Contents

Highlights

Background

Method

Findings

Conclusions and implications

Next steps

Studies included in the review

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Highlights

In recent years there has been an increased interest in the role that arts and culture play in the mental health and wellbeing of young people. This is in line with the fact that many mental health challenges have their first onset within adolescence, with it estimated that one in ten children and young people in the UK are living with a mental health diagnosis. We wanted to understand what evidence there is to support or challenge the value of culture in the context of young people’s (aged 11-25) mental health and wellbeing.

We identified 20 peer-reviewed studies which examined impacts and outcomes relating to young
people’s mental health and wellbeing. Across these published studies, music programmes were the most commonly represented. A wide range of populations were explored across studies, including: young people in youth justice contexts; young people experiencing homelessness; indigenous young people living in Canada; and young people at risk of developing mental health challenges.

The strongest evidence is currently represented within the qualitative literature. For methodological reasons, it is not possible at this point to draw any firm conclusions from the quantitative literature.This is because of the wide range of self-report questionnaires that were used within each individual study, which prevents comparison across studies.

The qualitative literature paints a picture of the value of cultural programmes in building young people’s confidence and self-esteem, and how this is built up through the opportunity to showcase artwork, compose music and devise theatre pieces. The positive feedback received through showcasing their work leads to young people feeling a sense of pride and achievement.

Engaging with culture also helps young people to cope with difficult feelings and act as a distraction from negative thoughts, with the phrase ‘safe space’ being a recurrent term within the literature. These spaces were referred to as ‘non-judgemental’, places for positive social experiences and an opportunity for escapism. Within these spaces young people were able to develop new friendships and feel a sense of belonging that they did not feel in other walks of life.

Music composition and lyric writing in particular offered young people a creative outlet without directly relating it to their own experiences. The ability to use music composition as a method to cope with challenging circumstances and reflect on trauma was observed, with three studies reporting a reduction in self-harming behaviour. This was particularly linked to hip hop and rap.

Not all experiences reported within the literature were positive, and there were instances of increases in ‘challenging’ or aggressive behaviours, and others noted that participation led to some young people re-living traumatic experiences.

Overall, while there is promising evidence that there is a positive value of cultural experiences in supporting young people’s mental health and wellbeing, there is a need to further explore concepts of ‘safe spaces’, the role of cultural practitioners in these complex contexts, and an exploration of longer-term outcomes through rigorous mixed-methods research.

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Background

In recent years there has been an increased interest in the role that arts and culture play in the mental health and wellbeing of young people. This is in line with the fact that many mental health challenges have their first onset within adolescence; it is estimated that one in ten children and young people in the UK are living with a mental health diagnosis. The Covid-19 pandemic has also led to a record number of young people being referred to mental health services, while at the same time as it has been revealed that high volumes of young people are not getting the support they need.

In order to evaluate the evidence around the value of arts and culture in supporting the mental health and wellbeing of young people, we synthesised and appraised literature published since 2011. This rapid review of the literature was conducted between November 2020 and May 2021 and was updated ahead of publication in November 2021. This review is part of our synthesis of research within the wider theme of culture, health and wellbeing.

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Methods

We conducted a rapid review of the academic literature that has been published since 2011 to present a snapshot of the recent evidence. We used a systematic approach to identify relevant literature, using academic databases as well as the Repository for Arts and Health Resources and the Center for Arts in Medicine (University of Florida) Research Database. We scanned the reference lists relevant journals as well as reference lists from systematic reviews in this topic area.

Review shaping

The research questions within this review were shaped in consultation with cultural practitioners and organisations as part of our research shaping event in November 2020. Stakeholders involved in this research shaping event helped us to narrow the focus of the review, so it is accessible and relevant to the questions the sector had about this topic. You can read more about our engaged research process here.

What we included

We included peer-reviewed, primary research that was published in English between 2011 and 2021. We looked for research where the focus of the research was on teenagers and young adults (11-25 years) and explored the value of culture in relation to wellbeing or mental health.

What we didn't include

We didn’t include studies that focused primarily on the role of culture in the curriculum rather than including aims relating to mental health or wellbeing. We also didn’t include studies which focused on creative arts therapies. While we recognise the vital work of creative arts therapists, the focus of this review was on the impacts and outcomes of work produced or supported by the arts and cultural sectors.

