The delivery of health care is undergoing a rapid evolution that is dramatically changing the way health care professionals perform their job responsibilities. In this increasingly stressful work environment, professionals are experiencing alarming rates of burnout. Recent efforts to enhance wellness have been directed toward organizations. However, because of the nature of the work performed in intensive care units, interventions to develop individual resilience are also needed. Currently, medical centers are environments in which the emotional impact of work-related trauma is often minimized and rarely processed. Some individuals may struggle to describe or express the impact of those traumas. Through nonverbal interventions, creative arts therapy can help people access, explore, and share authentic emotion in visual, musical, physical, or written form. By reconstructing meaning through transformative methods, participants may confront, reflect, and better cope with traumatic experiences while catalyzing social support networks and deepening relational bonds in the workplace.

Given the international public health focus on cost-effective and feasible solutions to the burgeoning crisis of burnout in health care professionals, creative arts therapy (CAT) holds great interventional potential.1-4  For decades, CAT programs have worked with patients, clients, and their families in clinical psychosocial treatment. These programs can comprise a variety of modalities of creative expression, including art, music, dance/movement, drama/psychodrama, poetry, and play therapy. Delivered by professional creative arts therapists with specialized bachelor’s, master’s, and doctoral degrees and expertise, each modality has been applied and integrated into psychotherapy and counseling with patients and clients of all ages. Creative arts therapists work across many domains, including hospitals, nursing homes, schools, community art centers, museums, mental health centers, addiction treatment programs, prisons, and homeless shelters. Art, music, dance, drama, and poetry therapies are referred to as “creative arts therapies” because of their historical and contextual development in the arts, with theoretical foundations grounded in both artistic expertise and psychiatric principles. CAT programs that use self-expression in treatment are also sometimes called “expressive arts therapies.”5-7  This article explores the existing evidence for the efficacy of CAT as a feasible and effective intervention to prevent burnout and promote resilience among health care professionals.

What Is Resilience?

Resilience enables one to thrive in the face of adversity.8  Characterized as the ability to remain positive despite difficult circumstances, resilience provides individuals with the capacity to overcome challenges and maintain or improve their mental health. A variety of qualities are associated with resilience, including the ability to engage the support of others, the belief that stress can be strengthening, a tendency to set personal goals, and optimism.9-11  Developing resilience may be one strategy for preventing and treating symptoms of anxiety and/or depression, burnout syndrome, and posttraumatic stress disorder in critical care health care professionals. Importantly, resilience can be learned. By fostering awareness, understanding, and communication, CAT programs can build resilience and benefit patients, their families, and even the staff members who deliver the interventions. Participation in a single CAT session has been shown to be effective in eliciting immediate, statistically significant mood changes among a wide range of adolescent psychiatric patients.12-14  Patients and families have found CAT therapies helpful in allowing safe exploration of experiences and emotions, promoting feelings of connection and empathy, reducing perceived isolation, and feeling supported by others.15  By participating in groups with CAT therapists, patients, and families, health care professionals in a range of disciplines have also reported improved job satisfaction, stress relief, and improved interactions with patients.16  One nurse at a large children’s hospital stated:

Here is a page I created about a patient who needed a heart transplant and had to go on a ventricular assistive mechanical device called the Berlin Heart. She was with us on the unit for at least 4-5 months waiting for a transplant. I was one of her primary nurses and she made a big impact on me; it was emotionally challenging but also rewarding to care for her and her family. She loved music, so we played a lot of songs while I cared for her, and she loved purple and sparkles; we made crafts and artwork often. When I attended the session this day, I was coming in stressed and overwhelmed and for some reason I thought of her and my role as her nurse. I created this page and it really was a great reflective moment that boosted my resilience for the day when I was able to think of all the positive moments we shared. (Figure 1, online at www.aacnacconline.org)

What Is Creative Arts Therapy?

CAT programs are often called “nonverbal” therapies, but this may be a misleading distinction. An explicit goal of CAT is to help clients or patients develop communication skills through the creative arts mediums and processes, usually including the verbal ability to articulate meaning. Participants are encouraged to use information gleaned through their artistic expressions to increase the clarity of communication as well as emotionally manage the content. If an individual does not have the vocabulary or ability to describe a trauma experienced, he or she may be able to depict its emotional impact through art, music, movement, or writing. The individual can then be guided and supported by a creative arts therapist and subsequently identify, explore, and process the feelings as words are found to match the emotional impact. As a partner with the patient in this process, the creative arts therapist can modulate the experience, allowing the individual to evolve at his or her own pace and eventually discover the words to identify and manage the emerging emotions. This process can help the individual understand that any trauma can be held, seen, and ideally healed within the therapeutic relationship. CAT can also elucidate the unseen, the unsaid, the unprocessed material, and turn it into something to be held, witnessed, heard, moved, and transformed. Throughout this process, clients or patients can develop new perspectives and skills to help them redefine their experience and develop a sense of agency to navigate life challenges.

Recent studies have shown that arts-based encounters can be effective in reducing stress and burnout in health care workers, specifically increasing participants’ self-esteem, reducing stress, stimulating personal growth, reducing work-related fatigue, improving communication and relationships, and promoting a sense of community at work.17-19 

Art Therapy

What Is Art Therapy?

