Interventions That Utilize Expressive Arts Therapy as a Strategy to Resolve Personal Issues
Behav Sci (Basel). 2018 February; 8(two): 28.
Creative Arts Interventions for Stress Management and Prevention—A Systematic Review
Katharina Bauer
2Section for Therapy Sciences, SRH University Heidelberg, Maria-Probst-Str. iii, 69123 Heidelberg, Germany; ed.liamtoh@reuab.anirahtak
Received 2017 Dec seven; Accepted 2018 Feb 13.
Abstract
Stress is one of the earth's largest wellness problems, leading to exhaustion, burnout, feet, a weak immune system, or even organ impairment. In Germany, stress-induced piece of work absenteeism costs almost 20 billion Euros per year. Therefore, it is not surprising that the Central Federal Association of the public Health Insurance Funds in Deutschland ascribes particular importance to stress prevention and stress management as well equally health enhancing measures. Building on current integrative and embodied stress theories, Creative Arts Therapies (CATs) or arts interventions are an innovative fashion to forbid stress and amend stress direction. CATs encompass art, music, trip the light fantastic/movement, and drama therapy as their four major modalities. In order to obtain an overview of CATs and arts interventions' efficacy in the context of stress reduction and management, nosotros conducted a systematic review with a search in the post-obit data bases: Academic Search Complete, ERIC, Medline, Psyndex, PsycINFO and SocINDEX. Studies were included employing the PICOS principle and rated according to their evidence level. Nosotros included 37 studies, 73% of which were randomized controlled trials. 81.1% of the included studies reported a pregnant reduction of stress in the participants due to interventions of 1 of the four arts modalities.
Keywords: creative arts therapies, arts interventions, art, music, dance, drama, stress management, prevention, systematic review
i. Introduction
According to the World Health Organisation (WHO), stress is currently the globe'southward most pronounced health risk [ane]. Consequences of stress are constant agitation, exhaustion, exhaustion, helplessness, fear, and eventually a weak immune organisation or even organ impairment [2]. The inability to cope with stress is a risk cistron for various epidemiologically pregnant illnesses: cardiovascular, muscular or skeletal diseases, depression or anxiety disorders [3]. Russ et al. [4] showed that stress and other psychological health problems have an outcome on the mortality gamble of otherwise healthy individuals. In Germany, for the last 15 years, health insurance companies take registered a drastic increase in stress-induced absenteeism at piece of work [5]. Interviewing 1200 German participants from diverse religious, age, and milieu backgrounds, the health insurance fund Techniker Krankenkasse (TK) [5] found that 6 out of 10 people report to experience stress privately or at work, with 23% out of those feeling extremely stressed. Stress-induced absenteeism costs High german companies about 20 billion Euros annually [5]. Furthermore, not only adults are afflicted: a comparative study of the WHO found children and adolescents to be frequently tired and exhausted, to have problems falling asleep, and to present as increasingly irritated due to stressful school and life weather [6].
i.1. Stress as a Preparation to Act
Stress is the well-nigh widespread illness of the modernistic historic period. Scientists have analyzed stress from a biological [vii], psychological [8,nine] and sociological [ten] signal of view and have created a number of explanatory theories and models. The nearly well-known is the transactional model of stress and coping of Richard Lazarus and his research group (e.yard., [11,12]). Lazarus and his colleagues conceptualized stress equally a consequence of the individual's appraisal of his or her environment. It emerges, when the private evaluates a situation or an incident as challenging or threatening (principal appraisement) and his or her own coping abilities as insufficient in the light of the state of affairs'due south requirements (secondary appraisal) [13]. Stress management, therefore, is an act of cognitive appraisement, which results in a certain coping beliefs [12].
Virtually contempo stress theories integrate biomedical, psychosomatic, cerebral-behavioral, and sociological approaches [2]. Edifice on appraisal theories [12,thirteen], the recent embodiment theory past Peter Payne and Mardi Crane-Godreau [14], assumes that stress emerges when the organism's preparation to act and cope—the so called Preparatory Set—does not resolve the aversive situation. This could occur, for case, because the behavior is disorganized or inappropriate, or merely because the situation exceeds the coping abilities of the organism (compare the Preparatory Set Theory bv Peter Payne: [14]). A Preparatory Prepare describes the rapid, largely sub-cortical, organismic preparation to respond to the environment. This training involves an organization of concrete posture and muscle tone, visceral country, affective or motivational country, arousal and orientation of attention, and (subcortical) cognitive expectations [fourteen]. If the aversive situation is not resolved, the complex activation of the organism is maintained and the organism stays in abiding excitation and eventually is burned-out [14]. Because a Preparatory Set involves the unabridged organism, leverage points to tackle stress and foster resources tin be manifold and are not restricted to cognitive-behavioral aspects.
1.two. Creative Arts Therapies and Arts Interventions for Stress Management and Prevention
Due to the increasing mobility, flexibility, and performance demands in today'south society, it is assumed that individuals' stress exposures volition increase farther in the future [iii]. Therefore, innovative and embodied interventions for stress prevention and health promotion are needed more than ever.
This is where Creative Arts Therapies (CATs) and arts interventions come in equally they accept into account what Lazarus and colleagues have missed. By conceptualizing torso, mind, action, and perception as a unity, CATs, such equally Music, Trip the light fantastic toe/Movement, Art, and Drama Therapy, too every bit simple arts interventions, use creative media to approach the client on a creative and nonverbal level [xv]. In addition to cognitive ways of coping, CATs target (en-)active creation, interoception (body experience), and expression in society to admission emotions and modify behavior (embodied appraisal) [16]. Utilizing a solutogenic approach of wellness and illness [17], CATs provide action opportunities geared toward health maintenance and focus on wellness promoting aspects. The recently adult model of embodied aesthetics past Koch [xv,18,xix] underlines the embodied enactive nature of CATS. Different from conventional therapies, all CATs encourage and enable their clients to actively create or generate. Attention and concentration, for instance, are influenced by the perception, exploration, and creation of artistic content as well as past the explicit use of the body (body perception and expression). The corresponding art media (fine art, music, dance, theater) thereby provide different methods to activate resources and coping abilities and increase activeness flexibility, self-efficacy, and empowerment [18,20,21]. See Box ane for a short overview on the four main CATs and a few exemplary fields of application.