What questions did we ask?

Our broad review questions:

1. What evidence is there to support or challenge the role of arts and culture in supporting the
   mental health and wellbeing of teenagers and young adults?
2. Which types of arts or cultural opportunities are represented within this literature?
3. How is the value of arts and culture researched and evaluated in this area?
4. What are the strengths and limitations of the research to date?
5. What are the current gaps in understanding and what does future research need to focus on?

Questions from the sector:

1. What training do cultural practitioners receive to be able to support young people taking part in these cultural experiences?
2. Is there any evidence of co-production or co-research approaches with young people’s voices being placed centrally within research?
3. Are there any uses of creative research methods?

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Findings

We identified 20 peer-reviewed studies which investigated outcomes relating to young people’s mental health (see the table of studies included in this review for more information). Of these studies, seven were conducted in England, four in Australia, four in Canada, two in Scotland, two in the USA, and one in Iran.

Location of studies

A range of participant types were represented within the literature:

• four studies specifically focused on young people living in ‘disadvantaged areas’ (though this was rarely clearly defined)
• three focused on youth justice settings (including custodial settings, secure children’s homes, young offender institutions)
• three focused on young people from refugee or migrant backgrounds
• two focused on young people from indigenous communities in Canada
• two focused on young people who were at risk for developing mental health problems (including psychosis)
• one focused on young people experiencing homelessness
• one focused on undergraduate students
• one focused on young people living in foster homes or in residential placements
• one focused on young people experiencing complex mental health challenges
• one focused on young people experiencing mild distress
• one focused on high school students

Which types of arts or cultural experiences were represented within this literature?

Music engagement was the most commonly represented cultural activity within the literature, with nine studies (45 per cent) focusing on a form of musical participation including: percussion and drumming groups; community-based music making; music composition and lyric writing; a music-based phone app. Four studies (20 per cent) focused on mixed programmes of engagement, including visual arts, sculpture, dance, drama, film etc. Four studies (20 per cent) examined the relationship between theatre-based workshops and wellbeing (including improvisation exercises; Theatre of the Oppressed; and creating an original play). The remaining studies focused on visual arts (1), creative writing (1) and hip-hop dancing (1).

A range of programme lengths were reported within the studies. The shortest engagement was three hourlong sessions on consecutive days (Sandmire et al., 2016) and the longest was across six months (Burnard et al., 2015; Hides et al., 2019).

Cultural activity

How is the value of arts and culture researched and evaluated in this area?

Ten studies were purely qualitative (50 per cent) and incorporated the following methods: case studies, video-based observation, interviews and focus groups and participant diaries. Typically, both young people and those supporting them (family members, teachers and social workers) were interviewed.

Six studies used mixed-methods (30 per cent) which included a combination of standardised questionnaires (including the Good Childhood Index, Warwick Edinburgh Mental Wellbeing Scale, and Rosenberg Self-Esteem scale) and focus groups or interviews.

Four studies were purely quantitative (20 per cent) and used a range of standardized questionnaires including the Kessler Psychological Distress Scale (10), Strengths and Difficulties Questionnaire, and Traumatic Grief Inventory for Children. There was one example (Sandmire et al., 2016) of measuring heart rate variability (which assesses the variation in time between heartbeats as a measure of anxiety) and one example (Rousseau et al., 2014) of examining school grades as an indicator of wellbeing.

Is there any evidence of co-production or co-research approaches with young people’s voices being placed centrally within research? Are there any uses of creative research methods?

Only one study used participatory research methods (Vettraino et al., 2017), which was framed as “a combination of community-based participatory research and theatre action research” (p.85). While the framing of this research was participatory in nature, there was very little reporting of the methods themselves, and little focus on how these methods facilitated young people to have agency, beyond more traditional qualitative methods.

