Creative Arts Interventions for Stress Management and Prevention—A Systematic Review

Stress is one of the world’s largest health problems, leading to exhaustion, burnout, anxiety, a weak immune system, or even organ damage. In Germany, stress-induced work absenteeism costs about 20 billion Euros per year. Therefore, it is not surprising that the Central Federal Association of the public Health Insurance Funds in Germany ascribes particular importance to stress prevention and stress management as well as health enhancing measures. Building on current integrative and embodied stress theories, Creative Arts Therapies (CATs) or arts interventions are an innovative way to prevent stress and improve stress management. CATs encompass art, music, dance/movement, and drama therapy as their four major modalities. In order to obtain an overview of CATs and arts interventions’ efficacy in the context of stress reduction and management, we conducted a systematic review with a search in the following data bases: Academic Search Complete, ERIC, Medline, Psyndex, PsycINFO and SocINDEX. Studies were included employing the PICOS principle and rated according to their evidence level. We included 37 studies, 73% of which were randomized controlled trials. 81.1% of the included studies reported a significant reduction of stress in the participants due to interventions of one of the four arts modalities.


Introduction
According to the World Health Organization (WHO), stress is currently the world's most pronounced health risk [1]. Consequences of stress are constant agitation, exhaustion, burnout, helplessness, fear, and eventually a weak immune system or even organ damage [2]. The inability to cope with stress is a risk factor for various epidemiologically significant illnesses: cardiovascular, muscular or skeletal diseases, depression or anxiety disorders [3]. Russ et al. [4] showed that stress and other psychological health problems have an effect on the mortality risk of otherwise healthy individuals. In Germany, for the last 15 years, health insurance companies have registered a drastic increase in stress-induced absenteeism at work [5]. Interviewing 1200 German participants from various religious, age, and milieu backgrounds, the health insurance fund Techniker Krankenkasse (TK) [5] found that 6 out of 10 people report to experience stress privately or at work, with 23% out of those feeling extremely stressed. Stress-induced absenteeism costs German companies about 20 billion Euros annually [5]. Furthermore, not only adults are affected: a comparative study of the WHO found

Researching CATs and Arts Interventions in the Context of Stress Prevention and Stress Management
From an empirical point of view, research on CATs and health-restoring arts interventions is metaphorically speaking in its infancy or adolescence. Drawing from experiential knowledge of individual practitioners a grand literature base of case studies and clinical recommendations has developed, with an only recently growing number of evidence-based studies that provide generalizable, and transferable data [37,38]. CATs are used world-wide in a variety of contexts with many different populations. In addition to creative arts therapists, there are artists offering creative interventions to the patients in health institutions. They most often work without a therapeutic professional background, but also use the potential of the arts in order to foster health. In addition, psychologists, physicians, and other health care professions are increasingly discovering the contribution of the arts in their settings and conduct studies to investigate the workings of the "arts in health". To do justice to the heterogeneity of creative arts intervention studies in health care, this review includes studies on all CATs as well as arts (art, music, dance and drama) interventions. Mere arts interventions include interventions conducted by, for example, an artist (no licensed creative arts therapist) as well as single session interventions that not necessarily have a therapeutic intention. Both, CATs and arts intervention studies are referred to collectively as creative arts interventions. To understand creative arts interventions, and to strengthen their development for instance by identifying indications and contraindications, it is indicated to inspect them in various applied contexts. The systematic review at hand provides an overview of evidence-based studies on stress management and stress prevention through creative arts interventions. Its goal is to promote a dialogue with various health practitioners and institutions on the potential and limitations of creative arts interventions in the context of stress prevention. To the knowledge of the authors this review is the first on the topic.

Methods
In a systematic data base search, we collected empirical studies from 1980-2016, which investigated CATs or arts interventions in the context of stress prevention. The cutoff date for the search was the third of August 2016. In addition, we contacted experts in the field and asked them to hand in studies until the end of 2016. The following data bases were searched: Academic Search Complete, ERIC, Medline, Psyndex, PsycINFO, and SocINDEX. Search terms were: art therapy OR art psychotherapy OR creative arts therapies OR drama therapy OR dance therapy OR music therapy AND stress; art AND music AND movement therapy; arts AND health OR mental health treatment OR prevention; arts AND professional education OR training. See Figure 1 for an overview of the search and study selection process. Only studies published in peer-reviewed journals were included. example, an artist (no licensed creative arts therapist) as well as single session interventions that not necessarily have a therapeutic intention. Both, CATs and arts intervention studies are referred to collectively as creative arts interventions. To understand creative arts interventions, and to strengthen their development for instance by identifying indications and contraindications, it is indicated to inspect them in various applied contexts. The systematic review at hand provides an overview of evidence-based studies on stress management and stress prevention through creative arts interventions. Its goal is to promote a dialogue with various health practitioners and institutions on the potential and limitations of creative arts interventions in the context of stress prevention. To the knowledge of the authors this review is the first on the topic.

