Experiences of a Circus Performance Among Patients with Depressive Symptoms: A Phenomenological Study

Abstract

Introduction:

Depression is the leading cause of disability worldwide. Support can be provided by the arts.

Objective:

The aim of the study was to explore the experiences of patients with depressive symptoms after a circus performance.

Methods:

A qualitative research study using a phenomenological approach was carried out. The design was approved by an ethics committee. Volunteers were referred by general practitioners to an ambulatory cultural program and were invited to express their experience throughout interviews that were analyzed with the interpretative phenomenological analysis method.

Results:

Twelve patients participated in the interviews. The effect on the patient was linked to interactions with the performance. It was an effective way of socializing for patients. The show offered patients distance from their daily difficulties. The circus provided specific elements as a resource for patient empowerment. The experience lived by patients during a circus performance is a cognitive phenomenon inducing an influence on the spectator with depressive symptoms. A beneficial effect depended on the artistic content selected, the support offered by the organization operator, and the medical orientation.

Conclusions:

The observations characterized the emotional reception of a circus show among people. This study invites further exploration of the impact of circus art on the quality of life of patients with depressive symptoms.

Introduction

Depression is the leading cause of disability worldwide.¹ It concerns 264 million people.² These statistics are complemented by the prevalence of patients suffering from depressive symptoms, without a complete diagnosis of depression. It can lead to suicide: more than 700,000 persons die by suicide every year globally.³ The alarming economic,⁴ ecological,^5,6 and geopolitical⁷ crises help to explain these prevalence data. They tend to bring the theme of well-being back to the center of sociological or philosophical discussions.

The feeling of sadness, which is not always apparent, is revealed through the individual distress that motivates the use of health care services. Current drug therapies do not guarantee remission or relief of symptoms and they remain causes of frequent medical consultations.⁸ Historically, complementary nondrug therapies have been developed. They can use artistic fields such as music therapy,⁹ art therapy,¹⁰ and therapeutic education through art.¹¹

In a recent report,¹² the World Health Organization (WHO) described the beneficial links between art and health. In France, since 2016, the nonprofit organization, J'ai Mal Partout–Cirque Médical, proposes circus initiatives designed for people in care. In the ambulatory project, designed by the network of general practitioners in Ile de France, circus shows are selected from the programming of a cultural operator constituted by the Académie Fratellini. The shows offer the beneficiaries access to the big tops and to a contemporary format without animals and are open to the public. The shows suggested are an overview of current circus practices. The performances (acrobatics, aerialists, and clowning) are presented in a succession of scenes with contemporary circus esthetics.

The aim of this study was to explore the experiences of a circus performance among patients with depressive symptoms.

Methods

Study design

This study, using a qualitative phenomenological paradigm, involved volunteer patients with depression or depressive symptoms, according to criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5),¹³ and who benefited from the ambulatory circus program of the organization, J'ai Mal Partout–Cirque Médical.

Recruitment

Upon leaving the show, participants were asked to participate in an in-depth individual interview. Nonstabilized patients, minors, persons whose condition was not suitable for an interview, and non-French-speaking patients were excluded. Study participants signed a consent form for interviews and audio recording.

Data collection and analysis

The interview guide explored patients' experiences of the artistic circus proposal, in the context of vulnerability related to depressive symptoms, before, during, and after the performance. Interviews were conducted in French. Data were collected from free expression (Table 1). The verbatim transcriptions were analyzed as data were collected using interpretative phenomenology analysis (IPA).¹⁴

Table 1.

Interview Guide

Introductory questions: How old are you? Do you live in the 93rd department?
Is this your first time participating in the project? Have you already attended another performance with the association?

Practical questions about how you were introduced to the project:
Have you found communication with the association easy since your doctor suggested this initiative? Can you summarize how this step went, the organization for obtaining invitations to the show, and the reception on the site by the association?

Questions about the circus:
Have you ever been to the circus before? Is it a discipline that you liked before or did you discover this artistic proposal with the association? Did you have any preconceived ideas about this discipline?

Questions about the existence of mood disorders:
The project that your doctor told you about is aimed at people with impaired health as these situations can have an impact on mood. Do you find the idea of a cultural proposal in the care management process to be a welcome one?

