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International Journal of Mental Health Nursing (2014) 23, 419–426
doi: 10.1111/inm.12073
Feature Article
Empathy at a distance: A qualitative study on the impact of publically-displayed art on observers John Hurley,1 Paul Linsley,2 Shelley Rowe3 and Freea Fontanella3 1
School of Health and Human Sciences, Southern Cross University, 3Headspace, Mid North Coast, Coffs Harbour, New South Wales, Australia; and 2School of Health and Social Care, University of Lincoln, Lincoln, UK
ABSTRACT: While there is some evidence in the literature on the impact of art therapy for consumers, there is comparatively little written on how art that has been created by consumers impacts on those observing the art. This paper reports on a qualitative research study that sought to determine if publically-displayed art created by young consumers impacted on stigma reduction and self-helpseeking behaviours of the observers. The findings derived from the thematic analysis of qualitative interviews suggested that publically-displayed art is a safe medium, through which empathy and understanding towards young people with mental illness can be enhanced, and that the art generates discussion and self-help behaviours for mental illness. These findings highlight how mental health nurses can promote social inclusion and reduce stigma through public mental health initiatives that are an important inclusion in the scope of mental health nursing practice. KEY WORDS: art, empathy, scope of practice, stigma.
INTRODUCTION The negative impact of mental health-related stigma has been recognized for many years as resulting in marginalization from participation in employment and social activities, as well as inhibiting treatment-seeking behaviours for those who experience mental illness (Carr & Halpin 2002; Queensland Alliance 2009; Sartorius 1998). Stigma is also recognized as contributing to a raft of negative social and health indicators, culminating in unfavourable social identities being formed towards consumers (Bates & Stickley 2013). Nursing practice, in general, and the practice of mental health nurses (MHN), more specifically, have historically focused their scope of practice on responding to illness (Department of Health and Ageing 2009). Correspondence: John Hurley, School of Health and Human Sciences, Southern Cross University, Hogbin Drive, Coffs Harbour, NSW 2450, Australia. Email: [email protected] John Hurley, PhD, MSc (Nurs), MHN. Paul Linsley, PhD, MSc (Nurs), MHN. Shelley Rowe, PhD, BSc (Hons). Freea Fontanella, BSocSc. Accepted March 2014.
© 2014 Australian College of Mental Health Nurses Inc.
However, there is increasing focus being placed on the need for a workforce that can also promote wellness and operate across public, primary, and tertiary services (Health Workforce Australia 2011). Australian College of Mental Health Nursing (2013) reflect this broader redesign of the workforce through the enabling of consumer self-determination and promoting wellness, prominently stated within the scope of mental health nursing practice. This compliments Standard 6 of the Standards of Practice for mental health nurses that necessitates nurses to not only reduce stigma, but promote social inclusion and community participation (Australian College of Mental Health Nursing 2013) However, despite this and wider strategic and policy-driven endeavours to remove stigma and the by-products of it, stigma continues to stifle the aspirations of consumers wanting to move from the fringes of society (Mendoza et al. 2013). Stigma can be understood as consisting of stereotype, prejudice, and discrimination, and can be commonly held across a community, or even be self-attributed by the individual who has internalized the prejudice of others (Corrigan et al. 2003). Within the context of mental illness, such stigma includes others wanting to maintain a
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social distance from those with a mental illness, often due to perceptions of dangerousness (Jorm & Griffiths 2008). Arguably, deinstitutionalization has perpetuated such stigma, as those with mental illness are more likely to be superficially in contact with the general public, but often without the opportunity of generating better understanding or knowledge about those with mental illness (Dickerson et al. 2002). The effects of stigma have made it difficult for people with a mental illness to obtain employment, find adequate housing, and become truly integrated in the community in which they reside (Thornicroft et al. 2009). Stigma associated with mental illness has been identified as reducing