While much of this issue focuses on addressing crises in healthcare caused by corporatization and a single-minded focus on the bottom line, Jill Sonke offers us something different: a glimpse of one of many ways healthcare could work and feel better if hospitals prioritized patient well-being over revenue. For a compelling introduction to Sonke’s work, watch her TEDxUF talk at go.aft.org/q7q.
When I was a kid, I had a hard time falling asleep at night. In my wakefulness, I would sneak down the stairs to the bookshelf where the family encyclopedias lived. I read over and over the sections about the brain, reproduction, and digestion. And when I did sleep, I dreamed of being a doctor. I couldn’t wait to turn 14, which was when I could volunteer in a hospital. By the time that day came, I had my application submitted and my requisite white shoes in hand; I was thrilled to begin the next week. I changed bedsheets and bedpans, helped patients eat, and spent hours reading and talking with them. I absolutely loved being in the hospital and being a small part of the care team.
I was also a competitive gymnast during that part of my life. One day when I was in my junior year of high school, a dancer came into the gym to help with our floor exercise routines. As she guided us, I found myself absorbed and lost in movement in a way I had never experienced. I felt a kind of energy and elation I had never felt. Although I didn’t know the words or what they meant, I was experiencing both transcendence (a shift in my state of consciousness) and self-transcendence (an expansion of my conceptual boundaries). I knew I wanted to have that experience every day for the rest of my life. This was both my first transcendent experience and my first life epiphany.
That summer, I auditioned for a spot as a dance major at Interlochen Arts Academy, a magnificent performing arts boarding school in northern Michigan. Miraculously, I got in with a scholarship based purely on potential. So, my trajectory toward medicine took a hard turn toward the arts. Or so it seemed. In the end, these two paths actually led to the same place. As I look back now, I can see experiences in my life that both foreshadowed and shaped what would become my understanding of how the arts and medicine are connected and why medicine needs the arts.
One of them happened at Interlochen. I woke up one winter morning when I heard my roommate, a vocal major, scream. She had woken early to study and made a cup of tea using our contraband hot pot. She sat on the floor with the hot pot on a shelf above her. When the shelf suddenly broke, she received second- and third-degree burns and began what turned into weeks of excruciating treatment in the hospital.
A few months earlier, I had given her a Joni Mitchell cassette tape. While she was in the hospital and going through very painful dressing changes and debridement procedures, she would play the tape, volume turned up loud, and sing at the top of her lungs. As she later described it to me, she transcended and survived her pain by singing. As an artist, that made perfect sense to me.
But I didn’t really think about transcendence or self-transcendence until years later, in 1994, when I became a dancer in residence with the University of Florida Health Shands Arts in Medicine program. As a member of the hospital staff, I worked on the bone marrow transplant and pediatrics units, dancing with patients. Nurses and doctors wrote referrals for me to see their patients when they felt that the patients could benefit from movement or creative engagement.
Early on, when I described my work to people and they noted what a great distraction it must be for patients, that comment felt demeaning, as if they didn’t recognize the depth of experience and transformation I was witnessing among patients who embraced the arts.
Although I wanted each patient to experience the joy of transcendence and the expansion of self-transcendence, I saw that patients benefited significantly from arts engagement even if they were merely distracted for a while. As human beings, we have limited cognitive capacity: we can only pay attention to so much at one time. While we think we are great multitaskers, we actually aren’t, and this can work to our advantage. When we experience pain or anxiety, focusing on something else—like a creative activity—can occupy our attention and reduce our perception and experience of pain.1 Over time, I came to realize that distraction can be a powerful mechanism and gift.
I also saw, through working with patients and delving into research, that arts engagement can make real changes in our brains and bodies. When we engage with the arts—either actively or receptively—we can experience a range of physiological and hormonal responses. Among those responses are heightened flows of hormones, including
- endorphins, our body’s natural inborn painkillers, especially when we are actively involved, such as by singing or dancing;2
- dopamine, which elicits a feeling of joy when we anticipate or experience a reward, such as what comes from artistic expression, discovery, and achievement;3
- serotonin, an emotional regulator and inborn antidepressant, which heightens our sense of self-esteem;4 and
- oxytocin, which is our bonding hormone.5
In addition, both music and dance/movement have been shown to reduce elevated levels of cortisol in the presence of stress.6 These mechanisms are clear in the literature, but I know them through my experiences with patients.
