• Visual arts, music, drama & theatre, movement art & dancing & creative writing based methods, interventions & tools can be used & incorporated in clinical & community settings

Various artistic modalities and activities including the visual arts, music, drama, theatre, movement based art and dancing, and creative writing, can be used or incorporated as alternative or supplementary treatment methods and interventions and tools in the psychiatric practice, both in the clinical and community settings, targeting the treatment and prevention of mental health issues and the awareness and promotion of mental health.

These observations were made in an opinion piece on ‘Towards the same goal from different ends: The use of arts in the psychiatric practice’ which was authored by N. Liyanage and published in the Sri Lanka Journal of Psychiatry's 14th Volume's Second Issue in April of this year.

By the beginning of the 20th Century, medicine had emerged as a scientific discipline. It is true for any branch of medicine, including psychiatry. More emphasis has been given to studying the biological basis of disorders, and there are developments in understanding the molecular genetics underlying diseases, the application of structural and functional imaging, and the development of more specific medications targeting specific receptors of the brain.

But, with all the recent advances in medicine, it has been debated in M. Greenberg and S.S. Shergill's ‘Narratives in psychiatry’ whether there is something missing in contemporary medicine known as the ‘art of medicine’. Nowadays, we frequently see concerns and criticisms in the public media, social media, and even professional literature about what is seen as a lack of confidence in modern doctors as good listeners, communicators, and healers. One of the major criticisms, as mentioned in A. Batistatou, E.A. Doulis, D. Tiniakos, A. Anogiannaki and K. Charalabopoulos's ‘The introduction of medical humanities in the undergraduate curriculum of Greek medical schools: Challenge and necessity’, is that modern day doctors are more inclined to see the ‘symptoms’ than the patient as a whole with their expectations, imaginations, hopes, fears, intuitions, beliefs, or perceptions. Therefore, most of the time, in modern times, patients become the victims of biology. The irony is that all these concerns occur in an era when scientific gains in diagnosis and treatment have never been more impressive. This concern is more important for psychiatrists as clinicians who deal with human psychology. Can they ignore their patient’s existence as a whole human being, which not only includes the biological aspect of the disorder? It is in this context that we see a growing emphasis on the concept of ‘medical humanities’. Medical humanities, per B. Hurwitz and P. Dakin's ‘Welcome developments in United Kingdom medical humanities’ include medical ethics, medical sociology, the social history of medicine and the application of literature and the arts to medicine. The application of principles of medical humanities, including the utilisation of arts and literature, provides, according to N. Rogers's ‘The creative connection?: Expressive arts as healing’, a platform for a better therapeutic relationship.

Use of artistic activities to promote expression, communication & treatment engagement

In psychiatry, the assessment, diagnosis, treatment, and prognosis heavily depend on the complex and sensitive relationship between the doctor and the patient. An empathic understanding of the patient’s context is pivotal throughout the doctor-patient relationship. This can however, as noted by P. Cowen, P. Harrison, T. Burns and M. Fazel in the ‘Shorter Oxford Textbook of Psychiatry Seventh Edition’, be a challenge in situations where patients present with poor or partial insight about their presentation and how they affect them and others. These sorts of presentations are not uncommon in the psychiatric practice compared to other medical specialties. Especially in situations where patients are treated involuntarily, the doctor-patient relationship, as pointed out in V. Harbishettar, K.R. Krishna, P. Srinivasa and M. Gowda's ‘The enigma of the doctor-patient relationship’, faces an extra challenge. One of the main reasons that patients are hesitant to continue treatment is that they believe that they are losing control of their lives once they are diagnosed with a mental illness. The stigma attached to mental illnesses, the fear of judgement, a sense that they have limited control over the changes that will occur as a result of the diagnosis, fears about what a therapist may discover about them, self pride that they do not require professional help, and a lack of mental health literacy are, as elaborated in J.W. Moore's ‘What is the sense of agency and why does it matter?’, some of the few reasons for not seeking psychiatric treatment. Considering all these factors, losing one’s sense of autonomy is a major contributor to poor treatment adherence.

In this context, as emphasised in J. Hu, J. Zhang, L. Hu, H. Yu and J. Xu's ‘Art therapy: A complementary treatment for mental disorders’ and A. Shukla, S.G. Choudhari, A.M. Gaidhane and Z.Q. Syed's ‘Role of art therapy in the promotion of mental health: A critical review’, art has long been recognised as a therapeutic tool for those with mental health issues, providing means of expression and communication that can help individuals to cope with emotional and psychological challenges.

It is beneficial if mental health clinicians can convince patients that their perceptions, imaginations, fears, hopes, and even their response to the illness have an impact on their inner world, and that that is something that they can, as maintained in K. Estrella's review of Rogers' ‘The creative connection: Expressive arts as healing’, change. It provides patients with some sense of agency. Expressive art therapy is helpful to bridge this gap between the outer world and the patient’s inner world.

