Youth mental health has undergone significant challenges globally, with increasing rates of anxiety, depression, and emotional dysregulation observed across diverse cultural and socioeconomic contexts (Racine et al., 2021; Knight et al., 2025). Conventional clinical models, which often rely on diagnostic categories and verbal cognitive processing, have been criticized for failing to resonate with many young people, particularly those from culturally diverse or marginalized backgrounds (Watters, 2010; Kirmayer and Gómez-Carrillo, 2019). Increasingly, evidence points to the importance of participatory, culturally embedded practices such as music, storytelling, ritual, and visual art in shaping emotional regulation, identity coherence, and psychosocial resilience (Fancourt and Finn, 2019; Koelsch, 2010). Clarifying who is encompassed by the term “youth” is essential for interpreting these findings, yet the literature reveals inconsistencies in how this group is defined.

Weinrabe and Hickie (2023) suggest that the term “youth” broadly encompasses individuals in the developmental stage spanning from early adolescence (around 12 years old) to young adulthood (up to approximately 24 years old). They argue that this wide age range reflects the ongoing maturation of brain regions involved in emotional regulation and decision-making, which continues into the mid-20s. However, they note that the literature often misconstrues or inconsistently applies age boundaries, sometimes equating “youth” strictly with teenagers or early adolescents. This inconsistency can lead to misinterpretation of research studies, as it overlooks the significant neurodevelopmental changes that occur during late adolescence and emerging adulthood. Such definitional ambiguities highlight the need for theoretical frameworks that move beyond narrow biological or age-based classifications, prompting a closer examination of how health and emotional well-being are conceptualized within different philosophical traditions.

Murphy (2015, 2025): Murphy et al. (2020) stresses that the concept of health is not just about physiological functioning but involves normative judgments based on context. And although physiological functioning is vital to mental health, it is in turn adapted to the mix of social, material and cultural environments that enable humans to flourish in mentally healthy ways (Murphy, 2023). The Culture-as-Practice (CAP) framework aligns with this orientation, acknowledging that cultural and relational scaffolding play a central role in emotional health, but it extends beyond previous philosophical critiques by framing participatory cultural practices in action as affective technologies that actively co-regulate emotional life.

The decision to begin this review in 2010 reflects a pivotal shift in youth mental health research. From 2010 onward, there was a marked increase in studies adopting participatory, arts-based, and culturally grounded approaches, coinciding with broader recognition of the social determinants of mental health and the influence of cultural and relational “scaffolding” on emotional well-being (Seah and Coifman, 2024; Basu and Banerjee, 2020). Before this period, most literature was dominated by individualized, pathology-focused frameworks with limited relevance to the CAP framework (Watters, 2010).

This paper also responds directly to the journal’s special edition focus on post-COVID mental health. The COVID-19 pandemic disrupted the cultural, social, and relational infrastructures that support youth mental health, producing what some scholars have termed a “crisis of affective scaffolding” (Zhang-James et al., 2025). Emerging research demonstrates that participatory arts, collective rituals, and other culturally embedded practices were central to rebuilding resilience and restoring emotional coherence during and after the pandemic (Stevenson and Alzyood, 2025; People’s Palace Projects., 2022). By applying the CAP framework to this evidence base, the review aims to advance a neurocultural understanding of youth mental health that highlights participatory cultural practices not as peripheral, but as central regulatory technologies in both pre- and post-pandemic contexts.

The primary objective of this paper is to critically examine how young people frame, interpret, and regulate their mental health experiences through culturally embedded, participatory practices. Rather than treating these practices as ancillary or recreational, we conceptualize these as affective technologies or structured cultural forms that actively shape and enable emotional life, identity, coherence, and resilience. Grounded in the Culture-as-Practice (CAP) framework, our analysis positions cultural engagement not as a peripheral adjunct to clinical care, but as a central infrastructure for youth mental health. Specifically, our research aims to clarify the theoretical foundations of CAP by extending the Culture-as-Interaction (CAI) model, offering a neurocultural and relational account of how participatory practices such as music-making, storytelling, ritual, and visual art scaffold a person’s emotional regulation.

