Arts in health revisited: A sketch of art practices in ancient and contemporary Chinese healthcare from an intercultural perspective

Recent efforts to internationalize the discourse on art practices in health have neglected Asian countries and China in particular. This is due to language barriers on the side of Western researchers, as well as the pilot stage and isolation of Chinese research within its own native publication platforms. Similarly, the discourse of arts in health is marked by a Euro-American perspective presenting this area of practice as a modern invention of the West. Firstly, the paper provides a sketch of the ancient medical canon to recount the Chinese history of art practices used alongside health. Next, based on a systematic review of current literature, I develop and apply an analysis grid to survey the functions of arts in health in contemporary China. Given that some art practices apply East Asian medical thought and have culture-specific functions, future research needs to investigate the non-Western world to develop cross-cultural approaches to art-in-health interventions. Subjects: Area Studies; Communication Studies; Humanities; Health and Social Care

ABOUT THE AUTHOR For more than 10 years, media and communication scientist Cornelia Bogen has been analyzing health communication from historical, intercultural, and information science approaches. She has published books and journal articles about communication structures and the role of emotions in (early) modern Western-European history and about elderly people's media use in today's Germany. In addition, her research has investigated contemporary transformation processes of doctor-patient interaction, media literacy, media activism, and social media in China, her book reviews covered historical aspects of medicine and media formats in China. Bogen is currently conducting a research project within the field of Digital Humanities which analyzes how diseases are represented in Chinese and European media systems. The research reported in this paper on ancient and current arts practices in China relates to her general interest in intercultural aspects of modernization processes.

PUBLIC INTEREST STATEMENT
Each of us may have an immediate picture in mind of how art can be used to improve people's health and well-being. However, when it comes to how art was used in the past and in cultures different from ours, we might be at a loss. This article explores how China, in comparison to Western culture, has been using arts practices in ancient and contemporary healthcare. Many authors have represented art-in-health practices as a modern Western concept. In contrast, I argue that they are neither modern nor exclusively Western by presenting examples of how creative activities were used in ancient China to heal body and mind for more than two millennia. Concerning present-day arts practices, I discover several key differences between China and Western countries. To name but one, Chinese practitioners use it not only as a therapy for patients, but also as a tool to study the psychological effects of modernization on Chinese society.
Notwithstanding that current art practices in Asia are subjected to a Western (North America, Western Europe) and Middle Eastern theoretical framework, they incorporate distinct Asian philosophical traditions (McNiff, 2012, p. 14). Contemporary Chinese art therapy practice, in particular, can be described as holistic, spiritual, and centered around the activation of energy circulation. This is linked to qi, a kind of edema (similar to the ancient European term of pneuma or spiritus rejected as a suitable medical concept during the European Enlightenment) permeating the whole world, also found in bound form in food and drinks and thus in the stomach, from where all the organs are supplied (Unschuld, 2003, pp. 27-28). According to ancient Chinese medical thought, illness is caused if the circulation of qi is disturbed or even blocked in the organism, for instance by an excessive arousal of emotions or by climatic influences. In such a case, the flow of qi cannot flow through single organs or whole organ areas anymore, which leads to pathological congestions of blood and qi (Unschuld, 2003, p. 30). If this ancient medical thought is applied to contemporary Chinese painting therapy, then a distinct role of the artwork and the art therapist becomes apparent when compared to the European-American perspective. In Chinese art therapy, the patient's artwork itself serves as a diagnostic tool for the therapist who interprets the flow of ink, brushstroke, or color in the images as potential blockages or wrong movements of energy within the artist's/patient's body and mind. This stands in sharp contrast to Western practice in which the concept of the body's energy flows is not a dominant feature of diagnosis, and in which the patient comments on the artwork first before the therapist makes a diagnosis (Richardson, Gollub, & Wang, 2012, p. 73).
Single Chinese art therapists have made an effort to combine Western and East Asian approaches by facilitating art methods which are adapted to ancient Chinese philosophical thought (e.g. Daoism) and Traditional Chinese Medicine (Yin Yang theory and the theory of the five elements), while using concepts of art therapy developed in the West (e.g. Gestalt theory) at the same time (Gong, 2012;Richardson et al., 2012). In return, Western psychological approaches like the acceptance commitment therapy, dialectical behavior therapy or energy diagnostic and treatment methods integrate Asian ideas of mindfulness and bioenergy into their (diagnostic) treatment methods (Kalmanowitz, Potash, & Chan, 2012b, pp. 318-319).
However, as far as the broader field, investigated in this paper, of arts in healthcare is concerned, practices and discourses need to become more global and interlinked for the sake of mutual learning and intercultural enrichment. For example, there is hardly any research that investigates the manifold application fields of arts outside the realms of medical therapy in China, for instance the role of arts practices in education, health research, health policy, or social sciences.
One obstacle of contributing to the internationalization of discourses on arts in healthcare by adding a Chinese perspective is that Chinese academic discourse on arts-in-health interventions cannot be accessed by the majority of Western scholars, owing to language barriers. Another obstacle is that Mainland Chinese scholars' contribution to the international dialog on the topic of art and health within English-speaking journals is almost non-existent. Thus, the healing function of art in both ancient and contemporary China remains a blind spot.