Methods
In a systematic data base search, we collected empirical studies from 1980-2016, which investigated CATs or arts interventions in the context of stress prevention. The cutoff date for the search was the third of August 2016. In addition, we contacted experts in the field and asked them to hand in studies until the end of 2016. The following data bases were searched: Academic Search Complete, ERIC, Medline, Psyndex, PsycINFO, and SocINDEX. Search terms were: art therapy OR art psychotherapy OR creative arts therapies OR drama therapy OR dance therapy OR music therapy AND stress; art AND music AND movement therapy; arts AND health OR mental health treatment OR prevention; arts AND professional education OR training. See Figure 1 for an overview of the search and study selection process. Only studies published in peer-reviewed journals were included.

Process of the Systematic Study Search
The systematic data base search yielded 243 studies. Studies were scanned following the PICOS principle (patient, intervention, control, outcome, study design) [39]. In a first step, the criterion "patient" was analyzed. To stay in the context of prevention and avoid an overlap with creative arts interventions for acute disorders, for example, in the area of mental health, only studies targeting healthy individuals or people at risk were included. Studies were excluded, if they did not analyze arts interventions in a preventive context. We included both adults and minors, because both groups have been found to be affected by stress. After the first round of exclusions on the base of these criteria, 86 studies remained. In a second step, the studies were scanned according to the criterion "intervention". Aside from studies that specifically applied CATs, we also included studies, which provided arts interventions (art, dance, music or drama with a group of participants, see reasoning for this decision above).
In Table 1 CATs are demarcated from mere arts interventions by color coding: clinical studies of  CATs are colored green, single session studies of CATs and studies on arts interventions are colored black. Single-session interventions conducted by CATs or other professions were rated as mere arts interventions, because those studies do not fulfill the criterion of containing a therapeutic process with a therapeutic relationship. Interventions neither had to be standardized, nor had to have the same duration. This heterogeneity reflects the variability of creative arts interventions in practice. Fifty-three studies remained. We included studies of evidence levels Ia-III. Evidence levels were defined according to the Agency for Healthcare Research and Quality (AHRQ) [40], rated by the first author and confirmed by the fourth author. Case studies were excluded. Concerning the criteria "control", "outcome", and "study-design", studies should at least operate with a quasi-experimental design, preferably have a control group, and should clearly state their outcome variables. Qualitative, quantitative, as well as mixed method studies were included, as long as their method was clearly stated (in the qualitative realm, e.g., content analysis after Mayring [41]). After checking the remaining studies for those criteria, 32 studies remained. Five studies were handed in by experts after the cut-off date and thoroughly checked for the criteria named above. In total, we analyzed and compared 37 studies.  Stress reduction, anxiety reduction and reduction of the degree of depression sig. higher in the EG with music therapy intervention than in the CG (see Table 4 Sig. stress reduction, increased energy, empowerment and a sense of community (see Table 3  Negative stress management strategies decreased sig. in short and long term comparisons, positive strategies of distraction increased, as well as relaxation; sig. short-term improvements in the BSI, especially with regard to anxiety scores; QoL dimensions were sig. better in the EG than in the CG (see Tables 4 and 5, pp. 447-448, in the original study).  Table 1 summarizes content, sample, and intervention characteristics, design, research methods, and results of the studies identified . In total, 37 studies met our inclusion criteria, 11 studies (29.7%) investigated the effect of AT or art interventions on stress, 20 studies (54.1%) focused on MT or musical interventions, and 6 studies (16.2%) assessed the effects of DMT or dance interventions. There were no studies on DT or drama interventions that met the inclusion criteria. In total, 2136 subjects were included: 465 took part in AT or art interventions for stress management, 1241 in MT or musical interventions, and 430 in DMT or dance interventions. Most participants were women (see Table 1). Some studies did not display demographic data of their samples, and were omitted in the respective calculations. The mean age of participants was M = 32.  Table 2 gives an analytical overview of the numbers of respective studies by arts modality. As presumed earlier, most of the studies were conducted and published after 2000. Only five studies (13.5%) were published between 1980 and 1999, four of them on musical interventions, one on MT. No meta-analysis (evidence level Ia) was found on CATs or arts interventions for stress management and stress prevention. In total, we found 27 randomized controlled trials (RCTs, evidence level Ib), accounting for 73% of the included studies. Ten of the RCTs analyzed CATs, the remaining seventeen examined the effects of arts interventions. Five studies (13.5%) were rated evidence level IIa (two on CATs, three on arts interventions), two studies (5.4%) were rated evidence level IIb (all on arts interventions), and three studies (8.1%) evidence level III (all on arts interventions). Most of the studies (16; 59.3%) on the highest evidence level came from the area of Music: 9 studies analyzed MT, seven examined music interventions. With eight studies, AT provided 29.6% of the studies on evidence level Ib (none on AT, all on art interventions), and DMT contributed 11.1% (3 studies; one on DMT, two on dance interventions). Within the arts modalities 72.7% (AT and art interventions), 80% (MT and music interventions) and 50% (DMT and dance interventions) of the included studies were RCTs. Most therapy intervention studies (with several intervention sessions) were found in MT (11 out of 20) and one in DMT (1 out of 6). In AT, only studies on effects of artistic activities or single-session interventions were found. Table 2. Overview of the reviewed studies. Evidence levels are defined according to AHRQ [40]. Note: The bold numbers stand for total numbers Active art interventions, such as drawing or working with clay significantly reduced stress and anxiety in eight out of eleven studies [42,[44][45][46][49][50][51][52]. None of the studies analyzed the effects of continuous interventions specifically defined as AT, Three studies [46,51,52] reported significant positive mood changes. Two studies [47,48] did not find a significant stress reduction or mood changes. Two studies [43,51] stated that stress reduction depended on the content of the art work: positive content induced stress reduction, negative content did not. Stress was assessed with various different instruments, such as the Stress Adjective Checklist, the State-Trait Anxiety Inventory, The Global Measure of Perceived Stress, or the Perceived Stress Questionnaire. Two of the studies [45,50] used physical measures (cortisol level [45]; pulse and blood pressure [50]) to operationalize stress. MT or musical interventions reduced stress and anxiety in 16 of 20 studies (10 on MT, 6 on music interventions) [53,54,[56][57][58][59][60][61][62][63][65][66][67][68]70,72]. Four studies (one of MT, three on music interventions) [53,61,68,70] reported reductions in cortisol level, as a physical measurement of stress, and two studies (both on MT) [53,58] found a decrease of sleeping problems through musical interventions. Four studies (one on MT, three on music interventions) [55,59,64] did not find a significant reduction of their stress outcomes.

