Can The Arts Help People Improve Their Mental Health? If So, How?

BA Essay. Written 2021.

The arts can play a critical role in improving how people with mental health issues are seen and understood by their communities but also more importantly, how they are understanding and looking after themselves. With Social Prescribed art based projects on the rise in the UK and Drama Therapy being recognised as a creative, expressive way to help people living with all kinds of mental health issues, The Arts have an incredible ability to adapt and continue to support its many, varied participants. Within this essay, we will look at how The World Health Organization and Mind differ on their definitions of mental health and how the wrong definition can often be problematic. We will explore the idea of Socially Prescribed Projects, touching on the process of Social Prescribing and looking at how singing can help with anxiety and breathlessness, through the lense of ENO Breathe. We will then discuss how Drama Therapy has begun to help people with anxiety become more playful and how in turn, this has decreased symptoms of anxiety within the participants. Finally we will look at how projects and reports go about ‘proving’ their project has worked and how this can be problematic.       

The World Health Organisation (WHO) claims that mental health is "a state of well-being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community" (World Health Organization). This definition is problematic in many ways, as it suggests that mental health prevents someone from coping or being an active member of society. WHOs definition also suggests that mental health is something static and goes as soon as someone can ‘cope with the normal stresses of life’ again. However this isn’t always the case with mental health.  MINDs definition of mental health takes into account everything that is problematic with the World Health Organisations definition and says that “Good mental health means being generally able to think, feel and react in the ways that you need and want to live your life. But if you go through a period of poor mental health you might find the ways you're frequently thinking, feeling or reacting become difficult, or even impossible, to cope with. This can feel just as bad as a physical illness, or even worse.” (MIND). The arts can play a critical role in improving how people with mental health issues are treated and the ways the person living with mental health issues reacts to their personal struggles. With relatively new ideas such as Social Prescribing for mental health, changing the ways GPs treat mental health issues, The Arts play a fundamental role in not only helping people with mental health struggles find their voice but also providing a way for them to begin to help themselves through their struggles, in a safe and expressive way. 

Social Prescribing has been around for a fair few years now. Projects aimed specifically at helping people with mental health problems are varied and widespread. The All Party Parliamentary Group (APPG) report defines Social Prescribing as something that “aims to address the broader causes of ill health by seeking solutions to psychosocial problems beyond the clinical environment. This may initially involve a GP, nurse, mental health professional or charity staff member referring someone to a voluntary, community or faith organisation offering access to advice, education, exercise, gardening, self help, volunteering or arts activities” (All-Party Parliamentary Group, 2017, p 72). Projects like ENO Breathe have appeared in recent years to help people with specific ailments in relation to COVID19 and anxiety. Social Prescribed projects can also include things like Drama Therapy or other drama related activities, using an already established way of expressing oneself in a new mental health orientated approach. 

ENO Breathe is a new Social Prescribing project run by the English National Opera. ENO Breathe is  “A breathing and wellbeing programme developed specifically for people recovering from COVID-19, who are still suffering from breathlessness and associated anxiety. Delivered by ENO in collaboration with Imperial College Healthcare teams entirely online, the programme focuses on breathing re-training through singing. (The National Opera). Through singing, ENO Breathe is aiming to improve people's posture, wellbeing and give them inventive ways to manage their anxieties. The participants, who are aged 18 and over, are involved in a six week online programme, where they get introduced to lullabies, practical tools and moments to connect with each other in a safe and supported way. The support doesn’t stop once the six week course is over, as ENO Breathe offers its participants a biweekly drop in session and they gain access to all the online tools they had been provided with, within the course, to help them continue the work by themselves. 

The BBC published the findings of several studies on the power of singing on our mental health and how singing affects our brains. What they found was that “When we sing, large parts of our brain “light up” with activity [...] We also see involvement of the emotion networks of the brain. Regions that control the movements we need to produce sounds and articulation also light up” (Keating) Singing has also been linked to the release of endorphins, which decreases stress levels by increasing your happiness. In relation to anxiety, singing forces the participant to breathe deeply, which is also linked to a decrease in stress and carbon dioxide levels in the body. By focussing on breathing deeply and often, the chance of a panic attack happening to the participant is decreased significantly. The studies also found that when you sing “As well as endorphins racing through your body, another hormone released when we sing is oxytocin.[...] oxytocin has a powerful effect in enhancing a feeling of connectedness between people”. (Keating). 

