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Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
An exploration of artists’ perspectives of participatory arts and health projects for people with mental health needs K.L. Margrove a,b,*, J. Pope a, G.M. Mark c a
Primary & Public Health, William Harvey Building, Anglia Ruskin University, Bishops Hall Lane, Chelmsford CM1 1SQ, UK b South Essex University Partnership NHS Foundation Trust, The Lodge, The Chase, Wickford SS11 7XX, UK c Symbiotics Ltd, Little Washbourne, Tewkesbury, Gloucestershire GL20 8NQ, UK
article info
abstract
Article history:
Objectives: This study addresses the views and experiences of artists who run participatory
Received 26 October 2012
arts and health courses for those with mental health or social problems.
Received in revised form
Study design: Qualitative research with 11 artists from three different organizations
18 September 2013
providing participatory arts and health courses.
Accepted 25 September 2013
Methods: Semi-structured in-depth interviews were conducted. Participants provided oral
Available online 22 November 2013
contributions that were transcribed and then thematically analysed by the authors. Results: Participants described perceived positive benefits of participatory arts and health
Keywords:
courses, including developing friendships, self-expression and creativity, a non-
Visual art
judgemental environment, along with key issues arising, including managing challenging
Mental health
behaviours and provision of follow-on options.
Qualitative
Conclusions: Results indicate that improvements in well-being can be identified by artists
Thematic analysis
during courses, the activity can help develop friendships, courses can be well managed in
Social inclusion
community settings, and benefits of follow-on activities should be investigated in future. ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Participatory arts and health courses are increasingly being run for people with mental health needs, by public and private health providers and charities. In 2008, over 100 projects were identified in England.1 Courses are often run in the community for 10e15 weeks and are facilitated by artists who may or may not have formal training.2,3 This study focused on visual art courses that provide opportunities for service users to work in different mediums such as clay, textiles, and paint. Programmes typically have a
referral process from health or social care practitioners,4 although some projects advertise within communities and take self-referrals, which can de-medicalize the intervention and assist with community integration.5 Researchers have largely focused on participants’ experiences of courses, to derive support for arts as a recovery tool.2,6e10 Stacey and Stickley found that participants benefitted by doing something for themselves and having a focus on something other than mental health.11 A recent study interviewed ten professionals who had referred clients to participatory arts and health courses,12 and identified
* Corresponding author. Tel.: þ44 845 196 4189. E-mail address: [email protected] (K.L. Margrove). 0033-3506/$ e see front matter ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2013.09.018
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benefits for clients including provision of a therapeutic environment, peer support, and opportunity for self-expression. However, most research has placed less emphasis on the views of the artists who provide courses, who may have key insights into the advantages of these activities for those with mental health needs.13 The aim of the current research therefore was to explore the perspectives of artists themselves, on the benefits for participants, and the challenges involved. The study was approved by the relevant Faculty Research Ethics Panel.
Methods
Transcripts were revisited to ensure themes reflected the data.
Findings Many of the benefits attributed to arts participation by the artists reflected those reported previously by service users,2,6,10,12 including provision of a safe environment, distraction from mental health issues, sense of achievement, and networking opportunities. However five themes that are less well reported also emerged: ‘Why Art?’, ‘Well-being & Behaviour’, ‘Developing Sustained Friendships’, ‘Volunteering’, and ‘Managing Mental Health Challenges’. Pseudonyms have been used for anonymity.
Design Why art? The study aim was essentially exploratory, so a qualitative approach was taken involving semi-structured interviews at one point in time.
Participants and recruitment Participants were contacted through three East of England art organizations. Artists were recruited if they had experience of working as an art tutor on visual participatory arts and health courses for people with mental health problems. Managers of organizations providing such courses were asked to promote the study to artists. Those wishing to participate contacted the researchers, who provided full information and the opportunity to ask questions. Artists were assured of their anonymity and asked to sign a consent form. Eleven artists participated (seven female). The majority (eight) were freelance, working with two projects operating in non-NHS community venues. Three worked within an NHS mental health day centre, and five participants had run between 50 and 100þ courses each, with the rest having run an average of five courses.
Procedure Semi-structured interviews were used to gather data. Interviews took approximately 60 min and were recorded and transcribed with permission by a trained interviewer. Topics covered included: Perceptions of how arts participation can improve well-being and key factors; Ways in which courses can help broaden social contacts and networks; Specific examples of observed changes/progress in course participants; What sort of issues/needs arts projects can help with; Perceived benefits of any follow-on activities; Any challenges experienced in running courses for people with mental health needs.