help-seeking behaviours, particularly in teenagers and young adults (Yap et al. 2011). Self-stigma, in particular, appears to be indicated in avoiding psychological interventions, poor follow up, and lack of treatment adherence (Fung et al. 2008). Goffman (1968, p. 3) identified stigma as an ‘attribute that is deeply discrediting’ and that results in the person holding it ‘different from others and of a less desirable kind’. Within mental health contexts, the reduction of stigma and the promotion of mental health are both corner stones to Australian mental health policy (Commonwealth of Australia 1996). Unlike physical illness, mental illness is often perceived as personal weakness, rather than an illness that is beyond the person’s control, and can often lead to bullying and harassment of the individual, particularly among the adolescent community (Corrigan & Watson 2007). Fear of being labelled as a person with a mental illness, and not being able to cope, can have a profound effect on the young adult, who might consider taking their life as a result of continued abuse (Department of Health 2011). Research has highlighted that much of the stigma that young people face comes from those who ironically represent potential support at a time of need, including friends, siblings, and parents (Department of Health 2011). The prospect of being stigmatized might be greater within smaller rural communities, where people and families are more readily known (Nicolson 2008). The fear of being labelled, ridiculed, avoided, or even abandoned looms large for many consumers, particularly those undergoing the transition from childhood to adulthood (Lau et al. 2012). Mental illness is often as devastating for the family as it is for the person affected. Family schedules, social life, and finances are often disrupted as a result. Compounding the problem for many families is the perception that they are somehow to blame for the person’s condition (Gray et al. 2010). The stigma associated with mental illness can be, in some instances, more
J. HURLEY ET AL.
acutely felt by families supporting a person with a mental illness as it can for the sufferer themselves (Robinson et al. 2012). Preoccupation with the problem in the family and feelings of guilt and shame can lead to the family isolating themselves from the larger community (Department of Health 2011).
ART Given the entrenched position of stigma within our communities towards mental illness (Mendoza et al. 2013), the need for mainstream policy responses to mitigate such negative perceptions is evident. Initiatives to reduce stigma predominantly seek to portray positive and rounded messages about consumers and the contribution they make to society (New South Wales Community Advisory Group 2008). Additionally, stigma-reduction programmes seek to encourage dialogue and wider understanding of mental health issues (Suicide Prevention Australia 2010). However, there is also opportunity for communities to initiate more creative and localized responses to the problem of stigma, with art being identified within the context of this study as a promising medium through which to communicate (Department of Health 2009; Lamont et al. 2009). Art is a well-established medium that has been predominantly used as a psychotherapeutic approach within the context of mental health treatment (British Association of Art Therapists 2010). Community-based arts projects are, by comparison, not a formal psychological intervention, but rather seek to creatively encourage people to engage with art, with the aim of maintaining mental well-being and enhancing artistic and social skills (Meeson 2012). The majority of studies on community art focus on the impact of participation upon the mental health consumer. Hacking et al. (2008) conducted a 2-year evaluation of participatory art projects, and identified improved selfesteem and confidence as the most common benefits to the mental health consumer. Empowerment, social inclusion, assertiveness, greater ability to regulate anxiety, and enhanced physical, social, and psychological well-being are further identified benefits of community-based art (Greaves & Farbus 2006; Spandler et al. 2007; Teall et al. 2006). However, Leckey (2011), in a systemic review of art projects, found little cohesive terminology towards key artistic constructs being measured, and a weak evidence base for its symptomatic efficacy due primarily to a lack of randomized, control studies utilizing established measures for specific mental illnesses. Nonetheless, Leckey (2011) acknowledged that evidence for art programmes © 2014 Australian College of Mental Health Nurses Inc.
