Art Therapy with the Extent of Health Promotion

Abstract

Health and art disciplines have worked in cooperation for the development of health from past to present. Today’s understanding of health requires the integration of concepts, such as creative thinking, intuitive and aesthetic knowledge, spiritual awareness, integration, and maturation, which are extremely important in the development of health. The examination of the process of making and creating art and the development of aesthetic sensations that occur at the end of this process play an important role in both the development of health, the growth and maturation of the individual, and the recovery and repair of illness. Art activities not only support holistic health but also act as a source of motivation for well-being. The inclusion of art in health care services has positive effects on society from the more broad perspective of health professionals, patients, and their families. In this review, the relationship between art and health, which is as old as human history, is discussed in line with the literature review, and the dimension of art in improving health is examined. In addition, in line with the studies carried out, the effects of art therapy on individuals with health problems and art therapy methods are discussed.

1. Introduction

While factors such as trade growth, ease of global travel, and technological progress affect health positively, on the other hand, changes in lifestyle, such as especially stress, unhealthy nutrition, and a decrease in physical activity, have caused health to be negatively affected. Besides, factors such as the increase in natural disasters, financial crises, and security threats are other conditions that negatively affect health. Today, the disease burden has increased significantly with the prolongation of a lifetime with the increase of infectious diseases and noncommunicable chronic diseases that have become active again with the effect of mass population movements, such as migration [1, 2].

Parallel to the social developments in this age, the changing necessities of individuals and communities have also changed the perspective on health, so a health-centered care approach that protects, maintains, and improves the health of the individual, family, and society has gained importance today. This understanding is based on enabling the individual to acquire behaviors that will protect and improve their well-being and make the right decisions about their own health [2]. The World Health Organization (WHO) defines health as “not only the absence of disease or disability but also a complete well-being in terms of physical, mental, and social” [3]. Health is a fundamental human right. In the Ottawa Convention, it is emphasized that to be healthy, there must be food, shelter, peace, as well as sufficient economic resources, a coherent ecosystem, and sustainable resources to maintain health. The acceptance of these prerequisites suggests the relationships between factors such as physical environment, economy, lifestyle, and health. These correlates provide a basis for a health holistic approach at the heart of the definition of health promotion [3, 4].

Health promotion is effective in improving the well-being of individuals physically, psychologically, educationally, and professionally, thanks to preventing health problems, encouraging healthy lifestyles, and facilitating access to health services. Besides, health promotion plays an important role in controlling overall health costs and making families, communities, workplaces, and organizations healthier [5]. Today, the health system and all professions serving in this field need to transform their laws and regulations, vocational training, and practices in a way that will help people to reach optimal health, which is defined as complete well-being in terms of physical, mental, social, emotional, and intellectual [6]. This situation maybe mediated through activities, such as lifestyle changes, raising awareness, changing behavior, and creating environments that support healthy behaviors. It is also the process of enabling individuals to increase control over and improve their own health [7]. Many health behaviors and health promotion theories have been adapted from social learning and behavioral theories and applied to epidemiology, biology, and health sciences. Art and creativity were often excluded from them. Nonetheless, today’s understanding of health requires the integration of concepts, such as creative thinking, intuitive and aesthetic knowledge, spiritual awareness, integration, and maturation, which are extremely important in the development of health [8]. The examination of the processes of making and creating art and the development of aesthetic sensations that occur at the end of this process play an important role in both the development of health, the growth and maturation of the individual, and the recovery and repair of illness [9, 10]. Art activities not only support holistic health but also act as a source of motivation for well-being. The inclusion of art in health care services has positive effects on society from the more broad perspective of health professionals, patients, and their families [11]. WHO [9] states that art therapy has an important effect on preventing diseases and finding solutions in the management of diseases.