Analysis Coding and analysis were conducted according to Braun and Clarke’s thematic analysis guidelines.14 This involved two authors independently coding data, sorting codes into themes and collating data to support themes. Themes were reviewed by the authors, with divergences resolved through discussion.
The majority of artists felt there were unique benefits of art for people with mental health needs. The most common theme revolved around opportunity to express feelings using nonverbal media: A lot of people, I think, don’t know how to talk about their feelings, and a lot of the time that can come out through their artwork. (Amber) It’s definitely being creative that helps people’s mental health because you’re giving people a positive outlet to turn all that negativity into something positive by trying out a new medium. (Suzie) This participant described how the process that could enable the expression of feelings: To make something that’s so personal is different I think than doing some kind of physical activity like gardening or exercise or cooking or something... it’s about that person’s soul a lot of the time and the process of art making, there is a lot of soul searching that goes on there, so yeah I think it is unique really. (Rosemary) For one participant, seeing the world through different eyes was a key factor, while two day centre workers drew comparisons with other mental health interventions, one highlighting social benefits and the other the joy of creativity. This latter finding supports previous research:10 Art works, it really does. And it gives you. that opportunity to look at things differently that you wouldn’t get through anything else. It opens your eyes in a different way rather than blinkered. (Suzie) I think it has a different place to therapy, to talking therapy. It’s a doing, practical thing. People get together, they socialise, they talk, they have fun, they do things together, they create together. (Morag) Art itself is such a therapeutic thing, it’s probably the most therapeutic thing of the whole lot because after a two or three hour session of painting when you get really engrossed in
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something and you can see it coming to life, it leaves you with a really good feeling inside. (Luke)
paid for their own venue and that sort of thing, so I think real friendships are formed. (James)
In contrast to the emphasis placed by most on the unique benefits of arts, one day centre worker thought similar benefits could be achieved through other activities:
This artist felt that working with people with a range of mental health needs rather than focussing on specific diagnoses had additional social and networking benefits:
. a lot of groups would give that standing benefit of social interaction and friendships, and they do. But you know, I suppose if you break it down, you know, something like gardening would be creative. A lot of those things are quite creative. (Morag)
People might be there for mild depression or really serious personality disorders and yet they will all befriend each other and support each other and they encourage and they suggest going to art galleries and stuff like that. (Diana)
Volunteering Well-being and behaviour Artists described observing positive changes in well-being and behaviour, including self-esteem, confidence and self-worth over the duration of the courses.
The researchers were interested in possible follow-on/ volunteering options for participants after the course, and generally the artists were in favour of this option for various reasons:
Like that guy with the major panic attack, he kept coming and in the end he wasn’t doing all this breathing business and he was quite relaxed, he’d come in and join in the conversation and that’s amazing. (Diana)
. people have wanted to give something back and there’s that sense of achievement and accomplishment through giving and sort of assisting with something. there’s lots of benefits. (Bradley)
It raises people’s self-esteem when they see their work exhibited, when they’re turning up each week and they’re not being judged because they’ve got a mental health problem, [it] builds their confidence because they’ve seen their work, they’re creating something good and beautiful. So I think art is a major factor towards people’s recovery, I’m convinced about it! (Suzie)
.It’s tangible proof to [the group].it works, someone’s done this and . it’s someone saying I’ve participated and it really did work for me. (Jane)
Behavioural changes included improved self-care, communication, and coping that had enabled a day centre user to move on in her recovery:
However some artists felt such options were not appropriate:
You can see changes in people’s personality, sometimes you can see changes in their physical appearance, they may be taking a bit more care over their hair or their clothes; vocally, they may be getting chattier.it won’t be so much that they say I’m feeling better, because we don’t sort of focus on mental health, but people will say things like “oh I’ve signed up for this”. or “I went to”. they’ll tell you what they’ve done and what their plans are. (Petra) She’s working again and she’s fine and that illness it hasn’t. I don’t know if it will ever go away, that was depression, but she’s coping and she’s moved on. (Morag)
. I’ve had students . that they do want to volunteer but elsewhere, outside of our project, but within the arts. (Petra)
We don’t encourage them back as volunteers actually.We’ve had a man who’s gone now, but that relationship got very difficult because he had been a client.There’s a lot of trouble stirred up because of that, very often, between clients and staff. It doesn’t work I’m afraid. Volunteering somewhere else is wonderful. Because they’re not in the environment they were ill in. (Morag).