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having positive outcomes for improved self-esteem, and social interacting is apparent. Hadland and Stickley (2010) recommended that art projects in mental health contexts be distanced from statutory bodies and imbedded within the grassroots of a community. While the impact of the social environment on mental health is well established (Truong & Ma 2006), there is less understanding of the impact of community-based art projects on those receiving the art, as distinct from those creating the art. Certainly, evidence exists that community art projects can act to build community cohesion, as well as social capital (Parr 2006; White 2006). However, the impact of art as a mental health-promotion and stigma-reducing intervention receives little attention in the literature. The exception to this is the use of the arts for mental health promotion within Australian indigenous settings (Nagel et al. 2009). Inequality of citizenship, and not being recognized as an active community member, are two areas whereby those with mental illness are marginalized. Conversely, social inclusion, where it is active and participatory, is seen as a vital response to stigma (Queensland Alliance 2009; Thornicroft et al. 2008). People experiencing mental illness are one of the most stigmatized and marginalized groups in Australian society, which in turn might be acting to delay early help seeking for emerging mental illness (Queensland Alliance 2009). Key recommendations to reduce stigma in the Queensland Alliance (2009) review include interacting with those experiencing mental illness and a creative use of the arts.
for people aged 12–25 years. The service runs a weekly social recovery project during the school term (the art group) attended by approximately 15 Headspace consumers, both male and female. The young people became involved in the art group via referral by Headspace practitioners, including those under the mental health nurse incentive programme that funds credentialed mental health nursing interventions for those with serious mental illnesses (Happell & Palmer 2010). The group’s mental illnesses included depression, anxiety, and personality disorder, as well as bipolar disorder and Asperger’s. The young people painted and drew on canvases with a weekly theme to work towards an exhibition with the common theme of ‘connect, celebrate, grow’. This theme sought to construct a message that challenges the marginalization of those experiencing mental illness, and to communicate the importance of both resilience and hope to achieve recovery (Mizock 2012). The young people in the group generated their paintings through their individual interpretations and personal experiences of this theme. With the support of 12 local merchants, the art created for the exhibition was prominently displayed within commercial retail outlets in late 2012 for approximately 2 months, and was clearly identified as being generated by young consumers of the Headspace mental health service. It was hoped that the artwork would encourage people to hold conversations with friends and family on mental health as a means of challenging the shame often associated with mental illness (Department of Health 2011), and that also inhibits people to seek mental health help (Carr & Halpin 2002).
RESEARCH QUESTION
Qualitative methodology and study design
The aim of this study was to answer the following questions: (i) What, if any, was the impact of the communitybased art (paintings) on individuals’ experiences towards mental health promotion/stigma reduction?; and (ii) What, if any, was the impact of the community-based art (paintings) on individuals’ likelihood of self-initiated helpseeking behaviours for emerging mental illnesses and/or self-initiated behaviours to encourage and protect strong mental health?
This topic of investigation has had little or no research undertaken, and an exploratory approach is hence required to direct larger studies of the phenomenon (Patton 2002). It was for these reasons that a phenomenological approach was used in the gathering and analysis of the data in the form of semistructured interviews and thematic induction. This approach proved useful in exploring the complexities of the topic under investigation, and provided rich data from studying a limited number of cases in depth. The use of thematic analysis meant that the findings were based on the participants’ own understanding and meaning of the phenomenon, as situated and embedded in contexts of their working lives. As such, this study sought to gain a deep and contextualized understanding of the participants’ individual experiences, and subsequently sought emerging shared essences of these experiences, which are then expressed as themes (van Manen 1997).
METHODS Ethics approval for the study was sought and gained through the Southern Cross University ethics committee (Coffs Harbour, NSW, Australia). The art was generated through a group of consumers attending the Headspace service; a non-government, early-intervention mental health and well-being service © 2014 Australian College of Mental Health Nurses Inc.
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Recruitment The study was undertaken in an area of regional Australia that has a comparatively low socioeconomic community profile to most other parts of the country (Australian Bureau of Statistics 2011). Local retailers (banks, cafes, retail shops, and community service organizations) were asked if they would participate in semistructured interviews regarding their observations, interactions, and experiences of the public (patrons) viewing the displayed art, as well as their personal experiences of engaging with the art. Staff from seven of the 12 retail outlets consented to participate in the study. These staff were also the staff in charge of setting up the displays around their central work station, where they could have frequent interaction with the public and the art. All seven participants were female, ranging from 25 to 60 years of age. All had worked in their outlets for at least a period of 1 year.