The concept of expressive art therapy was developed by N. Rogers in 1993. She is the daughter of American psychologist C.R. Rogers. She has extended C.R. Rogers' person centred approach by incorporating art, movement, writing, and music. It uses creative activities to help the patients process their feelings, memories and perceptions, which are hard to put into words. The objective was to connect with the clients and help them process emotions. ‘Emotional processing’ is defined by S. Rachman, as the modification of memory related structures that underlie emotions. Processing emotions is about learning to understand, make sense of and deal with emotions in healthy and productive ways so that the negative emotions, as detailed in ‘Emotional processing – An overview’, are diminished to the extent that other experiences and behaviours can proceed without disruption. J. Holmes's ‘Can poetry help us become better psychiatrists?’ found that song lyrics offered a personal connection to life events. This gives access to the human experience in non-technical language and helps to acquire more expressive language. In turn, this helps both the patient and the doctor to deepen their understanding of how that particular person presented with that particular symptom cluster at that time in his or her life. This will, according to A.C. DeDiego's ‘The use of song lyrics as an expressive arts tool in counselling: A literature review’, in a way, help in formulating the patient’s presentation and in devising a better collaborative treatment plan.

Use of artistic activities to develop empathy

On the other hand, art can be used as a tool to develop empathy in psychiatric practice. Empathy is defined as the ability to feel oneself in the situation of another. Empathy uses the ability of the psychiatrist, as a fellow human being, to experience the patient’s subjective state. The benefits of empathy are not limited to patients but also to doctors. Various artistic modalities can be used effectively to improve the empathy of mental health professionals. F. Oyebode's ‘Editorial: Literature and psychiatry’ notes: “like every other skill, our moral imagination, that is, our empathy, needs to be exercised and tested and literature provides a safe way of doing it”. By encouraging patients to express difficult experiences like trauma through artistic platforms, mental health clinicians can gain a better understanding of their clients’ experiences. And sometimes, as clinicians, certain artistic creations help understand as to why some people continue with what they are going through. As an example, consider the case of a survivor of domestic violence. As clinicians, how many times have the treating teams rushed to come up with solutions without understanding the patient’s real social context? It is common for clinicians to take a problem solving approach in these kinds of instances. But, the survivor’s experience and expectations may differ from what the clinicians suggest for them to practise. Artistic modalities like song lyrics give clinicians a better understanding of the patients’ experiences, thereby helping them empathise more with them. This resonates more with what patients go through simply because the lyricist is from their same cultural background.

I. Braito, T. Rudd, D. Buyuktaskin, M. Ahmed, C. Glancy and A. Mulligan's ‘Review: systematic review of the effectiveness of art psychotherapy in children with mental health disorders’ has shown that art therapy and art psychotherapy provide a non-invasive therapeutic environment for children and adolescents to work through their fears, traumas and difficulties. Techniques such as role playing and analysing other artists’ work (A.L.A. Haq and L. Qomariyah's ‘The effectiveness of play therapy and role playing in reducing children’s aggressive behaviour’ and J.S. Potash, R.T.H. Ho, J.K.Y. Chick and F.S.W.A. Yeung's ‘Viewing and engaging in an art therapy exhibit by people living with mental illness: Implications for empathy and social change’) allow patients to understand how others may feel in similar situations. It gives the patients the opportunity to see the world through new eyes.

Use of artistic activities in mental health promotion 

Each culture influences the way that people understand mental health and their regard for it. Therefore, it is necessary to understand a particular community’s concepts of mental health before engaging in mental health promotion. The advantage is that the messages delivered through these channels can be designed to match cultural variations and expectations. S.M. Gaiha, T.T. Salisbury, S. Usmani, M. Koschorke, U. Raman and M. Petticrew's ‘Effectiveness of arts interventions to reduce mental health related stigma among youth: A systematic review and meta analysis’, A.J. Carson, N.L. Chappell and C.J. Knight's ‘Promoting health and innovative health promotion practice through a community arts centre’ and N. Daykin, J. Orme, D. Evans, D. Salmon, M. McEachran and S. Brain's ‘The impact of participation in performing arts on adolescent health and behaviour: A systematic review of the literature’ have shown that various artistic interventions are effective in reducing the mental health related stigma and delivering important mental health related messages to the community. Thus, as pointed out in A. Renton, G. Phillips, N. Daykin, G. Yu, K. Taylor and M. Petticrew's ‘Think of your arteries: Arts participation, behavioural cardiovascular risk factors and mental well-being in deprived communities in London, England’, there is an advocacy for the substantial use of creative art related work to address social and cultural determinants of poor health.