one.three. Researching CATs and Arts Interventions in the Context of Stress Prevention and Stress Direction
From an empirical signal of view, research on CATs and health-restoring arts interventions is metaphorically speaking in its infancy or adolescence. Drawing from experiential cognition of individual practitioners a thousand literature base of operations of case studies and clinical recommendations has developed, with an only recently growing number of prove-based studies that provide generalizable, and transferable data [37,38]. CATs are used world-broad in a variety of contexts with many different populations. In addition to creative arts therapists, in that location are artists offering creative interventions to the patients in wellness institutions. They about often piece of work without a therapeutic professional background, only likewise use the potential of the arts in gild to foster health. In addition, psychologists, physicians, and other health care professions are increasingly discovering the contribution of the arts in their settings and acquit studies to investigate the workings of the "arts in wellness". To do justice to the heterogeneity of creative arts intervention studies in health care, this review includes studies on all CATs equally well as arts (art, music, trip the light fantastic and drama) interventions. Mere arts interventions include interventions conducted by, for instance, an creative person (no licensed creative arts therapist) as well as unmarried session interventions that not necessarily have a therapeutic intention. Both, CATs and arts intervention studies are referred to collectively as creative arts interventions. To sympathise creative arts interventions, and to strengthen their development for instance by identifying indications and contraindications, information technology is indicated to inspect them in various applied contexts. The systematic review at hand provides an overview of evidence-based studies on stress management and stress prevention through creative arts interventions. Its goal is to promote a dialogue with various health practitioners and institutions on the potential and limitations of creative arts interventions in the context of stress prevention. To the knowledge of the authors this review is the first on the topic.
2. Methods
In a systematic information base search, we nerveless empirical studies from 1980–2016, which investigated CATs or arts interventions in the context of stress prevention. The cutoff engagement for the search was the third of August 2016. In addition, we contacted experts in the field and asked them to manus in studies until the terminate of 2016. The post-obit data bases were searched: Academic Search Complete, ERIC, Medline, Psyndex, PsycINFO, and SocINDEX. Search terms were: art therapy OR fine art psychotherapy OR creative arts therapies OR drama therapy OR dance therapy OR music therapy AND stress; art AND music AND movement therapy; arts AND wellness OR mental health treatment OR prevention; arts AND professional education OR preparation. Encounter Figure i for an overview of the search and report selection process. Only studies published in peer-reviewed journals were included.
Menses-Chart of the data base of operations search on creative arts interventions for stress prevention.
Process of the Systematic Study Search
The systematic data base search yielded 243 studies. Studies were scanned post-obit the PICOS principle (patient, intervention, command, effect, written report blueprint) [39]. In a first step, the criterion "patient" was analyzed. To stay in the context of prevention and avoid an overlap with creative arts interventions for acute disorders, for example, in the surface area of mental wellness, but studies targeting healthy individuals or people at risk were included. Studies were excluded, if they did not analyze arts interventions in a preventive context. Nosotros included both adults and minors, because both groups have been found to exist afflicted by stress. After the outset round of exclusions on the base of these criteria, 86 studies remained. In a second step, the studies were scanned according to the criterion "intervention". Bated from studies that specifically applied CATs, we also included studies, which provided arts interventions (art, dance, music or drama with a grouping of participants, encounter reasoning for this decision above).
In Table 1 CATs are demarcated from mere arts interventions by color coding: clinical studies of CATs are colored light-green, unmarried session studies of CATs and studies on arts interventions are colored black. Single-session interventions conducted past CATs or other professions were rated as mere arts interventions, considering those studies exercise not fulfill the criterion of containing a therapeutic process with a therapeutic human relationship. Interventions neither had to be standardized, nor had to accept the same duration. This heterogeneity reflects the variability of creative arts interventions in practice. Fifty-three studies remained. We included studies of evidence levels Ia—3. Evidence levels were divers according to the Agency for Healthcare Enquiry and Quality (AHRQ) [twoscore], rated by the first writer and confirmed past the 4th author. Case studies were excluded. Concerning the criteria "control", "outcome", and "study-blueprint", studies should at least operate with a quasi-experimental design, preferably have a control group, and should clearly land their outcome variables. Qualitative, quantitative, likewise as mixed method studies were included, equally long equally their method was clearly stated (in the qualitative realm, e.one thousand., content assay later on Mayring [41]). After checking the remaining studies for those criteria, 32 studies remained. Five studies were handed in by experts after the cut-off date and thoroughly checked for the criteria named in a higher place. In total, nosotros analyzed and compared 37 studies.
Table i
Overview of Efficacy Studies on Stress Prevention and Stress Management with Artistic Arts Interventions.