Managing mental health challenges While most artists described challenges, specific difficulties relating to mental health issues were seen as minimal. Challenges could revolve around individual triggers for distress, or frustration with the process of art-making:
Developing sustained friendships Artists described evidence that people had developed sustained friendships, with some students going on to form their own art groups: In general a lot of friendships are made. With one of the courses, I think there are four or five ladies that carry on and they still meet each week. They run like a little art group. (Suzie) And we know that a lot of them stay friends, we’ve had some groups who have continued to meet as groups themselves and
Something may have triggered off something and they may have been tearful within the group. Sometimes they’ve maybe got angry with a process, it might have not worked out and they might have got frustrated with the equipment or with the materials or with themselves. (Rosemary) The nature of art, it can be quite frustrating for certain people if they don’t feel that they’re getting, you know, the results that they would want to get. You can see people becoming more, you know, finding it difficult to actually keep up with the rest of the class and things. (Ben)
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For those who described such challenges, sensitivity to distress and flexibility in responding were key to effective management: We had one person working in a different room, because she felt uncomfortable in that group, so we’ve, you know, said OK, that’s fine, if you’re not happy to be sitting in this group we can sit with you over here and we can do something else, you know, we can do something different.. So it’s just about having enough tools in your box to quickly change what you’re doing and be responsive to that change. (Amber) We always say if anybody wants to take time out, if they want a break, just go, don’t ask. So somebody will... they will generally step outside the room, and I would leave them for a couple of minutes, give them some time to themselves and go and see if there’s anything I can do, if they’re OK, if they want to talk about it. But give them space, I think it’s quite important to give people a bit of space just to sort of de-escalate. (Rosemary) We devise different ways of approaching the actual subject which kind of levelled out the skills base. as I say it also allowed people the opportunity to get involved in it in a very non-judgemental way and so no matter what your ability was, people were able to do these tasks, so I think that created a much more... what’s the word... well, calm. (Ben) Challenging behaviours were reported by several artists. At one project, flexibility was key to managing this, alongside a focus on art rather than mental health: .it’s just taking a step back and saying to people OK, just stop, breathe. Realising that people are going to have good and bad days, but that’s OK, realising that people might miss a session, making sure there’s a follow up phone call to let them know that, OK, they’ve missed a session but it’s fine to come back. (Suzie) Two students who were sort of having an argument and it created quite a bad atmosphere, and really I felt my role there was to diffuse things and to not... but not get involved in what they were talking about, but bring it back to the art. (Rosemary) At the day centre, flexibility and sensitivity were important, but in this setting withdrawing individuals from the group was also emphasized as important in managing behaviour: If we have a problem, if somebody’s distressed or really unwell we’ll take them out of the group and talk to them and make them a cup of tea. We keep our eye on everybody, you know, we’re experienced with that. (Luke) There can be trouble between various people in groups, you know, and personality, or they’ll be coming in crying or shouting. then I need to withdraw them. They’re not going to project that vibe onto the group, so we withdraw those people. (Morag) Across all projects, organizational arrangements important in managing challenges. In particular, having a second
person present (artist, volunteer, or staff member) was common practice to help enable the flexibility described. In one instance, the project manager could be contacted in case of difficulties, with group supervision and discussion of challenges and problem solving.
Discussion By exploring the perspectives of artists running these courses, a greater understanding of course benefits can be acquired. Here artists provided feedback on the key benefits of running participatory arts and health courses for people with mental health problems, the issue of providing follow-on activity options, and their experiences of some of the challenges of running such a project. It is not yet fully understood from the literature what it may be about participatory arts and health projects that differentiates them from other activities that can help with mental health issues. Why art, rather than exercise or gardening, for example? The majority of artists felt that art was special and it had particular advantages that other activities do not provide. Indeed, while many of the features artists generally listed can also be attributed to other interventions, such as opportunity for participants to be social, creative, fully engaged in practical activity, and to gain new experiences, a key difference was felt as the degree of one’s own personality and life experience that is embedded within their finished products. This sense of self, personal experience, expression, and engagement through artmaking has been described by other professional artists.15e17 Perhaps this adds a special element not found in other activities that are used to assist those with mental health issues. While it has been argued that if the participant’s interests do not lie with art, then such interventions may be less likely to succeed,18 there was evidence that some participants were surprised about the results, both in terms of its positive effects and their achievements, a finding reported previously.19 Almost all the artists expressed the therapeutic value and benefits of the courses, regardless of their background experience, and many gave examples of how they could determine that courses had effects on the well-being of students. For example, improvements in confidence were evidenced by a willingness to exhibit and sell work; better communication skills through increased eye contact; and development of coping skills through the ability to return to work. This suggests that real progress in mental well-being can be made and observed even before service users leave the projects, and such changes have been evidenced in previous research with service users themselves.6e11 A key aim in running participatory arts and health projects is to increase social networks of participants.5 Research has shown that service users have reported improved social relationships after attending arts and health courses,20 however it was not fully understood whether these connections have longevity, postintervention. In the current research, artists often referred to clients who continued to meet regularly after the course, suggesting that friendships outlasted their involvement with the projects, and while these accounts should be treated with caution, any developments of such social networks within the community may reduce demands