Ethnocentrism in the discourse of art-in-health practices
It is true that the sub-discipline of art therapy, which developed as a therapeutic discipline in midtwentieth century in English-speaking and in European countries, emerged from Euro-American principles that date back to the beginning of European modernity (Campanelli & Kaplan, 1996;Kristel, 2013, p. 32;Talwar, Iyer, & Doby-Copeland, 2004). However, the use of art practices for prevention and/or therapeutic treatment had been at the center of human interest thousands of years beforehand, as ancient medical canon in both European and Chinese culture demonstrates (discussed in Sections 3.1 and 3.2).
Thus, the use of art in everyday life for health purposes is far from being a modern invention of the West. Employing art as an outlet for hidden emotions has been particularly important in a collective culture like China, which has been sanctioning the individual display of emotions in public for the sake of collective harmony for over two thousand years (Chen, 2000, p. 9). Chinese societies have valued the practice of li, a set of conduct and communication rules that is believed to guarantee conflict free, harmonious interpersonal, and social relationships which are regarded as the ultimate goal of Chinese interaction (Chen & Starosta, 1997, p. 5). This is realized, among other behaviors, by self-restraint and by "subdu[ing] emotions in public as a symbolic expression of promoting group welfare" (Chen, 2000, p. 11). Thus, "since ancient times, painting, music, and poetry have been used as an outlet" for "buried emotions" and suppressed feelings (Chang, 2012, p. 253).
It is important to explore how culture-specific ways of living and social interaction influence art practices in healthcare. However, the goal should not be to better integrate Western art-therapy concepts into non-Western cultures. Instead, the persistence of an "ethnocentric monocultural approach" should be avoided by including historical experiences, ethnicities or lifestyles in other geographic regions (Talwar et al., 2004, p. 44). Thus, this paper argues there is a need to investigate the culture-specific differences between arts practices in health in different axial civilizations like China, India, Iran, Palestine, and Greece (Eisenstadt, 2011, p. 13) across different periods of time, to elucidate art interventions beyond a Euro-American centric approach (Campanelli & Kaplan, 1996, p. 66).

Research approach and methodology
The aim of the paper is twofold. First, in order to challenge the common wisdom of art-based methods in health as an invention of modern Western culture, the paper provides a sketch of the development history of art-in-health practices in China based on a systematic literature review of the ancient Chinese medical canon and of recent academic papers in the field of Traditional Chinese Medicine and ancient Chinese history and culture. I consulted the Chinese version of the online database of Tongji University (Tongji University Library, 2015), the largest Chinese online literature database named "CNKI.net"-which is associated to Tsinghua University and which provides fulltext access to Chinese journals, conference proceedings and academic theses (CNKI, 2015)-as well as "Wanfang Data" (Wanfang Data, 2015), affiliated to the Chinese Ministry of Science & Technology. I used keywords like "music", "dance" or "singing" in combination with "ancient China'" and "Yellow Emperor's Inner Canon", "Theory of Five Elements" or "music theory" to find primary and secondary literature that illustrate the use of art-based methods in ancient China. In the historical part of this paper, these collected examples serve as the basis for demonstrating that the application of art in the prevention and healing of diseases is at least as old in China as it is in Europe.
Second, in order to contribute to the recent endeavor of Western scholars to internationalize the discourse on art-in-health interventions (Parkinson & White, 2013, p. 177), the paper provides a hitherto neglected overview of the use of art-based methods in contemporary Chinese healthcare and beyond. The above-mentioned databases were used to conduct another systematic literature review. In addition, against the background of nascent Chinese academic research in the field of arts in contemporary healthcare, I consulted the few available government documents on websites of targeted political institutions mentioned further below, and I also reviewed recent conference proceedings in music therapy, since music therapy is the only university creative arts therapy program offered at Chinese universities (Richardson et al., 2012, p. 65). I also investigated the web presence of targeted organizations, such as special education centers, Chinese community and life care centers which employ art practices, and I consulted Chinese online media reports that introduce current projects run by these organizations. As far as pre-determined criteria for eligibility are concerned, only such art-in-health initiatives were included that have been realized in the People's Republic of China, including special administrative regions like Hong Kong and excluding Taiwan. Chinese keywords used in different combinations for searching literature in the databases were "art education", "special education", "art therapy", "psychological counselling", "crisis intervention" or "art in hospitals" in connection with physical illness (e.g. cancer) and mental health (including emotional or behavioral disorders), as well as particular age groups to ensure that a wide range of literature was included that sheds light on the different functions of various art-in-health interventions across today's China.
In a first step, after having studied current English-speaking literature including relevant academic journals like Arts & Health: An International Journal for Research, Policy and Practice or Art Therapy: Journal of the American Art Therapy Association, I identified seven general functions of art interventions: therapeutic purpose, crisis intervention, educational purpose, healing environments, public awareness, health research, and health policy. In a second step, I reviewed Chinese academic journals in the field of arts, medicine, psychology, behavioral medical sciences, (health) education, special education, and social sciences. In a third step, I grouped the projects and initiatives described in the Chinese literature consulted and assigned them to one of the seven functions in the analysis grid.
It turned out that there were some art-in-health interventions that could not be grouped into any of the seven categories. Besides, one category could not be occupied at all with examples from China. So, in a fourth step, the analysis grid was modified to better account for culture-specific functions of art-in-health practices. Thus, one item that I call "Others" has been added to the scheme to account for such functions of art projects that have been overlooked by both Chinese and Western researchers because they might only exist within the particular context of contemporary China. These culture-specific functions include, as my findings will demonstrate, the use of art interventions to improve the disturbed relationship between doctors and patient, as well as the use of artbased methods to study the impact of modernization processes on Chinese society. In contrast, the function of "Health Policy", that is influencing policy on art and health, has been excluded from the scheme or analysis grid, since no art-in-health intervention described in the reviewed literature could be identified as having a political purpose. Moreover, by spring 2015, they were almost 1 no official documents available 2 on the websites of the National Health and Family Planning Commission, the Center for the Prevention and Control of Diseases, the Ministry of Education, and the Ministry of Health in China that could have shed light on the Chinese government's stance on the use of art in the healthcare sector. 3 In total, the final analytical framework includes seven main functions that serve as an analysis grid to systematize current art initiatives in China ( Figure 1).
As the table shows, most of the types of arts practices in health occur in both Western and Chinese cultural contexts. However, as the paper will demonstrate, some of them are adapted in a different way in China. Moreover, there are some types of art-in-health interventions that are unique and culture-specific in the sense that they only seem to exist in present-day China.