| Study (Writer/Year) | Level of Evidence | Object of Investigation | N/Sample | Design | Intervention | Methods | Exemplary Results | |
|---|---|---|---|---|---|---|---|---|
| Data Collection | Analysis | |||||||
| Fine art THERAPY | ||||||||
| Abbott et al. (2013) [42] | Ib | Effect of an creative action vs. art reception on the stress level | 52 Students, 34f/18m, M = 22.7 years | 2 × two factorial, randomized, controlled | Active & passive artistic condition: painting/drawing vs. viewing art; active/passive non-creative condition: puzzle vs. viewing the puzzle pictures; one single interven-tion | Stress: Mental Arithmetic Task; Stress Induction Task, Stress Adjective Checklist; Creative Personality Scale; Subjective Stress Calibration | Multifactorial Analysis of Covariance (MANCOVA) | Stress reduction sig. higher in the group allocated to active artistic condition. F(ii, 44) = 3.45, p < 0.05 |
| Curl (2008) [43] | Ib | Brusk-term stress reduction by focusing on a positive, stress-free experience versus a negative, stressful feel during artistic activity | xl Psychology Students, 30f/10m, M = 19.65 years | 2 × two factorial, randomized, controlled | 4 experimental groups: drawing with positive and negative focus; creating collages with positive and negative focus; one single intervention | Stress, feet: State Trait Feet Inventory; collection of heartrate pre-mail Level of focusing on positive and negative experiences: Manipulation Check | t-test for contained samples; ANOVA | Focusing on positive experiences while artistic activity leads to stress reduction, regardless of the type of artistic technique. F(one) = 13.76, p < 0.01 |
| Huss & Sarid (2014) [44] | Ib | Result of irresolute compositional elements (shape, size, colour, texture) of a self-designed epitome of a memory vs. a simple retentivity (guided imagery) on the experience of stress. | 35 Healthcare professionals (doctors, nurses, social workers) | Intervention-evaluation-study, randomized, controlled | Group I (Fine art Therapy): Constructing a stressful work experience on newspaper, transforming the feel into a stress-free event; Group II (Guided Imagery): introducing and recalling a stressful work feel, 2 days workshop | Definition of artistic elements: Compositional Elements Scale Discomfort, Stress: Subjective Units of Discomfort Scale (SUDS) | Descriptive: frequency analysis of compositional elements, paired significance tests, mean and standard divergence calculation of individual values | Reduction of stress level in Group I and Group II. The compositional elements of shape, size and color are of detail importance. X 2 = eight.61(df = 1), p = 0.03; X 2 = 7.56(df = i), p = 0.04; t-test = three.27(df = 1), p = 0.03, t-exam = 2.03(df = 1), p = 0.04, respectively |
| Kaimal, Ray & Muniz (2016) [45] | IIb | The touch on of visual art making on the cortisol level | 39 Students, staff & kinesthesia from a big academy, 33f/6m, Chiliad = 38.88 | Single arm, pre-post-design, quasi-experimental | 1 single session: 45 min of art making using collage materials, modeling dirt, and/or markers, 15 min for consent and data collection before and after the session | Cortisol Level: Saliva Sample (pre/mail; ELISA kit method) Prior Art making experience: limited, some, extensive experience self-reported perceived affect of art making: Written responses from participants (qualitative data) converted into numeric information, entered into quantitative database | t-test for paired samples, one-way ANOVA, t-test for contained samples, Correlation Analysis: | Sig. reductions in cortisol following the intervention: cortisol levels pre- and posttest differed significantly t(38) = 4.54, p < 0.01 No sig. differences based on prior experiences on cortisol levels, F(2, 36) = 0.64, p = 0.53 No sig. differences based on gender on changes in cortisol, t(37) = 0.456, p = 0.65 Self-reported themes were not strongly correlated with changes in cortisol levels |
| Kimport & Robbins (2012) [46] | Ib | Effect of a guided intervention with clay on the mood | 102 Students of an American University, 74f/28m, M = 22.iii years | 2 × two × iii factorial, randomized, controlled | Creation of negative mood by showing a brusk film; 4 different 5-min interventions: Group A: clay + instruction; Group B: clay without instruction; Group C: stress ball + Pedagogy; Grouping D: stress ball without instruction; one unmarried session | Mood State, Anxiety: Profile of Mood States (POMS), State-Trait Anxiety Inventory (STAI) | Multifactorial Analysis of Variance (ANOVA) | Editing tone (with and without pedagogy) reduces negative mood (mood and anxiety) more than than working with stress balls; guided interventions (clay and balls) reduce negative mood more interventions without guidance; POMS: F(1, 98) = vii.6, p < 0.05; STAI-S: F(1, 98) = 4.four, p < 0.05. |
| Mercer et al. (2010) [47] | Iii | Stress reduction through visualization (Visual Journaling) | x 5 medical Students, 5 Lecturers | Single-arm, pre-postal service-design with follow-upward | Visualization of a stress-inducing vs. a stress-free emotion, drawing of these emotions, self-explanatory questions for a better understanding of the stress situation; ane single intervention | Mood State, Anxiety: quantitative: Country-Trait Anxiety Inventory (STAI-Y), the Positive and Negative Affect Schedule (PANAS) qualitative: Questions on stress situation | paired t-tests | Non-significant reduction of anxiety and improvement of mood. |
| Pizarro (2004) [48] | Ib | Comparing of art and writing therapy concerning their effects on psychological and health conditions | 45 Students, 27f/18m, M = 19 years | randomized, controlled, pre-post-pattern with follow-up | 2 experimental groups: Consecration of a stressful situation based on a text; painting this situation (art-stress) vs. writing near this situation (write-stress); control group: painting a still life later on a neutral text, 2 sessions on 2 days | Health, Stress, Physical Symptoms, Mood: General Health Questionaire (GHQ-28), The Global Measure of Perceived Stress (GMPS), Physical Symptoms Inventory (PSI), Profile of Mood States (POMS) (short version) qualitative: Questioning on satisfaction; Questionnaire for the Assessment of stress reduction in art and writing intervention (follow-upwards) | Analysis of Covariance (ANCOVA) | Sig. reduction of social dysfunction in the writing-stress group: F(2, 37) = 3.17, p = 0.05; No health improvements in the fine art groups: F(2, 37) = 0.ten, ns; Simply more joy and commitment of study participation in the fine art groups. |