Questions on the experience of the project: (possible retakes for precise description of the experience within the limits of 30 min).
Before:
Could you describe your state of mind as the appointment date approached? Were you excited about coming? Were you hesitant once the appointment was made to come after all?
During:
What was your impression upon arriving at the venue and then settling in to the preshow? How did it go? Could you describe how you felt during this wait?
During the show:
Let's talk about the show: did you enjoy the show? What was your favorite part? How did you feel during this part? Could you try to describe how you felt? Did you laugh? Did you smile? During the performance, would you say that you were distracted? I mean, for example, did you think about other concerns during the performance or everyday worries?
After the show:
What is your current state of mind? How do you feel? Are you glad you came? The association offers participation in several presentations during the cultural year, would you like to repeat the experience?

Iterative readings were performed to become familiar with the collected data. The analysis of the anonymized verbatim transcription was then carried out manually following an IPA coding procedure as follows: analysis of initial comments by studying the semantic content and the use of language at an exploratory level; development of emerging themes; search for connections across themes; search for patterns across cases; and modeling.

Characteristics of the researchers

One of the four researchers is involved in art and health research, one is involved in performing arts research, and the other two are general practitioners.

Institutional Review Board approval statement

This study was approved (No. 6091848) by the Ethics Committee of the National College of Teaching Generalists (IRB00010804).

Results

Sample description

Twelve patients, six women and six men, aged between 18 and 69 years, were interviewed (Table 2). The interviews lasted between 39 and 108 min.

Table 2.

Characteristics of Patients Interviewed

Anonymized scoring	Age, years	Genre	Performance involved	Place of residence	Level of introduction to the circus	Duration of the interview, min
P1	29	F	“L'Impossible”	Seine Saint Denis Departement. Part-time for professional reasons.	Has had previous contact with the circus as a child. Has never been introduced to the contemporary circus.	103
P2	69	F	“L'Impossible”	Seine Saint Denis Departement	Has had previous contact with the circus as a child. Has never been introduced to the contemporary circus.	63
P3	65	F	“L'Impossible”	Seine Saint Denis Departement	Has had recent contact with the circus. Already initiated into the contemporary circus.	75
P4	61	F	“L'Impossible”	Seine Saint Denis Departement. Part-time for family reasons.	Has had contact with the circus. Already initiated into the contemporary circus.	59
P5	18	M	“L'Impossible”	Seine Saint Denis Departement	Has had previous contact with the circus as a child. Has never been introduced to the contemporary circus.	38
P6	46	M	“L'Impossible”	Seine Saint Denis Departement	Has had previous contact with the circus as a child. Has never been introduced to the contemporary circus.	45
P7	48	M	“L'Impossible”	Seine Saint Denis Departement	Has had contact with the circus. Already initiated into the contemporary circus.	47
P8	27	M	“L'Impossible”	Seine Saint Denis Departement	Has had previous contact with the circus as a child. Has never been introduced to the contemporary circus.	51
P9	26	F	“Apéro Cirque”	Seine Saint Denis Departement	Never had any contact with the circus. First time at the circus with the programme explored in the study.	105
P10	32	F	“Apéro Cirque”	Seine Saint Denis Departement	Has had previous contact with the circus as a child. Has never been introduced to the contemporary circus.	66
P11	49	M	“Apéro Cirque”	Seine Saint Denis Departement. Precisely in Saint-Denis city.	Has had previous contact with the circus as a child. Has never been introduced to the contemporary circus.	64
P12	66	M	“Apéro Cirque”	Seine Saint Denis Departement	Has had contact with the circus. Already initiated into the contemporary circus.	49

Effects on patients were linked to interactions with the performance

The patients' lived experience during the performance appeared as a cognitive phenomenon influencing them.

“The benefits are perhaps concrete and palpable, we will say, right away we feel good” (P6)

Patients described the sensation of being inside the performance taking place in front of them, which alters their perception of reality, letting them adhere to the artistic context and distance themselves from their everyday feelings. Adhesion to the performance was facilitated by the variety of stimuli provided by the elements of the artistic composition and by the visual and auditory sensory information.

Participants described a connection with the performers, enabling them to empathically assimilate the experience presented by the actor on stage. The empathic mechanism interferes with the spectator's perception and state of consciousness to the point of altering the physical perception of his or her own body.

“At one point I am no longer in the negative, I am disconnected, I am at the performance, without realizing when or how, I am at the performance, and I see the beauty” (P2)

Difficulties to initiate the access at the cultural proposals were related to the immobility generated by depressive symptoms.