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on mental health services.21 Indeed several themes, particularly those relating to changes in behaviour support other research22 that has found community art projects can provide a ‘springboard’ to other activities that participants would not have been involved in otherwise, with significant benefits. Many artists viewed follow-on options, such as volunteering on future arts projects, as extremely beneficial for participants and artists reported concerns about leaving students without support after courses had ended. Offering volunteering to ex-students on projects could provide benefits for future participants, providing them with a role model e showing that somebody with mental health issues can succeed.23 These views were generally shared across artists; however some had reservations about the appropriateness of offering volunteering in settings where participants had experienced poor mental health. Nonetheless, it was clear that the artists wanted to ensure that their participants went on to play a significant part in society postintervention, which is an important feature of recovery-oriented care.20 Finally, an important finding was that no serious mental health crises had occurred on courses run by any artists involved. Challenges commonly reported included diffusing tension between service users who did not get along, the need to encourage wary service users to attend the first session, and the requirement for artists to pass on concerns to project managers. Given that many artists had run between fifty and over one hundred participatory arts and health courses, this indicates that courses are manageable within community settings and are fairly low risk.
Evaluation and conclusion There are some limitations to the described research, for example official qualifications were not recorded, and despite some having good experience (and several were trained therapists) not all of the artists’ mental-health related observations are likely to be in line with the views of trained practitioners. Reports on the ‘friendships’ of participants by the artists should be treated with caution, and the results are not generalizable due to the small sample size. Also as each artist has different experience levels and ways of working, there may have been variations in the effectiveness of their sessions. Finally, it was not considered if the different mediums of working (e.g. sculpture, painting, collage) might have different types or levels of therapeutic benefit. This could be a very interesting future topic e as could investigation of the value of the various follow-on activities proposed by artists. There were many interesting findings that came out of this research which build upon previous work,17,19 however it is clear that the perspectives of artists and facilitators can really add to the results from considering participants alone.13
Author statements Acknowledgements The authors would like to thank Lyn Kent for providing qualitative interviewing training. They would also like to
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thank the artists and organizations that participated in this study.
Ethical approval This study was approved by the Anglia Ruskin Health & Social Care Faculty Research Ethics Panel.
Funding Anglia Ruskin University.
Competing interests None declared.
references
1. Hacking S, Secker J, Spandler H, Kent L, Shenton J. Evaluating the impact of participatory art projects for people with mental health needs. Health and Social Care in the Community 2008;16(6):638e49. 2. Stickley T, Hui A. Social prescribing through arts on prescription in a UK city: participants’ perspectives (part 1). Public Health 2012;126:574e9. 3. Secker J, Loughran M, Heydinrych K, Kent L. Arts & health: promoting mental well-being and social inclusion through art: evaluation of an arts and mental health project. Arts & Health 2011;3(1):51e60. 4. Bungay H, Clift S. Arts on prescription: a review of practice in the UK. Perspectives in Public Health 2011;130(6):277. 5. Secker J, Heydinrych K. Open arts: promoting well-being and social inclusion through art. A Day in the Life 2009;13(4):20e4. 6. Makin S, Gask L. ‘Getting back to normal’: the added value of an arts-based programme in promoting ‘recovery’ for common but chronic mental health problems. Chronic Illness 2011;8(1):64e75. 7. Howells V, Zelnik T. Making art: a qualitative study of personal and group transformation in a community art studio. Psychiatric Rehabilitation Journal 2009;32(3):215e22. 8. Lloyd C, Wong SR, Petchkovsky L. Art and recovery in mental health: a qualitative investigation. British Journal of Occupational Therapy 2007;70(5):207e14. 9. Stickley T. The arts, identity and belonging: a longitudinal study. Arts & Health 2010;2(1):23e32. 10. Van Lith T, Fenner P, Schofield M. The lived experience of art making as a companion to the mental health recovery process. Disability & Rehabilitation 2011;33(8):652e60. 11. Stacey G, Stickley T. The meaning of art to people who use mental health services. Perspectives in Public Health 2010;130:70. 12. Stickley T, Hui A. Social prescribing through arts on prescription in a UK city: referrers’ perspectives (part 2). Public Health 2012;126:580e6. 13. Van Lith T, Fenner P, Schofield M. Toward an understanding of how art making can facilitate mental health recovery. Advances in Mental Health 2009;8(2):183e93. 14. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology 2006;3(2):15e28. 15. Nelson B, Rawlings D. Its own reward: a phenomenological study of artistic creativity. Journal of Phenomenological Psychology 2007;38:217e55. 16. Upitis R. Making art, making connections. Journal of the Canadian Association for Curriculum Studies 2003;1(2):1e7.