2. The concept of health promotion

The best-known definition of health promotion is the definition in WHO’s Ottawa Convention. Health promotion in the Ottawa Convention is stated as “a process that aims to increase people’s control on their health and creates opportunities for them to promote their health” [9, 12]. Health promotion is a process that uses biological, environmental, psychological, and physical components to create impacts on health and prevent illness, disability, and premature death through educational-oriented voluntary behavior change activities [12]. The promotion of health occurs by means of being realized comprehensively without considering each other separately of the social, cultural, political, and economic processes in the society. This process aims to change or improve the characteristics, feelings and thoughts, actions of people, as well as to positively change the health behaviors, possessed environmental and economic conditions in the society [1, 6]. Health has entered into the process of radical change and promotion through the awareness-raising of health promotion and the worldwide adoption of the importance of the concept. The common purpose of health policies particular to each country is to increase the number of healthy individuals in society and to promote public health [1, 2]. The main source of promoting health and reaching the targeted community criteria in health is to increase the “protective and preventive” activities, which are qualified as the first step in the health sector [5, 6]. In this context, ways to promote health may be specified as strengthening the health system, empowering the individual, empowering the society, forming healthy society policies and cooperating between sectors in health for implementing, and increasing the capacity to improve health [7]. One of the methods of improving health and empowering the individual can be through art. Art therapy began to be widely used, especially in the rehabilitation works carried out in the second world war. The term “Art Therapy” was first used by Adrian Hill in 1942 when he was teaching painting at the King Edward VII Sanatorium. Expressive art therapy is used for therapy that uses all art disciplines. Therapists practicing the discipline of expressive art therapy mostly determine their own therapy methods by integrating one or more of the limited areas of psychotherapy methods, such as painting therapy, reading therapy, dance therapy, drama therapy, music therapy, poetry therapy, and psychodrama. Since expressionist art therapy is a practice that took shape in the last half of the 20th century, it still continues to develop and continues to expand its scope and definition [8, 13]. People have benefited from art for centuries to eliminate mental and physical ailments and they still continue to use it as a treatment method. Many different cultures have embraced the idea that creative expression can make a powerful contribution to the healing process. Throughout recorded history, painting, stories, dance, and music have been part of people’s lives as healing rituals. Considering the physiological and psychological effects of art, many applications have been made as a method specific to the disorder [14]. Art, which is the way people express themselves, is a way of expressing their feelings, thoughts, and ideas with the help of artistic expressions. On this path, there is psychological relaxation, spiritual rest, and emotional calmness. With the materials used while doing this, it enables people to reflect their weakness, stress, and anxiety, in short, their negative feelings or positive feelings in the opposite direction, or what individuals want to tell, with shapes and symbols that they reveal through art [15]. Art therapy is to reveal the creative process by using art materials therapeutically together with an instructor who has received art therapy training to make individuals feel good. With this method, people rediscover their feelings and themselves, express their thoughts, make them question themselves, provide psychological relief, acquire the ability to manage their own behavior, gain skills, develop self-confidence, reduce stress and anxiety levels, and provide satisfaction, relaxation and comfort.

In all known societies in the world since prehistoric and primitive societies, artistic activities, such as temples, houses, painting, sculpture, and weaving, were carried out. Looking at ancient Greece, medicine and art have been accepted as an inseparable whole. It was believed that healing is spiritual as well as physical and this is possible with art. In the kingdom of Apollo, science and art were referred to as an indispensable part of human health as a whole. In other words, art has taken place in social life starting from an early age. Birth, death, marriage, harvest or crop ceremonies, and religious, spiritual and physical healing rituals were intertwined with art. Ancient people made art a part of their lives by singing, dancing, drumming, drawing, or telling stories [13, 15]. In general, art has an important contribution to human health. Since antiquity, music, painting, theater, and similar human creations have had a healing effect not only on sick individuals but also on normal people. Aside from the healing power of art in people with mental disorders, the positive effects it has on the morale of people, in general, have continued throughout human history [8]. Margaret Naumberg made the first definition of art therapy as a profession in America. She defined it in 1915 at the school where she was the principal and started to implement it. The discovery of the therapeutic power of art dates back to the 1940s. Its professional use began in the 1960s. Adrian Hill claimed that the drawings and paintings they made with tuberculosis patients not only allowed them to evaluate time but also allowed people to express their emotions and traumatic experiences. In 1958, the first art therapy course was opened at New York University, which also taught his methods and principles [8, 13, 15].

3. The concept of art therapy

Art has taken place in social life starting from ancient times. Birth, death, marriage, harvest or crop ceremonies and religious, spiritual and physical healing rituals were performed with artistic activities. Ancient people made art a part of their lives by singing, dancing, drumming, drawing, or telling stories [10, 11]. In a general manner, art has an important contribution to human health. Since ancient times, music, drawing, theater, and similar human creations have had a healing effect not only on sick individuals but also on normal people. In other respects, the healing power of art in people with mental disorders, and the positive effects it has on the morale of people, in general, have continued throughout human history [8, 16].

Art therapy has been used as a therapeutic method, which is characterized as a power to increase health and well-being since the beginning of the 21st century [8]. Art therapy, which is defined as the use of art to improve and strengthen the physical, mental, and emotional health of individuals, benefits from the creative, productive, and dynamic effect of art through artistic activities. Accordingly, art therapy is based on the belief that this creative process, which includes artistic self-expression, helps people resolve conflicts and troubles, improve interpersonal skills, reduce stress, manage behavior, increase self-esteem and self-awareness, and gain insight [17]. In other words, it is the use of performing art by professionals, as a developer and therapeutic, for people who experience disease, trauma, or life difficulties, or who only demand personal development. Performing and using art has been validated to overcome art and other traumatic experiences, improve cognitive skills, and increase getting pleasure in life [8, 13, 18].