Bertis: My First Teacher
One of the very first patients I worked with as an artist in residence was a six-year-old girl named Bertis. Bertis has sickle cell disease, which means she deals with episodes of extraordinary pain. She was reluctant to dance at first, but as soon as she stepped in, she fell in love with dancing and began to use it to manage her pain in the most masterful way. She was one of my greatest teachers. She taught me about flow state, relaxation response, and self-transcendence. Together, these three concepts became the theoretical and practical foundation of my work, and they also underpin the now-burgeoning field of arts in health.
In the first several years in which we worked together, Bertis danced to induce joy, pleasure, and fun as a counterbalance to her pain. We would play movement games in which we leapt out of her hospital room window, rowed clouds to the beach, and swam underwater with dolphins. By shifting her cognitive awareness in movement rich with imagery of her own making, she could distract herself from and reduce her perception of pain. She also wanted to learn about dance. In her small room, we did lessons in ballet, modern dance, and improvisation. Then as she got older, her pain got worse.
One day, when Bertis was 14, I got a call from her doctor saying that she had been admitted with a really bad pain crisis. When I walked into her room, she was alone and sobbing, rocking in a fetal position on her bed. She didn’t look up when I entered, so as I always did, I leaned over her and said softly, “Hi Bertis, it’s Jill. Do you want to dance?”
This would seem like an absolutely ridiculous question to anyone looking in, but it made perfect sense to Bertis, and she said yes. She struggled but managed to sit up. I turned on her favorite music and led her in gently moving her arms. Before long, she was in a state of deep concentration, with her eyes closed, and had taken the lead in the dance. I followed, and after about an hour of beautiful fluid movement, she was transformed. That day, a photographer was with me documenting my work. She asked Bertis, “What happens to your pain when you dance?”
Bertis replied, “Oh, it’s still there, but I don’t care because I feel so good.”
Later that week, Bertis’s doctor came into the room while we were dancing. Bertis didn’t notice, so he sat quietly and watched for almost 30 minutes. When he left, he put a big note at the front of her medical chart: “Dancing works better than meds—call Arts in Medicine.” After that, I got a call every time Bertis was admitted to the hospital; at her request, her pain meds were reduced by half before my visit, and she could maintain that lower dosage into the wee hours of the next morning.
Bertis taught her entire care team about how creative engagement can help with pain management and well-being, and she taught me more about creative processes than I had ever learned in my dance training. Bertis is extremely adept at doing what all artists strive to do—to get into that special creative space, the flow state, from which we can make truly authentic art. And she does it with amazing efficiency, perhaps motivated by her pain. Bertis is a master of flow state—that state of consciousness in which our awareness is highly focused on the present moment and on the activity at hand.7 Flow state is a merging of action and awareness and often results in a sense of euphoria as well as a suspended awareness of time, or the sense that “time flies.” It’s the transcendent state, the high, that I experienced myself when I danced for the first time in the gym decades ago.
When we engage in the flow state, we can also elicit a relaxation response, which is the antithesis of the stress response (fight or flight). It has been shown to reduce pain, anxiety, and the use of medication.8 Relaxation response is a hypothalamic response that decreases nervous system activity and increases parasympathetic activity.9 Essentially, it is an innate capability that can be summoned to reduce stress and enhance the body’s immune response. Just as stress has been linked to immune suppression, the relaxation response has been linked to enhanced immune response.10
Music has been ubiquitous throughout time and cultures as a means for counterbalancing the stresses of life and eliciting a relaxation response. I see this phenomenon in action every day in the city in which I live. As I move through the streets, a majority of people—myself included—are wearing headphones or earbuds. Many of us “dose” ourselves with music throughout the day to relax and to shift our state of being. While most of us are simply looking to boost our energy and lift our spirits, a vast array of research demonstrates the benefits of music for pain management.11
Numerous studies of the use of music during burn dressing changes and debridement procedures have validated the experience that my roommate described to me all those years ago. They have documented reductions in pain, anxiety, heart rate, and muscle tension, and found that music enhances relaxation and the patient’s experience.12 While music can’t replace pain medication in such scenarios, it can reduce anxiety, the perception of pain, and the amount of medication needed, thus reducing side effects and risks, including the risk of pain medication addiction.13 And, for those suffering from substance use disorder, a recent integrative review found that music has been shown to reduce pain, reduce the amount of pain medication taken, improve substance use disorder treatment readiness and motivation, and reduce substance craving.14
Many years ago, I had a visit with a patient on the bone marrow transplant unit. She told me about her home near the beach and her love of the ocean. When she said that she wanted to do some movement, I offered her a phrase of movement in which we stretched our arms out across the horizon as if we were on the beach, reached down and scooped up some water, and then tossed it over our heads to let it shower back down over us. She was repeating the phrase with her eyes closed when she took in a breath and said, “Now I know I’m going to be all right. The seashells all just turned to jewels.”