Methodological challenges and limits of study
With regard to the paper's first goal, one methodological challenge is the unclear publication history of the consulted ancient Chinese medical canon-Chinese scholars are often uncertain about the original author of a work and its publication date, since ancient texts were collected and rewritten by several authors over time. What made the undertaking even more difficult was that the exact time frame of a certain era in Chinese history is contested among Chinese intellectuals (Sun, 2007). For this reason, debate by Chinese scholars about the publication history of certain classical texts is depicted in the footnotes of this paper.  --As far as the second aim of this paper is concerned, another methodological challenge is the relative absence of a general overview of the various functions of current art projects in Chinese healthcare and in other fields. An exemption is the survey by Ni and Hu (2012) which, unfortunately, only takes educational and therapeutic purposes into account that are related to the sub-discipline of art therapy. In contrast, this paper widens the perspective by focusing on the broader discipline of arts in healthcare and by including functions of art practices that go beyond the ones investigated by Ni and Hu. Thus, I will show that the range of art-in-health interventions in China is wider than Ni and Hu claim (Ni & Hu, 2012, p. 95). Moreover, my paper will highlight the similarities as well as culturespecific differences in the current application of arts practices in and outside medical settings in China and the West.
A limitation of this study is that parts of the corpora consist of recent Chinese bachelor's and master's theses, dissertations or articles published in university journals that often do not meet high academic standards. Thus, it sometimes remains unclear why a certain art method was applied, where an art intervention took place and with what kind of patients (number, age) (Shang & Zhou, 2008), whether the author was a participatory observer or an art therapist (Wang, 2010) and what the specific result of a study was (Pan, 2008;Yi, Qian, & Cong, 2004). Another limitation of the consulted research is the low number of participants (Chen, 2007;Liu, 2008) or the short duration of an art intervention (Guo, 2014).

Art in the history of European medicine
The European canon of ancient medical texts, the "Corpus Hippocraticum" (500 BC-AD 200), contains references about the use of art in health, with doctors like Iamblichos and Prophyrius using rhythms, dance, songs, and incantation to cure physical and mental diseases (Hoessly, 2001, p. 183). During the European Age of Enlightenment, medical laypeople like the German theologian Adam Bernd or the Scottish literary writer James Boswell used literary arts to publicly cope with their mental disease and to express their experience of melancholy in a creative way (Bogen, 2013). By experimenting with literary genres like fictitious autobiography (Bernd) and journal columns (Boswell), these "patients" also challenged stereotypical presentations of the disease in contemporary health discourse (Bogen, 2011, pp. 35-36). In the nineteenth century, forerunners like the Scottish asylum doctor William A. F. Browne encouraged his patients experiencing mental health problems to engage in occupational therapy by painting pictures (Browne, 1837). This lay the foundations for art therapy in mid-twentieth century. Since then, art methods such as visual arts, performance arts, and literary arts have been used in Western countries to enhance the well-being, interpersonal skills, and self-knowledge of patients.
In contrast, it was not before the 1980s that the Western concept of music therapy was introduced to China (Zhang, 2010). With the first major in music therapy being established in 1991 (Li, 2012, p. 939), art therapy was gradually implemented during the 1990s in China's educational and medical field (Ni & Hu, 2012). The absence of a public sphere in eighteenth century China and the lack of a hospital system in the nineteenth century might be two explanations why Euro-American perspectives of art therapy are prevalent in present-day China. However, when it comes to daily life practices, the use of art methods is not a Western invention at all, since China had its own history of more than 2000 years during which art practices in health were popular.