An independent study published by The National Center for Biotechnology Information (NCBI) has also linked singing to an increase in people's mental health and wellbeing. This study focussed on a group of 62 people, attending weekly singing sessions. The participants all had depression or anxiety linked to a family member or close friend needing to be cared for due to cancer. The study split its participants into a choir and a control group (who continued life as normal). The choir group (of which there were 33 participants) “took part in a 90 minute session each week led by a professional choir leader, of which 60 minutes was dedicated to singing (including warm-up exercises, learning new songs and singing familiar songs) and 30 minutes to socialising. The repertoire focused on popular songs arranged specifically for the choirs with backing tracks. All songs were learnt by ear without participants needing to read music.” (Fancourt et al.) The study concluded that in six months the “Participants in the choir group showed a significantly greater decrease in anxiety over time than participants in the control group” (Fancourt et al.). 

ENO Breathe is combining everything the BBC and NCBI reports found; by creating a sense of community through singing, increasing breath control, thus decreasing the chance of an anxiety attack or other anxiety related breathlessness and focussing our brains on the act of singing, ENO Breathe seems to have all the right tools in place to help its participants deal with their anxiety. 

The pilot of ENO Breathe took place in October/November 2020 and the original group was found to be ranging in ages “from those in their 30s to their 70s, and were 41% ethnically diverse. For 25% of the group, English was not their first language and 20% expressed concern at the start of the programme that singing was ‘not for them’.” (The National Opera). Participants have left glowing reviews all over the website and The National Opera said that “The outcome of the pilot is overwhelmingly positive, with 90% of participants stating that they perceive ENO Breathe to have had either ‘positive’ or ‘strong positive’ impact on their breathlessness, and 91% stating that the programme had ‘positive’ or ‘strong positive’ impact on their anxiety levels.” (The National Opera). Some of the feedback mentioned the use of singing and how it helped the participant gain more of an understanding about how to control their breath and anxiety as a result. A participant even said “It’s (ENO Breathe) prevented me from calling my GP about anxiety brought on by breathing issues. I genuinely believe it will take pressure off medical facilities.” (The National Opera). Another said that “My experience with ENO Breathe has been fantastic, it has really aided me enormously with my breathlessness and also my anxiety a little around re-integrating myself back into society.” (The National Opera)

One final report that held some particularly pertinent information regarding anxiety, singing and breathlessness was a Brazillian report on the Psychology of Music. This report published back in 2017, focused, like ENO Breathe did, on the relation between the decrease of anxiety and choir singing. This report concluded that Regarding the psychological benefits, it seems that choral singing has two main general effects related to this dimension: (a) increase of positive feelings; and (b) reduction of negative emotional states [...].”(Caetano et al.) It was also noted that an  Increase of positive feelings psychologically is associated with an improvement in quality of life and  mental health. Alongside this increase of positive feelings, is the  reduction of negative emotional states which as I previously mentioned is also associated with a decrease in stress, anxiety and depressive symptoms. All of this information and feedback from ENO Breathe and other independent reports on the use of singing to decrease anxiety and breathlessness, firmly backs up ENO Breathes main aim and objective, which is “to empower patients in the management of breathlessness and anxiety” (The National Opera). 

By empowering patients, ENO Breathe is allowing its participants to be able to advocate for themselves through the use of breath work to calm their anxieties. Breathing calmly could allow ENO Breathes participants to be able to speak out more openly when they are struggling, as they would be able to notice changes in their breath. ENO Breathe has - as we have seen through the feedback - increased many of its participants self confidence and self esteem. Through this increase of confidence and self esteem many participants have felt much more comfortable speaking about their struggles with COVID_19 and the breathlessness they have experienced as a result. 

Much like Social Prescribing and ENO Breathe, Drama Therapy can also help people living with anxiety. “DRAMATHERAPY is a form of psychological therapy in which all of the performance arts are utilised within the therapeutic relationship. Dramatherapists are both artists and clinicians and draw on their trainings in theatre/drama and therapy to create methods to engage clients in effecting psychological, emotional and social changes.” (British Association of Dramatherapists, cited in Roundabout Annual report in 2013) Drama therapy gives equal validity to body and mind using drama based methods, such as; stories, myths, playtexts, puppetry, masks and improvisation to allow the participant to explore difficult life experiences in a safe environment. Drama Therapy has been proven by many researchers to work well with a wide variety of mental health issues, including but not limited to: Anxiety, Depression, Post Traumatic Stress and Schizophrenia. What differentiates Drama Therapy from other kinds of therapy is its focus on the person responding to their - for example -  anxiety, rather than trying to find a ‘cure’ for it like CBT or other more medicinal approaches. Drama Therapy can also be prescribed via Social Prescribing, as it can be used either as individual therapy or for groups, which gives strength to the theory that it’s focussing on more than just the mental health issue and delves into the health and wellbeing of the client/s involved. Roundabout, an organisation that uses Drama Therapy with a wide range of people with a broad selection of mental health issues, said that some of the aims of its sessions were to “establish and build relationships'' and “to build confidence and self esteem” (Roundabout). The idea of building relationships and self confidence and self esteem is a throughline of many different Drama Therapy reports and projects.