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17. Van Lith T, Fenner P, Schofield M. Identifying the evidencebase for art-based practices and their potential benefit for mental health recovery: a critical review. Disability and Rehabilitation 2013;35(16):1309e23. 18. Spandler H, Secker J, Kent L, Hacking S, Shenton J. Catching life; the contribution of arts initiatives to recovery approaches in mental health. Journal of Psychiatric and Mental Health Nursing 2007;14:791e9. 19. Collie K, Long B. A narrative view of art therapy and art making by women with breast cancer. Journal of Health Psychology 2006;11(5):761e75.
20. Margrove KL, SE-SURG, Heydinrych K, Secker J. Waiting listcontrolled evaluation of a participatory arts course for people experiencing mental health problems. Perspectives in Public Health 2013;133(1):28e35. 21. Davidson L, O’Connell M, Tondora J, Styron T, Kangas K. Top ten concerns about recovery encountered in mental health system transformation. Psychiatric Services 2006;57(5):640e5. 22. Heenan D. Art as therapy: an effective way of promoting positive mental health? Disability & Society 2006;21(2):179e91. 23. Warner R. Does the scientific evidence support the recovery model? The Psychiatrist 2010;34:3e5.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Original Research
An exploration of artists’ perspectives of participatory arts and health projects for people with mental health needs K.L. Margrove a,b,*, J. Pope a, G.M. Mark c a
Primary & Public Health, William Harvey Building, Anglia Ruskin University, Bishops Hall Lane, Chelmsford CM1 1SQ, UK b South Essex University Partnership NHS Foundation Trust, The Lodge, The Chase, Wickford SS11 7XX, UK c Symbiotics Ltd, Little Washbourne, Tewkesbury, Gloucestershire GL20 8NQ, UK
article info
abstract
Article history:
Objectives: This study addresses the views and experiences of artists who run participatory
Received 26 October 2012
arts and health courses for those with mental health or social problems.
Received in revised form
Study design: Qualitative research with 11 artists from three different organizations
18 September 2013
providing participatory arts and health courses.
Accepted 25 September 2013
Methods: Semi-structured in-depth interviews were conducted. Participants provided oral
Available online 22 November 2013
contributions that were transcribed and then thematically analysed by the authors. Results: Participants described perceived positive benefits of participatory arts and health
Keywords:
courses, including developing friendships, self-expression and creativity, a non-
Visual art
judgemental environment, along with key issues arising, including managing challenging
Mental health
behaviours and provision of follow-on options.
Qualitative
Conclusions: Results indicate that improvements in well-being can be identified by artists
Thematic analysis
during courses, the activity can help develop friendships, courses can be well managed in
Social inclusion
community settings, and benefits of follow-on activities should be investigated in future. ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
Introduction Participatory arts and health courses are increasingly being run for people with mental health needs, by public and private health providers and charities. In 2008, over 100 projects were identified in England.1 Courses are often run in the community for 10e15 weeks and are facilitated by artists who may or may not have formal training.2,3 This study focused on visual art courses that provide opportunities for service users to work in different mediums such as clay, textiles, and paint. Programmes typically have a
referral process from health or social care practitioners,4 although some projects advertise within communities and take self-referrals, which can de-medicalize the intervention and assist with community integration.5 Researchers have largely focused on participants’ experiences of courses, to derive support for arts as a recovery tool.2,6e10 Stacey and Stickley found that participants benefitted by doing something for themselves and having a focus on something other than mental health.11 A recent study interviewed ten professionals who had referred clients to participatory arts and health courses,12 and identified
* Corresponding author. Tel.: þ44 845 196 4189. E-mail address: [email protected] (K.L. Margrove). 0033-3506/$ e see front matter ª 2013 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.puhe.2013.09.018
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benefits for clients including provision of a therapeutic environment, peer support, and opportunity for self-expression. However, most research has placed less emphasis on the views of the artists who provide courses, who may have key insights into the advantages of these activities for those with mental health needs.13 The aim of the current research therefore was to explore the perspectives of artists themselves, on the benefits for participants, and the challenges involved. The study was approved by the relevant Faculty Research Ethics Panel.