Art practices in the history of Chinese medicine
Presumably originating around the same time as the Corpus Hippocraticum, one chapter of "Huangdi Neijing", 黄帝内经, the Yellow Emperor's Inner Canon, records the so called "Theory of the five elements music therapy", 五音疗疾理论 ("Huangdi Neijing" 黄帝内 经, 202 BC-AD 8). 4 It was designed to assist patients in coping with mental disorders (depression) and physical diseases (asthma, insomnia, palpitations, phthisis) related to the five inner organs (Shao, Pan, & Zhang, 2011, p. 62). Different types of music were meant to regulate the emotional mood of the listener. The Yellow Emperor's Inner Canon is the earliest record of the practice of music therapy in China.
Music therapy was often used in combination with dancing and singing, as illustrated by the physical exercise "Yin Kang Shi Dancing" mentioned in the chapter音乐篇 (Ancient Music Part) of the book on music 吕氏春秋 (Lü Shi Chun Qiu) by Lü Buwei, 吕不韦 (Lü,239 BC,p. 82f). It was invented by the ancient clan leader Yin Kang Shi, 阴康氏 (Yang, 2012, p. 21) who belonged to Yin Kang Clan in Shaanxi province presumably living before 4500 BC (Wu, 2012, p. 22). Yin Kang Shi Dancing was a method to stimulate blood circulation and enhance immunity (Wu, 2012, pp. 57-60), to relieve pain 5 (Lü,239 BC,p. 82) and to release emotions (Li, 2013, p. 7). In particular, the exercise targeted symptomsassociated today with arthritis (Wu, 2012, p. 57f) and rheumatism (Yang, 2012, p. 21)-which were presumably caused by flood disasters that frequently haunted the clan's populated region (Lü,239 BC,p. 82). Today, Ying Kang Shi Dancing is considered as a form of ancient Chinese music therapy (Chen, 2009, p. 4).
Another dancing activity connected to music performance is "Andai Dancing", applied by an ethnic group in Mongolia during the end of the Ming Dynasty to cure mental diseases (Li, 2013, p. 8). Various ancient legends trace back the origin of Andai Dancing to more than 1200 years ago (Bao, 2011, pp. 7-10).
According to the ancient book "Gao Shi Memoirist" (高士传) written by Huang Fumi, elderly people during Yao Era (2550-2150 BC) engaged in singing and dancing activities (Huang Fumi/皇甫谧, AD 266, p. 17). During the Yaodi Era (2367-2285 BC), singing and dancing served to strengthen the immune system (Rao, 1994, p. 25) Thus, for many centuries, dance-based exercises and Tai Chi were not only widely practiced as healing art forms, but functioned as rituals, religious practice, and relaxation method as well (Marks, 2005).
Music therapy was not only popular among the general populus, but also with people of higher socio-economic rank, of which Li, Wang, Li, Long, and Chen (2006) report interesting historical cases. One of them is that of litterateur Ouyang Xiu, 欧阳修, who, during the Song Dynasty (AD 1007-AD 1072), played Guqin to cure his depression. Another one is that of Mei Cheng, 枚乘, who composed the piece "Seven Senses" (七发) during Western Han Dynasty (206 BC-AD 9) in order to help cure the mental disease of Prince Chu. During Liao Dynasty (AD 907-AD 1125), Mongol doctor Yelu Dilü, 耶鲁 敌律, used the soldiers' drumming to cure the heat-toxicity of the prime minister's wife (Li et al., 2006(Li et al., , p. 2444. Apart from dancing and music, paintings were used by physicians like Mo Junxi, 莫君锡, during Sui Dynasty (AD 581-AD 618) to cure emperor Sui Yang Di, 隋炀帝 (Rao, 1994, p. 27). Calligraphy, as He Qiao Fan, 何乔璠, explained in his book "Xin Shu Part" (心术篇) on "the art of psychology", was used during Qing dynasty as a tool to release emotions, which was regarded as beneficial for depression and strengthening psychological defense strategies (Ying, 2013, pp. 31-33).
In sum, whereas the roots of twentieth-century' professionalization of the practice of art therapy can be traced back to the beginning of European modernity, the use of art-based methods for health preservation and healing purposes is neither a modern nor a Western phenomenon. As the discussion of the ancient Chinese medical canon and of contemporary Chinese research showed, the benefits of art for health had been developed as well as realized in the everyday life of ordinary and well-off people more than 2000 years ago.

Therapeutic purposes
In contrast to ancient times when music was the predominant art method, Chinese art therapy today mainly uses visual arts (photographs, photo voice, drawings, and paintings) as a supplement to the therapy of various groups, including young patients with mental disorders (autism, schizophrenia, depression), visual impairment and maladjustment (aggressive behavior), adult patients with drug addictions, and terminal cancer patients. Thus, apart from pain treatment or acceleration of recovery, art interventions mainly aim at managing emotions or fostering personal growth.
The Special Education Center of Changning District in Shanghai (长宁特教中心) organized a yearlong "photography therapy" in 2011-2012 with visually and mentally impaired children. Relatives of the participants found that the art intervention made their children more self-confident and outgoing (Dong, 2012).
Recent initiatives demonstrate that Chinese psychotherapists and art therapists have developed painting methods which are rooted in traditional Chinese medical thought. They are based on yin and yang theory and the theory of the five elements that link emotional disorders to an energy (qi) imbalance which can affect the physical body as well. For example, "Inkdance" or "DaDance therapy" uses dance movement and music exercises together with Chinese ink or brush painting as a method to stimulate the movement of qi and the five elemental energies to areas in the body in which energy is needed (Richardson et al., 2012, p. 69). The art therapist guides the patient in creating energetic movements and assists the patient's personal growth by changing his/her spirit (Richardson et al., 2012, p. 73). In contrast, the "Yi Shu" painting method combines the senses-centered meditative state of "awareness continuum" of Gestalt theory with Chinese Daoist philosophy (spontaneity, awareness in the presence, the authentic person) (Gong, 2012, p. 57). It makes the patient's emotional states visible and assists him/her in becoming consciously aware of inner conflicts.
The art method of painting is not only popular in the therapy of mental disorders and in the psychological rehabilitation of drug abusers (Li, Luo, & Lü, 2004), but also in end-of-life-care. In Shanghai, life care centers cooperated with local hospitals to assist terminal cancer patients in releasing emotional pressure with the help of self-portrait-painting activities (Shanghai Pudong shou qianshou shengming guan'ai fazhan zhongxin, 2014). Since 2008, the "Guardian Angel" -life care project ("守 护·天使" 生命关怀项目) has been promoting communication between patients and relatives who are often unprepared to cope with death (Du, 2009).

