An Introduction to the Arts-for-Health Movement, or How the Arts Sneaked in on the Medical Model

In 1978, I was deeply involved in building a partnership between the Durham Arts Council and the Durham Public Schools. We were sending teams of artists into the classroom to help children experience their own creativity, and when we discovered that the classroom teachers were just as needy as the children, we began offering creativity workshops for teachers through the schools’ continuing-education department.

Out of the blue, I was asked if I would be interested in developing an arts program in Duke University Hospital. This idea came from a Duke physician, Dr. James H. Semans, who believed that the arts could be used to provide "healthy distraction" for patients and their families. Dr. Semans had instigated a collaboration between the Durham Arts Council and the hospital to offer monthly performances in the cafeteria, but he felt that much more was possible.

I knew about the monthly performance program, and I was aware that there was such a thing as art therapy, but what was being suggested here was quite different. The idea was to figure out which arts resources in the community might be incorporated into the life of the hospital — this sounded very much like building an arts council in a small town.

The idea was exciting but scary to me. I was afraid of hospitals; I didn’t like some of the doctors I knew; and from TV shows and movies, it was clear that hospitals were theaters of power struggle. But I needed to get over my prejudices and it would be a fascinating challenge to see what could be done, and if it didn't work, I'd get another job..

I stayed in that job for 21 years, until I retired from Duke in 1999.

What surprised me right from the start was that the arts had a presence in hospitals all across the country. I knew, of course, that WPA murals had been painted in hospitals in the 1930s. But then I learned about the United Hospital Fund of New York’s art-acquisition program, and the astonishing art collections of the Mayo Clinic in Rochester and Cedars-Sinai Hospital in Los Angeles, all launched in the 1950s. Hospital Audiences Inc. in New York City was in full swing, placing artists in mental-health centers and escorting nursing-home residents to theatrical productions. Hospital arts programs were being birthed through percent-for-art programs in Seattle and Iowa City. This was an idea whose time was arriving all over the place, and though the public at large had no idea what was going on, the arts-for-health movement was already well underway.

How was all this activity being funded? Mayo's and Cedar-Sinai's art collections were supported by hospital patrons who contributed works of art themselves and convinced their friends to join in. In other hospitals, local art-guild volunteers saw win-win opportunities to exhibit members' works for a broad audience, while at the same time helping to enhance the healing environment. Hospital Audiences Inc. successfully applied for city and state social-services funds, as well as National Endowment for the Arts grants. At Duke, initial support came from the local Mary Duke Biddle Foundation, the National Endowment for the Arts and hospital monies. The art program at the National Institute of Health Hospitals and Clinics grew out of the institution's design office. In some children's hospitals, arts activities were a part of patient and family support programs. And the arts therapies (including visual, performing and literary arts) had become well established in (most commonly) psychiatric and rehabilitation services.

Gradually, those of us in the movement began to connect and share information and encouragement. In 1989, a few of us decided to get together to talk about starting a national support and service organization. That led to the establishment in 1991 of the Society for Arts in Healthcare Administrators, a name we soon recognized was too narrow, and so changed it to the Society for the Arts in Healthcare (SAH). SAH has sponsored wonderful conferences every year since; membership has grown into the hundreds; and the network has become international. We made contact with the various arts therapies, and with the International Arts Medicine Association, the Center for Health Design and colleagues in the United Kingdom, Canada, Germany and Japan. In 1994, we learned about UNESCO’s Arts in Hospital project, which had links with the World Health Organization, the Council of Europe, and the European Union. In 2000, a sister SAH was launched in Japan.

Scope of the Arts for Health

As the network grew, we learned that there was a very wide variety of arts-and-health programming, and our comprehension of the scope of the partnership was broadened. In Spring 2001, a group of arts-for-health practitioners in North Carolina took on the task of describing as clearly as possible the many-sided arts-for-health field. The group had convened to establish the North Carolina Arts for Health Network, and they felt that such a description was necessary in order to clarify the mission and purpose of the Network. Here’s what they came up with.

• Contributing to the healing process

  There are thousands of artists and certified expressive-arts therapists working in all kinds of community and healthcare settings — hospitals, rehabilitation centers, mental-health facilities, hospices — helping people do "soul work" through media such as music, dance, movement, words, paint and clay. The expressive therapist who is part of the medical team provides a holistic view of the patient and helps the team to understand the contribution the arts make in the healing process.

  Working on their own or through patient support groups that offer arts activities, people faced with life-threatening illness or adjusting to a traumatic disability have found solace, strength and affirmation by using the creative process to take an active role in their own healing.