Procedures: Data collection and analysis Semistructured interviews using open-ended questions were used as the data collection in an attempt to capture simple experiences, as well as social processes, that were generated from displaying or viewing the art. As such, data collection focused on the lived experience of the retail outlet staff interacting with the public through the displayed art. The semistructured questions specifically explored if (and how) the art influenced these participants directly, and how the participants’ experiences of the art impacted those members of the public they related with. The audio-recorded interviews were separately listened to by two of the researchers for emerging themes pertaining to the overarching research questions. Findings were then repeatedly explored until a consensus was reached on the emergent themes.
Findings Four key themes emerged from the thematic analysis of the participant interviews: (i) art as a means of engagement; (ii) art as a means of reducing stigma; (iii) art as a language that enables empathic understanding of others’ emotional positioning and (iv) art as encouraging helpseeking behaviours. Theme 1: Art as a means of engagement
A clear theme that emerged from the majority of participant experiences was that the publically-displayed art was a non-threatening medium by which to engage the public and raise awareness of mental health. One participant stated how the viewer (participant) was able to engage and communicate with the art, despite experiencing some of the art as being emotionally challenging:
J. HURLEY ET AL. You can get a picture of the art and what might be behind it, some of it can be a little bit sinister, there could be issues there, but from a distance, it (art) gets the message across. (Participant 1)
Furthermore, the participants reported that both they and the members of the public with whom they engaged with were able to suspend their fear towards those with a mental illness, and thus develop better empathy and understanding. Art could act as a communication conduit between the viewer and the person experiencing mental illness. The lack of physical proximity provided the necessary space and perceived safety for those holding stigmatized views that challenged their own beliefs, rather than being confronted about them by others: The public relate better (on mental illness) to something that is not going to talk back to them (consumers), something that is not going to give them an opinion but lets them form their own opinion. (Participant 5)
Theme 2: Art as a means of reducing stigma
The majority of participants reported that the art had a definite positive impact on themselves and the public observers of the art regarding young people with mental illness, especially in the formation of positive views towards the talents of those young people. These views were openly discussed, with participants experiencing the conversations as bringing mental illness out into the open and growing the public awareness of mental illness at a time and place of the observers choosing: They see the art work and think that is amazing what they have done, and obviously have a better understanding and are more accepting of their (the artists’) illness. (Participant 3) It (the art) opens up a dialogue on mental illness that had not existed before. It is unusual for someone to come in here and talk about mental illness, having mental illness. Art opened a dialogue about mental illness, something I have not had on the shop floor before. (Participant 2)
Theme 3: Art as a language that enables empathic understanding of others’ emotional positioning
Most participants expressed having the capability to experience art as a distinct language and mode of communication. Rather than the young person with a mental illness verbally describing their emotional state, the participants experienced the art works as each being an individualized expression of emotion from the artist to them, the viewer of the art. The unique characteristics of each piece of art were thus a personal message, enabling better understanding of the young people who created it. The © 2014 Australian College of Mental Health Nurses Inc.
