Dawn Snell (School of Graduate Studies)
Literature Review: Inclusive Creative Arts as an Educational Response to Trauma
Abstract
Schools are often challenged with meeting the needs of students experiencing symptoms of complex trauma. Neurological damage to the brain caused by trauma creates challenges with learning, self-regulation and attachments. Yet, there is evidence of plasticity of the brain and the possibility of post-traumatic growth. This literature review considers how the creative arts can be a mechanism by which the brain can be restored so that cognition, emotions and social connection can be improved. When quantitative, qualitative, mixed method, case studies and literature reviews were analyzed, results indicated that all types of creative art therapies have physical, social and emotional benefits. Studies in music produced the most benefit to the neurological structure of the brain. Visual arts therapies assist students in accessing non-verbal memories and facilitate the expression of emotions. It is suggested that due to the success of creative arts based therapies, schools adopt an inclusive, trauma-based approach to their creative arts programming.
Key words: post-traumatic growth, creative arts therapies, inclusion
Increasingly, schools are faced with the challenge of supporting students who have experienced childhood trauma. Students with complex trauma profiles demonstrate higher incidents of in-class misbehaviour stemming from emotional dysregulation and mental health issues, as well as learning difficulties such as focusing, listening, and transitioning from one activity to another (Coholic & Eys, 2016; Curan, Adamson, Rosato, & Leavey, 2018; Elzinga, Spinhoven, Berretty, DeJong, & Roelofs, 2010; Grasser, Al-Saghir, Wanna, Spinei & Javanbakht, 2019; Howard, 2016; Keyes et al., 2012; Mayer, 2019; Milot, Ethier, St-Laurent, & Provost, 2010; O’Neill, Guenette, & Kitchenham, 2010; Teicher & Samson, 2016; Thompson, Hannan & Miron, 2014; vanderKolk, 2005; Zilberstein, 2014).
Experiences of childhood trauma also lead to an interruption in attachment mechanisms, which are needed for building trusting teacher and peer relationships in the classroom (Callaghan & Tottenham, 2016; Chen, Chen, Ho & Lee, 2019; Erozkan, 2016; vanderKolk, 2005; Zilberstein, 2014). Multiple losses perpetuate a child’s perceptual bias that they are to blame for their misfortune, and therefore, expect abusive experiences to continue (Perryman, Blisard & Moss, 2019). As a result, they do not trust others and suffer from a variety of ailments including depression, anxiety, poor self-esteem and poor social skills (Chen et al., 2019; Coholic & Eys, 2016; Perryman et al., 2019).
Research has identified that these issues are difficult to overcome, as experiences of complex trauma, as a matter of fact, alter the neurological structure of the brain in developing children (Howard, 2016; vanderKolk, 2005). They suffer from “altered hemispheric lateralization” (vanderKolk, 2005, p. 308), which is a deficit in neural communication between the sides of the brain due to an underdeveloped prefrontal cortex (Teicher & Samson, 2016). This, therefore, hinders access to memories, clears reasoning processes and creates an inability to bring language to feelings (O’Neill et al., 2010, p. 191).
Post-traumatic Growth
However, there is hope. Coholic, Lougheed and Cadell’s (2019) research reveals that a child’s response to trauma is multi-faceted and influenced by their temperament, level of resilience, developmental level and support systems; it is possible for growth to occur. The authors explain that post-traumatic growth is more than mere resilience in that an “individual can undergo positive change as a result of difficult life struggles” (Tedeschi & Chalhoun, 1996 as cited by Coholic et al., 2019, p. 65). Given the right circumstances and therapy, growth can be achieved in the five domains of “new possibilities, relating to others, personal strength, appreciation of life, and spiritual change” (Coholic et al., 2009, p. 65).