| Sandmire et al. (2012) [49] | Ib | Reduction of anxiety through artistic activity | 57 Students, 45f/12m, One thousand = 18.8 years | randomized, controlled | experimental group: Choice of one of v creative activities (mandala, complimentary painting, collage, clay, cartoon), 1 single session, duration: 30 min.; control grouping: no intervention | Anxiety: State Trait Feet Inventory (STAI) | t-tests for paired samples; multifactorial Assay of Variance (ANOVA) | Sig. reduction of feet (state and trait) before final exams. p < 0.001, F(1) = 12.72 |
| Schrade et al. (2011) [50] | Ib | Relaxation and reduction of stress levels through painting mandalas. | 15 Adults with mental disabilities 9f/10m | Repeated measure, randomized, controlled | 3 conditions: painting mandalas, free painting, neutral control condition (puzzle, lath games, etc.), 1 single session | Stress: blood pressure, pulse (Sphygmomanometers) | three separate ANOVAs for repeated measures | Sig. reduction of blood pressure (systolic and diastolic) in the mandala grouping over time: F(2, 28) = six.05, p < 0.05; no sig. change of stress levels comparing the three groups. |
| Smolarski et al. (2015) [51] | Ib | Effect of instructions on emotional expression on the mood-enhancing qualities of drawing | 45 Students, 28f/17m | randomized, controlled, doubleblind, pre-post design | 1. Inducing a negative mood ii. Randomized resource allotment to three groups: Grouping A: drawing happiness (acting out a positive mood) Grouping B: drawing current stress (acting out a negative mood) Group C: tracing and coloring a simple drawing (command grouping, lark strategy), 1 single session | Mood Land: Profile of Mood States (POMS) | two-factorial ANOVA with repeated measures (3 groups; time: baseline, pre-post-treatment) | Sig. mood improvement through the expression of a positive emotion while drawing in comparison to the expression of a negative emotion (venting) or the drawing of uncomplicated lines (control grouping), F(2, 42) = iv.0, p < 0.05. |
| Walsh et al. (2004) [52] | IIb | Consequence of an artistic intervention on anxiety and stress among family members of cancer patients | forty family unit members of cancer patients, 30f/10m, M = 51.43 years | pre-post-design, quasi-experimental | Creative-artistic intervention, e.one thousand., painting mandalas, painting; Implementation in the hospital room of the patient, 1 single intervention | Mood State: Mini-POMS Feet: Beck Anxiety Inventory (BAI) Negative and positive emotions: Derogatis Affects Rest Scale (DABS) | t-tests for paired samples | Sig. reduction of stress, anxiety: t(40) = −3.42, p = 0.001; increase of positive emotions, t(46) = 11.87, p < 0.001. |
| MUSIC THERAPY | ||||||||
| Beck, Hansen & Aureate (2015) [53] | Ib | Result of MT on biopsychosocial parameter | 20 Danish workers with stress-related incapacity to piece of work, 16f/4m, M = 45.5 years | randomized, controlled | Music Therapeutic Intervention: Guided Imagery and Music (GIM) two-60 minutes-sessions, 6 sessions in ix weeks | Cortisol, testosterone, melatonin: analysis of saliva in the laboratory Stress: Perceived Stress Scale (PSS); Profile of Moods States (POMS-37); Visual analogue scale for immediate stress sensation before and after the sessions; Karolinska Sleep Diary (KSQ); Unpublished 16-detail calibration for concrete stress symptoms Willingness to work: single item Well-being: WHO-v Well-Being Index Anxiety: Generalized Anxiety Disorder 7 (GAD-seven) Low: Major Low Inventory | t-test for independent samples | Sig. comeback in well-being and sig. reduction in sleep disturbance and concrete distress. Early intervention leads to faster re-entry of work & positive sig. furnishings on stress, mood, sleep disorder, low, anxiety and physical symptoms of distress. (run into Table 2, p. 339, in original study) |
| Brodsky & Sloboda (1997) [54] | Ib | Comparison of consequence of Music Therapy and traditional verbal Psychotherapy | 55 Musician of a symphony orchestra, Yard = 36 years | randomized, controlled, pre/post design with follow-up | Three groups: (a) Somatron: traditional exact psychotherapy, abbreviated progressive relaxation training (APRT), recorded music complemented by music-generated vibrations (b) Music: verbal psychotherapeutic counseling, APRT relaxation exercises supplemented with recorded music (c) Counseling: exact psychotherapeutic counseling 1 h per week, viii weeks | Baseline (Anxiety, Stress, Mood Land, Burnout): General Health Questionnaire (GHQ-28), Spielberger Land Trait Feet Inventory (STAI), Derogatis Stress Profile (DSP), Profile of Mood States (POMS), Maslach Exhaustion Inventory of Music Performer's Stress (AMPS), and the Music Operation Stress Survey (MPSS) Pre-Post (Mood State, Relaxation): POMS, relaxation exercises | Multifactorial ANOVA with repeated measures | Music-supported forms of therapy as efficient as traditional counseling. 14 of the 52 sets of variables were statistically and clinically pregnant at measuring time 2 and 3. Differences between groups were not sig. F(2.46) = 4.16; p = 0.22. |
| Brooks, Bradt, Eyre, Hunt & Dileo (2010) [55] | Ib | Outcome of MT on self-assessment of exhaustion, sense of coherence and job satisfaction | 65 Medical nursing staff, 43f/9m One thousand = 42.16 years | Randomized, controlled | Guided Imagery with music and relaxation exercises, 3-half-dozen weeks, 60 min sessions | Exhaustion: Maslach Burnout Inventory Sense of Coherence: Sense of Coherence Scale Job Satisfaction: Task Satisfaction Survey Individual perception of interventions: Cocky-study on interventions (qualitative survey) | Independent t-test Grounded theory | Quantitative results: No sig. differences between experimental group (MT) and control group (waiting). Qualitative results: Music therapeutic Intervention helped subjects to relax and to recharge energy. |
| Byrnes (1996) [56] | Ib | Effect of audio, video and audio-video stimuli on the stress experience | 54 33 Adults (participants of a university summer course) 21 students of music and/or education | Randomized, controlled, pre-post-pattern | Iii groups: (a) Audio-Video: Music-Video excerpt from "Tropical Sweets" (with classical music) (b) Audio: "Aquarium" past Camille Saint-Saens (c) Video: Underwater moving picture virtually tropical marine life, 1 unmarried session | Questionnaire on socio-demographic data, music preferences and activities for relaxation, current level of stress Stress Experience Continuous Response Digital Interface (CRDI) | Paired t-tests | Stress reduction especially for participants with a loftier level of stress at the beginning: t = 3.695, df = 53, p = 0.001; Sig. reduction in sound-video status, sound or video status alone did not sig. impact stress. |