This patient had a self-transcendent moment. That image held deep meaning for her. And it meant even more to her than the statistics and prognoses she was given because it had come from within herself. In that moment, some of her fear turned to confidence. She had used her own inner resources, namely her creativity, to find confidence and a representative image to hold onto. The jewels on the beach became a symbol and affirmation of her survival and helped to fuel her confidence through her transplant and recovery.
Self-transcendence is a shift or expansion of our conceptual boundaries, a moment in which we see ourselves or the world around us differently. Self-transcendent moments are often described as insight or epiphany, or as “aha” moments. Viktor Frankl,15 a psychiatrist and Holocaust survivor, and Abraham Maslow,16 the psychologist who established humans’ hierarchy of needs, began writing about this concept in the 1960s. They understood that self-transcendence enhances our sense of well-being and wholeness. Well-being, in fact, can be described as a sense of wholeness.
Medical researchers have found direct correlations between self-transcendence and well-being.17 In healthcare-based studies, they have demonstrated relationships between vulnerability, self-transcendence, and well-being. Specifically, they found that when we are vulnerable, like when we are in the hospital or dealing with illness, we are more susceptible to self-transcendence, and when we self-transcend, our well-being is enhanced.18 These can be little moments, but they can make a big difference, and these moments can happen when we engage in the arts.
Frankl considered self-transcendence “the essence of existence” for humans because we live “by ideals and values.”19 Maslow placed self-transcendence at the top of his hierarchy of needs, above self-actualization, recognizing that transcendent experiences help a person develop a sense of identity that transcends or extends beyond the personal self; “this may involve service to others, devotion to an ideal (e.g., truth, art) or a cause (e.g., social justice, environmentalism, the pursuit of science, a religious faith), and/or a desire to be united with what is perceived as transcendent or divine.”20 Human beings across cultures have recognized the arts as a means for self-transcendence and have engaged them in healing practices for millennia. Today, artists and arts programs in hospitals provide patients with opportunities to self-transcend within some of the most critical moments of their lives.
Becoming a Patient Myself
Nearly a decade ago, and 20 years into my career as an artist, researcher, and educator in the field of arts in health, I found myself in the role of patient. I had to have two eye surgeries on the same day—one was a deconstruction and the other a reconstruction. I was most anxious about the hours I would have to pass between the surgeries. So, I reached out to my colleague who was the director of the arts in medicine program at the Mayo Clinic, where the surgeries were taking place, and asked if a musician could visit me between the surgeries. She said yes, and to my surprise, I felt both relief and panic. I was glad to know I would have a live music performance to distract and relax me, but a huge question immediately weighed heavily on me: What if I don’t like it?
I had invested the past two decades of my life in the belief that the arts and artists belong in hospitals and that medicine needs the arts to serve patients holistically. What if I felt differently as a patient? I had developed and taught thousands of students in degree programs in which people invested their trust, time, and money. I had helped drive the development of a field in which half of American hospitals invested in the arts.21 If I didn’t like it, would I have to find a new career?