“I hesitated. I was afraid of being bored. I'm not a person to easily escape what's in my head.” (P4)

The interaction linked to the performance generated an emotional change. Its peak occurred during the performance. Emotional anticipation was present upstream of the event. After the event, emotional memorization maintained a state of well-being, as during the performance.

“I'm calm, I'm like I took a drug to feel good. I'm relaxed. It's the dopamine, right? I'm full of dopamine, serotonin!” (P7)

Performances generated socialization of patients

The collective aspect of the performance generated a meeting space for isolated people.

“This moment was really a moment shared with them and with many people” (P3)

Live performance was a way for people to meet. The event acted as a socializing tool, bringing people together with contacts from the organizing association or with spectators. It was a break in the daily lives of isolated people.

“To meet someone you don't know, it's nice if it's for an occasion like that. To see a show.” (P3)

The participants revealed a perception of emotional closeness with family members sharing a common experience.

“To find each other, to share something different (…) to find my husband, to find each other, we usually pass each other” (P10)

In a context of vulnerability that can lead to discrimination, the communion generated brought a feeling of belonging to a collective regardless of one's own differences.

“I felt a thousand miles away. A thousand miles away from my life from what I saw around me. My experience of what I felt there was totally different from my daily life. I had the impression of being with people who were happy, joyful.” (P4)

The narrative of perceptions highlighted a “big top effect,” in particular because of the circular structure of the audience seating surrounding the ring, which favored emotional exchange and nonverbal communication between spectators and perception of equity for the audience.

“The fact that it's an arena, in 360, there's an equality you know that wherever you sit you'll see the show well.” (P1)

These elements were reported to promote social communication with other spectators.

“The big top, being in a circle like this, is the magic of the circus. We look at each other, we are together, we smile, we communicate with our looks.” (P10)

The effect of the encounter reflected in elements of language. A person arrived alone and yet left the show with the expression of plurality of the pronoun “we” to describe their own state.

“We had a great time, people were happy, children. A good time.” (P12)

The impermanence in the constitution of members of the audience generated the nonreproducible nature of the live performance. The unpredictable reaction of the audience could lead to transitory times when the perception of alterity with the other spectators was heavy.

“I was afraid of the school children who were yelling there, I was afraid I wouldn't like it, that it would spoil the moment..” (P1)

How performance distanced patients from their daily difficulties

The unusual experience of the show provided a break from the daily intellectual routine. Imagination and poetry were frequently cited by patients as bridges to their creative sensibilities. The variety of stimuli in the artistic composition was described as a factor of adhesion and vigilance.

The sense of connection with the artists led to expression of empathy, which meant the experience presented on stage assimilated into the experience of the viewer. The experience of the work was recognized as something that faded pain into the background of sensory attention.

“I didn't feel my body anymore (…) For me the body is a problem these days. Pain… so it's true that not feeling your body is… pleasant.” (P8)

After the performance, the desire to attend the show again extended the effects beyond the time of the performance. The spectacular perspective generated an attraction. At the end of the performance, the desire to return to the show continued this dynamic. It was a useful driving force to counter the anxious immobility that can be generated by depressive symptoms.

“The feeling after the show is that I want to come back, to go see shows again.” (P1)

The circus had often been encountered in childhood by patients: returning to it revived their memories.

“It's magic, it's memories that come back and it does you good.” (P10)

The circus was identified as a joyful art form, providing expectation of a pleasant moment. The dramaturgy of the acts and the use of comedy made the artwork accessible to the public. The variety of acts produced an entertaining presentation.

“In the movies there might be tragic or sad scenes. Here it's just … I would say positive emotion.” (P8)

The effect of the show was sometimes negative for patients.

“The numbers in the dark, we were in the dark for a long time, and it wasn't necessarily pleasant.” (P1)

An on–off effect, suggestive of hedonic adaptation mechanisms, was described. It may have induced anxiety when the event stopped, which called for prolonging the effects with the hope of reiteration of the experience.

“I don't want it to go down now. I don't want to get out of this bubble.” (P1)

The circus was a resource for patients' empowerment

The accessibility of the subject matter was perceived as benevolent. The morphological differences of the artists, according to their specialties, were received as metaphorical of integration. The team spirit and the mutual aid of the troop, in the face of adversity and peril, called for the spectators' demonstration of solidarity by their applause.