As defined by the American Art Therapy Association, art therapy is “an integrative mental health and human services profession that enriches the lives of individuals, families, and communities through active art-making, creative process, applied psychological theory, and human experience within a psychotherapeutic relationship.”20  Across the wide range of populations of clients and patients experiencing art therapy, the common thread is the expertise of the art therapist, combining knowledge of art materials and processes with the psychological, social, and emotional focus of their use. Historically in the United States, art therapy developed its identity within the Western medical models of psychology and psychiatry. More recently, professionals in the field have embraced critical theory to advocate for social justice.21  Talwar21  explains that “the cultural work of the art therapist is to consistently help clients increase awareness, re-inscribe their personal narratives, and destabilize the socially imposed identities that are a result of cultural marginalization, oppression, or mental health stigma.” This perspective on the role of art therapy uniquely situates it to help health care professionals explore and process their personal experiences within the context of a system and society riddled with stigma surrounding mental health issues.

Individual-focused art therapy is grounded in the development of a relational experience between the individual and the art therapist working as a unique dyad. The therapeutic session can consist of any sequence or combination of verbal dialogue, art materials exploration, individual art-making, collaborative art-making, and review of and reflection on visual art. The content of the art itself is generally dependent on the individual’s therapeutic goals in conjunction with the instruction of the art therapist. Art therapy has a natural facility with nonverbal material, allowing traumatic and difficult memories to move into conscious awareness through the act of creating visual imagery from unconscious mate- rial.22  The artistic material is processed within the therapeutic relationship, with modulation and guidance by the art therapist.

Group-based art therapy moves the therapeutic relationship from the dyadic to a group dynamic. The art therapist provides the structure and the norms of group therapy behavior, in collaboration with the group’s expectations, abilities, and goals. Therapeutic goals of the specific group determine interventional choices by the art therapist. For instance, a group of bereaved parents warrants a completely different interventional approach than a group of autistic adolescents. Generally, the goals of group art therapy are to reduce feelings of isolation, build relationships, and increase communication through the shared process of creating and talking about artwork together.23  A group dynamic allows sharing and exploration of multiple perspectives on the variety of emotional experiences encountered by the group. These interactions between group members become part of the therapeutic process. The art therapist acts as catalyst for conversation, active listener, collaborator, provocateur, conflict mediator, facilitator, advocate, supporter, questioner, and group member. The process itself of creating art, either individually or as a group, is generally the focus of the experience. Group reflection is a key component of group art therapy, as the verbal translation of the experience offers new perspectives, encourages social skills, and promotes development of emotional vocabulary. As an example of visual imagery helping to expand emotional vocabulary, a clinical manager at a large children’s hospital depicts her feelings with a collage of magazine images and markers (Figure 2): “This image helped me process the energetic tension created by all the different demands on my time, as contrasted by the pressure to appear together and calm as a leader.”

Art Therapy Research

The bulk of art therapy research has focused on specific populations, primarily patients with cancer and other chronic illnesses, as well as adults experiencing grief, loss, and trauma. For individuals with cancer and chronic illnesses, art therapy has been associated with reductions in stress, anxiety, and depression as well as increased self-worth and strengthened social identity.24-27  Art therapy interventions for traumatized and bereaved adults decreased stress and symptoms of compassion fatigue while increasing well-being and sense of purpose.28,29  Creative Forces, the National Endowment for the Arts-funded Military Healing Arts Network, found that art therapy with both active-duty military personnel and veterans can help expedite recovery from traumatic experiences, reduce flashbacks and nightmares, and reveal patterns of resilience and indicators of psychological risk.23,30  These studies with military service members have helped to demystify the clinical practice of art therapy, indicating that art therapy can (1) foster improvement in psychological and behavioral functioning; (2) promote neurologic and cognitive functioning; (3) alleviate social/relational difficulties; and (4) improve physiological, physical, functional, and occupational abilities.23,30-35  As stated by Jones et al,23  “The art therapy journey serves as an agent of change, during which service members establish a new sense of self as creator rather than destroyer, as productive and efficacious instead of broken, as connected to others as opposed to isolated, and in control of their future, not controlled by their past” (Figure 3, online at www.aacnacconline.org).

Music Therapy

What Is Music Therapy?

The American Music Therapy Association defines music therapy as “the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music therapy program.”36  The use of music in relation to healing dates back to antiquity, with all known cultures having some form of musical expression. Music is central to many rituals and social functions (eg, worship services, live concerts), and music is engaging and facilitative. As a profession, music therapy started formally after World War II, when it was noted that music volunteers were helping traumatized soldiers by reducing their anxiety and facilitating social engagement. Although musicians were being trained to work in hospitals as early as 1919, the first music therapy training program was established in 1944, and the National Association for Music Therapy was established in 1950.37 

Although many of the benefits of music therapy are included in the evidence for the general effectiveness of CAT, the use of music differs in several ways from other forms of CAT. The creation and perception of music entails not a single or even a limited number of neurologic and behavioral events but whole constellations of them. From the perception of sound and music to the motor movements used to create sound to the emotional and cognitive verbal and nonverbal processing that frames musical choices and shapes musical experiences, music involves many different interactions with an individual.