• Creating a healing environment through the arts

  The visual, literary and performing arts and crafts are enriching the healing process by bringing restoration and relief to patients, visitors and staff of hospitals, hospices and other health centers. Examples include healing gardens, paintings in patient rooms, live music in lobbies and on patient units, and art that helps people find their way through large and confusing buildings.

• Caring for caregivers

  For healthcare givers who see illness and death daily and who live constantly in a high level of stress, making art can be rejuvenating. Sharing their paintings or poems, singing in a group for patients or each other, moving expressively and rhythmically together can also bring a greater sense of cohesiveness to the work environment.

• Supporting access to the arts for people living with disabilities

  Working in outreach programs, day programs and community arts programs, or one on one, creative-arts therapists, artists and educators provide arts opportunities for people with disabilities to facilitate creative expression, personal growth and community inclusion.

• Delivering medical care to creative and performing artists

  "Vocational arts medicine" is practiced when, for example, an orthopedist takes a special interest in the dancer's knee problem or the pianist's hand problem. Body therapies such as the Alexander Technique and Feldenkrais can come to the aid of the performer, both as curative and in the prevention of injury. For visual artists, organizations like the Center for Safety in the Arts provide information on such things as toxic solvents in art materials.

• Enriching the medical curriculum

  Both doctors and humanists debate the role of nonmedical subject matter in the training of doctors, and no school of medicine as yet includes the arts and humanities in the required curriculum. However, several major schools of medicine offer noncredit, extracurricular opportunities in the arts and humanities, and a for-credit art studio course has been offered for a number of years at Hahnemann Medical Schools. The University of Virginia offers hands-on participation in an art studio for medical students. A program at the University of Massachusetts uses the arts to help students cope with death and dying. These programs are designed to help medical students and doctors who are seeking balance between the clinical aspects of medical care and the needs of patients, themselves and their families for tenderness and empathy.

• Helping communities in times of crisis

  Artists work with communities that have experienced trauma to deal with grief and loss and to celebrate solidarity and support for each other. Projects of this type have been generated in response to natural disasters, acts of violence and, more recently, the terrorist attacks in Oklahoma City, New York City, Washington, D.C., and Pennsylvania.

Research and Measures of Success

We are often asked, "Where’s the proof?" Research in any field is challenging, but it is particularly so in the arts. We can find numbers for some things — how many people attended this or that performance, exhibit or reading (which is useful in justifying funding) — but is it possible to place a number value on the gratitude felt by a family with a dying mother visited by a musician in her hospital room, or the consolation experienced by a nurse who reads — or better still writes — a poem about a suffering child?

Difficult as it is, however, the work of assessment and evaluation has begun. For example, music therapist Martha Burke has measured the effects of music on premature infants undergoing bronchial suctioning [1] and the impact of music on recovery time when incorporated into the physical-therapy program for patients with total knee replacement [2]. James Pennebaker’s study demonstrated that college students who wrote about their emotions made fewer visits to the doctor’s office.[3] Roger Ulrich’s work addresses the impact of the healthcare environment on patient outcomes, for example, his 1984 study relating pain medication use and length of stay to whether the patient’s window looked out on a brick wall or on a nature scene.[4]

An intriguing study was done in 1956 by Maslow and Mintz on the impact of aesthetic surroundings on perception. Students were asked to rate "fatigue/energy" and "displeasure/well-being" in photographs of faces[5]. In 1995, the Center for Health Design funded Haya Rubin and Amanda Owens to survey the state of research addressing the effects of the healthcare environment on patients’ health outcomes. Their report contains a useful survey of studies and a proposal for a research agenda.[6]

The Society for the Arts in Healthcare has received a grant from the Agency for Health Care Research and Quality to sponsor a symposium in January 2002 to take the first steps in designing a far-reaching, in-depth research project to measure the impact of arts and humanities programs in the education and care of patients with or at high risk of having diabetes type 2. Invited participants include doctors, patients, educators, artists, arts therapists, nurses and healthcare administrators, who will attempt to develop a conceptual framework for the many variables and to design specific research protocols.

"The ‘gold standard’ for research is the double-blind randomized controlled experiment, in which subjects are randomly assigned to a treatment and neither the subject nor the data collector know whether the subject is receiving the intervention."[7] While we are still trying to figure out how to do double-blind studies within the arts in healthcare, there are other data that can be measured and would be significant if enough data could be collected. For patients, measurements might include satisfaction surveys, length of stay and physical markers such as stress hormone levels and use of pain medication. For staff, research could address the connection between the arts and employee health, well being and job satisfaction, and such quantifiable measures as sick days taken and staff turnover.