Methods
Transcripts were revisited to ensure themes reflected the data.
Findings Many of the benefits attributed to arts participation by the artists reflected those reported previously by service users,2,6,10,12 including provision of a safe environment, distraction from mental health issues, sense of achievement, and networking opportunities. However five themes that are less well reported also emerged: ‘Why Art?’, ‘Well-being & Behaviour’, ‘Developing Sustained Friendships’, ‘Volunteering’, and ‘Managing Mental Health Challenges’. Pseudonyms have been used for anonymity.
Design Why art? The study aim was essentially exploratory, so a qualitative approach was taken involving semi-structured interviews at one point in time.
Participants and recruitment Participants were contacted through three East of England art organizations. Artists were recruited if they had experience of working as an art tutor on visual participatory arts and health courses for people with mental health problems. Managers of organizations providing such courses were asked to promote the study to artists. Those wishing to participate contacted the researchers, who provided full information and the opportunity to ask questions. Artists were assured of their anonymity and asked to sign a consent form. Eleven artists participated (seven female). The majority (eight) were freelance, working with two projects operating in non-NHS community venues. Three worked within an NHS mental health day centre, and five participants had run between 50 and 100þ courses each, with the rest having run an average of five courses.
Procedure Semi-structured interviews were used to gather data. Interviews took approximately 60 min and were recorded and transcribed with permission by a trained interviewer. Topics covered included: Perceptions of how arts participation can improve well-being and key factors; Ways in which courses can help broaden social contacts and networks; Specific examples of observed changes/progress in course participants; What sort of issues/needs arts projects can help with; Perceived benefits of any follow-on activities; Any challenges experienced in running courses for people with mental health needs.
Analysis Coding and analysis were conducted according to Braun and Clarke’s thematic analysis guidelines.14 This involved two authors independently coding data, sorting codes into themes and collating data to support themes. Themes were reviewed by the authors, with divergences resolved through discussion.
The majority of artists felt there were unique benefits of art for people with mental health needs. The most common theme revolved around opportunity to express feelings using nonverbal media: A lot of people, I think, don’t know how to talk about their feelings, and a lot of the time that can come out through their artwork. (Amber) It’s definitely being creative that helps people’s mental health because you’re giving people a positive outlet to turn all that negativity into something positive by trying out a new medium. (Suzie) This participant described how the process that could enable the expression of feelings: To make something that’s so personal is different I think than doing some kind of physical activity like gardening or exercise or cooking or something... it’s about that person’s soul a lot of the time and the process of art making, there is a lot of soul searching that goes on there, so yeah I think it is unique really. (Rosemary) For one participant, seeing the world through different eyes was a key factor, while two day centre workers drew comparisons with other mental health interventions, one highlighting social benefits and the other the joy of creativity. This latter finding supports previous research:10 Art works, it really does. And it gives you. that opportunity to look at things differently that you wouldn’t get through anything else. It opens your eyes in a different way rather than blinkered. (Suzie) I think it has a different place to therapy, to talking therapy. It’s a doing, practical thing. People get together, they socialise, they talk, they have fun, they do things together, they create together. (Morag) Art itself is such a therapeutic thing, it’s probably the most therapeutic thing of the whole lot because after a two or three hour session of painting when you get really engrossed in
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something and you can see it coming to life, it leaves you with a really good feeling inside. (Luke)
paid for their own venue and that sort of thing, so I think real friendships are formed. (James)
In contrast to the emphasis placed by most on the unique benefits of arts, one day centre worker thought similar benefits could be achieved through other activities:
This artist felt that working with people with a range of mental health needs rather than focussing on specific diagnoses had additional social and networking benefits:
. a lot of groups would give that standing benefit of social interaction and friendships, and they do. But you know, I suppose if you break it down, you know, something like gardening would be creative. A lot of those things are quite creative. (Morag)
People might be there for mild depression or really serious personality disorders and yet they will all befriend each other and support each other and they encourage and they suggest going to art galleries and stuff like that. (Diana)
Volunteering Well-being and behaviour Artists described observing positive changes in well-being and behaviour, including self-esteem, confidence and self-worth over the duration of the courses.
