# Against a “Lego Perspective” on Art and Health interventions: Comment on “Can arts-based interventions improve health? A conceptual and methodological critique” by Martin Skov & Marcos Nadal

Antoni Rodríguez-Fornells, Jennifer Grau-Sánchez, Clément François

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Antoni Rodríguez-Fornells, Jennifer Grau-Sánchez, Clément François. Against a “Lego Perspective” on Art and Health interventions: Comment on “Can arts-based interventions improve health? A conceptual and methodological critique” by Martin Skov & Marcos Nadal. Physics of Life Reviews, 2025, 54, pp.218-220. 10.1016/j.plrev.2025.07.020. hal-05201409

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# Against a “Lego Perspective” on Art and Health interventions

Comment on “*Can arts-based interventions improve health? A conceptual and methodological critique*” by Martin Skov & Marcos Nadal

Antoni Rodríguez-Fornells<fnref n="1" />,<fnref n="2" />,<fnref n="3" />,<fnref n="4" />,<fnref n="5" />, Jennifer Grau-Sánchez<fnref n="6" />, Clément François<fnref n="7" />.

## Corresponding authors:

Antoni Rodriguez-Fornells, Department of Cognition, Development and Educational Psychology, University of Barcelona, Barcelona, Spain.

[arfornells@gmail.com](mailto:arfornells@gmail.com)

Jennifer Grau-Sanchez, Complex Health Diagnoses and Interventions from Occupation and Care (OCCARE), Escola Universitària d’Infermeria i Teràpia Ocupacional de Terrassa (EUIT), Universitat Autònoma de Barcelona, Terrassa, Spain.

[jennifergrau@euit.fdsll.cat](mailto:jennifergrau@euit.fdsll.cat)

Clément François, Laboratoire Parole et Langage, Aix-Marseille University, CNRS, UMR7309, Aix-en-Provence, France.

[clement.francois@cnrs.fr](mailto:clement.francois@cnrs.fr)

<footnote n="1">¹ Cognition and Brain Plasticity Unit, Bellvitge Biomedical Research Institute, L'Hospitalet de Llobregat, Barcelona, Spain.</footnote>

<footnote n="2">² Department of Cognition, Development and Educational Psychology, University of Barcelona, Barcelona, Spain.</footnote>

<footnote n="3">³ Institute of Neurosciences, University of Barcelona, Barcelona, Spain.</footnote>

<footnote n="4">⁴ Institució Catalana de Recerca i Estudis Avançats, Barcelona, Spain.</footnote>

<footnote n="5">⁵ Aix Marseille Univ, IMERA, Marseille, France</footnote>

<footnote n="6">⁶ Complex Health Diagnoses and Interventions from Occupation and Care (OCCARE), Escola Universitària d’Infermeria i Teràpia Ocupacional de Terrassa (EUIT), Universitat Autònoma de Barcelona, Terrassa, Spain.</footnote>

<footnote n="7">⁷ Aix Marseille Univ, CNRS, LPL, Aix-en-Provence, France</footnote>
Skov and Nadal's incisive review offers a conceptual critique of arts-based interventions (ABIs), emphasizing the lack of methodological rigor and hypotheses on the putative underlying mechanisms. While we support the call for stronger scientific standards, their critique adopts an overly rigid and selectively narrow perspective, precluding generalizability across domains. Their analysis focuses almost exclusively on pain-related studies with healthy participants and cancer patients. In the case of pain studies, a single, outdated meta-analysis from 2012 serves as a key reference for assessing ABIs' efficacy. Although it is certainly appropriate to highlight methodological flaws in individual studies, broad conclusions such as "arts don't work" cannot be justified with such an unrepresentative sample. Drawing on our expertise in music-based interventions for stroke rehabilitation, we propose an alternative perspective that integrates the complex nature of ABI research.

Contrary to the authors' claims, the field of music-based rehabilitation has made notable progress in designing rigorous, well-controlled studies, supported by robust findings in the cognitive neuroscience of music [see for a review, 1-4]. Recent randomized controlled trials in stroke motor recovery have demonstrated positive outcomes and incorporated methodological refinements, including active control conditions, individualized treatment protocols, and the use of neuroimaging techniques to explore the underlying neuroplastic mechanisms [5-8]. Furthermore, recent studies account for individual differences in music reward sensitivity to predict therapeutic response, offering valuable insight into both clinical effectiveness and plausible mechanisms of action [7]. Over the past decade, the quality of music intervention trials has also largely improved, showing positive effects for neurodevelopmental and neurodegenerative conditions such as autism [9], dementia [10], and premature birth [11]. These developments point to a field that is far from static and is actively addressing the methodological challenges inherent to complex, person-centered interventions.