“When we see what they do for us, it is sure we are with them, we want to encourage them (…) during the equilibrist act I began to clap my hands with the public, we were together with her. It was a communicative energy.” (P11)

The composition of the numbers on the aerial apparatus was interpreted as a double victory: on the physical limitation of gravity and on the fear of danger. The artists' risk-taking was felt very strongly. The evolutions in height and the choreographic esthetics of the figures brought a described feeling of freedom that alleviated the experiment in a context of vulnerability.

“I was watching her evolution. She was airy, and it was a relief to my head (…) I had a feeling of freedom. For both of us.” (P4)

“When the acrobat was hanging, with the wires, he was pretending to fly (…) I see myself sitting, watching him, and I want to go and try to fly with him.” (P5)

The clowns in the two shows were followed by the patients with attention as their figure was seen as an alternative to the collective self. Their behavior favored the establishment of an emotional bond.

“I was sitting down, but my feet were starting to move, my hands, it was as if I was starting to dance, sitting down; my body was dancing with the athlete's body.” (P7)

Their demeanor stimulated giggles, and the relaxation effect described evoked the parasympathetic physiological implications of laughter.

“[Did you laugh, smile during the show?] Yes, and that hasn't happened to me in a long time!” (P12)

The use of failure in the clown narrative led to perceptions of altered coding. It revealed a message of empowerment. The attempt to rebalance the imbalance caused by the clown himself carried a resilient value. Whether it is an absurd feat or an extravagance in the face of major obstacles, the project undertaken symbolizes the unattainable. The clown tried to overcome it and when he succeeded, he transmitted a resilient message. It was perceived as a symbolic representation of courage that victoriously climbs the insurmountable.

“Everyone thought that this clown, he couldn't do anything (…) but I knew that in the end he was going to do something great (…) something incredible (…) it made me want to go to those who fail, to look at him, and to say to myself, but… No (…) he's going to succeed. We're going to succeed.” (P9)

Discussion

Main results

The impact of circus-type performing arts on the emotional state of patients with depressive symptoms is an elaborate cognitive phenomenon. The effects on the social health status of people were expected and are related to the circus arts being inclusion and community participation tools.¹⁵ The effects of entertainment interventions on people's perception, state of consciousness, and modification of other bodily and painful perceptions have already been documented.¹⁶

This study focused on the choice of circus arts in a precise and innovative way. The semiotic content conveyed by this art form made possible the observation of a positive impact on the perception of the circus performance experience for people with depressive symptoms. The results highlighted elements of the artistic content that have a significant impact. The emotional involvement observed through the circus experience underlined the attention paid to the artistic content.

Identification of the mechanisms that produce the positive experience encourages their reproduction for elaboration of solidarity programs. Peril is an intrinsic element of the circus dialectic. The importance of a happy outcome to the artistic risk-taking, which enables a favorable experience, was underlined by the beneficiaries.

These verbatim transcriptions were correlated with semiotic process theories describing the predominance of rebalancing mechanisms in the circus.¹⁷ They valued the impression of flight that the aerial support gives as well as optimistic virtuosity. The patients expressed the expectation of nondiscriminating messages. The role of comedy is a major element in production of a positive experience that is measured by laughter. The triumphant vulnerability of the clown generated the development of emancipatory resources.

The interviews revealed the role of light and the difficulty of getting through the dark scenes. The phenomenon of hedonic adaptation described in psychology,¹⁸ and observed at the end of the performance, underlined the importance of the artistic program and strategies for programming that guarantees continuity and follow-up.

Comparison with literature

The circus as a vector of salutogenesis

The IPA proved to be an ethical approach for a study in general practice, recognizing the importance of comprehensive care¹⁹ of the person and assigning an active place in the therapeutic process.²⁰ The theory of salutogenesis established by the sociologist, Antonovsky,²¹ consists of an homeostatic equilibrium in a continuum that can evolve.²¹

Adoption of the salutogenic paradigm allows for the epistemological flexibility²² necessary to establish recruitment criteria beyond diagnostic classifications. Studying the phenomenon experienced by people with symptoms expands the scope of medical attention and allows a phenomenological approach, close to the phenomenon perceived by the patient.

Phenomenological exploration is performed with an idiographic focus²³: the patient becomes the central point of evaluation of the need for intervention and the measurement of the benefit achieved. Considering the patient as an expert in his health contributes to the conception of quality of life in its lived dimension. The individualized optimistic posture works for improvement in the individual's starting condition.