The researchers were interested in possible follow-on/ volunteering options for participants after the course, and generally the artists were in favour of this option for various reasons:
Like that guy with the major panic attack, he kept coming and in the end he wasn’t doing all this breathing business and he was quite relaxed, he’d come in and join in the conversation and that’s amazing. (Diana)
. people have wanted to give something back and there’s that sense of achievement and accomplishment through giving and sort of assisting with something. there’s lots of benefits. (Bradley)
It raises people’s self-esteem when they see their work exhibited, when they’re turning up each week and they’re not being judged because they’ve got a mental health problem, [it] builds their confidence because they’ve seen their work, they’re creating something good and beautiful. So I think art is a major factor towards people’s recovery, I’m convinced about it! (Suzie)
.It’s tangible proof to [the group].it works, someone’s done this and . it’s someone saying I’ve participated and it really did work for me. (Jane)
Behavioural changes included improved self-care, communication, and coping that had enabled a day centre user to move on in her recovery:
However some artists felt such options were not appropriate:
You can see changes in people’s personality, sometimes you can see changes in their physical appearance, they may be taking a bit more care over their hair or their clothes; vocally, they may be getting chattier.it won’t be so much that they say I’m feeling better, because we don’t sort of focus on mental health, but people will say things like “oh I’ve signed up for this”. or “I went to”. they’ll tell you what they’ve done and what their plans are. (Petra) She’s working again and she’s fine and that illness it hasn’t. I don’t know if it will ever go away, that was depression, but she’s coping and she’s moved on. (Morag)
. I’ve had students . that they do want to volunteer but elsewhere, outside of our project, but within the arts. (Petra)
We don’t encourage them back as volunteers actually.We’ve had a man who’s gone now, but that relationship got very difficult because he had been a client.There’s a lot of trouble stirred up because of that, very often, between clients and staff. It doesn’t work I’m afraid. Volunteering somewhere else is wonderful. Because they’re not in the environment they were ill in. (Morag).
Managing mental health challenges While most artists described challenges, specific difficulties relating to mental health issues were seen as minimal. Challenges could revolve around individual triggers for distress, or frustration with the process of art-making:
Developing sustained friendships Artists described evidence that people had developed sustained friendships, with some students going on to form their own art groups: In general a lot of friendships are made. With one of the courses, I think there are four or five ladies that carry on and they still meet each week. They run like a little art group. (Suzie) And we know that a lot of them stay friends, we’ve had some groups who have continued to meet as groups themselves and
Something may have triggered off something and they may have been tearful within the group. Sometimes they’ve maybe got angry with a process, it might have not worked out and they might have got frustrated with the equipment or with the materials or with themselves. (Rosemary) The nature of art, it can be quite frustrating for certain people if they don’t feel that they’re getting, you know, the results that they would want to get. You can see people becoming more, you know, finding it difficult to actually keep up with the rest of the class and things. (Ben)
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For those who described such challenges, sensitivity to distress and flexibility in responding were key to effective management: We had one person working in a different room, because she felt uncomfortable in that group, so we’ve, you know, said OK, that’s fine, if you’re not happy to be sitting in this group we can sit with you over here and we can do something else, you know, we can do something different.. So it’s just about having enough tools in your box to quickly change what you’re doing and be responsive to that change. (Amber) We always say if anybody wants to take time out, if they want a break, just go, don’t ask. So somebody will... they will generally step outside the room, and I would leave them for a couple of minutes, give them some time to themselves and go and see if there’s anything I can do, if they’re OK, if they want to talk about it. But give them space, I think it’s quite important to give people a bit of space just to sort of de-escalate. (Rosemary) We devise different ways of approaching the actual subject which kind of levelled out the skills base. as I say it also allowed people the opportunity to get involved in it in a very non-judgemental way and so no matter what your ability was, people were able to do these tasks, so I think that created a much more... what’s the word... well, calm. (Ben) Challenging behaviours were reported by several artists. At one project, flexibility was key to managing this, alongside a focus on art rather than mental health: .it’s just taking a step back and saying to people OK, just stop, breathe. Realising that people are going to have good and bad days, but that’s OK, realising that people might miss a session, making sure there’s a follow up phone call to let them know that, OK, they’ve missed a session but it’s fine to come back. (Suzie) Two students who were sort of having an argument and it created quite a bad atmosphere, and really I felt my role there was to diffuse things and to not... but not get involved in what they were talking about, but bring it back to the art. (Rosemary) At the day centre, flexibility and sensitivity were important, but in this setting withdrawing individuals from the group was also emphasized as important in managing behaviour: If we have a problem, if somebody’s distressed or really unwell we’ll take them out of the group and talk to them and make them a cup of tea. We keep our eye on everybody, you know, we’re experienced with that. (Luke) There can be trouble between various people in groups, you know, and personality, or they’ll be coming in crying or shouting. then I need to withdraw them. They’re not going to project that vibe onto the group, so we withdraw those people. (Morag) Across all projects, organizational arrangements important in managing challenges. In particular, having a second
person present (artist, volunteer, or staff member) was common practice to help enable the flexibility described. In one instance, the project manager could be contacted in case of difficulties, with group supervision and discussion of challenges and problem solving.
