ problems of tone, harmony, line and so forth. The body is working, the mind is at full stretch, time disappears and out of it all comes—well—something or other.”

For Csikszentmihalyi (2004), immersion—or flow—leaves the body incapable of registering physical or psychological pain. A study of the effects of improvised somatic dance on children and young people recovering from surgery or brain injury found that 92 percent of participants experienced a reduction in pain (Dowler, 2016). Adults recovering from acquired brain injury also demonstrate a reduction in pain and an increase in well-being through exposure to live music (Live Music Now, 2014).

A multidisciplinary team in Finland has investigated music as a complex and versatile stimulus that engages emotional, cognitive, and motor processes in the brain. They have found that listening to music “activates a wide-spread bilateral network of brain regions related to attention, semantic processing, memory, motor functions, and emotional processing” (Särkämö et al., 2008, p. 866). Going beyond mere distraction to aid recovery from neural damage, listening to music daily shortly after a stroke “can improve auditory and verbal memory, focused attention, and mood as well as induce structural gray matter changes in the early poststroke stage” (Särkämö & Soto, 2012, p. 266). Several initiatives in the United Kingdom respond to such evidence, including Live Music Now, Strokestra, and Stroke Odysseys, the latter of which integrates singing and dancing.

Tay, Pawelski, and Keith (2018) also propose that “immersion in the arts and humanities may enhance human flourishing indirectly, through physiological and psychological reactions that are unpleasant in themselves but that ultimately serve to broaden experience, promote emotional breadth and depth, and increase eudaimonic well-being” (p. 217). For Aristotle, the purpose of tragedy was to arouse pity and fear, leading to catharsis of these emotions. Gillie Bolton (2008)—who played an early role in the British Association for Medical Humanities—notes that the arts may disturb us, but “neither powerful arts products nor therapeutic effects are gained solely with ease and enjoyment” (p. 18).

Evidence is emerging that people of all ages who have experienced trauma can be more comfortable communicating their experiences through arts therapies than through verbal therapies. A three-year research project in two special schools in London found that traumatized young people engaging in art, music, and drama therapies felt safe communicating their experiences in this way and showed significant improvements in their social, emotional, and behavioral development (Cobbett, 2016). Adults experiencing post-traumatic stress do not always respond to the cognitive behavioral therapy (CBT) recommended in clinical guidance (Harvey, Bryant, & Tarrier, 2003; Spinazzola, Blaustein, & van der Kolk, 2005). A small-scale randomized controlled trial offered group music therapy to people with symptoms of post-traumatic stress disorder (PTSD) who had already completed a course of CBT. Over ten weeks, improvisation sessions led by the Music Therapy Department of the Guildhall School of Music and Drama—accompanied by optional verbal reflection—led to a significant reduction in the symptoms of PTSD (Carr et al., 2012). In military veterans suffering from PTSD, group drumming has been found to provide an outlet for rage and a way of engendering positive emotions such as openness and connectedness (Bensimon, Amir, & Wolf, 2008, 2012).

In their list of possible outcomes pertaining to immersion, Tay, Pawelski, and Keith (2018) include endocrine and immune responses. A team spanning the Centre for Performance Science at the Royal College of Music, the Faculty of Medicine at Imperial College, the Department of Epidemiology and Public Health at University College London, and Tenovus Cancer Care in Cardiff found that cancer patients and caregivers taking part in hour-long sessions of group singing experienced not only positive affect, but also significant reductions in cortisol, beta-endorphin, and oxytocin levels. This led to the preliminary conclusion that “singing improves mood state and modulates components of the immune system” (Fancourt et al., 2016, p. 1). Related research showed that attendance at live concerts lowered stress by reducing secretion of glucocorticoids and the ratio of cortisol to cortisone. The same study indicated that levels of the steroid hormone dehydroepiandrosterone (DHEA)—which counteracts stress hormones and leads to positive emotional responses—went up as cortisol levels went down (Fancourt & Williamon, 2016).