A thesis submitted by Laura Brown in 2015 said that “ the use of response-based language in a drama therapy framework would help adolescents understand their anxiety in ways that are supportive of them experiencing less distress” (Brown). Through the use of response based language, people with anxiety are much more likely to feel supported, as opposed to a more medicalised approach of telling someone what they are feeling is wrong and needs to be ‘fixed’. When combining this approach to the aims and objectives of Drama Therapy providers like Roundabout, there’s grounds for not only improving someone's mental health but providing them a chance and a way to advocate for themselves too.  

The Arts in Psychotherapy published a report that hypothesized that adults with Anxiety Disorders (AD) and Obsessive Compulsive Disorder (OCD) are less playful. This report looked into using Drama Therapy as a way to increase its participants' playfulness and by doing so, hopefully decrease their anxiety based symptoms. The study recognised that “Playfulness can be accessed and enhanced by interactive dramatic play and improvisations, where one cannot be blamed for one’s unprepared action but instead be admired for one’s courage” (Versluys). Playfulness has also been linked to an increase in group trust and thus, an increase in the participants mental health and wellbeing. This report also mentioned the idea that  “A high level of playfulness was found to correlate with an increase of varied coping skills such as positive reframing, self-distraction, venting, etc.” (Versluys). The study concluded that “ Adults with an anxiety disorder (AD) experience anxiety, which is more intense, longer lasting or insufficient to the stimulus that evoked the anxiety. Those suffering with AD have fear reactions, while objectively there is no danger involved” (Versluys) but that “Drama therapy provides ways of exploring the Expressed World and of increasing coping and interaction.” (Versluys). The Expressed World Versluys is referring to is the idea first suggested by Vermeer who “constructed a play schema which she developed as far back as the 1950s. She positioned the Play World as an area between the Real World and the Fantasy World.” (Versluys). The Play World later became The Expressed World. 

Versluys goes on to explain that “The Expressed World is not allocated to specific moments like role-play in sales training nor to specific places like the theatre. It is a world one can enter and leave according to one’s needs and habits.” (Versluys) Something important to note is that actions in the Real World and in the Expressed World can be quite similar. However one can differentiate between the actions of the Real World and the Expressed by how these actions are carried out and performed - for example one can be thirsty in both the Real and Expressed Worlds but one is only able to physically drink in the Real World. This is an interesting concept to use through Drama Therapy, as the differentiation between the Three Worlds could help someone learn how to cope with their anxiety in the Real World by practising coping strategies in The Expressed World. The British Psychology Society, in a report published in a later edition of The Arts for Psychology, noted that “For people who struggle with engagement in the talking therapies the use of dramatherapy can offer an alternative way of engaging”  (Bourne et al.). This may be in part, due to the use and execution of The Three World technique. 

Through the use of Drama Therapy and the exploration of the Three Worlds, people who are diagnosed with Anxiety Disorders are able to safely explore and play through coping strategies, their struggles and their successes. Using the varied techniques of Drama Therapy can also allow its participants to find new and creative ways to self advocate, as the techniques can be applied to the Real world but practiced in the safety of the Expressed world. The techniques can be hugely beneficial to people with anxiety, boosting their self confidence, self esteem and ability to clearly communicate their wants and needs to those around them. 

A question that arises with all the projects and reports I have described is how they gather results from their studies. Some like ENO Breathe simply use their participants' feedback as a way to ‘prove’ their project is working. Others like the NCBI report led by Daisy Fancourt, use a more medicalised approach, with study groups and data analysis to ‘prove’ their projects and research are indeed helping their participants. This medicalised approach is controversial, as there will be people purposefully left out of a study, to be the ‘control group’. These people may need help just as much as the participants but are being denied that, on the ground of this art based project being more scientific and thus being able to ‘prove’ that it's been a success (or not). 

It’s important to ask why there is a need to ‘prove’ a mental health, arts based project has ‘worked’. Mental Health and the day to day symptoms and struggles participants may have, will differ from person to person. Someone may have a really great, very obvious external reaction to being involved in a 6 month long drama therapy study, while another participant may have a more internal, less obvious reaction, which if the project is purely focussed on the differences between a study group and the project group, may go unnoticed.   