Additionally, the neurobiological impacts of trauma that affect learning and relationships can, in fact, be reversed (Teicher & Samson, 2016). Plasticity of the brain is most evident in childhood (Herholz & Zatorre, 2012). Thus, as it responds and adapts to different types of experiences, the brain’s function and structure can change (Callaghan & Tottenham, 2016; McNamee, 2004). Of particular interest, are experiences and activities that restore the connections between the hemispheres of the brain that are interrupted by complex trauma (O’Neill, 2010; Teicher & Samson, 2016; vanderKolk, 2014).
Creative Arts as Healing Therapy for Trauma
It is hypothesized that engagement in creative arts during the sensitive years of early childhood development contributes to re-establishing necessary brain connections, leading to improved learning and attachment behaviours for students affected by trauma. It has been proven that the creative arts provide the unique opportunity for communication between the right hemisphere (which stores images and emotions) and the left hemisphere (which processes language), allowing children to process embedded and repressed memories (Perryman et al., 2019). Creative arts therapies, which include more than one type of intervention, have been found to significantly reduce trauma and depressive symptoms; treat various types of mental illnesses, neurological diseases and psychotic disorders; and improve self-esteem, self-expression, and emotional well-being (Chiang, Reid-Varley & Fan, 2019). Additionally, even though the plasticity of the brain has been found to be responsive the entire lifespan, early intervention through the creative arts has been found to be most effective (Herholz & Zatorre, 2012; Schlaug, Norton, Overy & Winner, 2005). If this is the case, then, how can schools create an environment that provides a strong foundation in the creative arts in order to holistically address issues of childhood trauma?
Literature Review
It is the purpose of this literature review to determine how engagement in the creative arts (music, visual art and drama/movement) helps support students towards post-traumatic growth. Specifically, how can the arts help to repair the damage to the brain? What types of benefits are there to different types of arts? How can the arts support social and emotional development of traumatized students? Finally, it is suggested that if the arts are a positive therapeutic approach, then benefits will also be seen school-wide and can be used as an inclusive approach to trauma informed school programming.
Procedure
Searches were conducted in the databases at the university related to trauma, creative arts therapy, and intermodal expressive therapy. Boolean searches were conducted using the search terms (brain lateralization) AND (fine arts); trauma AND (fine arts) AND education; (expressive arts) AND (trauma therapy); (effects of music therapy) AND trauma. Results were generated from Medline, ScienceDirect, EBSCOhost, APA PsycArticles, Academic Search Ultimate, Explora, Springer Link, ERIC, and Education Full Text. Reference lists of articles meeting inclusion criteria were reviewed to source additional studies and were found to be very helpful for this purpose.
Inclusion and Exclusion Criteria
Articles were chosen for relevance to a type of creative arts therapy. Inclusion criteria included peer-reviewed articles written in English from 2000-2019 with a preference for articles published after 2010. Topics included childhood arts therapy; benefits of arts therapy on neurological disorders and learning; and the neuroscience of the effects of arts on the brain. International studies were allowed if they fell within these parameters and included studies from Canada and the USA, as well as Taiwan, Syria, Australia, China and India. Exclusion criteria included articles written before 2000 and those prior to 2010 were closely scrutinized for relevance. Additionally, articles were excluded if they were not peer-reviewed; were not a study or literature review; were narratives or related to politics, social issues or war trauma; medical studies related to brain lateralization; or case studies that were not accompanied by a substantial literature review. Studies not available in full-text format, and those not written in the English language were excluded.
Critical Analysis
The articles selected were evaluated on their quality of research and findings relative to the effect of creative arts on the brain, learning, and social emotional development. The evaluation of the five literature reviews, five quantitative studies, two qualitative studies, one mixed method and one case study was based on Plano-Clark and Creswell’s (2015) rating scales. Studies were evaluated on a 21-point scale, with a score of 0-10 being a low quality study, 11-16 being an adequate study, and 17-21 being a high quality study.