Discussion By exploring the perspectives of artists running these courses, a greater understanding of course benefits can be acquired. Here artists provided feedback on the key benefits of running participatory arts and health courses for people with mental health problems, the issue of providing follow-on activity options, and their experiences of some of the challenges of running such a project. It is not yet fully understood from the literature what it may be about participatory arts and health projects that differentiates them from other activities that can help with mental health issues. Why art, rather than exercise or gardening, for example? The majority of artists felt that art was special and it had particular advantages that other activities do not provide. Indeed, while many of the features artists generally listed can also be attributed to other interventions, such as opportunity for participants to be social, creative, fully engaged in practical activity, and to gain new experiences, a key difference was felt as the degree of one’s own personality and life experience that is embedded within their finished products. This sense of self, personal experience, expression, and engagement through artmaking has been described by other professional artists.15e17 Perhaps this adds a special element not found in other activities that are used to assist those with mental health issues. While it has been argued that if the participant’s interests do not lie with art, then such interventions may be less likely to succeed,18 there was evidence that some participants were surprised about the results, both in terms of its positive effects and their achievements, a finding reported previously.19 Almost all the artists expressed the therapeutic value and benefits of the courses, regardless of their background experience, and many gave examples of how they could determine that courses had effects on the well-being of students. For example, improvements in confidence were evidenced by a willingness to exhibit and sell work; better communication skills through increased eye contact; and development of coping skills through the ability to return to work. This suggests that real progress in mental well-being can be made and observed even before service users leave the projects, and such changes have been evidenced in previous research with service users themselves.6e11 A key aim in running participatory arts and health projects is to increase social networks of participants.5 Research has shown that service users have reported improved social relationships after attending arts and health courses,20 however it was not fully understood whether these connections have longevity, postintervention. In the current research, artists often referred to clients who continued to meet regularly after the course, suggesting that friendships outlasted their involvement with the projects, and while these accounts should be treated with caution, any developments of such social networks within the community may reduce demands
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on mental health services.21 Indeed several themes, particularly those relating to changes in behaviour support other research22 that has found community art projects can provide a ‘springboard’ to other activities that participants would not have been involved in otherwise, with significant benefits. Many artists viewed follow-on options, such as volunteering on future arts projects, as extremely beneficial for participants and artists reported concerns about leaving students without support after courses had ended. Offering volunteering to ex-students on projects could provide benefits for future participants, providing them with a role model e showing that somebody with mental health issues can succeed.23 These views were generally shared across artists; however some had reservations about the appropriateness of offering volunteering in settings where participants had experienced poor mental health. Nonetheless, it was clear that the artists wanted to ensure that their participants went on to play a significant part in society postintervention, which is an important feature of recovery-oriented care.20 Finally, an important finding was that no serious mental health crises had occurred on courses run by any artists involved. Challenges commonly reported included diffusing tension between service users who did not get along, the need to encourage wary service users to attend the first session, and the requirement for artists to pass on concerns to project managers. Given that many artists had run between fifty and over one hundred participatory arts and health courses, this indicates that courses are manageable within community settings and are fairly low risk.
Evaluation and conclusion There are some limitations to the described research, for example official qualifications were not recorded, and despite some having good experience (and several were trained therapists) not all of the artists’ mental-health related observations are likely to be in line with the views of trained practitioners. Reports on the ‘friendships’ of participants by the artists should be treated with caution, and the results are not generalizable due to the small sample size. Also as each artist has different experience levels and ways of working, there may have been variations in the effectiveness of their sessions. Finally, it was not considered if the different mediums of working (e.g. sculpture, painting, collage) might have different types or levels of therapeutic benefit. This could be a very interesting future topic e as could investigation of the value of the various follow-on activities proposed by artists. There were many interesting findings that came out of this research which build upon previous work,17,19 however it is clear that the perspectives of artists and facilitators can really add to the results from considering participants alone.13
Author statements Acknowledgements The authors would like to thank Lyn Kent for providing qualitative interviewing training. They would also like to
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thank the artists and organizations that participated in this study.
Ethical approval This study was approved by the Anglia Ruskin Health & Social Care Faculty Research Ethics Panel.
Funding Anglia Ruskin University.
Competing interests None declared.
references
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