| Chang, Chen & Huang (2008) [57] | Ib | Effect of MT on the stress level, anxiety and the degree of depression | 236 meaning, Taiwanese women M = 30.48 years | randomized, controlled | EG: passive music therapy intervention: listening to music ii weeks, 30 min. per mean solar day CG: general prenatal handling without MT | Stress: Perceived Stress Scale (PSS) Feet: State Scale of the Country-Trait Anxiety Inventory (South-STAI) Depression: Edinburgh Postnatal Depression Scale (EPDS) | Paired t-test Analysis of Covariance (ANCOVA) | Stress reduction, anxiety reduction and reduction of the caste of depression sig. college in the EG with music therapy intervention than in the CG (come across Table 4, p. 2585, in the original study). |
| Du Rousseau et al. (2011) [58] | IIa | Comeback of sleep quality, mood state, everyday functions | 41 Law enforcement officers, firefighters, 13f/28m | pre-mail-design, controlled | Brain Music (BM) Music-based Neurofeedback Therapy | Indisposition, sleep quality, low, life satisfaction, everyday functions: Pittsburgh Indisposition Rating Scale, Subjective Sleep Questionnaire, Brook Depression Inventory, Life Satisfaction Scale, Daytime Operation Scale, 4 weeks intervention | Analysis of Variance (ANOVA), paired t-tests | Sig. comeback of sleeping quality, insomnia, mood and everyday performance (meet Table 1, p. 392, in the original report). |
| Goff et al. (1998) [59] | Ib | Comparison of the effects of music and nitrous oxide on the pain-, feet- and stress-levels of subjects during a dental handling | 80 dental patients | randomized, controlled, 2 × 2 factorial | (a) treatment under nitrous oxide and Level 1 = no music/level 2 = with music (b) treatment accompanied by self-selected music (Level ane = without nitrous oxide, level two = with nitrous oxide) | Pain, Anxiety, Stress: Saliva samples before and afterward treatment for determination of S-IgA concentration (secretory immunoglobulins A) | multifactorial Analysis of Variance (ANOVA) | No sig. differences between the two treatment methods; in women sig. stress reduction with music accompaniment (see Tables i and 2, p. 24, in the original study). |
| Hatta & Nakamura (1991) [60] | Ib | Result of Anti-stress Music-CDs on stress level | 52 Students, 28f/24m | Randomized, controlled, Pre-Mail-Design | EG: Classical Music vs. Nature Sounds vs. Popular music; CG: no intervention, single session | Stress, Arousal: Stress/Arousal adjective checklist (SACL) | ii-factorial Analysis of Variance (ANOVA) | Sig. reduction of stress and arousal through listening to music, regardless of the blazon of music, F(9, 144) = iv.25, p < 0.01. |
| Ilie & Rehana (2013) [61] | Ib | Result of playing music on the iPhone on the acute stress level | 54 Students, 27f/27m | Randomized, controlled, 2 × iii factorial, pre-mail-design | Group one: consecration of a stress situation Group 2: no stress induction Each: (a) Pressing the music app "Smule Ocarina" for ten min, i.due east., Playing the melody "Twinkle, Twinkle, Little Star" (b) listening to the tune; (c) Sitting quietly 1 unmarried session | Mood State, Arousal: Profile of Mood States (POMS) Level of Cortisol: Salimetrics Oral Swab (SOS) | Mixed-model ANOVA | Sig. reduction of cortisol level in the stress-induced group by listening to or playing the app compared to the control group, F(ane, 65) = 21.54, p < 0.001. |
| Jacobsen, McKinney & Holck (2014) [62] | Ib | Effect of MT on the parent-child interaction and parent-kid human relationship besides as the stress experience of the parents | xviii Parent-child dyads from Denmark with neglected children | Randomized, controlled | EG: music therapeutic Intervention CG: standard treatment without MT 10 weekly sessions, 45 to l min. | Parent Competencies: Cess of Parenting Competencies (APC) Stress experience of parents: Parenting Stress Index (PSI) Parent-Kid-Relationship: Parent-Kid Human relationship Inventory (PCRI) | Multifactorial Analysis of Variance (ANOVA) | Improvement of parent competencies and parent-child interaction, as well as stress reduction in the experimental group with MT intervention higher than in the control group (run across pp. 321–326 in original report). |
| Kim (2008) [63] | Ib | Consequence of two music therapy approaches on Music Performance Anxiety (MPA) | 30 Music Students (Piano) | Randomized, controlled, pre-postal service-blueprint | 2 Groups (a) improved-music-assisted-desensitization-group (b) music-assisted progressive muscle relaxation (PMR) and imagery-group vi weekly sessions | Feet, Stress, tension, relaxation: Visual Counterpart Scale (VAS), Land-Trait Feet Inventory (STAI), Music Performance Feet Questionnaire (MPAQ); Measurement of the finger temperature | Tests of significance, Analysis of Variance (ANOVA) | Sig. reduction of MPA in the music-assisted desensitization group at 6 out of seven measurement points; Anxiety reduction in the music-assisted PMR group to a bottom extent than in the erstwhile group, only sig. for stress and tension level. Level of tension: F = vii.55, p = 0.016, df = ane, xiv; state anxiety of the STAI, F = 5.57, p = 0.033, df = I, xiv; finger temperature measure, F = 7.87, p = 0.014, df = 1, fourteen |
| Lesiuk (2008) [64] | Ib | Consequence of listening to self-selected music at the workplace on stress levels | 33 air traffic controllers, 2f/31m, Yard = 34 years | Randomized, controlled; Pre-Post-Design | EG: 15 min. Listening to favorite music, in the intermission of 4 working shifts in 2 weeks; CG: sitting in silence instead of listening to music | Extraversion, Introversion: Eysenck Personality Inventory; Feet: Country-Trait-Feet Inventory (STAI); Measurement of heart rate, blood pressure, land anxiety and subjectively perceived aviation activity | Multifactorial Assay of Variance (ANOVA) | No sig. differences between physiological and psychological components in the comparison of both groups; Sig. feet reduction (country anxiety) in EG and CG over time, F = 19.22, d.f. = two, p = 0.000, and reduced perception of air traffic in both groups. |
| Maschi & Bradley (2010) [65] | Three | Upshot of relaxation drums on well-being, empowerment and social connectedness | 31 Social Piece of work Students, 29f/2m | Pre-Mail-Blueprint | I single session of 2 h relaxation drumming in the group | Stress, Free energy, Empowerment, Bonding: Session Impact Calibration | paired t-tests | Sig. stress reduction, increased energy, empowerment and a sense of community (see Table 3, p. 61, in the original report). |
| Mohammadi, Shahabi & Panah (2011) [66] | Ib | Event of MT on stress, feet and the caste of low | xix residents of a dwelling house for elderly, 9f/10m, M = 69.iv years | Randomized, controlled | Experimental Group: MT group intervention (music listening, singing, percussion), 10 weeks of 90 min. daily sessions Control group: standard day-to-twenty-four hour period acitivities | Stress, Anxiety & Depression: Low Anxiety Stress Scale (DASS) | Isle of mann-Whitney U-Examination | Stress reduction, feet reduction and reduction of the degree of depression sig. higher in the experimental group with MT than in the control group (standard mean solar day-to-24-hour interval activities) (meet Table i, p. 63, in the original study). |