Results
For ease of analysis and evaluating themes, chosen articles were organized into three categories: (a) how different arts affect the traumatized brain – music, visual arts, and drama, (b) the social and emotional benefits of arts therapy, and (c) generalized benefit of creative arts to clients with trauma or mental illnesses. Several other sub-themes were noted and have been included under each of these categories. Articles were evaluated and were determined to be of high quality according to Plano-Clark & Creswell’s (2015) twenty-one-point rating scale, receiving scores between 17 and 21. All articles included rigorous research designs, thorough data collection, and extensive analysis procedures. Articles were synthesized around themes and sub-themes based on their findings. Limitations included small sample sizes of the studies as well as a lack of longitudinal data. Further research could be completed on how the development of creative competencies contribute to resiliency and the best types of arts for each stage of development.
Discussion
Various types of creative art therapies have been proven effective in the treatment of trauma. They provide a non-threatening environment to discover and process memories and experiences (Hannigan, Grima-Farrell, & Wardman, 2019; Perryman et al., 2019). Through the combined use of both the right and left hemispheres of the brain, experiences in the creative arts enable the left hemisphere to bring language to feelings in a relaxed and comfortable setting (McNamee, 2004; Perryman et al., 2019). Research indicated that the brain has plasticity even in old age and brain structures can be altered through arts benefitting higher order cognition, non-verbal memory, executive processes, and effects on mood (Hannigan et al., 2019; Herholz & Zatorre, 2012). Chiang et al.’s (2019) extensive research review discovered that creative arts therapy positively influenced psychotic, trauma based, depressive, neurological and age related disorders. Benefits included improvements to social emotional perceptions, feelings of emotional well-being and increased artistic skill (Chiang et al., 2019).
Engagement in Creative Arts Produces Positive Results
There are many different reasons engagement in the arts produces positive results. First of all, they engage non-verbal mediums of expression, combining sensory and physical experiences (Chiang et al., 2019; Grasser et al., 2019). These experiences enable clients to reframe their emotional responses and engage with others around them in a different way (Chiang et al.; Perryman et al., 2019). For children, in particular, the creative arts provide additional ways to express, communicate, and process emotions they did not even know they possessed (Hannigan et al., 2019; Perryman et al., 2015).
Secondly, the creative arts engage several parts of the body, stimulating more than one aspect of the brain (Mayer, 2019; McNamee, 2004; Perryman et al., 2019; Thergaonkar & Daniel, 2019). The use of movement supports the cooperation of both the left and right hemispheres of the brain thus strengthening the corpus callosum (McNamee, 2004). It also enables clients to gain physical, emotional, and behavioural self-awareness (Coholic & Eys, 2016; Hannigan et al., 2019; Perryman et al., 2019).
Thirdly, experiences in the creative arts stimulate academic and intellectual growth. This can be attributed to the growth that occurs in the corpus callosum (Herholz & Zatorre, 2012; McNamee, 2004). Children engaging in forms of creative arts therapy have demonstrated improvement in motor and cognitive skills: auditory speech discrimination, quantification, symbol recognition, memory and sensorimotor systems (Herholz & Zatorre, 2012; Schlaug et al., 2005; Thergaonkar & Daniel, 2019).
Fourthly, the social emotional domain is also an area of growth attributed to engagement in the creative arts. Improvement has been noted in the areas of expressing ideas and emotions, impulse control, behaviour and body control (Thergaonkar & Daniel, 2019). In addition, students gain self-awareness and have a more positive self-concept. They begin to be able to identify and express emotions, have better coping mechanisms, improved socialization skills, and overall better psychosocial functioning (Coholic et al., 2009).
Finally, the creative arts promote holistic health, thus increasing the quality of life (Chiang et al., 2019; Coholic & Eys, 2016; Hannigan et al., 2019). Studies indicate that engagement in the creative arts produces a sense of achievement when feelings are physically expressed through a tangible product (Perryman et al., 2019). There is improved relational connection, group cohesion and a general feeling of fulfillment and gratification (Chen et al., 2019; Coholic et al., 2009; Mayer, 2019; Perryman et al., 2015; Perryman et. al, 2019;). Self-esteem and overall resilience are also increased (Coholic & Eys, 2016; Kim, 2015; Mayer, 2019).