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participants reported being able to connect with the mood that the artist was in, the emotions being communicated by the artist, and even that the mental state of the artist could inhibit emotional expression: The style of the art, such as the use of colours (and) rigid or flowing lines, communicated a sense of mental state and personality. (Participant 4) That somebody tries to express feelings, and when they can’t, you can see it, so it’s not necessarily anger or whatever they have feelings of, but they can’t get them out. (Participant 7)
Theme 4: Art as encouraging help-seeking behaviours
The majority of participants identified the art as a potential trigger for initiating help-seeking behaviours, including encouraging the observer to create art themselves as a means for improving mental health. Many participants’ description of their personal experiences, and those expressed to them by members of the public, was that the art was a mechanism to build mental well-being. For some participants, this was about creating their own art. For others, the publically-exhibited art raised awareness that local organizations and groups are active within the community, and that there are tangible and valued outcomes emerging from these groups: People said we can see, we can understand this is a troubled youth. I have a troubled child at home, how do I contact Headspace? Can I get them into some type of programme? Can I get them into an art group for them to be part of so that they can display their problems, and you know, get some relief, find some outlet for their expressions? (Participant 2)
DISCUSSION The findings from this small study suggested that the publically-displayed art triggered positive views towards the young artists with mental illnesses. Additionally, the art appeared to have acted as a form of communication that enabled viewers of the art to emotionally connect with the artist. Given that negative social identities (Bates & Stickley 2013) and marginalization (Department of Health 2011) are key constructs of stigma, these initial findings are suggestive that publically-displayed art might contribute to reducing stigma and social marginalization associated with mental health. Although not reported as a theme, some of the participants believed that an important context was to have the art displayed in a ‘natural setting’, such as a retail outlet, rather than having it as a special exhibition. Through situating the art within the context of mainstream © 2014 Australian College of Mental Health Nurses Inc.
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daily community life, the artwork reached a greater proportion of the community, and was arguably normalized and communicating the necessary social inclusion needed to reduce stigma (Queensland Alliance 2009). While art has long been recognized as a major contributor to the physical and aesthetic quality of neighbourhoods and communities (Thiele & Marsden 2003), there is comparatively little research on how art that has been created by consumers impacts on the observer of that art. However, a broader view of art as a means of intervention and public engagement is emerging internationally as part of health-promotion activity and social networking (World Health Organization 2010). This goes beyond the traditional view of art as pieces of work and visual assets of communities, but engenders art as a means of strengthening community identity and social capital (Commonwealth of Australia 2004). Art, as described in the present study, provides a system of communication in which the young people could not only express themselves, but more importantly, be potentially understood and accepted as contributing to their community. The connectedness that enabled this understanding and acceptance of the young artists is suggestive of increased empathy. Burnard (1988) highlighted that empathy is a skill that enables understanding towards another on a level that explores the very drivers of that person’s behaviours, with art, as reported on in the present study, being highly effective in communicating deep understanding. Additionally, the construct of empathy is widely understood as moving beyond understanding another’s feelings to also being non-judgmental (Wiseman 1996). Non-judgmental understanding seemingly represents a powerful tool against the stereotyping and prejudice that drives stigma towards those with mental illness (Corrigan et al. 2003). Art, when used in this way, can be seen as a public health intervention. Public health works to promote healthy behaviour and respond to health concerns in populations and communities (Linsley et al. 2011). Mental illness remains stigmatized and difficult to access. One of the challenges of health and social care professionals is to devise strategies to engage with communities and deliver health initiatives within limited resources. Increasingly, alternative models of community engagement are being developed in the field of mental health that challenge the way in which consumers access services. Art can be seen as a valid intervention for engaging with the public, as one commentator put it: We must remember that art is present in all cultures, all communities, art is not an ‘extra’, instead art is a universal
424 trait of human culture. In providing public health programs to communities it only makes sense to incorporate art into services. (Speak Art Loud 2010)
This study reinforced the role that art can and does play in promoting dialogue on mental health and illness. Art acquires meaning, in part from the context in which it was undertaken and the setting in which it is displayed (Freeland 2001). Additionally, this and other studies (Parr 2006; Staricoff 2006; Stickley et al. 2007) add to the growing body of literature that participation in the arts and crafts can be beneficial for consumers of mental health services, particularly in the context of reducing stigma and social exclusion. This latter point is particularly important for MHN, whose practice has historically been associated with containment, and who struggle to create ways by which to fully engage with promoting social inclusion and community participation (Australian College of Mental Health Nursing 2013), and who have an identity that has been associated with stigma (Halter 2008). We recommend that the role of art for health-promotion strategies be systematically investigated by MHN in partnership with art organizations.