The American Art Therapy Association defines art therapy as a mental health profession that uses the creative process of making art to heal and enhance the mental, physical, and emotional well-being of individuals of all ages [17]. The American Art Therapy Association considers this process as the process of making art in a professional relationship with individuals who have mental disorders, experience traumatic processes, and are exposed to difficult living conditions. Individuals’ awareness can be improved with the process of making art and what is reflected in the art product, and individuals with mental disorders can better cope with the symptoms caused by their illness. The art creation process provides support to clients in terms of increasing cognitive functions and life satisfaction. According to the Canadian Art Therapy Association, art psychotherapy is the use of what the client reflects on the art product to increase mental, physical, and emotional well-being in the creative process.

Art therapy is a means of creating psychological maturation in individuals by benefiting the power of imagination to create insight, integrity, and healing using art materials. Art therapy is a quite successful and effective means of expressing repressed emotions and underlying conflicts through verbal language. Art therapy is a treatment method used in many spiritual, developmental, neurological, mental, and behavioral disorders. Art therapy is a treatment method used in many spiritual, developmental, neurological, mental, and behavioral disorders. Many art therapists agree that the creative process has a healing power itself [8, 9, 10, 11]. For example, a Cochrane review looked at the impact of dance/movement therapy on psychological and physical outcomes in people with cancer. It was determined that dance/movement therapy may have beneficial effects on quality of life and somatization [19]. In another study, which included 421 people and examined nine studies, it was determined that music therapy reduced depressive symptoms and anxiety and supported individuals to continue their daily activities [20]. In a study on Alzheimer’s disease testing the feasibility and effectiveness of a multidimensional visual arts intervention called Art, Colors, and Emotions therapy (ACE-t), they reported an improvement in the management of behavioral and psychological symptoms in dementia and a significantly higher measured quality of life [21]. In a study conducted on 55 cancer patients, it was found that there was a significant decrease in pain, fatigue, and anxiety levels after art therapy sessions [22]. Ataseven (2018) applied a 10-week art therapy program to schizophrenic patients receiving inpatient treatment, and it was found that it was beneficial in improving symptom profile, subjective well-being, and insight levels in schizophrenic patients who attended the sessions [23]. According to the findings of another study conducted to improve the psycho-emotional and motor skills of the elderly, using dance and theater elements in art therapy is effective in the treatment and rehabilitation of nervous system and musculoskeletal system diseases and injuries of the elderly, getting away from different problems and gaining new skills [24]. Art therapy enables individuals to express themselves creatively using art and to communicate differently with themselves, others, and their reality. The National Institute for Health and Clinical Excellence (NICE) guidelines for psychosis and schizophrenia emphasize that art therapies, including art therapy, improve negative symptoms of psychosis. As a result of the review of 18 articles on the subject, it was determined that art therapy is a useful, meaningful, and acceptable intervention for patients with schizophrenia. For this reason, NICE guidelines recommend art therapy for all patients with schizophrenia, especially for symptom relief [25, 26].

The art therapy process is based on the discovery that our most basic thoughts and emotions are engraved in the subconscious, and that reaching their full expression will be through shapes rather than words. The aim of art therapy is not to eliminate one’s fears, anxieties, restlessness, and unhappiness, but to transform these negative emotions into honest expressions using some creative ways and forms [8, 27]. The aims of art therapy are as follows [27]:

1. To resolve after reaching the “I” phenomenon and the trouble by the individual’s self-expression, creativity, and ability method, to put the emotions and troubles that are difficult to express verbally on paper through art, and to overcome the formidable interferences between the specialist and the patient in a safe environment. The patient individual actually draws his troubles.

2. To solve the potential of the individual with natural expressions, the purpose here is to make easy access of the specialist to the troubles and to establish a bridge between the drawn picture, the person who draws, and the specialist. It helps to resolve emotions and thoughts that are formidable to overcome, thanks to therapy.

3. Through this practice, the person has the opportunity to think and compare by experiencing the trouble and emotions the person has experienced over and over again. Thus, a person beholds by relating between the past and the future, and he learns to take the right steps by choosing how he will react in the same situations he will encounter in the future, with the experience he has gotten as a result of his experiences.

4. The most important feature of art therapy is to compare by confronting the emotions and the unconscious subconscious through the active imagination.

The therapeutic functions of art therapy are listed below [8, 23, 28]:

• Art therapy can be used for people with different needs and challenges. By sharing thoughts and feelings through a visual, a person can experience risk-taking in a supportive relationship. Art therapy provides the emotional maturation of the person, increases self-esteem, and provides psychological and social integration.

• Externalizing the experience by creating images and objects makes it possible to talk through the embodied artwork.

• Some clients can control emotions that they cannot cope with through the images and objects they create.

• The symbols created in art therapy and the interpretation of this symbolic content lay the groundwork for self-understanding and emotional development.

• The work of art that emerges in the art therapy process with its color, shape, and stylistic aspects is permanent. The permanence of the artwork – as opposed to the temporary nature of oral expression – enables art therapists and clients, in particular, to follow and reflect on the changes that occur during therapy. It helps build a sense of focus and continuity that can be difficult to maintain in therapy.