Why We Do What We Do

Shortly after I began work in Duke Hospital, Dr. Semans gave me a copy of "The Healing Role of the Arts," in which Michael Jon Spencer wrote: "Hospitals, prisons, and nursing homes are societies in perpetual crisis," and he maintained that "the need for art escalates in crisis."[8] Those were thought-provoking words, and we set to figuring out what kind of art might alleviate the stress of perpetual crisis. Obviously, there were different needs for the different populations. How could the arts help a patient who would be in the hospital only a few days? And what about the families in the surgical waiting room? The almost 10,000 people who work in the hospital — the nurses and doctors who have so little time, the secretaries and mail clerks and cleaning staff?

We tried many things. Some worked well; others didn’t. Among the more successful were art for patient rooms and art exhibits in public halls; gardens and art in the hospital’s outdoor spaces; a Touchable Art Gallery in the Eye Center; performances on patient units and in public spaces; a poet-in-residence introducing patients and staff to creative writing; an arts-medicine clearinghouse to assist artists with their vocational medical problems; a North Carolina arts-and-humanities channel on the patient television system; and, especially for employees, an annual employee arts-and-crafts festival, an annual fully-staged music revue, weekly meetings of a literary-arts interest group and biannual poetry competitions.

But why did those things work? Over the years, we’ve come to recognize three simple and basic tenets:

• Bring Beauty into the Space Around Us

Beautiful surroundings can change our experience. In 1888, Florence Nightingale wrote: "The effect in sickness of beautiful objects, of variety of objects and especially of brilliancy of color is hardly at all appreciated. I have seen in fevers (and felt, when I was a fever patient myself) the most acute suffering produced from the patient not being able to see out of the window and the knots in the wood being the only view. [How much worse if the view is an IV pole and a cardiac monitor?] I shall never forget the rapture of fever patients over a bunch of bright colored flowers. People say the effect is only on the mind. It is no such thing. The effect is on the body, too. Little as we know about the way in which we are affected by form, by color and light, we do know this, they have an actual physical effect. Variety of form and brilliancy of color in the objects presented to patients are actual means of recovery."[9]

• Celebrate Community

  Celebrating together helps to forge stronger communities of support for each other. More and more in the U.S., the workplace has become the community for employees. Singing together, displaying their arts-and-crafts creations, reading aloud their poetry — all these make it possible for employees to know each other outside their work roles and to build stronger connections. Experiencing the arts together helps coworkers become friends. And those good feelings will extend outward from the staff to patients and their families, like the ripples from a pebble tossed in a pond.

• Touch the Spirit

  We have all felt the power of music to move us, to bring consolation or joy. A poem at the right moment can quiet an emotional overload.

  A patient told us: "Your gift of music heals something in me that medicine and surgery don't touch. [It] slowly calmed a frightened part of me, this child of five in an adult of 48."

  A nurse said: "There are no words to express to you what this means to the morale of the patients and staff and everyone."

• And here’s another perspective:

Each Friday at noon, doctors, nurses and other staff, students and friends meet in Duke Hospital to read and discuss literature. The group named itself the Osler Literary Roundtable (OLR) in honor of Sir William Osler, a physician/teacher/writer who advocated the cultivation of the arts for doctors in training and in practice.[10] Dr. Frank Neelon, one of Cultural Services’ strongest supporters, wrote the following about his participation in OLR:

A casual look at Osler's advice, or conversation with even devotees of the arts, sometimes leaves one with the perception that the arts function in a merely recreational way, that they divert or refresh the doctor after the toil and burdens of the medical day, that they help because they differ so from the usual business of doctoring. In point of fact, I believe that those opinions are precisely wrong! The doctor's job is always an act of creative interpreting. It is analogous in detail to the reader's job of understanding the written or spoken word. The more we attune ourselves to the "hearing" that forms the basis of careful reading; the more we see the multitude of ways in which readers can interpret the same words displayed on the same printed page, then the better we prepare ourselves for the doctor's great and fearsome task: listening to the patient's story and trying to make sense — anatomical sense, physiological sense, psychological sense, social and societal sense — out of it. ... Every week, at the meetings of the OLR, I am schooled again in the nuances of interpretation, my ear is honed in the ways of hearing. And every day in the clinic thereafter, it helps me as I try to understand the metaphor of the body and the story the patient tells.[11]

So Where Do We Go From Here?

Despite the challenges that the arts face everywhere — the suspicion of many of the public towards the arts, the need for leadership, manpower and resources to fulfill the potential of the arts — arts-for-health programs are proliferating all around us. I get anxious when I think about what it will take to bring the movement into full bloom, but when I stop and look at where we’ve come from and what we’ve accomplished, my spirits rise.