Crisis intervention after natural disasters
Taiwan was among the first East Asian countries that used Western art-based methods to provide psychological counseling to the victims of an earthquake in 1999 (Ni & Hu, 2012, p. 94). Since then, the benefit of art practices to cope with trauma has been growingly appreciated in Asian countries like Japan (2011) and southeast Asia (2008) (Kristel, 2013, p. 32).
In China, art methods are predominantly applied to the psychological counseling of children and students after earthquakes. In Qinghai province, more than 5,000 pupils from primary schools, middle schools and colleges participated in a three-day painting activity after the earthquake in November 2008. Earlier in the same year, group counseling and painting activities assisted the victims in Sichuan province to cope with the death of their classmates after the devastating "Great Wenchuan earthquake" in May 2008 (Lu, 2010;Zhang, 2008).
Surprisingly, despite the provision of such post-disaster art interventions, one of the few publicly accessible governmental documents published two months after the disaster in Sichuan only mentions art therapy in the context of treating children with depression (Chinese Ministry of Health, 2008). For other mental diseases that might occur in victims of natural disasters-the document lists emotional, behavioral/anxiety disorders, post-dramatic stress disorders in children and posttraumatic stress disorders, depression and suicide in adults-other treatment methods like cognitive behavioral therapy, psychotherapy, and medication are suggested as treatment options, but not art therapy. It seems as if art practices in the field of crisis intervention have not yet been assigned an important role by the respective government authorities for psychological counseling.
In contrast to the Euro-American conception of art therapy as a primary vehicle for the expression of individual feelings, art therapy in China during crisis intervention has an intersubjective component. Interpersonal relationships and collective identity are addressed during group activities which make participants feel less cautious in exploring their creative talents (Kalmanowitz & Potash, 2012, p. 199ff).
Against the background of the above mentioned ad hoc art-interventions, Chinese scholars argue in favor of a long-term focus of art therapy interventions in crisis-struck regions (Ni & Hu, 2012, p. 94).

Educational purposes
Concerning the training of medical students, I did not find any examples that demonstrate how art courses are used to help them acquire diagnostic and empathetic skills. When it comes to the training of art therapists, China's educational system still lacks systematization and standardization, as opposed to other East Asian countries like Korea and Taiwan (Ni & Hu, 2012, p. 96). Music therapy, being offered as a major at 13 art and medical colleges (Zhang & Zhao, 2013), is the only creative arts therapy program (Richardson et al., 2012, p. 65). In contrast to the U.S., music therapy lacks qualified personnel and a nation-wide examination system, and students lack clinical practice (Zhang & Zhao, 2013, p. 42).
The art method of painting is applied to investigate how the method of psychotherapy can be adapted in such a way that it better serves the needs of particular patient groups. For example, medical researchers analyze paintings of drug addicts to learn more about their mental state (Li et al., 2004). Art therapists enhance their communication skills by learning how to instruct handicapped children in a playful way during painting activities and how to react properly to their art work by avoiding pre-judgment and criticism (Zhou, 2007). This corresponds to the Western distinction between the role of an artist and that of an art therapist in the process of art making, according to which the artist is allowed to make esthetic judgments on the patient's artwork, whereas the art therapist's primary concern is not the artwork itself but the artwork as an interpretative, symbolic, and communication-promoting tool (Broderick, 2011, p. 97). Hence, Chinese arts programs incorporate features from models of Western art therapy training and lag behind its Western counterpart as far as the diversity of art therapy programs and their standardization is concerned.

Healing environments
Despite Ni & Hu's assessment that art is not used for creating healing environments (Ni & Hu, 2012, p. 95), an effort has been made in China within the last decade to beautify and personalize medical spaces. Art works, either created by artists or by the patients themselves, are exhibited in hospitals to assist the patients' healing process, to help their relatives to feel more relaxed and to increase the job satisfaction of medical personnel.
With regard to outdoor facilities, hospitals in Shanghai, Xiamen, Beijing, Macao, and Hongkong display sculpture art works in front of the hospital entrance (Chen, 2014, p. 74f). With regard to indoor facilities, sterile clinical settings have been turned into spaces with an artistic interior design, like a hospital in Fujian province that displays an art gallery in its corridors . In cooperation with the Art Therapy Alliance, a hospital in Beijing organized an art exhibition that showed art works from colleges and artists (Peng, 2008).

Public awareness
Current exhibitions of patient art aim at increasing the public's health literacy and empathy for patients with predominantly mental illnesses, like the ones organized by Shanghai Mingyuan Culture & Art Center, which hosts art exhibitions by mentally and visually impaired children (Pan, 2011). In March 2015, in cooperation with Shanghai Changning Special Education Center, it showed paintings by autistic children who had been guided by young artists during the creative process. The art intervention aimed to increase the children's self-confidence and to integrate them better into society by raising public attention to autism (Sun, 2015). In Hongkong, the "Art in Hospital" initiative has been cooperating with different Cantonese hospitals since 1994 to launch painting and photography workshops and to exhibit patient art at regular intervals for showcasing patients' hidden talents (Hongkong Arts Development Council, 2015). Since 2011, photography workshops have been directed at mentally impaired teenagers to assist their self-exploration, to improve their communicative skills and to provide them with a sense of success.