4. Health promotion and art therapy

Art therapists offer a creative “helping” environment to their beneficiaries by integrating the types of artistic expression with helping techniques for humans. The inclusion of art therapy in health promotion practices has been known to be beneficial for so long [8, 27, 29]. Findings show that art-based practices are effective in the formation of general well-being and the improvement of mental health [30, 31]. Art practices contribute to the improvement of individuals’ health and increase their awareness of themselves and their well-being. According to WHO [9], art contributes significantly to the development of children, the prevention of health-related problems, the provision of quality care, and the formation of health-promoting behaviors. Besides, it may be possible to prevent dementia and aging-specific problems, treat stress, depression, and anxiety, and also prevent situations such as discrimination, social isolation, and loneliness, which are risk factors for mental health with the use of art therapy in health promotion programs. While it is necessary to be at least a literacy level in health education, which is important in the promotion of health, it has contributed to the improvement of individuals’ health by overcoming this interference with many practices of art therapy [32].

Art therapy has been used in clinics for more than a century and is professionally maintained. In recent years, the healing effects, benefits, and significant contributions of art to the healing process have been revealed through systematic and controlled studies, and these studies are becoming increasingly common. The art therapy method, which has been proven in Europe and America and later all over the world with scientific studies and data, has been accepted within the framework of Alternative Medicine practices in the CAMBRELLA study carried out within the European Union, in the American National Health Institute and the World Health Organization (WHO) 2014–2023 strategy document [33]. With the development of technology, it is seen that the ways of applying art therapy are diversified today. In recent years, potential possibilities for art therapy have been tried to be developed using digital technology. Interest in digital technology-based studies and applications is increasing day by day. A review was published on this topic, which included 12 studies with more than 400 records scanned. In this review, it was determined that the possibility of sharing images online and applying art therapy digitally increased by art therapists. It also concluded that technology can increase the relevance and reach of art therapy without compromising the core principles of the profession [14]. In another study examining a total of 563 works on art therapy in the visual arts, it was determined that painting, painting, and photography were the most used modalities in the field of visual arts for art therapy purposes. In these studies, it was concluded that art therapy had effects that improve rehabilitation and reduce psychological distress in patients [34]. Different clinical guidelines from the National Institute for Health and Care Excellence (NICE) include art therapy as an indication with recommended evidence. Evidence-based practices related to art therapy are included in different guidelines. The National Institute for Health and Care Excellence (NICE) presents art therapy as an indication with evidence. Nursing Interventions Classification (NIC) has accepted art therapy as a nursing intervention since the beginning of the 21st century [34, 35].

Art therapy can serve as a link through which individuals can explore past and present experiences, review one’s life, cope with, adapt to and adapt to age-related changes, and receive support or physical care during an emotional crisis, such as the loss of an organ, memory, or mobility. Art therapy is especially applied in oncology, dementia, and mental care. Oncological patients are one of the patient groups in which art therapies are most frequently used. Kaimal et al. (2019) applied art therapy to cancer patients and their caregivers. In this study, they reported that art therapy demonstrated positive behaviors, such as pleasure, relaxation, and creative problem solving, in cancer patients and caregivers after treatment. Thus, they showed that short-term art interventions can be beneficial for cancer patients and their stressed caregivers [36].

It is stated that symptoms that affect physical integrity, such as pain, are reduced in cancer patients who are treated with art therapy, the psychosocial process is positively affected, and fatigue and anxiety are reduced [36, 37]. Nainis et al. (2016) evaluated the symptoms of patients after art therapy in their study with cancer patients and observed a reduction in eight of the nine symptoms present in the patients [22].

One of the diseases in which art therapy is widely used is dementia. The NICE guideline for dementia (2016) highlights the value of art therapy for different stages and symptoms of dementia, including non-pharmacological treatments. It also discusses the value of interventions that acknowledge the complexity of the situation and address the person as a whole, including their physical, emotional, social, and cognitive processes [37]. Dementia patients often experience neuropsychiatric symptoms that reduce their quality of life. The pharmacological treatment efficacy of these symptoms is limited. People with this diagnosis need treatment that improve neuropsychiatric symptoms and quality of life. Art therapy has been found to be beneficial in dementia as a result of examining the current 45 literature. With the appropriate structure, dementia patients can produce and evaluate visual art. When a few sample art therapy studies were examined, it was observed that patients enjoyed and improved their neuropsychiatric symptoms, social behavior, and self-esteem. The use of art therapy is recommended for Alzheimer’s and other dementia disorders. In a study [38], it was found that art therapy had significant effects on improving attention and some other cognitive functions in dementia patients. In addition, it has been revealed that art therapy methods have many benefits, such as reducing behavioral and psychological symptoms in patients with dementia and their caregivers, improving the social skills of patients, and relieving the burden of dementia caregivers. In a study on another neurological problem, it was determined that art therapy improved perceptual symptoms by acting as a restorative behavior training in Parkinson’s patients [39].