| Irish potato et al. (2014) [67] | Ib | Result of harp therapy on the stress level and clinical outcome values | 181 Women in an in vitro reproduction surgery | Prospective, randomized, controlled, pre-mail design | EG: harp therapy for in vitro fertilization CG: standard therapy | Anxiety: Land-Trait Anxiety Inventory; Pulse, respiratory charge per unit, claret pressure | t-test for paired samples, Wilcoxon rang sum test | Sig. college reduction of anxiety (land anxiety) over fourth dimension in the EG than in the CG; Conception rate higher in EG than in CG; positive effect on the acute stress level; no sig. Improvement of heart rate and respiratory rate (encounter Tables 6–ix, pp. 96–97, in the original study). |
| Rider et al. (1985) [68] | III | Event of music/progressive muscle relaxation (PMR)/guided imagery (GI) on stress hormones | 12 Nurses | Quasi-experimental, pre-post design | 20-min plan of classical music (audio cassettes) incl. PMR and GI (visualization of imaginative images); 5 times a week over 3 months | Adrenal Corticosteroid (Stress hormones): Urine samples, temperature measurements; Taylor-Johnson Temperament Analysis, State-Trait Anxiety Inventory, Torrance Exam of Creativity, Circadian Type Questionnaire | t-tests | Reduction of circadian aamplitude and corticosteroid temperature rhythms during music listening; The average corticosteroid level did not improve sig. over time. |
| Sharma & Jagdev (2012) [69] | Ib | Effect of MT on the cocky-esteem of adolescents | 60 adolescents with high school stress levels & low self-esteem, M = 16.85 years | pre-mail service blueprint, controlled | EG: 30 min listening to classical Indian music (raga, flute) per day, 15 days; CG: word of study irrelevant topics | School Stress (Anxiety, Frustration, Pressure Conflict): Calibration of Bookish Stress (SAS-3) Cocky Esteem: Self Esteem Inventory (SEI) | t-tests | Sig. increment in self-esteem in the EG compared to the CG. (see Table 2, p. 59, in the original report) |
| Smith & Joyce (2004) [70] | IIa | Effect of MT on the land of relaxation and stress | 63 students, 45f/18m, One thousand = 20.88 years | Quasi-experimental, controlled | EG1: receptive MT-Intervention (Mozart). EG2: receptive MT-Intervention (New Historic period Music) CG: reading offering without MT Relaxation Sessions of 28 min, 3 days in a row, once a day | Country of Relaxation and Stress: Smith Relaxation States Inventory (SRSI) | Pearson chitwo-examination | Stress reduction and increase of the relaxation country higher in EG1 (Mozart) compared to EG2 (New Age Music) or to the control grouping (reading of leisure magazines). (see p. 220) |
| Smith (2008) [71] | Ib | Effect of MT on Anxiety | fourscore Employees of a phone call eye 40f/40m, M = 37.5 years | Randomized, controlled | Experimental group: Progressive musculus relaxation with music Command group: verbal discussion, i single session | Anxiety: State Trait Anxiety Inventory | t-exam with repeated measures | Anxiety reduction sig. higher in the EG with musical relaxation intervention than in the CG (verbal discussion): subtract in tense rating: t(39) = 12; p < 0.01; increase in pleasant and relaxed rating: t(39) = −20.27; p < 0.01; t(39) = −16.2; p < 0.01. |
| Toyoshima, Fukui & Kuda (2011) [72] | Ib | Effect of creative activities on cortisol levels and anxiety | 57 Students, 30f/27m, M = 21.5 years | Randomized, controlled | 3 experimental groups (ane piano playing, 2 dirt modulations, 3 calligraphy) and a command group (lingering in silence) i unmarried session | Anxiety: Country Trait Feet Inventory Detection of cortisol in saliva | Multifactorial Analysis of Variance (ANOVA) | Anxiety reduction and cortisol degradation higher in the EG (creative interventions) than in the CG (lingering in silence). Playing the pianoforte shows the biggest effects. F(1,113) = v.57, p = 0.0202 |
| DANCE/MOVEMENT THERAPY | ||||||||
| Bräuninger (2012) [21] | Ib | Improvement of stress management and stress reduction, too every bit the influence of DMT group intervention on quality of life (QoL) | Northward = 162 Clients suffering from stress (self-assessed), 147f/15m G = 44 years | Randomized, controlled, pre-postal service-pattern with follow-upwardly later half-dozen months | EG: DMT, group intervention, 10 weeks CG: waiting command group | Stress management and stress reduction: Stress processing questionnaire/SVF 120 General Stress Level and Psychopathology (Brief Symptom Inventory/BSI) Quality of Life (QoL): The World Health Organization Quality of Life Questionnaire 100 (WHOQOL-100) and Munich Life Dimension List (MLDL) | Stress Data: Multifactorial Analysis of Variance (ANOVA) Quality of Life: Analysis of Variance with repeated measures (repeated measures ANOVA) | Negative stress management strategies decreased sig. in short and long term comparisons, positive strategies of distraction increased, equally well as relaxation; sig. short-term improvements in the BSI, specially with regard to anxiety scores; QoL dimensions were sig. better in the EG than in the CG (run into Tables 4 and 5, pp. 447–448, in the original study). |
| Pinninger, Brown & McKinley (2012) [73] | Ib | Comparison of tango and mindfulness meditation regarding stress reduction, reduction of feet and depression symptoms and improvement of well-being | Sample N = 79 (self-assessed) depressedPersons, 19.5f/80.v, Yard = 38.68 years | 3 × 2 factorial design, randomized-controlled, pre-postal service test | Three interventions: Tango: 6 weeks, one ½ h per calendar week Mindfulness meditation: 6 weeks, ane ½ h per week Waiting control group | Anxiety, Depression: Depression, Feet and Stress Scale (DASS-21-Scale); Rosenberg Self Esteem Scale; Satisfaction with Life Scale, and Mindful Attention Sensation Scale. | Analysis of Covariance (ANCOVA) and Multiple regression analysis | Significantly reduced depression symptoms in both (F(two, 59) = half dozen.00, p = 0.004), the tango group and the mindfulness group compared to the control group; reduced stress only in the tango group (F(2, 59) = 3.88, p = 0.026); participation in the tango dance was a pregnant predictor of improved mindfulness. |