The secondary objective is to evaluate how participatory practices function as embodied regulatory environments, bypassing cognitive-linguistic barriers and enabling emotional recalibration in ways often inaccessible to conventional talk-based or diagnostic approaches. Particular attention is given to the sonic and symbolic modalities that facilitate co-regulation, social attunement, and nervous system synchrony. As Ross (2023) argues, affect and symbol are inseparable in the making of mental health, a claim that underpins our framing of participatory arts as affective technologies. Thirdly, we assess CAP’s potential as a context-sensitive and scalable model of youth mental health care, especially in settings where formal clinical services are inaccessible, culturally incongruent, or under-resourced (Ranjbar et al., 2020). This includes identifying how CAP principles can inform trauma-informed, community-based interventions and complement existing mental health infrastructures.

The results from this research suggest two core hypotheses: First, participatory cultural practices, particularly those involving rhythm, repetition, symbolic patterning, and collective meaning-making, seem to act as affective technologies that regulate emotional states by engaging embodied, non-verbal, and relational mechanisms, as demonstrated in neuroscience research on music-induced dopamine release (Salimpoor et al., 2011) and on neural plasticity through music training (Thompson and Schlaug, 2015). Such practices exemplify what Slaby (2016) describes as “situated affectivity,” where external cultural forms and environments scaffold and modulate emotional states, making them more resonant and accessible for youth than conventional interventions requiring verbal processing or diagnostic agreement.

Second, emotional distress among youth frequently reflects ruptures in cultural, aesthetic, and relational infrastructures rather than solely internal psychopathology, suggesting that mental health challenges should be understood as ecological consequences of disrupted cultural participation, with recovery also dependent on restoring symbolic and communal support.

Collectively, these objectives and hypotheses contribute to a growing paradigm shift in youth mental health care–one that recognizes culture not as an optional enhancement to therapy, but as the foundation through which emotional life is regulated, restored, and shared.

The global youth mental health crisis has led to a notable rise in research exploring participatory arts-based interventions as culturally responsive alternatives to traditional clinical models. These interventions–including music, storytelling, visual arts, and ritual–are increasingly recognized for their potential to foster emotional regulation, identity coherence, and psychosocial resilience among youth, consistent with research showing that cultural frameworks of selfhood shape cognition, emotion, and motivation (Markus and Kitayama, 1991). However, their effectiveness varies according to sociodemographic factors such as gender, socioeconomic status, and cultural background, prompting several scholars to call for periodic, context-sensitive reviews (Golden et al., 2024; Williams R. et al., 2023). In this vein, Hugh-Jones and Munford (2025) provide an international review of youth participatory arts in post-pandemic contexts, demonstrating how creative practices contribute to recovery and resilience in ways that complement biomedical and psychosocial approaches. More recently, Williams E. et al. (2023) provide a mixed-methods meta-review demonstrating how youth participatory arts facilitate collective healing, reinforcing the evidence base for their role as culturally responsive alternatives to traditional models.

In low- and middle-income countries (LMICs) such as India, participatory arts have been shown to support youth in addressing depression and anxiety, providing culturally relevant and accessible pathways for emotional expression (Bux and Van Schalkwyk, 2022). In Bangladesh, social and academic pressures, family dynamics, and financial instability intersect with youth mental health, underscoring the need for contextually adapted interventions (Khan et al., 2025). Similarly, Tan et al. (2020) demonstrate the application of art therapy in humanitarian crises, highlighting its capacity to provide culturally responsive, non-verbal pathways for emotional expression and recovery in settings of acute social disruption. Sub-Saharan African contexts have also seen the use of participatory arts to reduce stigma and foster community-based mental health engagement, reinforcing the potential of culturally embedded approaches (Mendelsohn et al., 2022).