The day came, and two musicians gently entered my room as I rested after the first surgery. One of them asked if I had any requests. I didn’t have the focus to answer the question and asked them to play whatever they liked. They played three songs. These weren’t songs I might have chosen on my own, but as I listened, they transformed that moment of anxiety and pain into a moment of beauty and bliss. Tears flowed, not because I was afraid or in pain, but because I was wonderfully overwhelmed by the beauty of the music and the gift of presence, connection, and caring that the artists brought. I felt deeply cared for and safer in an institution that was concerned enough about their patients to have artists available to attend to my spiritual well-being. All of that made a huge difference. When I think back on my whole experience, that moment rises to the top instead of the difficult moments. I felt well, whole, and joyful, rather than broken and afraid.
That is why medicine needs the arts. Art can’t replace medicine. Art doesn’t cure diseases, and artists who work in this field are not healers or therapists.* But artists are important members of our interprofessional healthcare teams.22 They can attend to some of the needs of patients in ways that caregivers—as much as they would like to—simply don’t have time for. And, as I describe in “How the Arts Can Support Clinical Staff,” artists are essential partners in the realization of a healthy and holistic system of care, for patients, for caregivers, and for the system itself.
Today, as we continue to contend with the COVID-19 pandemic, our healthcare systems are radically overburdened and understaffed. Care providers have suffered deep moral injury as a result of the pandemic, and they need more tools to support their own health, well-being, and professional longevity.† Our healthcare systems must embrace new approaches, resources, and partners to accomplish the changes that are necessary for healing from the pandemic and for building and sustaining systems of care. The arts have been shown to support the health and well-being of hospital staff by improving working conditions, levels of concentration, efficiency, and enthusiasm, and also by reducing anxiety and stress.23 Thankfully, the arts and artists are available resources in every community.
By 2007, there were arts programs in approximately half of the hospitals in the United States.24 These programs use the arts to provide more holistic care, and their artists work from the deep knowing that engaging in art helps us in so many ways. It is transcendent. It is joyful. It connects us to others. It can provide distraction from pain and anxiety. And all those things are simple but profound gifts in healthcare.
I still live for the transcendence I discovered in the art of dance and for the meaning I first felt when I volunteered in a hospital. All of that is amplified when I see the arts helping to make medicine, including the patients it serves and the extraordinary people who provide care, more whole. Even Plato recognized that we need more than medicine to heal when he wrote, “For this … is the great error of our day in the treatment of the human body, that physicians separate the soul from the body.”25 Medicine can do extraordinary things today, and with the arts, it can do more.
Jill Sonke, PhD, is the research director in the Center for Arts in Medicine at the University of Florida, the director of national research and impact for the One Nation/One Project initiative, and a codirector of the EpiArts Lab. She has written dozens of articles on the benefits of the arts and serves as a consulting editor for the Health Promotion Practice journal.
*However, there is a whole field of creative arts therapies that arts in health professionals work alongside. (return to article)
†To learn more about moral injury, see “Moral Injury: From Understanding to Action” in the Spring 2021 issue of AFT Health Care. (return to article)
1. V. Legrain et al., “A Neurocognitive Model of Attention to Pain: Behavioral and Neuroimaging Evidence,” Pain 144, no. 3 (2009): 230–32; S. Lunde et al., “Music-Induced Analgesia: How Does Music Relieve Pain?,” Pain 160, no. 5 (2019): 989–93; and S. Suleman, A. Atrushi, and K. Enskär, “Effectiveness of Art-Based Distraction on Reducing Pediatric Patients’ Pain and Anxiety During Venipuncture: A Randomized Controlled Trial,” Complementary Therapies in Clinical Practice 48 (2022): 101597.
2. S. Chaudhry and W. Gossman, Biochemistry, Endorphin (Treasure Island, FL: StatPearls Publishing, 2022); G. Kaimal, The Expressive Instinct: How Imagination and Creative Works Help Us Survive and Thrive (Oxford: Oxford University Press, 2022); and R. Dunbar et al., “Performance of Music Elevates Pain Threshold and Positive Affect: Implications for the Evolutionary Function of Music,” Evolutionary Psychology 10, no. 4 (2012).
3. L. Ferreri et al., “Dopamine Modulates the Reward Experiences Elicited by Music,” Proceedings of the National Academy of Sciences 116, no. 9 (2019): 3793–98.