| Pinninger, Brown & McKinley (2013) [74] | Ib | Result of an intensive program of Tango trip the light fantastic on self-reported stress, anxiety or symptoms of depression | N = 41 (experimental group: xx, waiting command group: 21) | Randomized, controlled (RCT) Pre, Mail service-Test, follow-up afterward one calendar month | EG: Tango trip the light fantastic program (four × i ½ h in 2 weeks), waiting control group | Self-assessment scales of stress, anxiety and depression symptoms: Depression Anxiety and Stress Calibration (DASS-21); Insomnia Severity Index; Satisfaction with Life Calibration; General Self-efficacy Calibration; Mindful Attention Awareness Scale; Qualitative feedback | Analyzes of Covariance (ANCOVAs) | Self-assessed stress-, anxiety- and depression-symptoms in the experimental group sig. improved compared to the control group; effects were retained at follow-upwards time (1 month); life satisfaction and self-efficacy sig. improved; mindfulness did non alter sig.: stress, F(1,38) = 12.59, p = 0.001; anxiety, F(one,38) = 8.31, p = 0.006; depression, F(ane,38) = 25.60, p = 0.001; insomnia, F(i,38) = 8. 30, p = 0.006 |
| Quiroga Murcia, Bongard & Kreutz (2009) [75] | IIa | Effects of tango dance on psychophysiological emotion or stress measurements | 22 good for you individuals with min. one twelvemonth tango experience, 11f/11m M = 43.09 years | two × 2 factorial, controlled | four Weather condition: 1. Regular tango dance with partner and music two. Tango dance with partner without music 3. Trip the light fantastic without partner but with music 4. Movement without a partner and without music xx min sessions | Stress: Positive and Negative Affect Schedule (PANAS) Saliva samples for the written report of cortisol and testosterone | Multivariate Assay of Variance (MANOVA) with repeated measures | Sig. reduction of negative bear on, sig. improvement of positive touch on (F(i, 21) = 5.06, p < 0.05), and sig. reduction of cortisol concentration in saliva through tango dance with music and partner (F(1, nineteen)= 5.45, p < 0.05). The outcome was dependent on the music, just non on the partner. |
| West et al. (2004) [76] | IIa | Comparison of African Trip the light fantastic and Hatha Yoga regarding their influence on well-beingness | 69 Students 47f/22m M = nineteen years | 3 × iii factorial, controlled | 3 Conditions: 1. Hatha Yoga 2. African Trip the light fantastic three. Biology Lecture 90 min courses, single session | Stress: Perceived Stress Scale (PSS), Positive and Negative Bear upon Schedule (PANAS), saliva samples for the measurement of cortisol | Multivariate Assay of Variance (MANOVA) with repeated measures | Sig. reduction of perceived stress and negative bear upon as well as comeback of the positive affect in Hatha Yoga and in African dance: F(2, 66) =11.77, p < 0.0001; Sig. reduction in cortisol concentration in saliva in the yoga status (F(2, 59) = 17.28, p < 0.0001); Increase of cortisol in saliva in the dance condition and no change of cortisol in the command status. |
| Wiedenhofer & Koch (2016) [77] | IIa | Comparison of non-goal-directed movement and goal-directed movement in terms of their influence on stress and well-being | Northward = 57 Students, 44f/12m M = 23.21 | 2-factorial, controlled, pre-post design | EG: not-goal-directed movement improvisation to music, 1-time participation xl–50 min. CG: goal-directed motion improvisation to the aforementioned music. Colorful post it-notes were used as target points in the room, quondam participation | Perceived Stress: PSQ30 questionnaire Well-being: HSI (Heidelberg State Inventory) Self-efficacy: General Perceived Self-Efficacy Calibration (GSE scale) Body-self-efficacy: Self-Efficacy-Scale (BSE) | MANOVA with repeated measures t-tests for paired samples | Perceived stress in EG sig. more reduced than in CG F(56,one) = four.71, p = 0.034 ; Body-Self-efficacy increased sig. in EG F(56,i) = seven.00, p = 0.011, no departure in well-being:. |
three. Results
Tabular array one summarizes content, sample, and intervention characteristics, pattern, research methods, and results of the studies identified [42,43,44,45,46,47,48,49,50,51,52,53,54,55,56,57,58,59,threescore,61,62,63,64,65,66,67,68,69,70,71,72,73,74,75,76,77,78]. In total, 37 studies met our inclusion criteria, 11 studies (29.vii%) investigated the event of AT or art interventions on stress, 20 studies (54.1%) focused on MT or musical interventions, and half-dozen studies (xvi.2%) assessed the effects of DMT or dance interventions. At that place were no studies on DT or drama interventions that met the inclusion criteria. In full, 2136 subjects were included: 465 took function in AT or art interventions for stress management, 1241 in MT or musical interventions, and 430 in DMT or dance interventions. Near participants were women (see Tabular array i). Some studies did not brandish demographic information of their samples, and were omitted in the respective calculations. The mean age of participants was Thousand = 32.xviii years (AT: 1000 = 27.54 years, MT: K = 35.42 years, DMT: M = 33.59 years). Duration times of interventions varied from single sessions on one day to weekly sessions for 10 weeks. Due to the not bad heterogeneity of interventions and the lack of reported effect sizes in many of the single studies, we did non calculate an overall effect size for the arts modalities. Due to space limitations only the most central qualitative and quantitative results of the included studies are displayed.
Table two gives an analytical overview of the numbers of corresponding studies past arts modality. As presumed earlier, most of the studies were conducted and published after 2000. Just five studies (13.5%) were published between 1980 and 1999, iv of them on musical interventions, i on MT. No meta-analysis (evidence level Ia) was found on CATs or arts interventions for stress management and stress prevention. In total, nosotros found 27 randomized controlled trials (RCTs, evidence level Ib), bookkeeping for 73% of the included studies. Ten of the RCTs analyzed CATs, the remaining seventeen examined the effects of arts interventions. Five studies (13.5%) were rated evidence level IIa (two on CATs, three on arts interventions), two studies (5.4%) were rated evidence level IIb (all on arts interventions), and iii studies (8.1%) evidence level III (all on arts interventions). Virtually of the studies (16; 59.three%) on the highest evidence level came from the expanse of Music: 9 studies analyzed MT, seven examined music interventions. With viii studies, AT provided 29.6% of the studies on evidence level Ib (none on AT, all on art interventions), and DMT contributed 11.1% (3 studies; 1 on DMT, ii on trip the light fantastic interventions). Inside the arts modalities 72.7% (AT and art interventions), 80% (MT and music interventions) and 50% (DMT and trip the light fantastic toe interventions) of the included studies were RCTs. Most therapy intervention studies (with several intervention sessions) were found in MT (eleven out of xx) and one in DMT (1 out of half dozen). In AT, only studies on furnishings of creative activities or single-session interventions were found.