The search for balance that is congruent with the intimate psychological architecture makes it possible to raise the level of health. Resilience is a psychological mechanism that has been studied as a factor in improving psychological health.²⁴ Optimism and happiness are dispositions that measure a beneficial effect on mental homeostasis, and research establishes that they generate motivation for well-being.²⁵

The interpretive output of the circus performance generates a resilient behavioral adaptation status, contributing to the genesis of an empowering discourse. By describing pleasant feelings produced, the interviews in this study globally tend to underline a positive modification of the appreciation of the circus experience. It contributes to an improvement in the quality of life during the period of exposure to the spectacular event.

Salutogenesis focuses on empowerment²⁶ through appropriation of space for development and resources for resistance against health alterations.²⁷ In this study, the pleasant experience seems to favor decision-making abilities. By becoming aware of the needs and then of the possibilities of fulfillment offered by the artistic experience, the person appropriates the emancipating cultural resource. The decision to individually pursue an artistic activity observed in the population is a demonstration of the empowering influence.

This study is part of a health promotion approach for a supportive organization, which takes a systemic look at the health of a person within his environment. By taking care of the quality of life of each person, it will also influence the quality of life of the community in which the person evolves. It tends to idealize the collective level of quality-of-life states.

What can be expected from the circus and art

Large-scale studies have highlighted the effects of art therapy, particularly for depression, in reducing depressive symptoms in the adult population.²⁸ Art therapy interventions in specific artistic fields, such as visual therapy, have been studied,²⁹ and the contributions of music³⁰ have been documented. These studies are consistent in highlighting the effectiveness of complementary art therapy strategies in alleviating depressive symptoms. There is a community of action in the circus arts, which could play their part in providing complementary artistic support for the therapeutic support of depressive symptoms.

This qualitative study introduces the promising attributes of the artistic discipline of circus for supporting patients suffering from depressive symptoms. Future research would aim to consolidate the results of this study with larger samples. The prevalence of people suffering from depressive symptoms is multifactorial. A proposal for artistic support during treatment opens a perspective of care that includes the emotional dimension, which has an impact on the individual's social, psychological, and physical states. The observations characterize the emotional reception of a circus show among people.

For Damasio, emotions contribute to the construction of one's homeostatic physiological response to environmental events that promote or degrade one's ability to survive.³¹ The study shows that the joyful emotions produced by a circus performance can be a resource for resilience to resist the psychologic imbalances generated by accidental life courses.

Strengths and limitations

There are few similar programs³² in the ambulatory field and among adults, in comparison with the hospital and pediatric sectors. The external validity of an IPA research requires homogeneity of the population.³³ This was a prerequisite in this study. The characteristics that participants in the interviews had in common were the presentation of depressive symptoms and the ambulatory follow-up. Application of the conclusions of this study can only be established in the observed field of circus arts and in this precise context of vulnerability.

Observing the interactionist phenomenon leads to the opening of complementary research in social and medical sciences as well as in the performing arts. Proposing a reflection at the intersection of circus semiotics and public health would make it possible to confront this observation with the pluralities of the circus arts, with the various contexts of vulnerability, or by questioning the lasting socializing effect with longitudinal observations.

This study joins the findings of the WHO report valuing art as a tool to improve health.¹² By clarifying the specific contributions of the circus arts, it insists on the interest in pursuing research programs investigating the impact of their use in the support of mental health disorders.

The individual historical relationship to the circus, the contemporary style of the proposed acts, the free nature of the intervention, and the physician's orientation to the show were elements that could interfere with the reading of the results. One point of weakness concerned recruitment. The artistic project observed is intended for all audiences and all ages, but the study did not include children or people whose communication impeded the interview.

There is a loss of information about the impact of the interactionist phenomenon involving these audiences. The “nonreproducibility” of live performance is an element that changes the perception at the scale of the population studied. A performance, unlike a film or an exhibition, will never be strictly similar. The IPA is an effective method for collecting perceptions. At the end of the show, the images were intense.

Conclusions

This study invites further exploration of the impact of circus arts on the quality of life of patients with depressive symptoms, both at the individual level and at the level of a societal project. Construction of valid evaluation procedures requires the development of complementary studies using transdisciplinary research with clinical psychology, psychiatry, and neuroscience.

Footnotes

Acknowledgments

The authors would like to thank all participants who cooperated with this survey. The authors would like to thank the Académie Fratellini and the J'ai Mal Partout–Cirque Médical association for allowing the study to be conducted on their artistic program. The authors would like to thank Pr. Alain Mercier and Dr. Jean-Sébastien Cadwallader for their insightful reading and suggestions while writing this article.