Health research
The application of art-based methods for health research in order to increase the understanding of how patients experience a certain disease is still in its early stages. For example, the Special Education Center of Changning District in Shanghai has started a project in 2012 to develop a solid method for the use of photography therapy with mentally impaired children, lasting until 2017 (Dong, 2012).
The few studies that exist are applied in the field of mental health and predominantly use visual arts. These are merely used as tools for the purpose of knowledge production-the generation of data about a certain disease (Fraser & al Sayah, 2011)-than knowledge dissemination (e.g. performance arts). For instance, two studies use the art method of painting and the House-Person-Tree (HPT) test as a diagnostic tool to better understand the inner world of patients with emotional disorders and behavioral problems. One of these studies aims to analyze the psychological conflicts of six teenagers in Guanxi province, however, the author doesn't succeed in making the inner conflicts of the participants transparent to the reader (Pan, 2008). The other study which successfully examines the causes (here physical violence) for the aggressive behavior of two male kindergarten children in Nanjing is limited by the low number of participants (Chen, 2007). The author comes to the conclusion that the visual projection of the children's inner world assists young patients in their cognitive and emotional development by confronting them with hidden conflicts.
Apart from exploring patient's inner feelings, the potential of art methods to psychologically treat emotional disorders is examined by Chinese researchers. A study by Shang and Zhou (2008), based on a sample of thirty college students, found that due to a high degree of competition, classmates lacked a positive communication style which could turn into social anxiety disorders in the long run. After engaging the students into a group painting activity, the authors conclude that such art interventions encouraged the participants to become more open-minded and active in approaching fellow students.

Others
Arts in healthcare in China has certain purposes that go beyond the common use in Western countries. Those special functions of art-in-health interventions are culture-specific in that they tackle problems which are either inherent in the specific structure of the national health care system (3.3.7.1) or related to the effects of the ongoing modernization process on Chinese society (3.3.7.2).

Improving doctor-patient interaction.
Within the last two decades, due to an increase of patient attacks on medical personnel, the relationship between Chinese doctors and their patients has become more tense (FlorCruz, 2011;Verhasste Helfer, 2014). One of the main reasons are the low income of Chinese physicians (Jiang, 2011), the common practice of patients bribing their doctors, and underfunded hospitals. Against this background, art methods have been used since 2014 to create more peaceful hospital environments.
A series of one-day painting workshops organized by the Chinese Academy of Medical Science in cooperation with the U.S. American Hospital Art Foundation, took place at various hospitals in Beijing in June 2014, each with around 40 participants; they aimed to improve the relationship between hospitalized patients, their relatives, and medical personnel (Hui chu xinling de cai tu -ji zhengxing waike yiyuan yishu caihui huodong, 2014; Guo, 2014; Yishu caihui huodong tuijin yiyuan wenhua jianshe, 2014).
It can be taken for granted that such art interventions alone cannot help to solve the structural problems of the Chinese healthcare system. But as a supplement strategy they can contribute to improve the interpersonal relationship between the involved parties.
3.3.7.2. Analyzing the effects of modernization. According to Confucian tradition, it is the family which is the place for character-building, a place where children learn how to become human (Tu, 2002, p. 204ff). However, in the course of China's modernization process, urbanization, industrialization, and migration have deeply impacted China's family structure within the last decades. As a consequence, the number of (rural) left-behind children that are being raised by people other than their parents has increased to 69.7 million in 2010 (UNICEF China, 2015). The rising number of studies in China that explore the impact of art education on the health of the young implicitly suggests current problems with the functionality of the family.
One study concludes that art-based methods enhance the character-building and self-awareness of college students (Lin, 2008). An art intervention with sixty left-behind children in Ningbo that applied the HTP test to evaluate the paintings found that some of the participants showed the so called "left-behind children syndrome", including cold-heartedness and poor communication and social skills (Liu, 2008). 6 Another case study found that left-behind children, due to their lack of a basic feeling of security, are more likely to develop anxiety disorders during adolescence (Wang, 2010). Other studies conclude that the specific family constellation harms the mental health of left-behind children and explains an increase in psychological problems of children and teenagers (Xiang, 2008). During a painting activity in which thirty students were asked to portray their actual and ideal family situation, half of the participants wished they had a better relationship with their parents (Yi et al., 2004).
In sum, although none of the above presented studies states it explicitly, art-based methods appear to be employed for the sake of investigating the effects of modernization on the Chinese social structure, on the well-being of the family and on the mental health of children in particular.
My observation about the relation of modernization processes and their impact on Chinese people's mental health is supported by two studies outside the field of arts in health. With regard to the phenomenon of left-behind children, one psychological study with 8-14 year-old children in Hubei province demonstrated that left-being children are reported to have a higher chance of insecure attachment relationships and of a depression risk (He et al., 2012, p. 310). Another top current study demonstrates that China's modernization and population migration from rural to urban settings is accompanied by a growing appreciation of individualistic values (Sun & Ryder, 2016). This was expressed in the decline of certain traditional values like Confucian ethics or multigenerational living, changing parenting styles that support urban children's initiative-taking, self-expression, and selfassertiveness, and changing norms of concealment and display of emotions which result in new manifestations of symptoms of mental diseases like depression (Sun & Ryder, 2016, pp. 6-9). Thus, while life satisfaction has declined in China from 1990 to 2010 (p. 7), psychiatric disorders have increased, especially in all age groups in rural areas (p. 2), due to the unjust household registration system (hukou) which prevents Chinese citizens categorized at their birth as rural residents from enjoying the same privileges as urban residents (Sun & Ryder, 2016, pp. 7-8).
These findings about the negative impact of modernization on the mental health of Chinese citizens born in the countryside complement my observation that art-based methods are used with left-behind children to examine the impact of disrupted family structures on rural children's emotional health, behavior, growth, and development. In addition, the studies presented, which aim to illustrate the effectiveness of arts practices in improving the interpersonal and communication skills of adolescents and students in general (Lin, 2008;Shang & Zhou, 2008;Yi et al., 2004), suggest between the lines that modern developments like a more competitive socioeconomic environment, a higher socioeconomic status, one-child status, and urban living lead to higher levels of narcissism in young adults (Sun & Ryder, 2016, p. 5, 9) and a lack of social skills that need to be tackled with art interventions.