Benefits of Specific Art Forms
It is evident, then, that engagement in the creative arts has positive holistic effects and that “training in the arts leads to improved general cognition” (Thergaonkar & Daniel, 2019, p. 66). There are, however, specific benefits for each type of art, which are outlined below.
Music. There is extensive research on music therapy. Overall, it produces positive neurological, social and emotional benefits (Chiang et al.; Chen et al., 2019; Herholz & Zatorre, 2012; Perryman et al., 2015; Perryman et al., 2019; Schlaug et al., 2005). Music therapy can be passive (listening and responding) or active (actively creating music); however, active music making produces the best results (Chiang et al., 2019).
Plasticity of the brain is increased through music therapy, more so than any other creative art (Chiang et al., 2019; Herholz & Zatorre, 2012). Due to the simultaneous involvement of sensory and motor systems, higher-order cognitive processes are engaged (Chiang et al., 2019; Herholz & Zatorre, 2012). This causes several neurological changes in the brain which include changes in the motor and premotor cortex, the corpus callosum and cerebellum; increased white matter; restoration of inflammatory pathways; and more focal cortical thickness causing greater cognitive organization (Chiang et al., 2019; Herholz & Zatorre, 2012; Schlaug et al., 2005). Learning new motor skills and spatial learning through continued practice also increases myelination, allowing the connections in the brain to solidify (Chiang et al., 2019). These multiple stimulations through musical training achieve plasticity which not only produce short term changes, but also long term results (Herholz & Zatorre, 2012). Students benefit in areas of fine motor and auditory discrimination skills, spatial and mathematical reasoning, and phonemic awareness (Schlaug et al., 2005).
Reward circuitry. Making music is enjoyable. In addition to the benefit to the brain from studying music, the reward circuitry is activated, releasing dopamine (Herholz & Zatorre, 2012). Moods are thus affected, leading to a decrease in anger, depression, stress, anxiety and various mental disorders (Chen et al., 2019; Chiang et al., 2019). Additionally, a reduction in cortisol levels has been noted through the engagement in music therapy, leading to long term well-being (Chen et al., 2019).
Social and emotional benefits. Engagement in group music making is beneficial due to the encouragement of imitation learning, social rewards and positive relationships (Hannigan et al., 2019; Herholz & Zatorre, 2012, p. 495). Improvisation and reflection that encourage processing feelings lead to positive self-perceptions, improved social functioning and greater peer attachments (Chen et al., 2019; Chiang et al., 2019; Herholz & Zatorre, 2012; Perryman et al., 2015).
Visual arts. Art therapy is also very successful. It is a “meaning-making endeavor that develops creative problem solving, flexibility, and resourcefulness; addresses various perspectives; and requires persistence and vision” (Kim, 2015, p. 196). Through the experience of making visual art, children are able to process and express a range of emotions, understand the meaning of beauty, direct their aggression into constructive energy, and use their imaginations (Coholic et al., 2009; Hannigan et al., 2019; Kim, 2015). It is a conduit for students to use kinesthetic and sensory pathways to activate their nonverbal memories (Hannigan et al., 2019; Perryman et al., 2019).
Mindfulness. The process of creating visual art includes an element of mindfulness. Coholic and Eys (2016) note that many vulnerable children have difficulty engaging in direct mindfulness activities, can be disengaged, have poor listening skills and troubles sitting still. However, they learned that the process of visual art includes mindful meditation activities that requires a child to pay attention, focus and sit still without having to focus on their painful memories. This develops skills that then lay the foundation for academic learning, setting up the child for future success (Coholic & Eys, 2016).
Social and emotional benefits. Engaging in visual arts not only develops aesthetic skill, but also carries social and emotional benefits (Kim, 2015). Students develop an improvement in personal growth, self-awareness, self-esteem, confidence, and emotional regulation (Coholic et al., 2009; Coholic & Eys, 2016; Hannigan et al., 2019; Kim, 2015; Perryman et al., 2015). When done in a group setting, there is an element of fun that fosters empathy, social skills, and the development of intimate relationships (Coholic et al., 2009; Coholic & Eys, 2016; Perryman et al., 2015). Since creative expression is self-directed, it “promotes an internal locus of control” (Hannigan et al., 2019, p. 246). This internal locus of control enables students to feel in more control, and when transferred to other areas in their lives, they are able to make better decisions (Perryman et al., 2015).