4. N. Yehuda, “Music and Stress,” Journal of Adult Development 18, no. 2 (2011): 85–94.
5. Y. Ooishi et al., “Increase in Salivary Oxytocin and Decrease in Salivary Cortisol After Listening to Relaxing Slow-Tempo and Exciting Fast-Tempo Music,” PLOS One 12, no. 12 (2017): e0189075.
6. S. Khalfa et al., “Effects of Relaxing Music on Salivary Cortisol Level After Psychological Stress,” Annals of the New York Academy of Sciences 999, no. 1 (2003): 374–76; G. Kaimal, K. Ray, and J. Muniz, “Reduction of Cortisol Levels and Participants’ Responses Following Art Making,” Art Therapy 33, no. 2 (2016): 74–80; J. Smyth, J. Hockemeyer, and H. Tulloch, “Expressive Writing and Post-Traumatic Stress Disorder: Effects on Trauma Symptoms, Mood States, and Cortisol Reactivity,” British Journal of Health Psychology 13, pt. 1 (2008): 85–93; and T. Vrinceanu et al., “Dance Your Stress Away: Comparing the Effect of Dance/Movement Training to Aerobic Exercise Training on the Cortisol Awakening Response in Healthy Older Adults,” International Journal on the Biology of Stress 22, no. 6 (2019): 687–95.
7. O. de Manzano et al., “The Psychophysiology of Flow During Piano Playing,” Emotion 10, no. 3 (2010): 301–11; and J. Nakamura and M. Csikszentmihalyi, “The Concept of Flow,” in Flow and the Foundations of Positive Psychology (Dordrecht, Netherlands: Springer, 2014).
8. A. Gonzalez et al., “The Relaxation Response Resiliency Program (3RP) in Patients with Headache and Musculoskeletal Pain: A Retrospective Analysis of Clinical Data,” Pain Management Nursing 20, no. 1 (2019): 70–74; and A. Ibrahim et al., “The Effect of Benson Relaxation Method on Anxiety in the Emergency Care,” Medicine 98, no. 21 (2019): e15452; and C. Mandle et al., “The Efficacy of Relaxation Response Interventions with Adult Patients: A Review of the Literature,” Journal of Cardiovascular Nursing 10, no. 3 (1996): 4–26.
9. H. Benson, J. Beary, and M. Carol, “The Relaxation Response,” Psychiatry 37, no. 1 (1974): 37–46; and M. Dossett, G. Fricchione, and H. Benson, “A New Era for Mind–Body Medicine,” New England Journal of Medicine 382, no. 15 (2020): 1390–91.
10. G. Jacobs, “The Physiology of Mind-Body Interactions: The Stress Response and the Relaxation Response,” Journal of Alternative & Complementary Medicine 7, no. 1 (2001): 83–92; E. Peters et al., “To Stress or Not to Stress: Brain-Behavior-Immune Interaction May Weaken or Promote the Immune Response to SARS-CoV-2,” Neurobiology of Stress 14 (2021): 100296; and A. Reig-Ferrer, “A Relaxation Technique Enhances Psychological Well-Being and Immune Parameters in Elderly People from a Nursing Home: A Randomized Controlled Study,” BMC Complementary and Alternative Medicine 14 (2014): 311.
11. S. Damayanti et al., “Music Therapy on Pain Management Among Post-Operative Patients: A Systematic Review,” Jurnal Keperawatan Komprehensif (Comprehensive Nursing Journal) 8, no. 3 (2022); A. Kühlmann et al., “Meta-Analysis Evaluating Music Interventions for Anxiety and Pain in Surgery,” British Journal of Surgery 105, no. 7 (2018): 773–83; and J. Martin-Saavedr et al., “Standardizing Music Characteristics for the Management of Pain: A Systematic Review and Meta-Analysis of Clinical Trials,” Complementary Therapies in Medicine 41 (2018): 81–89.