Uses for Music Therapy

Music therapists work with a wide variety of populations at all developmental levels, including individuals with a range of emotional, cognitive, social, and neurologic challenges. Music therapy provides potential benefits in a number of different dimensions. Neurologically, music-making can stimulate, calm, and/or coordinate neural systems. Autonomic functions such as heartbeat, breathing, and other physiologically rhythmic events can be affected by skillfully applied musical stimuli. For a child on the pediatric intensive care unit, a music therapist playing calming music might attempt to match the patient’s heartbeat, with the goal of subsequently slowing the heart rate. Many music therapists work in rehabilitation settings, using music to facilitate muscle function in repetitive, rhythmic tasks such as walking. In addition, gait laboratories, transitional care units, and skilled nursing facilities often employ music therapists to help achieve these neurologic goals.

Regarding emotional and behavioral health, music evokes and contains emotional responses, creating a safe “holding space” in which emotional states can be held and reflected. These responses can occur with both recorded music and live performances. Music therapy has been reported to reduce stress in a variety of patients including those with schizophrenia.38,39  The relational qualities of music (ie, the need to both listen and self-express) make music a powerful way to represent relationship and practice communication dynamics, a common focus in behavioral health settings. In this sense the music therapist is not attending to the music in and of itself but primarily to the client’s affect and relational dynamics and the ways in which the client makes meaning out of participation in the music.

Regarding cognition, music evokes explicit memories and images. While making music, we continually make choices that require reflexive thought. Within this group context, musical interactions can promote group cohesion and individual expression. Music-listening exercises including lyric analysis, patientchosen music, and music for relaxation and/or visualization serve to activate emotions and memories, calm the nervous system, and provide context for focused discussions of themes and shared experiences. Receptive music listening can be used in many contexts, although its effects may be easiest to observe with the elderly among whom it can be used to facilitate life review, or with teens for whom musical tastes are an important part of identity development. Music therapy groups using active music-making (group drumming, group singing, or musical improvisation) create relatedness, focus motor functions, and safely exercise a variety of different central nervous system functions.

Regarding music therapy as a tool for fostering resilience, the auditory, nonverbal, and periodic nature of music accesses core functions of the nervous system while also stimulating higher orders of thought. In a study exploring aesthetic engagement with the arts, Samaritter40  identified 5 core themes of CAT formulated through a thematic analysis of current literature, which supports this understanding of active processing in musical settings. Embodied presence refers to active, purposeful engagement in a process; somatosensory engagement describes an individual’s engagement with neurophysiological functioning; emotional engagement refers to the activation and expression of emotion; in musical interactions the awareness of nonverbal communication increases, raising the level of attunement and empathy among group members; and finally, intercultural involvement refers to the creation of social relatedness by group members.40  Music therapy provides the opportunity to access, identify, and work through challenges related to emotional and mental wellness, as it teaches the client how to engage with emotions while also making conscious choices about how to express and relate in that moment of experiencing. In this way music therapy often emphasizes musical process over musical product, allowing for a safe space to practice self-awareness, regulate emotions, and relate socially. The goal of music therapy is not the creation of perfectly executed pieces of music but rather participants’ engagement in all the physiological, subjective, and relational processes that music-making entails (Figure 4, online at www.aacnacconline.org): “This image was made when I focused my attention on Joy.”

Dance/Movement Therapy

What Is Dance/Movement Therapy?

The American Dance Therapy Association defines dance/movement therapy (DMT) as “the psychotherapeutic use of movement to promote emotional, social, cognitive and physical integration of the individual.”41  As with other creative arts practices and therapies, DMT achieves this goal by fostering the experience of one’s relationship to self and others through artistic expression.39  A specific feature of DMT is that artistic expression is attained through the body and expressive movement. Dance/movement therapy emphasizes experiencing the body not only as a vehicle capable of functional movement but as a body of feeling and meaning-making that is the basis for all human endeavors and relationships. Because of the growing appeal of body-based practices and treatments over the years, DMT can be found in a variety of settings, including but not limited to “mental health, rehabilitation, medical, educational and forensic settings, and in nursing homes, day care centers, disease prevention, health promotion programs and in private practice.”41  Although DMT is used for individual mental health and wellness work, it is classically a group modality with facilitated group process and experience.42  Bringing awareness to the body’s innate capacity for feeling and the invitation to express that feeling within a group can create an openness that allows for positive social connection. The emotional validation of being both witnessed and mirrored in nonverbal expression can cut through social isolation, remove perceived pressure to be verbally articulate about emotionally challenging material, and positively reinforce vulnerability as a social skill. Though considered a nonverbal therapeutic modality, DMT also provides a “bottom up” approach to integrating emotional experience, which can then be verbally articulated to the self and others.42 

Uses of Dance/Movement Therapy

Dance/movement therapy was originally applied in psychiatric settings. One of the earliest applications of dance in a health care setting is attributed to Marian Chace, who in 1942 developed a program called “Dance for Communication” at the historic St Elizabeth’s Hospital in Washington, DC.42  In its early stages, DMT was implemented in the psychiatric setting using a group format that focused on the movements and nonverbal communication of chronically withdrawn and socially isolated patients. Using music and her training in kinesthetic awareness as a dancer and dance teacher, Ms Chace would nonverbally greet each individual and mirror his or her fine and gross motor movements. The organizing structure of music and rhythm served to create group cohesion from which she could begin to bring seemingly unreachable people together into a shared experience, thus providing them with nonverbal social connection.