Art therapy also has different effects on other health problems. For example, it enables people with disabilities to understand and express their emotions through artistic creation and creative thinking, thereby promoting self-awareness, relaxation, confidence, and self-efficacy. Blomdahl et al., (2018) reveal in their study that the patient contributes to more knowledge by deepening the understanding of the importance of talking to himself in an internal dialogue that occurs when the patient participates in the image, art materials, and art-making process [40]. According to Holmqvist et al., (2017), art therapy has proven that there are situations in which an internal change can be observed in patients by affecting consciousness, self-awareness, and ego-strength, which concerns the work in the therapeutic process [41]. On the other hand, Wahlbeck et al., (2018) proved in their study that the therapy acts as a catalyst for the healing process in women using art therapy. Art therapy has been accepted by women, and by creating visible images, they have shared the burdens of fear, gaining hope and self-confidence in the face of their upcoming birth [42].

In a Health Evidence Network synthesis report from the World Health Organization [43], they determined that there is evidence that the arts play an important role in promoting health, preventing a variety of mental and physical health conditions, and treating or managing conditions that occur throughout life.

Different modalities of art therapies, such as visual arts, music therapy, dance therapy, and drama therapy, are also used as complementary treatments for cognitive and psychological disorders of depression, stress, anxiety, or some neurological symptoms that occur with stroke [44]. In addition, art therapy methods are used to reduce the negative effects of chronic diseases, such as diabetes on the individual [45].

Art therapy as a therapeutic process is an interdisciplinary practice that uses art as an expressive process for self-knowledge and expression of conflicts and inner feelings. It is a therapeutic resource that absorbs different knowledge from many disciplines and therefore aims to heal the individual as a whole through processes of self-knowledge and transformation. Studies show that art therapy has significant effects on health promotion. A mixed-method study was conducted to examine the effects of art therapy on smoking cessation in Taiwanese young smokers. The need for smoking, nicotine addiction, self-esteem, self-efficacy, and smoking cessation were examined. Art therapy reduced adolescents’ attachment relationships and the need for an ego identity found by smoking together [46]. The intervention also improved participants’ self-efficacy, motivated their willingness to draw, and gave them the opportunity to share challenges and befriend others. Art therapy intervention in youth improved self-efficacy and self-esteem [47]. Roy and Manley (2017) conducted a dance and movement session with people in the UK who were recovering from substance abuse. They found that these activities helped establish therapeutic relationships, friendships, and bonds [48]. The value of incorporating arts-based approaches into health promotion programs has long been recognized as beneficial in influencing change. Such approaches have been used in many Australian schools and have been found to improve general well-being and mental health [29]. According to Silva (2019), the cathartic function of painting, the fluidity of the paint, and the energetic movement of the painting liberates and expands consciousness, allowing the elderly to know more about motor coordination, alertness, awakening sensitivity, intuition, creative and creative spirit, themselves and the world, and provides the expansion of perception [49]. In another study, the effect of art therapy on healthy aging was investigated and it was determined that artistic programs increased the quality of life, decreased negative emotions, anxiety, and increased self-esteem [50].

Art and health can meet in effective coping with crisis situations in a region or the world. As a matter of fact, during the COVID-19 pandemic, art therapy methods were used a lot. The World Health Organization and a coalition of cultural partners called for action to mobilize the arts in the fight against isolation, anxiety, and mourning against the mental health crisis caused by the COVID-19 pandemic. Organizations such as University College London, the Tate galleries, Italy’s Castello di Rivoli Contemporary Art Museum, England’s newly established National Center for Culture and Arts, Hospital Rooms charity and Saudi philanthropic Art Museum have united under the umbrella of the UK’s Healing Arts 2021. From 2 to 26 March, these organizations and the UK’s National Center for Culture and Arts arranged weekly virtual meetings and events [51]. In addition, the event “Visions And Voices Of A Healthy Planet: The Healing Arts for World Health Day 2022” drew attention to human-induced climate change. It was emphasized that this climate change poses a threat to the survival of people. It was also stated that climate change significantly changed people’s understanding of their own health, well-being, and place in the world. For this purpose, events, where health professionals and artists came together in times of crisis, were organized. To this end, Christopher Bailey, the Art and Health leader of the World Health Organization, headquartered in Geneva, Switzerland, focuses on mobilizing the global media to support the health benefits of art in everyday life. On the other hand, they are mapping the evidence for the physical, mental, and social health benefits of arts and art therapies for the World Health Organization, with a commission from the New York University (NYU) Creative Arts Therapies Consortium and the International Research Alliance [52].

5. Art therapy techniques

People have benefited from art for centuries to eliminate mental and physical ailments and they still continue to use it as a treatment method. Many different cultures have embraced the idea that creative expression can make a powerful contribution to the healing process. Throughout recorded history, painting, stories, dance, and music have been part of people’s lives as healing rituals. Considering the physiological and psychological effects of art, many applications have been made as a method specific to the disorder. As explained below, many ideas have been put forward and studies have been made about the contribution of art to the healing process [53]. In the art therapy process, in addition to applying the expression of only one of the different art branches, it is possible to switch from one art branch to another with an intermodel expressive approach. Major art therapy techniques are music therapy, dance therapy, poetry therapy, visual arts therapy, and drama therapy.