12. R. Fratianne et al., “The Effect of Music-Based Imagery and Musical Alternate Engagement on the Burn Debridement Process,” Journal of Burn Care & Research 22, no. 1 (2001): 47–53; M. Gillum et al., “Nonpharmacologic Management of Procedural Pain in Pediatric Burn Patients: A Systematic Review of Randomized Controlled Trials,” Journal of Burn Care & Research 43, no. 2 (2022): 368–73; J. Li, L. Zhou, and Y. Wang, “The Effects of Music Intervention on Burn Patients During Treatment Procedures: A Systematic Review and Meta-Analysis of Randomized Controlled Trials,” BMC Complementary and Alternative Medicine 17 (2017): 158; N. Ghezeljeh et al., “The Effects of Music Intervention on Background Pain and Anxiety in Burn Patients: Randomized Controlled Clinical Trial,” Journal of Burn Care & Research 37, no. 4 (2016): 226–34; X. Tan et al., “The Efficacy of Music Therapy Protocols for Decreasing Pain, Anxiety, and Muscle Tension Levels During Burn Dressing Changes: A Prospective Randomized Crossover Trial,” Journal of Burn Care & Research 31, no. 4 (2010): 590–97.
13. M. Richard-Lalonde et al., “The Effect of Music on Pain in the Adult Intensive Care Unit: A Systematic Review of Randomized Control Trials,” Journal of Pain and Symptom Management 59, no. 6 (2020): 1304-19.e6; D. Kim et al., “A Review of Adjunctive Therapies for Burn Injury Pain During the Opioid Crisis,” Journal of Burn Care & Research 40, no. 6 (2019): 983–95; H. Trainor, “Effects of Using Music Therapy for Patients Suffering from Dementia,” Health Care Manager 38, no. 3 (2019): 206–10; and Suleman, Atrushi, and Enskär, “Effectiveness of Art-Based Distraction.”
14. J. Leis and C. Morrison, “An Integrative Review of Arts-Based Strategies for Addressing Pain and Substance Use Disorder During the Opioid Crisis,” Health Promotion Practice 22, no. 1 (suppl.) (2021): 44S–52S; and C. Morrison, K. Keene, and J. Leis, Arts Strategies for Addressing the Opioid Crisis: Examining the Evidence (Washington, DC: National Endowment for the Arts, 2020), arts.gov/sites/default/files/Arts-Strategies-Opioid-Crisis.pdf.
15. V. Frankl, “Self-Transcendence as a Human Phenomenon,” Journal of Humanistic Psychology 6, no. 2 (1966): 97–106.
16. A. Maslow, “The Farther Reaches of Human Nature,” Journal of Transpersonal Psychology 1, no. 1 (1969): 1–9.
17. P. Reed, “Theory of Self-Transcendence,” in Middle Range Theory for Nursing, ed. M. Smith and P. Liehr, 3rd ed. (New York: Springer, 2018), 109–40; and E. Fiske, “Self-Transcendence Theory and Contemplative Practices,” Holistic Nursing Practice 33, no. 5 (2019): 266–72.
18. P. Reed and G. Haugan, “Self-Transcendence: A Salutogenic Process for Well-Being,” in Health Promotion in Health Care – Vital Theories and Research, ed. G. Haugan and M. Eriksson (New York: Springer, 2021), 103–15.
19. Frankl, “Self-Transcendence as a Human Phenomenon,” 104.
20. M. Koltko-Rivera, “Rediscovering the Later Version of Maslow’s Hierarchy of Needs: Self-Transcendence and Opportunities for Theory, Research, and Unification,” Review of General Psychology 10, no. 4 (2006): 302–17.
21. J. Sonke et al., “The State of the Arts in Healthcare in the United States,” Arts & Health 1, no. 2 (2009): 107–35.
22. J. Sonke et al., “Nurse Perceptions of Artists as Collaborators in Interprofessional Care Teams,” in Health Care 5, no. 3 (2017): 50; and J. Sonke, “Training for New Jobs: Professionalizing the Role of the Musician in Healthcare,” in Music as Care: Artistry in the Hospital Environment, S. Hoover (New York: Routledge, 2021).
23. D. Fancourt and S. Finn, “What Is the Evidence on the Role of the Arts in Improving Health and Well-Being?: A Scoping Review,” Health Evidence Network synthesis report no. 67, World Health Organization, Regional Office for Europe.
24. Sonke et al., “The State of the Arts.”
25. Plato, Charmides, or Temperance, translated by B. Jowett (Oxford: Oxford University Press, 1871), pages.ucsd.edu/~dkjordan/arch/greeks/PlatoCharmides.html.
[Illustrations by Jasu Hu]