By contrast, studies in high-income countries like the United Kingdom and the United States demonstrate the promise of participatory arts as complementary to established mental health services. In the United Kingdom, arts-based programs have shown improvements in youth well- being, though gaps remain in measuring outcomes across different population groups (Williams R. et al., 2023). In the United States, Youth Participatory Action Research (YPAR) is gaining ground as a model that centers the lived experiences of youth while empowering them to co-create mental health solutions (Anyon et al., 2018). A comparative view reveals both convergence and divergence. While participatory arts are effective in both Global South and North contexts, implementation methods differ significantly due to disparities in infrastructure, resources, and cultural dynamics. For example, while digital platforms and formal evaluations are common in the North, community-driven, oral, and embodied approaches are more prevalent in the South. Gender norms, socio-economic conditions, and historical-cultural legacies influence how and whether youth engage with artistic practices across contexts (Pavarini, 2021; Fancourt and Finn, 2019).

The reviewed literature presents a shared global recognition of the potential of cultural framings in youth mental health but also highlights the need for tailored intersectional strategies. i.e., programs must consider sociodemographic and cultural nuances to ensure equitable access and meaningful impact. This research therefore aims to fill critical gaps by investigating not only the effectiveness of participatory arts-based approaches but also their differential reception and resonance across diverse global contexts.

Over the past decade, there has been a growing recognition of the role that participatory arts and cultural practices play in supporting youth mental health. These approaches are increasingly viewed not merely as supplementary to clinical interventions but as integral to fostering emotional regulation, resilience, and social connection among young people. A comprehensive global review by Golden et al. (2024) highlights the potential of arts-based strategies to address youth mental health challenges. The study highlights the accessibility and cultural adaptability of such interventions, emphasizing their capacity to engage youth in meaningful ways that resonate with their lived experiences. Similarly, Williams R. et al. (2023) conducted a systematic review revealing that participatory arts-based programs significantly contribute to various aspects of children’s and young people’s mental health and well-being, including reductions in anxiety and depression symptoms.

In the Australian context, the “Creating Well-being” report by Creative Australia. (2023) provides insights into public engagement with arts and health initiatives. The findings indicate a strong public interest in integrating arts into health strategies, with many viewing arts engagement as beneficial to mental well-being. This aligns with the principles of the Culture-as-Practice (CAP) framework, which posits that cultural practices are foundational to emotional life.

Further supporting this perspective, Pavarini (2021) discuss the ethical considerations in participatory arts methods for young people with adverse childhood experiences. Their work emphasizes the importance of co-creating interventions with youth, ensuring that their voices and cultural contexts are central to the development of mental health strategies. Moreover, the integration of digital platforms in arts-based interventions has shown promise. Kumar et al. (2025) explored the design and evaluation of “CUBE” an arts-based digital platform aimed at assisting trauma-impacted youth. The study found that such platforms could provide accessible avenues for youth to express and process their experiences creatively.

Collectively, these studies generate a paradigm shift toward embracing culturally grounded, participatory approaches in youth mental health. They highlight the efficacy of integrating arts and cultural practices into mental health interventions, resonating with the CAP framework’s emphasis on the co-construction of emotional well-being through cultural engagement.

The object of study in this project was not individual participants but defined sets of materials and programmes. In the narrative review (Group 1), the object of study was a body of peer-reviewed publications addressing youth mental health, participatory or arts-based practices, and cultural or symbolic approaches to wellbeing. From an initial pool of 650 records retrieved through database searches, 30 documents met the inclusion criteria and were retained for analysis. Studies were excluded if they focused exclusively on biomedical interventions, lacked sufficient methodological detail, or were unavailable in English.

In the qualitative strand (Group 2), the object of study consisted of two purposively selected programmes: Whānau Ora in Aotearoa New Zealand and GEMAH in Pakistan and Australia. These programmes were chosen because of their explicit alignment with Culture-as-Practice principles and the availability of both qualitative and quantitative data. Importantly, we did not conduct primary data collection; instead, we analyzed the data as presented by the programme teams, which included interviews, workshops, ethnographic observation, and reported quantitative measures. Youth involved in these programmes ranged from 12 to 25 years in Whānau Ora and from 18 to 25 years in GEMAH, an age span characterized by neuroplasticity, identity formation, and heightened sensitivity to socio-cultural influences.