Results
All studies analyzing DMT or dance interventions found a significant reduction of stress signs or stress coping abilities in their subjects. Only one of the studies analyzed the effects of DT. In all but two studies [75,76] stress was measured by different self-evaluation tests. In the two other studies, stress was tested with saliva samples for cortisol levels. Four studies [73][74][75][76] furthermore reported a decrease in anxiety levels and negative affect.
In total, stress was significantly reduced in 30 out of 37 included studies (81.1%). Eleven out of twelve (91.7%) included studies on CATs found a significant stress reduction. Nineteen out of 25 (76%) included studies on mere arts interventions found a significant reduction in their stress measurement.

Discussion
Recently, besides being an important part in clinical health care practice, creative arts interventions have become an important area of integrative medicine research. Despite the novelty of CATs, a notable evidence-base on the efficacy of creative arts interventions in various contexts and with many different populations is emerging.
In the context of stress prevention, the quality of efficacy studies analyzing creative arts interventions is high. Three quarters of the included studies could be allocated to evidence level I and over 80% found a significant improvement in one of their stress-related outcomes. Looking at CATs, conducted by licensed therapists, the percentage rises to more than 90%. Similar to other health care contexts, MT and music interventions contribute the highest quality studies. This can be attributed to the comparably early establishment of MT, its specific focus on group therapy as well as its comparably low psychoanalytic and high empirical orientation (see [25]). CATs and creative arts interventions seem to have a positive impact on perceived stress and stress management. They reduce anxiety levels and improve subjects' mood. This may be due to certain therapeutic mechanisms that researchers assume to be relevant for all creative arts therapies. Hedonism/play, aesthetic experience/authenticity, nonverbal communication/symbolizing, test-acting in an enactive transitional space, and creation/generativity are named as therapeutic mechanisms, which are active across all CATs ( [18,19]; compare [25]). It remains mostly unclear how these therapeutic mechanisms interact or whether they are active in all clients and contexts. Their empirical validation is a task for future research.
Creative arts interventions' impact on perceived stress and stress management could not be evaluated by means of an overall effect size for each arts modality. Very few of the studies clearly reported all necessary statistics needed for the calculation of effect sizes. Some did not even report the full demographic data. Furthermore, varying interventions in content and duration impede a final statement on creative arts interventions' efficacy in the context of stress prevention. This high heterogeneity might be the biggest problem of the young academic field. Being a benefit of the creative approach in practice, the variety of procedures, methods, and interventions makes it hard to assess and judge creative arts interventions' efficacy with conventional evidence-based research. The high heterogeneity of interventions and measures makes the application of meta-analyses difficult. This is true not only across creative arts interventions but also within each single arts modality (art, music, dance, drama). It might thus be worth looking at specific and common features of the individual CATs, delineating them from mere arts interventions and starting to relate them to features of populations and contexts. This may be a good way to find out, what is specific about each arts modality, and which contexts they work best in (indications and contraindications; see for example [25,[78][79][80]). Demarcating core characteristics and mechanisms of CATs or arts interventions individually also helps to choose an adequate control group for intervention studies. Finally, finding commonalities across creative arts interventions could help clarify the benefit they bring to the health system and its agents. Patients already acknowledge these benefits, and the evidence-base on creative arts interventions is in the process of being built.