Discussion
The historical part of this paper introducing the ancient Chinese medical canon showed that the use of art for preventive and healing purposes is at least as old in China as it is in Europe. In combination with the concept of music therapy recorded in the Yellow Emperor's Inner Canon, dancing and singing practices were realized across all social strata throughout Chinese history of the last 2000 years. However, the lack of a public sphere and of a hospital system in eighteenth and nineteenth century China might be an explanation why, in mid-twentieth century, art therapy emerged as a therapeutic discipline not in China, but in European and US American countries.
If one looks at how art-in-health-interventions and art therapy in particular are applied in presentday China, commonalities, and differences with Western cultures become apparent.
Similar to Western countries (Malchiodi, 2003, p. 2), art therapy in China does not exclusively focus on people with physical disabilities and mental and cognitive disorders anymore, but also on people with cancer, dementia, children with behavioral and learning problems, individuals with addictions, and bereaved children and parents. Notwithstanding parallel development processes with regard to the expansion of target groups, Chinese psychotherapists and art therapists have developed their own therapeutic concepts which, by being based on yin and yang theory and the theory of five elements, are nourished by Chinese Traditional Medicine. In contrast to Western art therapy, these culture-specific notions are centered around the stimulation of qi in those bodily parts where its circulation is disturbed or blocked in order to address emotional disorders and physical illness. As far as Chinese painting therapy is concerned, local materials like Chinese brushes or ink are used, and the patient's artwork serves as a mirror of misguided energy movements within the patient's body and mind. Thus, unlike Western practice in which the art therapist-who tends to reject projective drawing techniques as invalid-relies on the process of art production (behavioral information about the patient) and on the patient's own interpretation of the artwork (cognitive information about the patient) to make a diagnosis (Kaplan, 2003, p. 26, 28), Chinese art therapists use the artwork itself as a diagnostic tool (Richardson et al., 2012, p. 73). Thus, in contrast to authors who bemoan a lack of Chinese characteristics and of local materials in realizing art therapy (Ni & Hu, 2012, p. 96), a recent genesis of non-Western art-based concepts and methods based on a distinct cultural heritage can be observed in China.
Another difference is that Western art-based methods are sometimes applied differently in contemporary Chinese healthcare. For example, single Chinese art therapists combine ancient Chinese philosophical thought (Daoism) and Traditional Chinese Medicine (TCM) with Western concepts of art therapy (Gestalt theory) in order to integrate mindfulness meditation into the process of healing (Gong, 2012). Thus, they make an effort to combine forms of creative expression and therapeutic methods from both East Asian and Western culture.
Whereas art-based methods in Western countries are primarily meant to assist the individual's expression of feelings, Chinese participants feel more confident expressing themselves creatively in the form of group activities (Kalmanowitz & Potash, 2012, p. 199ff). Thus, in collectivist cultures like China in which harmonious interpersonal relationships are the ultimate goal of social interaction (Chen & Starosta, 1997, p. 5), current art practices emphasize an intersubjective component when it comes to improving the communicative and social skills of (college) students (Shang & Zhou, 2008) and when it comes to crisis intervention after natural disasters (Lu, 2010).
Arts-in-health practices are used beyond the therapeutic context to create more personalized medical settings in Chinese hospitals with the help of patient art. Another similarity to Western countries is the showcasing of patients' talents and creativity in cultural, art, and community centers to bolster their self-esteem and to increase the public's awareness and understanding of how illness is experienced by various patient groups (Pan, 2011;Sun, 2015). However, as far as the use of artbased methods for health research and for educational purposes is concerned, China still lags behind Western countries. As it has been pointed out, the quality of Chinese academic studies and papers on the use of art methods for the generation of knowledge about emotional and cognitive disorders is relatively low. In addition, the training of medical students via art courses and other creative arts therapy programs beyond music therapy are non-existent and the training of art therapists lacks systematization, standardization, and clinical practice (Zhang & Zhao, 2013, p. 42).
Moreover, there are, as this paper showed, culture-specific adaptations of art practices that are rooted neither in distinct medical theories nor in particular art methods but in specific contexts in which art interventions are applied. One culture-specific purpose of art practices identified here is the creation of more peaceful hospital environments. This function of art-in-health-interventions appears to exist only in today's China due to the unique structural problems inherent in the national healthcare system. Against the background of the tense relationship between medical personnel and patients which has culminated in attacks on physicians and nurses during the last two decades, art workshops have been launched in hospitals within the last three years that involve the respective parties, including family members, to create harmonious relationships. Of course, in order to bring about successful outcomes, these art interventions need to be combined with policies which address the shortcomings of the current healthcare system, such as the bribery of doctors or the two-tier medical system (Li & Luo, 2014).
A second culture-specific function of art-in-health interventions that was identified in this paper is the use of art-based methods by Chinese researchers to study the impact of modernization on the development and social skills of the young generation. This function of art-in-health-interventions appears to exist only in today's China, owing to massive migration waves from rural to urban areas which impact traditional Confucian values like the role of the family as a stronghold for learning how to be human. Studies that aim to demonstrate how art practices can help to improve ordinary children's, adolescents' and students' interpersonal and communicative skills suggest that the family cannot fulfill its role anymore in the cultivation of virtue and solidarity and as a place for a "continuous flow of intimate sentiments of human care" (Tu, 2002, p. 205). This impression is further nourished by studies which use art-based methods to analyze how migration effects the mental health of left-behind children. In a time of profound social and economic transformations in which the traditional value of the importance of the family still remains valid, art education, and its advancement at Chinese schools is regarded as necessary by the government to assist the pupils' "healthy" and "moral growth", especially in rural areas (Chinese Ministry of Education, 2014). Since families struggle to fulfill their traditional function, the education system, whose function in Confucian tradition is to provide further character-building and the acquisition of social skills and spiritual values (Tu, 2002, p. 206), is more important than ever. Hence, art practices come to be viewed as additional tools for character-building and for diagnosing social ills.
A last difference worth mentioning is the lack of using art practices for health policy. No study could be found that demonstrates how Chinese citizens employ art to influence healthcare politics. In addition, during my literature review I could not identify examples of socially engaged arts practices in which patients challenge claims of truth made by medical sciences or institutional ideologies related to the medicalization of life. Furthermore, there are no government documents available that pay tribute to the role of art practices in Chinese healthcare in reducing healthcare costs or improving patients' quality of life. The reason for this finding might be that the Chinese political system is less transparent and less participatory than its Western counterpart.