5.1 Music therapy

This method is also a method that has been used since ancient times, shamanism. It is a widely used therapy method in the world and especially in our country. “Music has influenced people by creating a trance and time has directed the masses. Because especially music has a feature that intensifies emotions, it has been used as a quite common method in many civilizations to strengthen religious feelings and to treat diseases [8, 54]. The music therapist helps basically treat the patient’s health by reaching the treatment methods and goals through using their musical experiences (improvisation, singing, lyricising, listening and discussing music, and moving with music) in various fields, such as cognitive functions, motor skills, emotional and effective development, behavior and social abilities, and quality of life [55]. Music therapy involves using music in a therapeutic relationship to address clients’ physical, emotional, cognitive, and social needs. Music therapy, according to the World Federation of Music Therapy [54], is defined as “the use of music and/or musical elements (sound, rhythm, melody, and harmony) to develop and increase the communication, relationship, learning, expression, mobilization, organization, and the other related therapeutic effectiveness, which they need, after designed by a trained music therapist for the purpose of physical, emotional, social, and cognitive requirements of one person or a group.” Music therapy provides different ways of communication for people who have difficulty expressing themselves with words. Research on music therapy has demonstrated the effectiveness of treatment by focusing on many areas,s such as general physical rehabilitation, increasing motivation for treatment compliance, providing emotional support to clients and their families, and providing an outlet for the expression of emotions [15, 27, 53].

In the early 1800s, music was used as a therapeutic practice to maintain and improve comfort, and music therapy was defined as a part of the healing process. In the literature, it has been emphasized that music therapy affects individuals positively by establishing a connection between their physical and cognitive characteristics. In many studies, it was found that music therapy has positive effects on health. In the meta-analysis study of Amaral et al. [55], it was found that music lowers blood pressure. In the study by Ekinci and Gökalp [56], it has been found that music therapy reduces the effect of the neuroendocrine response to stress. In the study of Zander et al. [57], it was found that the psychological and physiological health of university students who took music education for 2 years improved and the students showed healthy behaviors. In another study, it was concluded that music strengthens the body’s immune system and reduces stress level [58]. In addition, it has been reported in the literature that music therapy supports neuroplasticity in functional brain network organization [59].

Bradt et al (2021) published the results of a review called music interventions for improving psychological and physical outcomes in people with cancer. This study included 81 studies with 5576 participants. Of the 81 studies, 74 included adults and seven included children. This systematic review showed that, compared to standard care, music interventions can have beneficial effects on anxiety, depression, hope, pain, and fatigue in adults with cancer. It was concluded that music therapy, but not music medicine interventions, can improve adult patients’ quality of life and fatigue levels [60]. A meta-analysis of nine studies with a total of 421 people from any age group (adolescents to the elderly) found that music therapy was more effective than standard therapy alone. In this study, it was determined that music therapy reduced depressive symptoms and anxiety and helped to improve functioning as well as maintaining participation in work, activities, and relationships [61].

5.2 Film therapy

In movie group therapy, the film or documentary selected by the specialist is watched and discussed and commented on it with the specialist. The people who watch the movie talk about the characters of the movie among themselves, identify with them, and reveal their similar emotions. Thus, individuals experience a non-verbal relief, seriously dwell on the troubles and the causes they watch and think about the measures they can take to solve their troubles by establishing a connection between these and their own troubles, starting from the solutions in the movie. While the synthesis and the discussion of the movie are made, the troubles that are engraved in the subconscious of the individual unwittingly arise [31, 62].

It has been reported in the literature that important learning environments for health promotion can be created by using film therapy [63]. In a study conducted with 24 elderly people, it was found that film therapy had positive effects on happiness and quality of life in elderly individuals. Similarly, another study states that film therapy is an important approach to improve the health of the elderly [36]. It was contributed significantly to the promote the health of individuals with a movie therapy practice organized with 15 young women doing the sex trade. Together with this practice, it was observed that women’s sense of branding decreased and there were positive changes in the personal and professional lives of individuals [62]. In a study conducted in the United States, movie therapy was applied to enable schooled youth to have healthy sexual intercourse and to promote health in this direction. As a result of the study, it was reported that young people developed positive knowledge, attitude, and behavior toward sexuality [64].

5.3 Visual art therapy

Visual art is a field that allows people to reveal their journeys to their inner worlds with lines and colors. This expressive feature of visual arts helps individuals to discover themselves and develop their inner perceptions. These non-verbal and expressive supports enable people to be treated psychologically. This functional dimension of visual arts serves as a bridge established in the field of health [8, 17]. The American Art Therapy Association, which carries out studies on art therapy and health, has defined visual art therapy as helping individuals develop interpersonal skills in solving conflicts or individual troubles, directing behavior, reducing stress, increasing self-worth and individual awareness, and self-realization of the individual [17]. Visual art therapy is performed with dry paint, such as pastel and colored pencils; wet paint, such as gouache, marbling, oil paint, and acrylic; sculpture materials, such as play dough, clay, wire, and colored papers, that can be used for assemblage and collage; and art materials that can be prepared with recyclable wastes collected from the environment [65, 66].