There were two examples of creative research methods within the literature, predominantly framed around the use of participant-led filming of the programmes and photo elicitation (using photos taken by young people to stimulate conversations). Young people in one study (Clennon et al., 2014) were able to document their own and their peer’s experiences through documentary-style films, which were subsequently analysed by researchers. There was also an example of photo elicitation (Ritchie et al., 2020), where researchers used photos taken during the programme to stimulate discussion within interviews with young people. While these are examples of participatory and creative research methods, there was little discussion of how these methods worked in practice and the ways in which they complemented the more traditional qualitative methods used in studies.

So, although there were examples of participatory and creative research methods within the literature, they did not sufficiently demonstrate or explicate how they may have afforded more agency for young people themselves compared to other research methods. In framing research as ‘participatory’, it is important to acknowledge the power held by researchers within these contexts, and to think about whether the involvement of young people through these methods was truly participatory or merely driven by the objectives of the researchers.

What evidence is there to support or challenge the role of arts and culture in supporting the mental health, wellbeing or resilience of teenagers and young adults?

Qualitative findings

Overall, the qualitative data paints a very positive picture for the value of arts and culture, specifically music, in supporting the mental health and wellbeing of young people. In particular, the research highlights the role of arts and cultural experiences in helping young people to build their confidence and self-esteem (observed in 60 per cent of studies). Although the mechanisms for these factors were not explicitly explored within studies, being able to perform or showcase artwork, compose music and devise theatre productions led to young people feeling a sense of pride and achievement through the positive feedback they received.

A number of studies (50 per cent) referenced the idea that cultural experiences provided a ‘safe space’ for younger people: a space which was referred to as ‘non-judgemental’, a place for positive social experiences and an opportunity for escapism. Young people also developed strong relationships with cultural practitioners who showed empathy and understanding towards the challenges they faced. There were groups of young people who could be considered to be ‘vulnerable’ within the research we looked at, so this is an important element to be explored in future research.

For example:

• How are safe spaces created and why do cultural experiences facilitate feelings of safety for young people?
• Are there any instances where arts and cultural experiences are not deemed to be safe?
• Are some spaces that are perceived to feel safe to some perceived to feel unsafe for others?
• Are digital spaces perceived to be as safe as face-to-face settings?
• What role do professional cultural practitioners play in creating and facilitating safe spaces?

A further 50 per cent of studies reported a relationship between cultural experiences and young people’s emotional expression. On a simple level, a large proportion of studies reported that young people found the programmes enjoyable and fun, which led to sustained involvement over time. On a deeper level, young people reported that taking part enabled them to cope with difficult feelings and acted as a distraction from negative thoughts. Music composition and lyric writing in particular, offered young people an outlet without directly relating it to their own personal experiences. The ability to use music composition as a method to cope with challenging circumstances and reflect on trauma was observed, with three studies reporting a reduction in self-harming behaviour. This was particularly linked to hip hop and rap genres.

There was also reference to the ways in which taking part in cultural experiences fostered young people’s future aspirations (observed in 45 per cent of studies). For example, post-engagement some young people enrolled within further educational opportunities or engaged better with school, while others aspired to work within creative and cultural industries (for example as a music producer or theatre technician).

The mechanisms that may have underpinned this outcome included young people feeling more independent and having the opportunity to develop new skills. While this was reported across a number of studies, no direct links were reported that made specific links such aspirations and mental health or wellbeing. While there may have been a relationship between these outcomes, there were no examples of longitudinal research which could have examined the longer-term benefits of the aspirations that were cultivated through engaging with arts and culture.

Young people reported in a number of studies (30 per cent) that they were able to develop new friendships within the context of programmes. Factors which may have led to the feelings of connection felt by young people engaging with these programmes included building a sense of trust and respect and developing teamwork skills through working towards a shared goal. Young people reported that feeling connected to a group of other young people helped them to feel a sense of belonging that they did not feel in other walks of life, with supporting staff and cultural practitioners reporting that they observed young people ‘open up’ as a result of the programmes.

However, as with our other reviews in this area, it is difficult to pinpoint the specific role of arts and culture in affording these opportunities for enhanced social connection between young people. This is due in part to the emphasis being placed on mental health and wellbeing outcomes above and beyond what is considered about the creative and cultural experiences themselves.