Resilience. Finally, resilience has been a notable benefit to art therapy (Kim, 2015; Mayer, 2019). Resiliency is dynamic and ongoing and represents “a set of qualities that foster a process of successful adaptation and transformation despite risk and adversity” (Kim, 2015, p. 194). Through creativity in art, resilience is developed as one is persistent and resourceful, learns from experiences, problem solves, and develops flexible thinking (Coholic & Eys, 2016; Kim, 2015). As such, resilience has been noted as the “power of recovery” (Kim, 2015, p. 194). Since creating visual art is such a positive experience, students gain a sense of autonomy and use it as a coping mechanism to manage stress in a more productive way (Coholic & Eys, 2016; Kim, 2015; Perryman et al., 2015); thus, shifting how they experience the world.
Drama, dance, and movement.
Dance therapy.
Admittedly, the literature on dance therapy remains sparse (Chiang et al., 2019). Regardless, dance and movement therapy also activate the right hemisphere of the brain and the the limbic system, therefore, creating a mind-body connection that has proven to be therapeutic (Chiang et al., 2019; Grasser et al., 2019; Mayer, 2019; Perryman et al., 2019). Through non-verbal modalities, memories and traumatic experiences can be accessed and self-expression can be facilitated (Chiang et al., 2019; Grasser et al, 2019). The available research on dance therapy reveals a benefit to emotional, cognitive, social and physical domains, as well as a reduction in negative symptoms such as anger, stress, depression, anxiety and panic (Chiang, et al.; Grasser et al., 2019).
Drama therapy. Again, there is a limited amount of research on drama therapy. However, Chiang et al. (2019) note that it can be of use in novel ways when combined with other arts therapies. They found that drama therapies are of most benefit to social and emotional domains, particularly an improvement to mental health, self-esteem, emotional regulation and expression, and social engagement with others. Drama enables one to “explore alternative ways of being and thinking” (Hannigan et al., 2019, p. 765), thus allowing one to address their own conflicts while also developing empathy for others (Hannigan et al., 2019).
Implications for Practice and Future Action
It is important to note that given the extensive holistic benefits of the arts, it is vulnerable students (ie. those students with trauma backgrounds) who have the most to gain from arts experiences (Coholic & Eys, 2016). They have many challenges in life, and the mindful approach to the arts creates a safe space, supporting emotional receptiveness and relationship building skills (Coholic & Eys, 2016; Perryman et al., 2019). Learning strategies to relax and engage with their emotions lays the groundwork for future learning (Coholic & Eys, 2016; Coholic et al., 2009, Mayer, 2019; Perryman et al., 2019).
Inclusion
Being included as part of a larger group is important for vulnerable students to develop new coping strategies, social skills and cooperation (Chiang et al., 2019; Coholic & Eys, 2016). Therefore, if creative arts therapies are effective in small groups, they could be incorporated into the general arts program of schools? Through an inclusive approach, all students (not only those who are vulnerable) benefit, leaving only a select few with complex needs requiring individual and deeper therapy.
Hannigan et al. (2019) and Chiang et al. (2019) are strong proponents of such an inclusive arts based approach. They advocate for providing for the needs of all students in a general classroom (regardless of their abilities or challenges), with acceptance and awareness of different points of views.
There would need to be some initial training for teachers. An art therapist working collaboratively with teachers and students will help to facilitate this immersive model (Hannigan et al., 2019). They will be able to model strategies and approaches to guiding group reflections and dealing with any emotional issues that arise.