Tabular array 2
Overview of the reviewed studies. Evidence levels are defined according to AHRQ [40].
| Fourth dimension of Publication | Evidence Level | ||||||
|---|---|---|---|---|---|---|---|
| Arts Modality | 1980–1999 | 2000–2016 | Total | Ib | IIa | IIb | 3 |
| Fine art therapy/art interventions | 0 (0/0) | 11 (0/11) | 11 (0/11) | 8 (0/8) | 0 (0/0) | 2 (0/2) | 1 (0/1) |
| Music therapy/music interventions | 5 (1/4) | 15 (ten/5) | 20 (11/ix) | xvi (nine/7) | 2 (2/0) | 0 (0/0) | 2 (0/2) |
| Dance/movement therapy/dance interventions | 0 (0/0) | 6 (i/5) | 6 (1/v) | 3 (1/2) | 3 (0/3) | 0 (0/0) | 0 (0/0) |
| Drama therapy/drama interventions | 0 (0/0) | 0 (0/0) | 0 (0/0) | 0 (0/0) | 0 (0/0) | 0 (0/0) | 0 (0/0) |
| Total | 5 | 32 | 37 | 27 | v | 2 | three |
Active fine art interventions, such as drawing or working with dirt significantly reduced stress and feet in viii out of 11 studies [42,44,45,46,49,50,51,52]. None of the studies analyzed the effects of continuous interventions specifically defined as AT, 3 studies [46,51,52] reported pregnant positive mood changes. Two studies [47,48] did not discover a significant stress reduction or mood changes. Two studies [43,51] stated that stress reduction depended on the content of the art work: positive content induced stress reduction, negative content did not. Stress was assessed with various dissimilar instruments, such as the Stress Adjective Checklist, the State-Trait Anxiety Inventory, The Global Measure out of Perceived Stress, or the Perceived Stress Questionnaire. Two of the studies [45,50] used physical measures (cortisol level [45]; pulse and blood pressure [fifty]) to operationalize stress. MT or musical interventions reduced stress and anxiety in sixteen of 20 studies (ten on MT, 6 on music interventions) [53,54,56,57,58,59,threescore,61,62,63,65,66,67,68,seventy,72]. Four studies (i of MT, three on music interventions) [53,61,68,seventy] reported reductions in cortisol level, equally a concrete measurement of stress, and ii studies (both on MT) [53,58] found a decrease of sleeping issues through musical interventions. Four studies (1 on MT, three on music interventions) [55,59,64] did not find a significant reduction of their stress outcomes.
All studies analyzing DMT or dance interventions plant a significant reduction of stress signs or stress coping abilities in their subjects. Only one of the studies analyzed the furnishings of DT. In all but two studies [75,76] stress was measured by different self-evaluation tests. In the two other studies, stress was tested with saliva samples for cortisol levels. Iv studies [73,74,75,76] furthermore reported a decrease in feet levels and negative affect.
In full, stress was significantly reduced in 30 out of 37 included studies (81.1%). 11 out of twelve (91.seven%) included studies on CATs constitute a significant stress reduction. Nineteen out of 25 (76%) included studies on mere arts interventions constitute a significant reduction in their stress measurement.
4. Discussion
Recently, as well beingness an important part in clinical health care practice, creative arts interventions take become an important area of integrative medicine research. Despite the novelty of CATs, a notable evidence-base of operations on the efficacy of creative arts interventions in various contexts and with many unlike populations is emerging.
In the context of stress prevention, the quality of efficacy studies analyzing creative arts interventions is high. Three quarters of the included studies could be allocated to evidence level I and over 80% found a significant improvement in ane of their stress-related outcomes. Looking at CATs, conducted by licensed therapists, the per centum rises to more than 90%. Similar to other wellness intendance contexts, MT and music interventions contribute the highest quality studies. This can be attributed to the comparably early on institution of MT, its specific focus on group therapy too equally its comparably low psychoanalytic and high empirical orientation (meet [25]). CATs and creative arts interventions seem to have a positive impact on perceived stress and stress management. They reduce anxiety levels and improve subjects' mood. This may exist due to sure therapeutic mechanisms that researchers presume to exist relevant for all artistic arts therapies. Hedonism/play, aesthetic experience/actuality, nonverbal communication/symbolizing, test-acting in an enactive transitional infinite, and creation/generativity are named as therapeutic mechanisms, which are active across all CATs ([18,xix]; compare [25]). It remains generally unclear how these therapeutic mechanisms collaborate or whether they are active in all clients and contexts. Their empirical validation is a task for hereafter enquiry.
Creative arts interventions' touch on perceived stress and stress management could not be evaluated by means of an overall effect size for each arts modality. Very few of the studies clearly reported all necessary statistics needed for the adding of upshot sizes. Some did non even report the full demographic information. Furthermore, varying interventions in content and duration impede a final argument on creative arts interventions' efficacy in the context of stress prevention. This loftier heterogeneity might be the biggest problem of the young bookish field. Existence a benefit of the creative arroyo in exercise, the variety of procedures, methods, and interventions makes it hard to appraise and gauge artistic arts interventions' efficacy with conventional evidence-based enquiry. The loftier heterogeneity of interventions and measures makes the application of meta-analyses difficult. This is true not only across creative arts interventions but too within each unmarried arts modality (art, music, dance, drama). It might thus exist worth looking at specific and common features of the individual CATs, delineating them from mere arts interventions and starting to chronicle them to features of populations and contexts. This may exist a practiced way to observe out, what is specific about each arts modality, and which contexts they work all-time in (indications and contraindications; meet for example [25,78,79,80]). Demarcating core characteristics and mechanisms of CATs or arts interventions individually likewise helps to choose an adequate control group for intervention studies. Finally, finding commonalities across creative arts interventions could help clarify the benefit they bring to the health arrangement and its agents. Patients already acknowledge these benefits, and the evidence-base on creative arts interventions is in the procedure of being congenital.
Acknowledgments
The review was conducted at the Enquiry Institute for Creative Arts Therapies (RIArT) at Alanus University for Arts and Social Sciences in Alfter/Bonn, Germany. Nosotros would like to give thanks the Software AG Foundation (SAGST) for funding.
Author Contributions
S.K. and M.Thou. initiated the study; R.O. did the systematic data base search; L.M. supervised the systematic data base search; L.M. & R.O. divers inclusion and exclusion criteria for the studies.
Conflicts of Interest
The authors declare no conflict of involvement.
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Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5836011/
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