Conclusion
The use of art practices in fields like health research and education in China is still in a pilot stage or, as far as the field of health policy is concerned, non-existent. However, this assessment should not obscure recent interesting and culture-specific developments in the use of arts in health for therapeutic purposes, crisis intervention or for investigating and addressing social ills like tense relationships in families and between doctors and patients. Art interventions with a therapeutic purpose have been developed that either adapt Western concepts of art therapy in a distinct way (e.g. emphasis on the intersubjective component of art interventions), that merge Western concepts with East Asian medical and philosophical approaches, or that develop unique art methods based on medical theories distinct from those in the West. Furthermore, some functions of arts in healthcare can only be found in contemporary China, owing to its particular health, political, and socio-cultural system and its distinct modernization process. As such, art-based methods are employed in health research by Chinese scholars not to understand a particular disease, but to understand the negative effects of modernization on the family centered social structure and the mental health and communication skills of Chinese children.
Against this background, two conclusions for further research can be made. First, given the fact that the theory and practice of art for preventive and healing purposes in China dates back to ancient times, we need to avoid an ethnocentric perspective on the historiography of arts in health by giving prominence to the medical history and cultural practices of ancient non-Western civilizations. Second, we need to avoid an "ethnocentric monocultural approach" in current academic discourse (Talwar et al., 2004, p. 44) by investigating how either Western art-based methods are applied differently in non-Western cultures or how non-Western art-based methods are generated based on a distinct cultural heritage. Such an undertaking can contribute to the generation of a cross-cultural approach to art-in-health interventions lacking in the current academic discourse.
Notes 1. Only one document could be found that mentions in passing the word "art therapy" in relation to the psychological counseling of children after natural disasters (Chinese Ministry of Health, 2008). It will be discussed in Section 3.3.2 of this paper. 2. In addition, during summer 2015, telephone inquiries with the respective governmental institutions and personal inquiries at local offices in Shanghai by my Chinese assistant Qiu Han revealed that there are no government policies publicly available for the time being. 3. One governmental document could be found online which is related to the general topic of art education at Chinese schools (Chinese Ministry of Education, 2014), which will be briefly mentioned in Section 4. 4. Both author and publishing time of "Huangdi Neijing" and the exact time frame for Huangdi Era in Chinese history are heavily debated among Chinese scholars. For a detailed description of the main assumptions among Chinese scholars, see Sun (2007). In this paper, the publishing time of Western Han Dynasty (206 BC-AD 9) suggested by Liu (1982, p. 17) and Qian (1990, p. 293f) was chosen. 5. Lu Buwei chooses the description "宣导", meaning "to relieve pain", what can be related in Chinese language to either emotional or physical pain. 6. After the HTP test had been conducted with sixty children, the subsequent art therapy intervention only involved one child.

Ma Wang Dui (top half)
Picture shows an artwork created during early Western Han Dynasty (202 BC-9 AD), found in a tomb named "Mawangdui" in Changsha/Hunan province. The artwork is made of silk and shows 44 people doing partially bionic guided exercises that imitate the movements of animals like bear, bird, tiger, chicken etc. to strengthen physical fitness.