Not long after her therapeutic work with nonverbal patients in psychiatric wards, Ms Chace’s work was brought to individuals suffering from chronic stress and trauma as a result of their vocation. The American Red Cross hired her to use “dance action with servicemen,” although the nature and the efficacy of her work with service members at that time are merely anecdotal.42  These 2 early applications of dance and movement with specific therapeutic intent with adult psychiatric patients and members of the armed services show early interest in the potential for DMT to be an effective method of promoting health and wellness in adults. In the decades since, DMT has been used with numerous populations. Although not exhaustive, current research explores efficacy and outcomes in work with children and adults in medical and psychiatric settings, those recovering from trauma and grief, elderly patients with Parkinson disease and dementia, and adults with depression and anxiety.43-45 

Dance/movement therapy specifically and explicitly engages body awareness and body action, making it a multidimensional phenomenological approach to present moment experience. The phenomenological nature of the modality lends itself to numerous approaches and perspectives within the field, which are subsequently informed by the particular needs and goals of the individual or group. Some believe that the dynamic and time-based nature of dance as an art form highlights the felt experience of the mind-body connection and movement’s ability to mediate stress and trauma.46,47  Further, a meta-analysis of 41 controlled intervention studies (21 DMT interventions and 20 dance interventions) indicated that both types of interventions had effects on psychological outcomes similar to those of meditation interventions.45  These findings highlight the benefits of a body-based modality that goes beyond the physical and social benefits of dance to reflect its capacity to mitigate psychological challenges (Figure 5, online at www.aacnacconline.org): “These pages helped me manage the feelings of not having control.”

Therapeutic Writing

What Is Therapeutic Writing?

Therapeutic writing is based on the philosophy that writing is a form of making, and making humanizes the world.48  Writing is one of the most valuable and vibrant forms of making, because its sole material is language, our most common means to connect with one another. Researchers have demonstrated with functional magnetic resonance imaging that reciting poetry engages with the mesolimbic pathway, the primary reward center of the brain, which suggests that lyrical poetry and music can reduce pain and the need for higher doses of opioids.49,50  This type of intervention, termed “prescription art” and “culture vitamins” by a group of artists and business leaders in Denmark, makes the case that communicating through poetry strengthens interpersonal bonds.51 

Therapeutic writing workshops are tailored to individuals who want to learn more about writing and self-expression. Each workshop session aims to meet a participant wherever that person is in his or her creative life. The curriculum is usually relatively fluid, and an individual may choose to journal one week and write a poem the next. The focus is generating new material, and a group’s goal is to support and respect, listen to, and acknowledge each other as creatives. In this way, significant connections are forged among participants.

In an article by Katherine Parker,52  the 2014 Neustadt Prize laureate Mia Couto refers to the importance of cultivating literary community: “Never before has our world been so small, but this does not solve our solitude. Never before have there been so many roads and never before have we made so few visits. What could bind us together would be the desire to tell, to listen to stories.” This sense of connection can ameliorate a host of issues, such as feelings of loneliness, depression, anxiety, and low self-esteem.

Uses for Therapeutic Writing

Participation in therapeutic writing workshops can improve self-confidence, resilience in the face of traumatic life events, and empathy toward fellow writers and community members. Gavin Francis53  writes: “It’s said that literature helps us to explore ways of being human, grants glimpses of lives beyond our own, aids empathy with others, alleviates distress, and widens our circle of awareness. The same could be said of clinical practice in all of its manifestations: nursing to surgery, psychotherapy to physiotherapy.” Writing workshops can make a significant positive impact on individuals experiencing homelessness and extreme poverty, veterans, those diagnosed with cancer and their caregivers, individuals transitioning out of incarceration, older adults, men serving life in prison, and people in addiction recovery.

The benefits can be especially pronounced for individuals who have experienced trauma. Through therapeutic writing, an individual can capture an experience in words, thereby gaining a sense of control over the narrative. By sharing his or her writing aloud with peers, a person may build resilience through community awareness and acceptance. But such sessions require focus and guidance. As Bridget Murray54  writes,

There is evidence that the nature of a person’s writing is key to its health effects, notes health psychology researcher Susan Lutgendorf, PhD, of the University of Iowa. An intensive journaling study she conducted recently suggests that people who relive upsetting events without focusing on meaning report poorer health than those who derive meaning from the writing…. [T]hose who focus on meaning develop greater awareness of positive aspects of a stressful event.

Writing is often seen as a solitary art; however, all writers need the inspiration and care of others. Workshops engage students, teachers, and peers in deeply collaborative relationships. Storytelling takes many forms. For example, when participants explore the technique of ekphrasis—the vivid, written description of a piece of art, music, or dance—a deep, normalizing connection is made between the writer and the place where the art was created. Whereas before participants might not have felt welcome at a cultural institution, once they have used ekphrasis (a notable meaning-making creative process) and artistically engage with that organization’s art form, artifacts, or attractions, these writers feel bonded to the place and may return using their writing identity as an entry point. In addition to ekphrastic writing, therapeutic workshops explore other genres, fostering innovation and encouraging experimentation.