Safe and Trusting Environment
Keeping the needs of vulnerable students in the forefront is the first step to create a safe and trusting environment to share arts activities (Perryman et al., 2015). In a therapy environment, a primary goal of the therapist is to create a relational attachment with clients so that they can explore art materials in a non-judgmental way (Chiang et al., 2019). There needs to be acceptance of any form of self-expression and the exercising of choice and reflection (Mayer, 2019). Engaging in the arts with a trusting adult lays the foundation to develop relationships, focus on prosocial interactions, and build on student strengths (Mayer, 2019).
Strong school-wide arts programming that spans grades and includes all modalities of creative arts achieves this goal. Normalizing engagement in the arts creates an inclusive space that encourages active participation of all and an opportunity to build trusting relationships with teachers and peers. Students will have a wide opportunity to discover the arts for which they have the greatest affinity. Through engagement in continued and varied opportunities, self-confidence can begin to grow.
Enjoyment and Fun in a Group Environment
Part of creating a safe environment is providing fun, experiential activities in a group setting. Engaging in fun, arts based activities with others enables students to not only use their imaginations and develop self-confidence, but also provides an opportunity to develop peer relationships, learn how to help others, and overcome feelings of isolation (Coholic & Eys, 2016; Coholic et al., 2009; Thergaonkar & Daniel, 2019).
Students must be actively engaged in creating art for themselves, rather than passively listening or watching. It has been found that active music therapy has a greater effect (Chiang et al., 2019). Thus, a music program should focus on intentional instrument instruction. Likewise, a visual arts program should focus on students producing works of art. Students should be actively engaged in creating, participating in, and performing drama and dance. There should be opportunities for authentic performance and presentation of learning.
Programming throughout the Grades
Research states that the greatest benefit of creative arts therapy occurs with a greater investment of time (Chiang et al., 2019). It is through time and practice that skills are developed and honed, and relationships can be built (Chiang et al., 2019). Therefore, when developing an inclusive arts program in schools, there must be a consideration to provide arts opportunities that span a significant amount of time over a child’s academic career. Chosen arts must be continuously offered throughout the grades. Consistent teachers and approaches must be engaged. Skills must be systematically developed throughout the grades. Transitions to other schools in the district must be strategic.
Since music has proven to have the most effect on brain development (Chiang et al., 2019), and particularly effective at the younger ages (Hannigan et al., 2019), schools should focus on developing a strong music program as a first step to inclusive arts based programming. Primary classes should have a strong program based on play, group activities, whole body engagement and exploration. Intermediate classes should then begin to move into instrument instruction.
Resource constraints
Finally, an inclusive arts based approach is accessible to schools that face resource constraints (Thergaonkar & Daniel, 2019). Singing or listening to music costs nothing. Visual art supplies can be minimal or easily sourced. Drama and dance do not require any expensive equipment. Inexpensive musical instruments can be sourced. It is only when a school needs to purchase specialized musical instruments or visual arts equipment and supplies that a larger budget needs to be accessed.
Additionally, an inclusive arts based approach is beneficial when there is a shortage of trained specialized professionals, or when their caseloads become unmanageable (Thergaonkar & Daniel, 2019). If such trained professionals can work with generalist teachers and train them in accessible therapeutic creative arts approaching techniques, the capacity for services within a school will increase.
Conclusion and Areas for Further Research
In conclusion, including elements of creative arts therapies into inclusive school arts programming is a relatively new approach. However, recent research indicates that this could be a very positive, holistic, school-wide approach to providing social-emotional support to all students, including vulnerable and trauma affected students. With limitations on funding, professional specialists and services, arts programming is a way for a school to autonomously support students in need. It is also an opportunity for teachers to build capacity in inclusive social and emotional practices, which span all subject areas and grades.
Further research still needs to be done. The benefits of creative arts therapy are yet to be documented with respect to decreasing aggressive behaviours. There needs to be more research conducted on the benefits of drama, dance, and movement therapies. More North American, and specifically Canadian, research needs to be conducted. Research documenting the long term effects of arts training on students in the form of longitudinal studies into adulthood would be helpful. Finally, school models where art therapists are working in an inclusive model with teachers are yet to be found.
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