Authors' Contributions

M.G. was involved in conceptualization and methodology; collection, analyses, and interpretation of data; drafting of the manuscript; review and editing of the manuscript; and approval of the final version for publication.

S.H. was involved in review and editing of the manuscript and approval of the final version for publication.

P.G. was involved in collection, analyses, and interpretation of data; review and editing of the manuscript; and approval of the final version for publication.

Y.R. was involved in conceptualization and methodology; drafting of the manuscript; review and editing of the manuscript; and approval of the final version for publication.

Author Disclosure Statement

All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest in the subject matter or materials discussed in this article. M.G. is an unpaid member of the operating organization.

Funding Information

No funding was received for this article.

References

Mental Health and Substance Use. Mental health atlas 2017. World Health Organization; 2018. Available from: https://www.who.int/publications/i/item/9789241514019 [Last accessed: June 21, 2023 ].

GBD 2017 Disease and Injury Incidence and Prevalence Collaborators. Global, regional, and national incidence, prevalence, and years lived with disability for 354 diseases and injuries for 195 countries and territories, 1990–2017: A systematic analysis for the Global Burden of Disease Study 2017. Lancet, 2018; 392(10159):1789–1858; doi: 10.1016/S0140-6736(18)32279-7

Mental Health and Substance Use. Suicide worldwide in 2019. World Health Organization; 2021. Available from: https://www.who.int/publications/i/item/9789240026643 [Last accessed: June 21, 2023 ].

Frasquilho

, Matos

, Salonna

, et al. Mental health outcomes in times of economic recession: A systematic literature review. BMC Public Health, 2016; 16:115; doi: 10.1186/s12889-016-2720-y

Hayes

, Blashki

, Wiseman

, et al. Climate change and mental health: Risks, impacts and priority actions. Int J Ment Health Syst, 2018; 12:28; doi: 10.1186/s13033-018-0210-6

Roberts

, Arseneault

, Barratt

, et al. Exploration of NO2 and PM2.5 air pollution and mental health problems using high-resolution data in London-based children from a UK longitudinal cohort study. Psychiatry Res, 2019; 272:8–17; doi: 10.1016/j.psychres.2018.12.050

Persaud

, Day

, Gupta

, et al. Geopolitical factors and mental health I. Int J Soc Psychiatry, 2018; 64(8):778–785; doi: 10.1177/0020764018808548

Wang

, Aguilar-Gaxiola

, Alonso

, et al. Use of mental health services for anxiety, mood, and substance disorders in 17 countries in the WHO world mental health surveys. Lancet, 2007; 370(9590):841–850; doi: 10.1016/S0140-6736(07)61414-7

Gómez-Romero

, Jiménez-Palomares

, Rodríguez-Mansilla

, et al. Benefits of music therapy on behaviour disorders in subjects diagnosed with dementia: A systematic review. Neurologia, 2017; 32(4):253–263; doi: 10.1016/j.nrl.2014.11.001

10.

Chancellor

, Duncan

, Chatterjee

. Art therapy for Alzheimer's disease and other dementias. J Alzheimers Dis, 2014; 39(1):1–11; doi: 10.3233/JAD-131295

11.

Pellecchia

, Gagnayre

. Art as support in therapeutic education for patients affected by cancer: Results of an exploratory study. Medical Pedagogy, 2010; 11(1):57–66; doi: 10.1051/pmed/2010007

12.

Fancourt

, Finn

. What is the evidence on the role of the arts in improving health and well-being (Health Evidence Network Synthesis Report, 67). World Health Organization—Regional Office for Europe; 2019. Available from: https://apps.who.int/iris/handle/10665/329834 [Last accessed: June 21, 2023 ].

13.

American Psychiatric

Association

. Diagnostic and Statistical Manual of Mental

Disorders

, 5th ed. American Psychiatric Association Publishing. Pte. Ltd.: Arlington, TX; 2013.

14.

Rodriguez

, Smith

. Phenomenology as a healthcare research method. Evid Based Nurs, 2018; 21(4):96–98; doi: 10.1136/eb-2018-102990

15.

Hurley

, Linsley

, Rowe

, et al. Empathy at a distance: A qualitative study on the impact of publically-displayed art on observers. Int J Ment Health Nurs, 2014; 23(5):419–426; doi: 10.1111/inm.12073

16.