The instruments used were tailored to the two strands of the study. For the narrative review, literature searches were conducted in PubMed, PsycINFO, Scopus, Google Scholar, and JSTOR using Boolean combinations of terms relating to youth, mental health, culture, and participatory or arts practices. Screening and selection followed PRISMA-informed protocols to ensure replicability, with the process illustrated in Figure 2. This systematic approach enabled transparent reporting of inclusion and exclusion decisions and produced a final set of 30 studies. While two programmes are examined in detail in the main text, a summary of findings from the remaining 28 studies is provided in the Supplementary Material to maintain focus and coherence.

For the case studies, data collection involved semi-structured interviews, participatory arts-based workshops, and ethnographic observation. These methods enabled in-depth exploration of how cultural and symbolic practices support youth wellbeing. Analysis drew on Braun and Clarke’s (2006) six-phase reflexive thematic framework. Deductive coding was guided by constructs from the CAP and CAI models (such as “plumbing” and “scaffolding”), while inductive coding allowed themes to emerge directly from participants’ accounts. The analytic process was iterative and supported by reflexive journaling and memo writing to ensure rigor. Together, these instruments addressed the study’s objectives by combining the systematic scope of PRISMA with the interpretive depth of qualitative thematic analysis.

The research unfolded in a series of steps. First, a systematic literature search was conducted across five databases for publications from 2010 to 2025. After removing duplicates and applying inclusion and exclusion criteria, 30 studies were retained for synthesis. In parallel, two case programmes–Whānau Ora and GEMAH–were purposively selected for detailed analysis. These programmes were chosen because they exemplify Culture-as-Practice principles in contrasting cultural and geopolitical contexts and provide both rich qualitative and quantitative data. Data collection in these programmes involved interviews, workshops, and observation in Pakistan, Australia, and Aotearoa New Zealand. The resulting material was subjected to both deductive and inductive thematic coding. Finally, findings from the review and case studies were integrated using a convergent mixed-methods design (Creswell and Plano Clark, 2018), allowing insights from both strands to be displayed in a joint analytic roadmap.

Data analysis was adapted to each strand. In the narrative review, studies were coded by arts modality (y-axis) and mental health outcome (x-axis), then summarized in a cross-tabulation matrix and visualized as heatmaps and network graphs (Figure 3). Modalities included multiple arts, community arts, music and drama, cultural performance, storytelling and painting, art therapy, performing arts, and digital arts. Outcomes included emotional regulation, social connection, reduced anxiety and stress, cultural identity, trauma processing, and self-esteem/agency. This visualization enabled the distribution of modalities across outcomes to be interpreted at a glance and highlighted patterns across the evidence base.

For the case studies, we interpreted the data presented by the programmes, which included their interviews, workshops, and ethnographic observations, as well as reported quantitative measures analyzed with STATA using paired t-tests to examine pre- and post-intervention changes in emotional expression, self-efficacy, social connectedness, and anxiety symptoms. The qualitative materials were analyzed thematically, guided by Lincoln and Guba’s (1985) trustworthiness criteria of credibility, dependability, confirmability, and transferability.

Integration followed a convergent mixed-methods design in which the narrative review provided deductive frameworks, while the case studies generated inductive, culturally grounded insights.

This project was conducted in line with recognized ethical standards for literature reviews and qualitative synthesis. As it analyzed previously published studies and secondary data, no new human subjects were recruited, and formal ethics approval was not required. Ethical responsibility therefore focused on ensuring transparency, accountability, and cultural respect in how evidence was interpreted and presented.

Records were managed systematically, with a clear audit trail of inclusion and exclusion decisions to minimize bias. Data from reviewed studies and case descriptions were reported accurately and with sensitivity to cultural and contextual meaning. Reflexivity was embedded throughout: the research team maintained positionality notes, documented analytic decisions, and discussed assumptions regularly to ensure interpretive accountability.