Through their Able Art Movement, the Tanpopo-No-Ye Foundation in Japan makes it possible for people with disabilities to create paintings, pots, music, weaving, calligraphy, poetry, and to incorporate this art-making into the larger community through a process they call "community symbiosis." When I questioned my colleagues at Tanpopo about their mission, they told me it is to restore the soul of Japan. That quite took my breath away. Yasuo Harima, Tanpopo’s director, said: "As we enter a new century, I feel our big subject is ‘humans to become humans,’ and regain ties between humans and humans, between humans and nature, and between humans and society which were severed in the 20th century. I think the key to recovery is art, for it has the power to make people what they really should be and to restore the ties."[12]

How’s that for vision! I had only been trying to make an impact in one hospital and to link up with others in the field, to learn how to make our program at Duke better and to share what we were learning. Although I do certainly believe that the arts can transform on a personal and communal level, my pragmatic approach hadn’t engendered philosophical thinking of that amplitude. Whether or not it can possibly be achieved, restoring the soul of a people is a powerful guiding vision.

Back down at my pragmatic level, here are a few things I would like to see happen:

1. I would like for the "pure" arts world to understand that the arts for health are not by definition inferior arts. I would like for local, state and national arts agencies to recognize that what we are doing is real art and not just activity. Sometimes what gets produced is "good" and sometimes it isn’t. Just like in every studio and performance venue anywhere else.

2. I would like to see the arts for health become part of the standard agenda and strategic plans of arts agencies at every level, and particularly at the community level.

3. I would like to see greater collaboration between national and international arts-for-health organizations, including joint conferences.

4. I would like for the national health organizations and social-service organizations to recognize that the arts can help achieve their goals and to include the arts in their strategic plans.

5. I would like for schools and training programs in health and social services to include the arts in their offerings for students.

6. I would like to see arts for health included in the curricula of arts-administration training programs.

7. I would like to see many more creative minds turned to the needs of people who are suffering.

I am grateful to the Community Arts Network for giving me this soapbox. If you would like to join me up here, there are many Web links on this site to organizations who would welcome your contribution.

The art of medicine helps to keep us alive. The arts help us to understand what we are living for.

NOTES

[1] Burke, M.A. and J. Walsh, J. Oehler, and J. Gingras. Music therapy following suctioning: Four case studies. Neonatal Network, 1995; 14(7), 41-49. [return]

[2] Burke, M.A. and K. Thomas. Use of physioacoustic therapy to reduce pain during physical therapy for total knee replacement patients over age 55. In T. Wigram and C. Dileo, eds., Music Vibration 1997: 99-106. New Jersey: Jeffrey Books. [return]

[3 Pennebaker, J.W. and S.K. Beall. Confronting a traumatic event: toward an understanding of inhibition and disease. Journal of Abnormal Psychology. 1986; 95: 274-81. [return]

[4] Ulrich, R.S. View through a window may influence recovery from surgery. Science. 1984. 224:420-421. [return]

[5] Maslow, A. and N.L. Mintz. Effects of esthetic surroundings: I. Initial effects of three esthetic conditions upon perceiving "energy" and "well-being" in faces. Journal of Psychology. 1956; 41:247-254. [return]

[6] Rubin, H.R., M.D., PhD. and A.C. Owens, J.D. Report: An Investigation to Determine Whether the Built Environment Affects Patients’ Medical Outcomes. 1996. The Center for Health Design. (http://www.healthdesign.org) [return]

[7] Statement by Christine Kovner, PhD., R.N., FAAN, Professor of Nursing Education, NYU, at the Agency for Health Care Policy and Research "Effect of Working Conditions on Quality of Care" conference, Washington, DC, October, 1999 [return]

[8] Spencer, Michael Jon (director of Hospital Audiences, Inc.). A Case for the Arts. The Healing Role of the Arts, a Rockefeller Foundation Working Paper. 1978; 2. [return]

[9] Nightingale, Florence. Notes on Nursing: What It Is and What It Is Not. 1888. [return]

[10] Sir William Osler was a "Physician and professor of medicine who practiced and taught in Canada, the United States, and Great Britain and whose book The Principles and Practice of Medicine (1892) has been a leading textbook in the field of medicine. When Osler died in 1919, he was probably the most famous and beloved physician in the English-speaking and perhaps the whole world. He remains so more than 50 years later." Encyclopedia Britannica. 15^th edition, 1974. [return]

[11] Presentation by Francis A. Neelon, M.D., at the Annual Meeting of the American Osler Society in Pittsburgh, Pa., on May 10, 1995. [return]

[12] Yasuo Harima, speaking at the 2001 conference of the Society for the Arts in Healthcare. The "Toolkit" from the conference which includes Mr. Harima’s comments is available from the SAH office. [return]

Janice Palmer directed Duke University Medical Center's Cultural Services Program from 1978 to 2000. In 1989, she helped launch the Society for the Arts in Healthcare, and in 1991, she co-authored The Hospital Arts Handbook.

Original CAN/API publication: November 2001