Writing empowers greater understanding of self and others and thereby encourages compassion and empathy in our society. Literary community is an important contributor to a healthy state and nation. In the words of Tara Parker-Pope,55  “We all have a personal narrative that shapes our view of the world and ourselves. But sometimes our inner voice doesn’t get it completely right. Some researchers believe that by writing and then editing our own stories, we can change our perceptions of ourselves and identify obstacles that stand in the way of better health.” As more and more community stakeholders—libraries, hospitals, reentry centers, senior-living establishments, recreation centers, cultural institutions, and others—recognize the value of storytelling, it will become easier for a culture to embrace therapeutic writing as a valuable method for addressing a host of challenges (Figure 6, online at www.aacnacconline.org).

How Can CAT Programs Promote Health Care Professional Well-being?

Recently, a shift has occurred from considering burnout as an individual problem to regarding it as reflecting a broader problem of the health care system. Burnout syndrome has been associated with the following organizational factors: (1) increasing workload, (2) lack of control over the work environment, (3) insufficient rewards, and (4) a general breakdown in the work community.56  Several studies have examined the effects of organization- directed interventions to ameliorate burnout in health care professionals.57  Examples of such interventions are changes in the duration of work shifts, interruption of daily work activities to allow protected time, quality improvement projects, and changes in workflow. A recent meta-analysis showed that these organization-directed interventions were associated with greater treatment effects compared with individual-directed interventions.57  Although some of the organization-directed interventions were studied in the critical care setting, we believe that individual-directed interventions are also necessary for critical care health care professionals.

Health care providers report an increase in stress when health care facilities do not recognize the importance of creating healthy work environments, allowing time to connect meaningfully with patients, developing structures for peer support, and prioritizing health care professional self-care. Often, critical care providers hold their own traumatic memories and emotional experiences in isolation, feeling the need to process these events silently, if at all. No matter what organization-directed programs are implemented, tragic and difficult events will continue to occur in a critical care setting. Examples are performing cardiopulmonary resuscitation; seeing massive bleeding, open surgical wounds, and traumatic injuries; dealing with combative patients; and witnessing the death of a patient.58  Balancing these traumatic experiences with the need to conduct research and tabulate data can create a different kind of stress for frontline staff. A surgery nurse coordinator in a large children’s hospital stated, “I was in the midst of completing our team’s data collection for the end of the year. My head was swirling with numbers while I was trying to keep the peace. Here’s my first journal entry” (Figure 7).

Numerous studies have been conducted on individual-focused interventions to address symptoms of burnout. Many of these interventions focused on mindfulness-based stress reduction training, mindfulness meditation, communication, debriefing sessions, and self-care workshops. One study examined an 8-week educational program for primary care physicians that included training in mindfulness, communication practices, and self-awareness.59  In this trial, study participants demonstrated improvements in all 3 components of burnout, measures of empathy, and their mood state. A second clinical trial enrolled practicing physicians who participated in 19 biweekly discussion groups that incorporated elements of mindfulness, reflection, shared experience, and educational sessions.60  Study participation improved meaning and engagement at work and reduced symptoms of depersonalization. Importantly, these positive effects were sustained to at least 12 months. More recently, critical care nurses participated in a clinical trial examining a 5-day course designed to reduce the prevalence of job strain by improving the ability to cope with stressful work situations and conditions.61  The course included explanations of nursing theories and simulation scenarios that focused on patients with deteriorating conditions followed by debriefing sessions. Compared with a control group that did not participate in any activities, the intervention arm showed reductions in the prevalence of job strain, the degree of absenteeism, and the amount of turnover.

Because CAT programs are based on many of the same tenets as other individual-focused interventions that have been tested to reduce symptoms of burnout, they may help critical care providers connect to the purpose of their work, develop adequate coping skills, and gain time to reflect and connect with their peers. Participation in the arts holds the potential to catalyze social support networks and deepen relational bonds in the workplace.62  CAT group participants can bring authentic emotions to their experience and then use the resulting expression to communicate in visual, musical, written, or physical form. Participants may be able to confront, reflect on, and better cope with traumatic experiences by reconstructing meaning and developing transformative methods. CAT becomes the vehicle for the externalization of the trauma, allowing the participant to separate from the psychological stress. Creative arts therapists focus on that expression itself, fostering a more tolerable and emotionally safe experience for the participants to witness and adapt their own perspective. In this creative process, vulnerability fosters the potential to feel validated, to validate others, and to create a sense of community.

Karpavičiūte and Macijauskienè19  found that after a collective art intervention, health care professional participants felt more useful to, more interested in, and closer to other people, with an overall positive impact on community building (Figure 8): “These pages helped me process the completed suicide of an 18-year- old patient. Though we work to manage the realities of psychological risk, ultimately we each have to process loss and grief individually. It helped tremendously to share these pages with our patient’s treatment team. It was my way of honoring her life and its impact on me. And our community felt stronger through the sharing.”