Embeddedness

When considering embeddedness, Tay, Pawelski, and Keith (2018) refer to the “set of socio-cognitive psychological processes that underlie the development of particular perspectives, habits, or skills”—including mastery, self-efficacy and autonomy—which “may be activated through engagement with the arts and humanities and can lead to positive outcomes that remain with us and enrich other domains in our lives” (pp. 217–218). Research suggests that learning to play a musical instrument helps the brain to encode sound (Hallam, 2015), enhancing listening and aural processing in a way that lasts into later life (White-Schwoch, Woodruff Carr, Anderson, Strait, & Kraus, 2013). Similarly, close listening to the grammatical explorations of Shakespeare has been found to activate the brain in areas beyond those typically associated with language processing (Davis, Keidel, Gonzalez-Diaz, Martin, & Thierry, 2013).

Singing—which is thought to create connections between the parts of the brain responsible for hearing and motor function (Kleber, Veit, Birbaumer, Gruzelier, & Lotze, 2010)—has been found to alleviate the symptoms of Parkinson’s disease. The ability to speak is often impaired by Parkinson’s, but singing has been shown to aid the intensity and articulation of speech (Haneishi, 2001; Di Benedetto et al., 2009). Researchers at the Sidney De Haan Research Centre for Arts and Health have published case studies of extant singing groups for Parkinson’s in the United Kingdom and tips for setting up new ones (Vella-Burrows & Hancox, 2012).

A similar body of research and practice is accumulating in the United Kingdom in relation to dance and Parkinson’s. Balance and gait are adversely affected as dopamine cells in the brain deteriorate. Studies show that music and rhythm help to improve general motor function and to regulate walking in people with Parkinson’s (Pacchetti et al., 2000; Elston, Honan, Powell, Gormley, & Stein, 2010). A study of a twelve-week dance for Parkinson’s project at English National Ballet (ENB) found that regular dance sessions increased improvements in balance, stability, and range of movement, while generating positive psychological impacts. A three-year mixed-methods study commissioned by ENB from the University of Roehampton found that, while bodily strength improved through dance, physical benefits were no greater than with other forms of exercise and secondary to psychosocial benefits. The researchers concluded that “dancing is a good and challenging mental workout for people with Parkinson’s and allows some participants to cope better with symptoms and disability” (Houston & McGill, 2015, p. 39).

In England, an estimated one in five visits to the family doctor is made for psychosocial, rather than medical, reasons (Dixon & Polley, 2016). As a result, National Health Service (NHS) England is championing social prescribing, which looks to the community beyond the clinical environment for solutions to psychosocial problems. This might involve a health professional referring someone to an organization that offers access to advice, education, exercise, gardening, self-help, volunteering, or arts activities. The most common outcomes of such community referral schemes are: increases in self-esteem and confidence; a greater sense of control and empowerment; improvements in psychological well-being; and reductions in anxiety and depression (Thomson, Camic, & Chatterjee, 2015). South West Yorkshire Partnership NHS Foundation Trust, which set up Creative Minds to promote engagement in creative activities to improve health and well-being, estimates a social return on investment of £4 for every £1 invested in the arts.

Socialization

Tay, Pawelski, and Keith (2018) take socialization to mean the adoption and diversification of roles, identities, and relations that can give rise to personal enrichment and resilience. Endorsing Creative Health, Martin Green, chief executive of Care England, noted that “[a]ccess to arts and culture is vital to maintaining a sense of identity,” and Eva Okwonga, Peer Support Advisory Board Member for Mind and Music, observed, “Artistic self-expression gives participants an identity beyond illness. I have seen the arts build confidence and community and provide hope in the midst of suffering.” Creative Health offers examples of arts engagement engendering a sense of identity in marginalized communities and older populations, and helping to overcome stereotyping and stigma.

Creative Health also brings to the fore a discussion of personhood in people with dementia. This rejects the idea that the mind is predominant in defining the self and reclaims the emotional and social capacities of people with dementia (Beard, 2012). A systematic review looking at the value of person-centered participatory arts to people with dementia found evidence of increased confidence, self-esteem, and social participation and observed that “[t]he arts have a unique application for uncovering and communicating the interior worlds of those living with a dementia” (Zellig, Killick, & Fox, 2014, pp. 18–19). To take just one example, qualitative research into interventions involving the recitation of poetry and new compositions being produced as an exchange between performers and people with dementia accentuated the expressive potential for participants (Swinnen, 2016).