In keeping with best practice for review-based research (Committee on Publication Ethics (Cope)., 2017), the emphasis was on accurate synthesis, avoidance of misrepresentation, and acknowledgment of limitations. These measures ensured compliance with standards of integrity and transparency while distinguishing our methodological responsibilities from those of the original study teams.

We synthesized the key theoretical outcomes relevant to the Culture-as-Interaction (CAI) framework, streamlining the conceptual background to foreground findings that directly connect to the case study outcomes presented in Section “3.2 Findings: cultural scaffolding and emotional regulation.” These outcomes suggest that CAI reframes youth mental health not as an individualized, pathology-based construct but as an emergent property of relational, cultural, and symbolic interactions. Central to CAI is the premise that affective regulation arises through participation in shared cultural forms, where identity, belonging, and meaning are co-constructed.

The findings align with this theoretical position, revealing that emotional suffering can be interpreted as a rupture in relational and symbolic infrastructures, consistent with Kirmayer and Gómez-Carrillo’s (2019) notion of cultural affordances for coherence. Participants described regaining a sense of “being held” or “finding rhythm with others” during participatory practices, echoing CAI’s argument that psychosocial recovery is scaffolded through collective cultural engagement. Our analysis extends CAI by integrating empirical examples where relational scaffolding translated into tangible shifts in emotional regulation. Recent work in the foundations of psychology has stressed the role of scaffolding in enabling cognitive processing (Sterelny, 2010), but we draw attention to the way in which emotional life is also regulated and enabled by the environments in which we are embedded, and the importance of therapeutic regimes that work with the grain of those environments. Participants consistently highlighted the importance of cultural rituals, shared rhythm, and symbolic practices, findings that establish CAI not merely as a theoretical construct but as an observable process in youth mental health contexts. These outcomes provided the foundation for the CAP framework, which is elaborated in the following section.

The analysis revealed two key themes with four sub-themes that explain how cultural scaffolding supports emotional regulation. These findings demonstrate that emotional regulation emerged not as an isolated internal process but through embodied, aesthetic co-regulation and culturally grounded practices. A detailed summary of themes and sub-themes, including illustrative quotes, is provided in the Supplementary Material.

Theme 1: Collective Symbolic Scaffolding

Artistic and symbolic practices acted as affective technologies for emotional regulation and social connection. Participants described experiencing validation and recognition through non-verbal practices (Sub-theme 1.1: Non-verbal symbolic connection). A GEMAH Programme participant explained, “I just paint, but I feel seen when I do,” illustrating how non-verbal artistic engagement fostered belonging and recognition without requiring verbal disclosure. Shared rhythmic practices, such as group singing, movement, and drawing, helped regulate emotional states and created a sense of bodily grounding (Sub-theme 1.2: Ritualized rhythmic co-regulation). Participants described “releasing tension through rhythm” and “breathing differently when drawing or moving,” reflecting the embodied and co-regulated nature of emotional care.

Theme 2: Identity-Driven Cultural Grounds

Cultural identity functioned as a central scaffold for emotional and relational well-being. Whānau Ora participants emphasized that connection to ancestry and community provided emotional grounding (Sub-theme 2.1: Cultural identity as emotional scaffold). One navigator stated, “I draw on whakapapa and mana to guide whānau through their wellness plan.” Participants also reported subtle, pre-verbal shifts in emotional states expressed through symbolic and ritual practices (Sub-theme 2.2: Ineffability and symbolic enactment), describing “feeling something shift” or “being held in the rhythm of others.” These findings highlight the somatically felt and symbolically enacted dimensions of emotional regulation, which often elude linguistic articulation.

These two themes illustrate CAP’s core proposition: emotional regulation emerges through cultural, relational, and symbolic scaffolding. Artistic, ritual, and identity-based practices provided embodied pathways for emotional recalibration, positioning CAP as a functional and culturally resonant framework for youth mental health care.