Conclusion

In response to growing awareness of burnout and psychological distress in health care professionals, creative arts therapists have been increasingly asked to provide therapeutic interventions in the workplace. Art, music, dance/movement, and writing programs have been developed for staff to promote stress relief, processing of traumatic events, and community building. Arts activities as workplace interventions have been found to promote well-being and psychological health, manage occupational stress and health risks at work, and strengthen organizational well- being.19  Community building can include collaboration among clinical creative arts therapists, local arts organizations, and academic researchers to maximize the potential for new creative partnerships in program development. Using the arts to process trauma, foster expression, build community, and promote healing, these partnerships can support resilience for health care professionals. With the perspective that resilience can be learned, CAT may be an ideal organizational intervention that is both cost-effective and feasible. Further research is needed to determine the benefits of CAT interventions aimed at reducing burnout and promoting resilience among health care professionals.

REFERENCES

REFERENCES
1
Cameron
M
,
Crane
N
,
Ings
R
,
Taylor
K
.
Promoting wellbeing through creativity: how arts and public health can learn from each other
.
Perspect Public Health
.
2013
;
133
(
1
):
52
-
59
.
2
Broderick
S
.
Arts practices in unreasonable doubt? Reflections on understandings of arts practices in healthcare contexts
.
Arts Health
.
2011
;
3
(
2
):
95
-
109
.
3
Stuckey
HL
,
Nobel
J
.
The connection between art, healing, and public health: a review of current literature
.
Am J Public Health
.
2010
;
100
(
2
):
254
-
263
.
4
Philipp
R
,
Gibbons
N
,
Thorne
P
,
Wiltshire
L
,
Burrough
J
,
Easterby
J
.
Evaluation of a community arts installation event in support of public health
.
Perspect Public Health
.
2015
;
135
(
1
):
43
-
48
.
5
Malchiodi
CA
.
Expressive Therapies
.
New York, NY
:
Guilford Press
;
2005
.
6
Malchiodi
CA
.
Art Therapy and Healthcare
.
New York, NY
:
Guilford Press
;
2013
.
7
Malchiodi
CA
.
Creative arts therapy approaches to attachment issues
. In:
Malchiodi
C
,
Crenshaw
D
, eds.
Creative Arts and Play Therapy for Attachment Problems
.
New York, NY
:
Guilford Press
;
2014
:
3
-
18
.
8
Luthar
SS
,
Cicchetti
D
,
Becker
B
.
The construct of resilience: a critical evaluation and guidelines for future work
.
Child Dev
.
2000
;
71
(
3
):
543
-
562
.
9
Davidson
JR
,
Payne
VM
,
Connor
KM
, et al
.
Trauma, resilience and saliostasis: effects of treatment in posttraumatic stress disorder
.
Int Clin Psychopharmacol
.
2005
;
20
(
1
):
43
-
48
.
10
Hoge
CW
,
Terhakopian
A
,
Castro
CA
,
Messer
SC
,
Engel
CC
.
Association of posttraumatic stress disorder with somatic symptoms, health care visits, and absenteeism among Iraq war veterans
.
Am J Psychiatry
.
2007
;
164
(
1
):
150
-
153
.
11
Hoge
EA
,
Austin
ED
,
Pollack
MH
.
Resilience: research evidence and conceptual considerations for posttraumatic stress disorder
.
Depress Anxiety
.
2007
;
24
(
2
):
139
-
152
.
12
Anderson
AN
,
Kennedy
H
,
DeWitt
P
,
Anderson
E
,
Wamboldt
MZ
.
Dance/movement therapy impacts mood states of adolescents in a psychiatric hospital
.
Arts Psychother
.
2014
;
41
(
3
):
257
-
262
.
13
Kennedy
H
,
Unnithan
R
,
Wamboldt
MZ
.
Assessing brief changes in adolescents’ mood: development, validation, and utility of the Fast Assessment of Children’s Emotions (FACE)
.
J Pediatr Health Care
.
2015
;
29
(
4
):
335
-
342
.
14
Shuman
J
,
Kennedy
H
,
DeWitt
P
,
Edelblute
A
,
Wamboldt
MZ
.
Group music therapy impacts mood states of adolescents in a psychiatric hospital setting
.
Arts Psychother
.
2016
;
49
:
50
-
56
.
15
Solomon
M
,
Kennedy
H
,
Reed
K
, et al
.
Impact of integrating complementary and alternative medicine therapies into multi-family group setting for children and adolescents with eating disorders
.
Colorado J Psychiatry Psychol
.
2019
;
3
,
1
:
40
-
51
.
16
Kennedy
H
,
Reed
K
,
Wamboldt
MZ
.
Staff perceptions of complementary and alternative therapy integration into a child and adolescent psychiatry program
.
Arts Psychother
.
2014
;
41
(
1
):
21
-
26
.
17
Repar
PA
,
Reid
S
.
Creatively caring: effects of arts-based encounters on hospice caregivers in South Africa