Skov and Nadal's review also builds on a longstanding position that art does not engage uniquely specialized brain mechanisms distinct from other pleasurable experiences. This view provides a timely critique of the prevailing belief, rooted in philosophical tradition, that art holds a unique capacity to evoke transcendence or profound emotional responses. We agree on the importance of questioning essentialist assumptions about art. However, a deeper concern lies in the authors' understanding of intervention research and clinical practice. They advocate for isolating the "art components" within treatment, as if one could cleanly separate "music" from its cognitive, psychological, contextual, and cultural dimensions. We favor a view where a common group of factors (including for example, therapist influence and alliance, expectations, a healing context and social engagement), may all synergistically contribute to the therapeutic effect of music-based interventions (see for a similar long-standing and unresolved debate in psychotherapy, [12-13]).
Overall, Skov and Nadal’s review reflects a reductive “Lego model,” in which interventions are conceived as the sum of discrete, separable, and independent elements. Nonetheless, like any complex behavioral intervention in health, music-based interventions are inherently holistic, with common and specific components interacting in dynamic and synergistic ways. Their therapeutic value arises from the interplay between sensory stimulation, emotional resonance, social bonding, and cognitive engagement. Thus, attempting to isolate a single “art component” from this matrix risks removing the very features that make the intervention meaningful, ethical, acceptable, and clinically effective.

As an example, we experienced this challenge directly in one of our own stroke rehabilitation trials, in which we sought to isolate the role of sensorimotor integration by comparing training with a real keyboard to a control condition involving a mute keyboard, thus lacking auditory feedback. The rationale was to preserve the motor component while removing auditory stimulation to determine the specific contribution of sensorimotor integration to neural plasticity and associated functional recovery. Although the design appeared methodologically sound in theory, it failed in practice, and the trial had to be discontinued. Participants found the mute condition meaningless and demotivating, leading to poor engagement. As researchers, we came to recognize the futility of removing elements that make music meaningful. This experience highlights the risk of implementing overly reductionist control conditions that may preserve internal validity but at the cost of ecological and clinical relevance.

Skov and Nadal further propose that music interventions should be compared to “control stimuli with similar acoustic features that are not considered music.” It remains unclear what such stimuli would entail, but they would likely lack the motivational and hedonic properties necessary for engagement, especially in vulnerable populations. In clinical practice, patient engagement is not a side effect but a core therapeutic mechanism. Removing motivational, hedonic, or socially meaningful elements may thus undermine the intervention’s practical efficacy. The authors’ suggestion may reflect a lack of familiarity with clinical realities of intervention delivery and research and highlights the disconnect between theoretical approaches and patients’ needs.

Ultimately, the core tension lies between a process-isolation framework and a more holistic, system-based view. Music is a multisensory, emotionally engaging activity that simultaneously recruits interconnected processes such as reward, agency, motivation, social bonding, and more. Rather than viewing this complexity as a limitation, we argue that it should be embraced as a central and differential feature of ABI research. Attempting to isolate components in art is akin to studying the health effects of nature exposure by isolating the color green. Other effective interventions, such as cognitive behavioral therapy or mindfulness, are similarly multifactorial
and resist mechanistic dissection, yet they are evaluated through mixed methods, adaptive designs, and pragmatic trials [13]. ABIs deserve the same methodological pluralism.

While the article offers a sharp critique, it falls short in proposing concrete solutions to improve the field. The authors miss a valuable opportunity to suggest clear operational definitions, hybrid trial designs, or interdisciplinary collaboration. Instead, the review's dismissive and overly harsh tone risks delegitimizing interventions that, while imperfectly studied, may offer meaningful adjunctive benefits for people living with chronic illness, disability, or psychological distress.

What ABI research needs is not dismantling based on early-stage trials, but rather thoughtful and sound methodologies. This requires continued collaboration with methodologists, the development of theory-informed interventions, component analysis, and adaptive designs, with openness to both quantitative and qualitative methods. Capturing the full impact of ABIs requires time, creativity, and a research culture that values complexity over reductionism. ABIs are not flawed science; they represent emergent, complex research that calls for an inclusive evidence culture grounded in methodological innovation.

## Acknowledgements

ARF has been supported by the FIAS fellowship Program, co-funded by the European Commission, Marie-Skłodowska-Curie Actions - COFUND Program, Grant n°945408. This work, carried out within the Institut Convergence ILCB (ANR-16-CONV-0002), has benefited from support from the French government (France2030), managed by the French National Agency for Research (ANR) and the Excellence Initiative of Aix-Marseille University (A*MIDEX). JGS is supported by grant PID2023-149792OA-I00 funded by MICIU/AEI/10.13039/501100011033 and by ERDF/EU.

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