Laukka

Uses of music and psychological well-being among the elderly. J Happiness Stud, 2007; 8:215–241; doi: 10.1007/s10902-006-9024-3

17.

Goudard

The circus between momentum and fall: An aesthetic of the risk (in French). Editions Espaces 34. Pte. Ltd: Saint-Gély-du-Fesc; 2010.

18.

Lyubomirsky

, Martin-Krumm

, Nelson

. Positive psychology and hedonic adaptation model. Prat Psychol, 2012; 18(2):133–146; doi: 10.1016/j.prps.2012.02.007

19.

Giorgi

The descriptive phenomenological psychological method. J Phenomenol Psychol, 2012; 43(1):3–12; doi: 10.1163/156916212x632934

20.

Ribau

, Lasry

, Bouchard

, et al. Phenomenology: A scientific approach to lived experiences. Rech Soins Infirm, 2005; 81(2):21; doi: 10.3917/rsi.081.0021

21.

Eriksson

, Lindström

. Antonovsky's sense of coherence scale and the relation with health: A systematic review. J Epidemiol Community Health, 2006; 60(5):376–381; doi: 10.1136/jech.2005.041616

22.

Pérez-Wilson

, Marcos-Marcos

, Morgan

, et al. ‘A synergy model of health’: An integration of salutogenesis and the health assets model. Health Promot Int, 2021; 36(3):884–894; doi: 10.1093/heapro/daaa084

23.

Smith

, Shinebourne

Interpretative Phenomenological Analysis. In: APA Handbook of Research Methods in Psychology, Vol. 2. Research Designs: Quantitative, Qualitative, Neuropsychological, and Biological. ( Cooper

, Camic

, Long

DL.

eds.) American Psychological Association Publishing. Pte. Ltd.: Arlington, TX; 2012; pp. 36–73.

24.

Sisto

, Vicinanza

, Campanozzi

, et al. Towards a transversal definition of psychological resilience: A literature review. Medicina (Kaunas), 2019; 55(11):745; doi: 10.3390/medicina55110745

25.

Cramer

Feeling good, living well: The importance of happiness for health. J Integr Complement Med, 2023; 29(5):269–270; doi: 10.1089/jicm.2023.0176

26.

García-Moya

, Morgan

. The utility of salutogenesis for guiding health promotion: The case for young people's well-being. Health Promot Int, 2017; 32(4):723–733; doi: 10.1093/heapro/daw008

27.

Lindström

, Eriksson

. Salutogenesis. J Epidemiol Community Health, 2005; 59(6):440–442; doi: 10.1136/jech.2005.034777

28.

Jenabi

, Bashirian

, Ayubi

, et al. The effect of the art therapy interventions on depression symptoms among older adults: A meta-analysis of controlled clinical trials. J Geriatr Psychiatry Neurol, 2023; 36(3):185–192; doi: 10.1177/08919887221130264

29.

Yin

, Dong

, Zhang

. Effects of visual-art therapy on depression in patients: A systematic review and meta-analysis. Asian J Surg, 2023; 46(5):2259–2260; doi: 10.1016/j.asjsur.2022.12.005

30.

Aalbers

, Fusar-Poli

, Freeman

, et al. Music therapy for depression. Cochrane Database Syst Rev, 2017; 11(11):CD004517; doi: 10.1002/14651858.CD004517.pub3

31.

Damasio

, Carvalho

. The nature of feelings: Evolutionary and neurobiological origins. Nat Rev Neurosci, 2013; 14(2):143–152; doi: 10.1038/nrn3403

32.

Fournier

, Drouin

, Marcoux

, et al. Cirque du Monde as a health intervention: Perceptions of medical students and social circus experts. Can Fam Physician, 2014; 60(11):e548–e553

33.

Smith

JA.

Evaluating the contribution of interpretative phenomenological analysis. Health Psychol Rev, 2011; 5(1):9–27; doi: 10.1080/17437199.2010.510659

Supplementary Material

Please find the following supplemental material available below.

For Open Access articles published under a Creative Commons License, all supplemental material carries the same license as the article it is associated with.

For non-Open Access articles published, all supplemental material carries a non-exclusive license, and permission requests for re-use of supplemental material or any part of supplemental material shall be sent directly to the copyright owner as specified in the copyright notice associated with the article.

0.00 MB

0.54 MB