.
J Pain Symptom Manage
.
2014
;
47
(
5
):
946
-
954
.
18
Huss
E
,
Sarid
O
.
Visually transforming artwork and guided imagery as a way to reduce work related stress: a quantitative pilot study
.
Arts Psychother
.
2014
;
41
(
4
):
409
-
412
.
19
Karpaviciute
S
,
Macijauskienè
J
.
The impact of arts activity on nursing staff well-being: an intervention in the workplace
.
Int J Environ Res Public Health
.
2016
;
13
(
4
):
435
. doi:
20
American Art Therapy Association
.
Definition of art therapy
.
American Art Therapy Association website
.
2019
. . Accessed November 13, 2019.
21
Talwar
S
.
Creating alternative public spaces: communitybased art practice, critical consciousness, and social justice
. In:
Gussak
D
,
Rosal
M
, eds.
The Wiley Handbook of Art Therapy
.
Chichester, UK
:
Wiley-Blackwell
;
2016
:
840
-
847
.
22
Councill T
.
Art therapy with children
. In:
Gussak
D
,
Rosal
M
, eds.
The Wiley Handbook of Art Therapy
.
Chichester, UK
:
Wiley-Blackwell
;
2016
:
242
-
251
.
23
Jones
JP
,
Walker
MS
,
Masino Drass
J
,
Kaimal
G
.
Art therapy interventions for active duty service members with post-traumatic stress disorder and traumatic brain injury
.
Int J Art Ther
.
2018
;
23
(
2
):
70
-
85
.
24
Ross
EA
,
Hollen
TL
,
Fitzgerald
BM
.
Observational study of an arts-in-medicine program in an outpatient hemodialysis unit
.
Am J Kidney Dis
.
2006
;
47
(
3
):
462
-
468
.
25
Walsh
SM
,
Martin
SC
,
Schmidt
LA
.
Testing the efficacy of a creative-arts intervention with family caregivers of patients with cancer
.
J Nurs Scholarsh
.
2004
;
36
(
3
):
214
-
219
.
26
Nainis
N
,
Paice
JA
,
Ratner
J
,
Wirth
JH
,
Lai
J
,
Shott
S
.
Relieving symptoms in cancer: innovative use of art therapy
.
J Pain Symptom Manage
.
2006
;
31
(
2
):
162
-
169
.
27
Reynolds
MW
,
Lim
KH
.
Contribution of visual art-making to the subjective well-being of women living with cancer: a qualitative study
.
Arts Psychother
.
2007
;
34
(
1
):
1
-
10
.
28
Samoray
JM
.
The healing effects of creative expression experienced by people who identify themselves as having compassion fatigue: a phenomenological study
.
Diss Abst Int
.
2006
;
66
(
9B
):
5103
.
29
Weiskittle
RE
,
Gramling
SE
.
The therapeutic effectiveness of using visual art modalities with the bereaved: a systematic review
.
Psychol Res Behav Manag
.
2018
;
11
:
9
-
24
.
30
Kaimal
G
,
Walker
MS
,
Herres
J
,
French
LM
,
DeGraba
TJ
.
Observational study of associations between visual imagery and measures of depression, anxiety and posttraumatic stress among active-duty military service members with traumatic brain injury at the Walter Reed National Military Medical Center
.
BMJ Open
.
2018
;
8
:
e021448
. doi:
31
Jones
JP
,
Gonzaga
A
,
Landless
BM
,
Kaimal
G
.
Evaluation of the Art Therapy Program at Fort Belvoir Intrepid Spirit One
.
Report prepared for the Fort Belvoir Community Hospital and the National Endowment for the Arts
.
Philadelphia, PA
:
Drexel University
;
2015
.
32
Berberian
M
,
Walker
MS
,
Kaimal
G
.
‘Master My Demons’: art therapy montage painting by active-duty military service members with traumatic brain injury and posttraumatic stress [published online August 4, 2018]
.
Med Humanit
. doi:
33
Kaimal
G
,
Jones
JP
,
Dieterich-Hartwell
R
,
Acharya
B
,
Wang
X
.
Evaluation of art therapy programs for active duty military service with TBI and post-traumatic stress
.
Arts Psychother
.
2019
;
62
:
28
-
36
.
34
Walker
MS
,
Kaimal
G
,
Gonzaga
AML
,
Myers-Coffman
KA
,
DeGraba
TJ
.
Active-duty military service members’ visual representations of PTSD and TBI in masks
.
Int J Qual Stud Health Well-being
.
2017
;
12
(
1
):
1267317
. doi:
35
Walker
MS
,
Stamper
AM
,
Nathan
D
,
Riedy
G
.
Art therapy and underlying fMRI brain patterns in military TBI: a case series
.
Int J Art Ther
.
2018
;
23
(
4
):
180
-
187
.
36
American Music Therapy Association
.
What is music therapy?
2019
.
American Music Therapy Association website
. . Accessed October 15, 2019.
37
Crowe
B
.
Music and Soulmaking
.
Lanham, MD
:
Scarecrow Press
;
2004
.
38
Gold
C
,
Heldal
TO
,
Dahle
T
,
Wigram
T
.
Music therapy for schizophrenia or schizophrenia-like illnesses
.
Cochrane Database Syst Rev
.
2005
;(
2
):
CD004025
.
39
Pelletier
CL
.
The effect of music on decreasing arousal due to stress: a meta-analysis
.
J Music Ther
.
2004
;
41
(
3
):
192
-
214
.
40
Samaritter
R
.