Visual art therapy works with a therapist to gain awareness with the expressions that the individual creates, to cope with anxiety, depression, trauma or chronic diseases, and build self-confidence. With the use of lines and colors in visual art therapy, the person transfers his inner world to paper and works with the emotions conveyed by the therapist. The product embodied gains meaning in the therapeutic intermediate area, accompanied by the therapist. The supportive relationship of the therapist plays an important role in the meaning-making process. The unconscious material symbolized by the picture strengthens the ego [66]. In the literature, a study was conducted on women to improve breast health by using the visual art therapy method. As a result of the study, it was found that visual art is an innovative and quite suitable approach to improving breast health [65]. It was found that the stress and anxiety levels of the caregivers decreased, their positive emotions increased, and their satisfaction with handmade arts improved during the 6-month visual art therapy intervention, which was conducted with the caregivers of cancer patients. Besides, it has been reported that positive communication between caregivers, individuals with cancer, and health professionals has increased by means of visual art therapy [67]. The visual art therapy method was used in the prevention of sexually transmitted diseases through health education among high school youth. At the end of the study, it was concluded that visual art therapy is an innovative method to engage young people and that individuals’ knowledge and attitudes toward preventing hepatitis and HIV have increased [68]. In another study, it was reported that visual art therapy practiced with old persons helps individuals to age healthy and increases their well-being and quality of life [69]. Visual art therapy was included in health promotion practices, and as a result, it was observed that students’ awareness of health behaviors and their level of well-being increased in his study that Mckay and McKenzie conducted for school-age students [29].

5.4 Dance therapy

The feature of dance as an integrative and healing art dates back to ancient cultures. Dance therapy is a psychotherapy method that helps the individual’s social life and physical and emotional development [70]. Dance therapy, according to the definition of Dance and Movement Psychotherapy Institution [71], is the experience of the individual’s personal, emotional, physical, and social development and awareness of art within the framework of a creative process with the psychotherapeutic practice of movements and dance. The basis of dance therapy is based on the principle that a person’s movements reflect his thought system and emotions. As a result of perceiving and recognizing the movements of the person and expanding the movement repertoire, the dance therapist who witnesses this process helps to increase the awareness of the person, create new movement perceptions, and thus develop new communication mechanisms in their emotions and verbal communication [70].

In one study, healthy women aged 50 years and older were given a 15-week jazz dance program once a week, and significant improvements were observed in the static balance of women as a result of the study [72]. In another study using the Profile of Mood States (POMS) in people with dementia, POMS was administered to 36 people with dementia. POMS was applied to individuals with dementia before and after four therapeutic creative dance sessions, and the scores were analyzed. After the therapeutic creative dance sessions, the patients’ stress, depression and confusion decreased, the vitality factor increased significantly. Thus, it was concluded that therapeutic creative dance can provide emotional benefits to dementia patients [73]. In another study, it was found that individuals reached a higher range of motion and knee torque values, and therefore, the risk of falling of individuals decreased with the low-impact dance program performed with 26 middle-aged and old individuals [74]. In the study of Kim et al. [75], a 3-month health promotion program was conducted with old individuals to examine changes in health behaviors, cardiovascular risk factors, and life satisfaction. It has been reported that Korean traditional dance figures practiced by elderly individuals for 3 months are effective in improving health behaviors, increasing life satisfaction, and reducing cardiovascular risk factors in the study. A Greek traditional dance program was practiced for 24 weeks in the study conducted with women with 27 breast cancer survivors. In the study, it was found that dance could be an alternative physical activity option for breast cancer survivors and could provide significant improvements in strength, physical function, and mood [76]. In the study of Argiriadou et al. [77], a Greek traditional dance program was practiced by middle-aged women. It has been concluded that dance significantly improved the subjective health of middle-aged women in the study.

Combining science and art, psychoballet makes use of artistic activities, such as dance, ballet, and theatre. It is aimed to improve the quality of life of people with psychiatric problems or people with disabilities, through artistic activities, such as dance and ballet, and they are rehabilitated, thus helping them to integrate with society and not be socially disconnected. With psychoballet, its effectiveness has been confirmed in people with body image and eating disorders, chronic diseases (human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) and breast cancer), fibromyalgia, and people with disabilities [78].

In another study, Cernuda and Andrés (2019) studied the benefits of Cuban psychoballet in Alzheimer’s patients. In this study, psychobalding by Alzheimer’s patients had effects such as delaying neurodegeneration and recovering cognitive memories in them [79]. The results of this study revealed that psychobalene is an important and useful non-pharmacological method in patients with Alzheimer’s and other dementias.