Eno Breathes use of feedback forms and personal reflection is less likely to miss someone's small changes, as the participant would be able to tell their truth and have their experience and voice heard in full. While it’s less data based and may be harder to prove to a funding body that the project has been a success, ENO Breathes' way of collecting data is much more personal and ensures that everyone who wishes to be heard, has a way to do so.   

The Arts can be so beneficial to people living with mental health, as it's more accessible, playful and community based than a lot of other therapy or medicine based help available. There is no clear cut way to prove a project has worked, as even a medicalised approach can miss the small, personal improvements, so it’s down to the participants themselves to kick start the change and take from The Arts skills they would need to help relieve their anxiety based symptoms. This means there is a broad scope of possibilities for projects like ENO Breathe and Socially Prescribed Drama Therapy. We’ve seen throughout this essay that The Arts have been successful in not only helping people deal with their mental health in a safe, supportive and explorative way but also in finding inventive and creative ways for the participants to self advocate. The Arts can create communities, support systems and decrease symptoms of anxiety; and has the ability to teach people skills in self expression, self advocating, playfulness, singing, breath work and more. Even a worldwide pandemic couldn’t stop The Arts from adapting and finding new, online approaches to supporting the people who need it most. So to conclude, the work of Socially Prescribed Arts  “is provocative, challenging and exciting, offering alternative ways of addressing and understanding health and wellbeing” (Baxter and Low, 2017:250) 

Bibliography: 

Works Cited

All-Party Parliamentary Group On Arts, Health And Wellbeing. Creative Health : The Arts for Health and Wellbeing. The All-Party Parliamentary Group, 2017.

Baxter, Veronica, and Katharine E Low. Performing Health and Wellbeing. London, Bloomsbury Methuen Drama, 2017.

Bourne, Jane, et al. “A Systematic Review to Investigate Dramatherapy Group Work with Working Age Adults Who Have a Mental Health Problem.” The Arts in Psychotherapy, vol. 61, Nov. 2018, pp. 1–9, 10.1016/j.aip.2018.08.001. Accessed 27 Jan. 2019.

Brown, Laura. RESPONSE-BASED DRAMA THERAPY: A VIABLE OPTION for YOUTH EXPERIENCING ANXIETY a Thesis Submitted RESPONSE-BASED DRAMA THERAPY: A VIABLE OPTION for YOUTH EXPERIENCING ANXIETY. , 2015.

Caetano, Kátia A. de Souza, et al. “Choir Singing as an Activity to Manage Anxiety and Temporomandibular Disorders: Reports from a Brazilian Sample.” Psychology of Music, vol. 47, no. 1, 16 Nov. 2017, pp. 96–108, 10.1177/0305735617739967.

Fancourt, Daisy, et al. “Psychosocial Singing Interventions for the Mental Health and Well-Being of Family Carers of Patients with Cancer: Results from a Longitudinal Controlled Study.” BMJ Open, vol. 9, no. 8, 10 Aug. 2019, www.ncbi.nlm.nih.gov/pmc/articles/PMC6701813/, 10.1136/bmjopen-2018-026995.

Good Therapy. “Drama Therapy.” Goodtherapy.org, 15 Sept. 2009, www.goodtherapy.org/learn-about-therapy/types/drama-therapy.

Keating, Sarah. “The World’s Most Accessible Stress Reliever.” Www.bbc.com, 19 May 2021, www.bbc.com/future/article/20200518-why-singing-can-make-you-feel-better-in-lockdown.

MIND. “About Mental Health Problems.” Www.mind.org.uk, 2020, www.mind.org.uk/information-support/types-of-mental-health-problems/mental-health-problems-introduction/about-mental-health-problems/.

Roundabout. Roundabout Dramatherapy. , 2012.

The National Opera. “ENO Breathe | English National Opera.” ENO Breathe | English National Opera, eno.org/eno-breathe/.

Versluys, Benthe. “Adults with an Anxiety Disorder or with an Obsessive-Compulsive Disorder Are Less Playful: A Matched Control Comparison.” The Arts in Psychotherapy, vol. 56, Nov. 2017, pp. 117–128, 10.1016/j.aip.2017.06.003. Accessed 10 Dec. 2018.

World Health Organization. “Mental Health: Strengthening Our Response.” World Health Organization, World Health Organization: WHO, 30 Mar. 2018, www.who.int/news-room/fact-sheets/detail/mental-health-strengthening-our-response.