It must be noted that not all outcomes reported within the literature were positive. For example, a handful of studies noted increases in ‘challenging’ or aggressive behaviours, and others noted that participation led to some young people reliving traumatic experiences. Other young people simply reported that the programmes were ‘something to do’ without any further impact on mental health or wellbeing.

Quantitative findings

It is not currently possible to be able to draw any firm conclusions about the value of cultural programmes for young people’s mental health and wellbeing from the quantitative findings. This is because of the wide range of self-report questionnaires that were used within each individual study, which prevents comparison across studies.

Furthermore, four studies showed no significant differences in scales used to assess wellbeing. One study reported that data gathered through the Warwick Edinburgh Mental Wellbeing scale were insufficient to draw any conclusions (see Appendix 1 in PDF download for more information).

We must also ask questions about how appropriate the different questionnaires are with young people in this context. The qualitative literature paints a far clearer picture about the lived experiences of young people who take part in cultural programmes that aim to address mental health and wellbeing needs.

What training do cultural practitioners receive to be able to support young people taking part in these cultural experiences?

Two studies reported that practitioners received training in order to work with vulnerable young people. However, the information provided was minimal:

"Theatre directors attended an initial training session where they were introduced to psychotic symptoms and disorders…" (Tang et al., 2019, p. 165)

“They [musicians] were trained to work with vulnerable participants, including prisoners and children, and they were supervised by the charity’s senior project manager.” (Daykin et al., 2017, p. 943)

While it may be the case that practitioners in other studies did receive training, it is concerning that it was only reported twice within the literature we reviewed. Practitioners represented in the literature experienced young people making disclosures of previous abuse, self-harm, aggression, and past traumatic experiences.

This ties into a wider concern that the role of practitioners themselves were very infrequently represented within the literature. We have observed the same concern in a scoping exercise relating to the experiences of cultural practitioners working in healthcare settings.

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Conclusions and implications

While there are some promising findings emerging from the qualitative literature in relation to the role that culture can play in supporting the mental health and wellbeing of young people, there is still a way to go to produce a rigorous, participant-centred evidence base in this area. However, we can draw the following conclusions:

1. Music programmes were the most represented within the literature. This means that there is further opportunity to explore other cultural experiences that may contribute to young people’s mental health and wellbeing. Furthermore, the age ranges represented within studies were often quite broad (i.e., 11-25) so it is important to consider greater specificity within future research. For example, those in early adolescence may have substantially different needs to those in their twenties.
2. As has been seen in our other research digests in the culture, health and wellbeing theme, there is a strong reliance on outcome over process, with very few studies providing insights into the experiences of young people and the practitioners facilitating the cultural activities. This means that there is scope for further research that explores session-by-session, as well as ‘in the moment’, experiences to begin to build a greater understanding of the shortto-medium term outcomes for engagement. There is a need for longitudinal follow ups to be built into study designs which will allow for the ripple effects, such as future employment or engagement with educational opportunities, to be accounted for rather than predicted.
3. There also appears to be a need for methodological development within this area. A lot of the qualitative studies relied on traditional research methods in order to understand the experiences of young people. However, these may not always be appropriate for younger people and we must consider the ways in which rigorous qualitative research that centres young people’s experiences may offer up opportunities to further understand the value of culture in this context. This may go some way to helping young people to define their own wellbeing and how it relates to their experiences of positive or negative mental health.
4. The concept of ‘safe spaces’ warrants further exploration. For example, what features of a space make it safe for young people? There should also be an examination of the role cultural practitioners play in developing and maintaining safe spaces for young people. For example, in the literature cultural practitioners were able to develop trust and empathy with young people which allowed them to open up about negative thoughts or emotions. Young people seemed to connect most with those who had come from similar backgrounds to them so they could relate to their experiences. Thus, future research could seek to understand the value of culture, and cultural practitioners in particular, in creating spaces that feel safe for younger people to share their mental health challenges.

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Next steps

Our research and evidence base for cultural value needs to respond to what works now and what needs to change in the future, so that we support practitioners and policymakers to develop models and practices that are more robust, equitable and sustainable.

If you are aware of new publications or feel we have missed a vital piece of research or evaluation please get in touch at: ccv@leeds.ac.uk

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Studies include in this review

Please see this table for a full list of studies included in this review.