When it comes to resilience, research shows how this might be improved through arts engagement at all stages of life. A study of primary school children in Wales identified resilience as a key component of academic functioning, emotional health, and well-being and recommended programs to prevent or reduce emotional difficulties (Banerjee, McLaughlin, Cotney, Roberts, & Peereboom, 2016). An independent evaluation of the Art Room—which offers school-based therapeutic creative interventions to children and young people with emotional or behavioral difficulties—showed that sessions significantly reduced emotional and behavioral problems and increased pro-social behaviors, especially within pupils’ peer groups (Eaude & Matthew, 2005). A study of post-retirement adults found that participants who actively produced art over ten weeks showed greater functional connectivity in the brain, which was related to stress reduction and psychological resilience (Bolwerk, Mack-Andrick, Lang, Dörfler, & Maihöfner, 2014).

In addition to resilience, the Mental Wellbeing Impact Assessment—developed by a group involving the Local Government Association, New Economics Foundation, and South London and Maudsley NHS Foundation Trust—identified the determinants of well-being to include control, participation, and inclusion (Cooke et al., 2011). We have already seen that increased control is among the outcomes of social prescribing initiatives. It also enters the literature in relation to a lack of control over one’s illness, treatment, or bodily functions, as compared to the mastery of oneself and one’s materials when engaging in creative activity (Dobbs, 2008). The second of the six Marmot principles for tackling inequalities reads: “Enable all children, young people and adults to maximise their capabilities and have control over their lives” (Marmot et al., 2010, p. 15).

When it comes to participation and inclusion, Age UK (2018a, 2018b) reports that 1.9 million of the 3.6 million older people living alone in the United Kingdom often feel ignored or invisible, and 1.4 million are chronically lonely. Social participation in older age is considered more beneficial for health than giving up smoking (Marmot, 2015). Research suggests that “frequent engagement with certain receptive arts activities and venues, particularly museums, galleries and exhibitions, may be a protective factor against loneliness in older adults” (Tymoszuk, Perkins, Fancourt, & Williamon, 2019, p. 1). Studies also show that the social contacts of older people are improved through participatory arts activities (Victor et al., 2018). For example, learning music in older adulthood can enhance social interactions both within and beyond sessions, not only providing opportunities to meet and socialize with new people, but also enabling new forms of interaction with family members and friends (Perkins & Williamon, 2014). The National Institute for Health and Care Excellence (2016) recommends the provision of group or one-to-one creative activities to older people on the basis that such activities build or maintain social participation.

Reflectiveness: Insight, Critical Thinking, Meaning, Purpose

Tay, Pawelski, and Keith (2018) identify reflectiveness as a conscious process of self-analysis, abetted through engagement with the arts, which promotes “critical thinking and perspective taking,” as well as “an evolution of the self and enhanced meaning and purpose” and the “development of a greater moral compass and the questioning of current social practices, triggering civic engagement and social change” (p. 218).

A chapter of the final report for the aforementioned Cultural Value Project gives detailed consideration to the “ability of arts and cultural engagement to help shape reflective individuals, facilitating greater understanding of themselves and their lives, increasing empathy with respect to others, and an appreciation of the diversity of human experience and cultures” (Crossick & Kaszynska, 2016, p. 7). Research conducted as part of that project shed light on many aspects of reflexivity, with arts engagement producing a safe space in which to challenge preconceptions through both cognitive and emotional processes.

The Centre for Research into Reading, Literature and Society (CRILS) at the University of Liverpool has partnered with The Reader, an organization that promotes shared reading, discussion, and subjective response in a range of locations. The research team has found that the act of reading aloud creates a non-judgmental, compassionate space in which moments of personal reflection can occur (Longden et al., 2015). Participants in a shared reading group talked about “what may be happening within themselves as individuals (in terms of reflections about personal feelings and thoughts, opinions and experiences, for example) as an articulated and evolved response to the shared reading of the text and wider group discussion” (Dowrick, Billington, Robinson, Hamer, & Williams, 2012, p. 15). This was seen to lead to a reduction in depressive symptoms.