Cross-case analysis revealed that CAP operates as a culturally embedded alternative to dominant biomedical and therapeutic art models. The following themes and sub-themes highlight how participants and programme data contrasted CAP-based practices with more individualized models of care. These findings are based on patterns identified across GEMAH and Whānau Ora and demonstrate how emotional regulation and well-being were supported through collective, culturally grounded approaches. Thus, we found this as a third theme that arose, i.e., CAP offers a culturally embedded alternative: participants and programme outcomes highlighted that emotional regulation was socially distributed rather than individualized. The following sub-themes outline the specificity:

(i) Socially distributed emotional regulation

Participants consistently described care as arising through collective cultural practices rather than through individualized talk-based therapy. In both cases, group singing, storytelling, and shared ritual created co-regulated emotional states.

(ii) Resonance with cultural lifeworlds

CAP-aligned approaches were viewed as meaningful and accessible because they reflected participants’ cultural values, traditions, and aesthetic practices. A Whānau Ora navigator noted, “Whānau trust this because it’s our way, not someone else’s model.” This resonance increased participation and perceived relevance, contrasting sharply with clinical approaches described as “distant” or “not for us.”

These findings demonstrate that CAP does not function merely as a theoretical alternative but as a practical, culturally resonant model of care. Rather than centering on symptom reduction through individual talk-based methods, CAP facilitated emotional regulation by embedding support within culturally meaningful, relational, and symbolic practices. A summary of these cross-case contrasts with biomedical and therapeutic art models is provided in Table 2. Further detail on how CAP differs from conventional therapeutic art practices, including a comparative analysis, is provided in the Supplementary material.

However, Whānau Ora is not solely a youth mental health programme, but a government-supported commissioning approach spanning health, housing, education, and cultural identity. Its effectiveness is evaluated through whānau-led outcomes frameworks. Both created affectively charged, rhythmically structured environments that facilitated emotional recalibration. Practices such as Māori kapa haka, karakia, and whakapapa, alongside GEMAH’s storytelling and group art, enabled participants to regulate emotions, strengthen social connection, and restore a sense of belonging. Participants described feeling “held” by collective rhythm, with emotional shifts occurring without the need for verbal introspection or diagnostic framing.

The effectiveness of these programmes lies not in generic “artmaking” but in ritualized, embodied aesthetic engagement. By mobilizing sound, rhythm, and symbolic participation, both models established co-regulatory spaces where nervous systems synchronized, and identities cohered. Emotional well-being was reframed as a relational, culturally embedded process rather than an individual pathology.

Quantitative outcomes confirmed these effects. Whānau Ora participants consistently reported increased psychological safety and relational grounding, while GEMAH showed significant improvements in emotional expression, self-efficacy, and social connectedness across Pakistan and Sydney cohorts. Anxiety symptoms declined markedly in both contexts.

Figure 5 displays a grouped bar chart illustrating the relative emphasis of CAP-aligned outcome domains across GEMAH and Whānau Ora programmes. GEMAH showed greater emphasis on symbolic and ritual emotional regulation (SR) and psychological safety (PS), while Whānau Ora prioritized relational grounding and belonging (RG) and cultural identity reinforcement (CI), reflecting their respective cultural contexts. SR = Symbolic/Ritual Emotional Regulation; RG = Relational Grounding and Belonging; CI = Cultural Identity Reinforcement; PS = Psychological Safety.

These findings are consistent with RANZCP’s assessment of Whānau Ora as an evidence-based, culturally safe model that embeds Te Ao Māori values in service delivery and whānau-led outcomes.

Culture-as-Practice’s adaptability across diverse settings are clearly defined through integrated health approaches that utilize participatory arts. Whether grounded in Māori cosmology or adapted to postcolonial urban realities using Arts-based education, both models steer clear of diagnostic reductionism in favor of culturally resonant, non-clinical tools. Their success illustrates that symbolic and embodied practices function as effective technologies of care, offering scalable, community-led alternatives to conventional mental health approaches in post-pandemic contexts.