5.5 Drama therapy

The aim of drama therapy is to show the emotions, thoughts, and characters undertaken in the closest possible way to reality. Individuals are offered the opportunity to judge their own emotions and thoughts and the events they experience from a different perspective [8, 80]. It has been proven that theater is a quite effective and enjoyable practice in promoting health, developing healthy lifestyle behaviors, and strengthening positive health perceptions in the literature [18, 80]. The content of theatrical production in any drama therapy aimed at improving health should be prepared by taking into account the knowledge, attitudes, and behaviors of individuals. In the content, the situations that prevent individuals from changing their behavior should be analyzed and this area should be especially focused on. Individuals to ask questions, discuss, and being allowed for role play about the current trouble enables them to experience behavioral change toward these troubles with this therapy method [32]. In drama therapy, especially socially isolated and shy individuals open up, and the importance they attach to group values and interpersonal relationships begins to increase. Since the client knows that he is pretending, he gets rid of the anxiety caused by revealing himself. Even if individuals pretend, they will start to be themselves after a while, so the problems and conflicts they experience outside begin to be seen during the game. Drama therapy is a very useful method in both diagnosis and treatment. It also has significant effects on older individuals.

In one study, an intergenerational theater group was formed of older adults and university students. As a result of the study, it was reported that the theater improved intergenerational relations and age discrimination decreased. Besides, it has been reported that this practice contributes to the development of health by helping to build self-esteem and confidence, and the development of empathy, social justice, and support feeling between university students and older adults [81]. In Wimpenney’s study [82], a theater group was formed from individuals over 50 years of age. It has been stated that this practice provides healing to the health and well-being of individuals. Drama therapy was performed with individuals 6 and 7-year-old in the literature. As a result of the therapy, it was observed that the children began to speak fluently, their mental lexicon improved, and their creativity and concentration increased. Moreover, children’s self-confidence and motivation have increased and their communication skills have improved, thanks to this practice [80].

5.6 Poetry therapy

Poetry therapy, based on the healing power of words, offers unique opportunities for individuals to improvise and exhibit creative behaviors. Poetry has a healing power in itself; therefore, it is used efficiently and effectively for the purpose of establishing therapeutic relationships with individuals. Reading and writing poetry positively affect both the personal and interpersonal aspects of the individual. Poetry therapy contributes to becoming clear in the individual’s perception of himself and others; increased creativity, self-confidence, and self-expression skills; relieving stress by putting intense emotions on paper; creating new meanings by synthesizing new ideas, insights, and information; to the development of mature coping skills that will enable change in behavior and attitudes [8, 11, 83]. Poetry is used as a tool for the expression of emotions that are difficult to express. This method allows individuals to express themselves, increase self-awareness, help individuals understand their own world, redefine their situations by opening new ways of perceiving reality, and enable therapists to gain deeper knowledge about their clients.

It has been proven that poetry therapy is important for end-stage individuals receiving palliative care treatment, their caregivers, and health professionals in a study in the literature. In this study, it was determined that the feeling of loneliness was reduced and the quality of personal care increased with poetry treatment [11]. It is stated the importance of using poetry therapy by health professionals in a health promotion program for health education in another study [83]. In another study, it was reported that poetry therapy is an effective method to eliminate the loneliness in society and to establish social interaction between individuals during pandemic periods [84].

5.7 Mandala

Mandala is a circle consisting of geometric or organic forms, starting with a point and continuing indefinitely. In nature, sunflowers, tree trunks, and animal patterns, many examples can be seen. Man-made mandalas reflect symbols of eastern and western cultures that have different meanings together. In art therapy, the mandala has a different place because it helps to heal and develops consciousness. Starting with a point in the center and continuing, this technique grows as you draw, creating a meditative effect on individuals. It relaxes them, relaxes them, increases creativity and individual awareness. Mandala is a method of concentration. While drawing, all attention should be given to the drawn lines. Thus, it is ensured that the person stays in the moment. This helps the person to keep himself away from stress, worry, and anxiety [53]. Mandala making in art therapy is used to help patients feel at the center of their lives, to express themselves, and to help people discover who they are in the group [85].

6. Conclusion

As a result, the increase in communicable diseases and noncommunicable chronic diseases has provided preventive and preventive studies gain importance. This situation reveals the necessity of integrating art therapy into health promotion practices. By means of integrated art-based approaches, individuals gain and maintain health-promoting knowledge, attitudes, and behaviors. In this study, it has been proven that healthy life and well-being for individuals of all ages, which is the main purpose of health promotion programs, is possible with art therapy practices. Despite the critical importance of art therapy in the health promotion program, studies on this field in the literature are insufficient. Therefore, health professionals and disciplines in the field of art should direct their work together, and increase the health and well-being of society by increasing the evidence on this subject.

Acknowledgments

This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.

Conflict of interest

The authors declare no conflict of interest.