In the criminal justice system, health inequalities are well above the national average, with an estimated 90 percent of prisoners having mental health problems—including anxiety, depression, and substance misuse—and rates of self-harm and suicide being at an all-time high. In conjunction with the National Criminal Justice Arts Alliance (NCJAA), the APPGAHW (2017) hosted a round-table discussion on Arts, Health and Wellbeing in the Criminal Justice System at which we heard many compelling examples of arts practice in prisons and detention centers. A former prisoner powerfully conveyed the reality of prison life:

[ … ] pockets of trapped individuals with limited skills in terms of coping mechanisms, in an environment where it’s not socially acceptable perhaps to talk about their feelings. So expressing these things is really important. For me, my art became a way of externalising certain emotions, certain thoughts, almost stabilising them. So, once I got them out there onto a canvas, it felt like that took up less space in my head perhaps. And there was a physical distance between me and them, and that made it much more easy to manage them (p. 110).

The NCJAA evidence library contains evaluations of creative and cultural projects in the criminal justice system, several of which point to increased reflexivity, alongside impacts such as self-esteem and self-efficacy, the encouragement of pro-social behaviors, and a reduced likelihood of re-offending.

A chapter of Creative Health considers the accumulating body of literature about arts engagement at the end of life. Largely centered on case studies, this demonstrates the abiding nature of the creative impulse. In an introduction to a co-edited volume, Hartley and Pyne (2008) at St. Christopher’s Hospice in London describe how the “arts bring with them possibilities: possibilities for motivation and growth, for coping and change, for self-actualisation and self-realisation” (p. 14).

And finally, in seeking to embed the arts in the widest range of aspects of healthcare, we look at how the arts can enhance the training of medical and nursing students (Perry, Maffulli, Willson, & Morrissey, 2011). Performing Medicine is a charitable organization set up to deliver creative training opportunities to healthcare students and practitioners. It focuses on both verbal and nonverbal communication and seeks to stimulate collaboration, critical thinking, and self-care.

A 2009 review of health and well-being in the NHS found that NHS organizations which valued staff health and well-being had better outcomes, higher levels of patient satisfaction, better staff retention, and lower sickness absence (Boorman, 2009), and the Royal College of Physicians (2015) has made explicit the relationship between staff health and patient care. Performing Medicine (n.d.) has developed a framework called Circle of Care, which helps healthcare professionals to think about and practice the skills involved in compassionate care.

Summary and Conclusion

It seems clear from this consideration that engagement with the arts has a significant contribution to make to human flourishing. Immersion in creative activity engenders a sense of flow that can diminish pain and help injured brains to recover and trauma to be overcome. Mastering an art form can yield enduring benefits, alleviate the symptoms of degenerative conditions, and help communities to flourish. Arts engagement can confer a sense of identity, heightening personhood and increasing resilience. Both participation in creative activity and attendance at cultural events can help to overcome loneliness, bringing tangible mental and physical health benefits. Creative and cultural activity can offer us new insights about ourselves and the world around us while promoting self-esteem, self-efficacy, and self-care.

In summary, we believe the evidence on the links between the arts and human flourishing demonstrates important potential in preventative care and in healthcare approaches that provide a supplement, or indeed an alternative, to expensive conventional treatments.

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1 At the time of writing, there are 685 all-party parliamentary groups registered in the UK Parliament on topics from Afghanistan to Zoroastrianism. As the name suggests, they include representatives from the main political parties, and they span the House of Commons and the House of Lords. These groups meet informally to pursue their particular areas of interest, and they vary in their levels of activity. One such group, the All-Party Parliamentary Group on Arts, Health and Wellbeing (APPGAHW) was set up in 2014 by Lord Howarth of Newport (coauthor of this article) to take stock of, and inform developments in, the fast-growing field of arts, health, and well-being.