The aesthetic turn in mental health: reflections on an explorative study into practices in the arts therapies
.
Behav Sci (Basel)
.
2018
;
8
(
4
):
E41
. doi:
41
American Dance Therapy Association
.
What is dance/movement therapy?
2019
.
American Dance Therapy Association website. http://adta.org/faqs
. Accessed September 13, 2019.
42
Levy
F
.
Dance Movement Therapy: A Healing Art
.
Reston, VA
:
National Dance Association
;
2005
.
43
Bernstein
B
.
Empowerment-focused dance/movement therapy for trauma recovery
.
Am J Dance Ther
.
2019
;
41
:
193
-
213
.
44
Harris
DA
.
Dance/movement therapy approaches to fostering resilience and recovery among African adolescent torture survivors
.
Torture
.
2007
;
17
(
2
):
134
-
155
.
45
Koch
SC
,
Riege
RFF
,
Tisborn
K
,
Biondo
J
,
Martin
L
,
Beelmann
A
.
Effects of dance movement therapy and dance on health-related psychological outcomes: a meta-analysis update
.
Front Psychol
.
2019
;
10
:
1806
. doi:
46
Stern
D
.
Forms of Vitality: Exploring Dynamic Experience in Psychology, the Arts, Psychotherapy, and Development
.
New York, NY
:
Oxford University Press
;
2010
.
47
Thom
L
.
From simple line to expressive movement: the use of creative movement to enhance socio-emotional development in the preschool curriculum
.
Am J Dance Ther
.
2010
;
32
(
2
):
100
-
112
.
48
Rhodes
R
.
How to Write: Advice and Reflections
.
New York, NY
:
HarperCollins
;
1995
.
49
Wassiliwizky
E
,
Koelsch
S
,
Wagner
V
,
Jacobsen
T
,
Menninghaus
W
.
The emotional power of poetry: neural circuitry, psychophysiology and compositional principles
.
Soc Cogn Affect Neurosci
.
2017
;
12
(
8
):
1229
-
1240
.
50
Huang
ST
,
Good
M
,
Zauszniewski
JA
.
The effectiveness of music in relieving pain in cancer patients: a randomized controlled trial
.
Int J Nurs Stud
.
2010
;
47
(
11
):
1354
-
1362
.
51
Russell
H
.
The culture cure: how prescription art is lifting people out of depression
.
Guardian
.
July
31
,
2019
. . Accessed December 4, 2019.
52
Parker
K
.
Neustadt Prize laureate Mia Couto talks poetry, literature importance
.
Norman Transcript
.
October
24
,
2014
. . Accessed December 4, 2019.
53
Francis
G
.
Storyhealing: literature can enthuse medicine, and medicine can inspire literature: they are complementary treatments for being human
.
Aeon
.
March
6
,
2017
. . Accessed December 4, 2019.
54
Murray
B
.
Writing to heal: by helping people manage and learn from negative experiences, writing strengthens their immune systems as well as their minds
.
Am Psychol Assoc Monitor Psychol
.
2002
;
33
(
6
):
54
.
55
Parker-Pope
T
.
Writing your way to happiness
.
New York Times
.
January
19
,
2015
. . Accessed December 4, 2019.
56
Moss
M
,
Good
VS
,
Gozal
D
,
Kleinpell
R
,
Sesier
CN
.
A Critical Care Societies Collaborative statement: burnout syndrome in critical care healthcare professionals: a call for action
.
Am J Respir Crit Care Med
.
2016
;
194
(
1
):
106
-
113
.
57
Panagioti
M
,
Geraghty
K
,
Johnson
J
, et al
.
Association between physician burnout and patient safety, professionalism, and patient satisfaction: a systematic review and meta-analysis
.
JAMA Intern Med
.
2018
;
178
(
10
):
1317
-
1330
.
58
Mealer
ML
,
Shelton
A
,
Berg
B
,
Rothbaum
B
,
Moss
M
.
Increased prevalence of post-traumatic stress disorder symptoms in critical care nurses
.
Am J Respir Crit Care Med
.
2007
;
175
(
7
):
693
-
697
.
59
Krasner
MS
,
Epstein
RM
,
Beckman
H
, et al
.
Association of an educational program in mindful communication with burnout, empathy, and attitudes among primary care physicians
.
JAMA
.
2009
;
302
(
12
):
1284
-
1293
.
60
West
CP
,
Dyrbye
LN
,
Rabatin
JT
, et al
.
Intervention to promote physician well-being, job satisfaction, and professionalism: a randomized clinical trial
.
JAMA Intern Med
.
2014
;
174
(
4
):
527
-
533
.
61
El Khamali
R
,
Mouaci
A
,
Valera
S
, et al
.
Effects of a multimodal program including simulation on job strain among nurses working in intensive care units: a randomized clinical trial
.
JAMA
.
2018
;
320
(
19
):
988
-
997
.
62
Jensen
A
.
Beyond the borders: the use of art participation for the promotion of health and well-being in Britain and Denmark
.
Arts Health
.
2013
;
5
(
3
):
204
-
215
.

Footnotes

Supplemental materials are available online at www.aacnacconline.org.

The authors declare no conflicts of interest. This work was supported by the National Endowment for the Arts.