STUDY LIMITATIONS As with any qualitative study, the findings from this research could not be generalized to other people or other settings, and might be unique to the relatively few people that took part in the interviews. That is not to say that the study itself is flawed, but might need adaptation if applied to another setting. What the study does allow is an insight into the topic area that could act as indicator for future research.
ACKNOWLEDGEMENT We acknowledge and thank the Australian College of Mental Health Nursing for the 2012 Partnership in Wellbeing Award, which funded the running of the art group, but not any aspect of the research or this paper.
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© 2014 Australian College of Mental Health Nurses Inc.
International Journal of Mental Health Nursing (2014) 23, 419–426
doi: 10.1111/inm.12073
Feature Article
Empathy at a distance: A qualitative study on the impact of publically-displayed art on observers John Hurley,1 Paul Linsley,2 Shelley Rowe3 and Freea Fontanella3 1
School of Health and Human Sciences, Southern Cross University, 3Headspace, Mid North Coast, Coffs Harbour, New South Wales, Australia; and 2School of Health and Social Care, University of Lincoln, Lincoln, UK
ABSTRACT: While there is some evidence in the literature on the impact of art therapy for consumers, there is comparatively little written on how art that has been created by consumers impacts on those observing the art. This paper reports on a qualitative research study that sought to determine if publically-displayed art created by young consumers impacted on stigma reduction and self-helpseeking behaviours of the observers. The findings derived from the thematic analysis of qualitative interviews suggested that publically-displayed art is a safe medium, through which empathy and understanding towards young people with mental illness can be enhanced, and that the art generates discussion and self-help behaviours for mental illness. These findings highlight how mental health nurses can promote social inclusion and reduce stigma through public mental health initiatives that are an important inclusion in the scope of mental health nursing practice. KEY WORDS: art, empathy, scope of practice, stigma.
INTRODUCTION The negative impact of mental health-related stigma has been recognized for many years as resulting in marginalization from participation in employment and social activities, as well as inhibiting treatment-seeking behaviours for those who experience mental illness (Carr & Halpin 2002; Queensland Alliance 2009; Sartorius 1998). Stigma is also recognized as contributing to a raft of negative social and health indicators, culminating in unfavourable social identities being formed towards consumers (Bates & Stickley 2013). Nursing practice, in general, and the practice of mental health nurses (MHN), more specifically, have historically focused their scope of practice on responding to illness (Department of Health and Ageing 2009). Correspondence: John Hurley, School of Health and Human Sciences, Southern Cross University, Hogbin Drive, Coffs Harbour, NSW 2450, Australia. Email: [email protected] John Hurley, PhD, MSc (Nurs), MHN. Paul Linsley, PhD, MSc (Nurs), MHN. Shelley Rowe, PhD, BSc (Hons). Freea Fontanella, BSocSc. Accepted March 2014.
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However, there is increasing focus being placed on the need for a workforce that can also promote wellness and operate across public, primary, and tertiary services (Health Workforce Australia 2011). Australian College of Mental Health Nursing (2013) reflect this broader redesign of the workforce through the enabling of consumer self-determination and promoting wellness, prominently stated within the scope of mental health nursing practice. This compliments Standard 6 of the Standards of Practice for mental health nurses that necessitates nurses to not only reduce stigma, but promote social inclusion and community participation (Australian College of Mental Health Nursing 2013) However, despite this and wider strategic and policy-driven endeavours to remove stigma and the by-products of it, stigma continues to stifle the aspirations of consumers wanting to move from the fringes of society (Mendoza et al. 2013). Stigma can be understood as consisting of stereotype, prejudice, and discrimination, and can be commonly held across a community, or even be self-attributed by the individual who has internalized the prejudice of others (Corrigan et al. 2003). Within the context of mental illness, such stigma includes others wanting to maintain a
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social distance from those with a mental illness, often due to perceptions of dangerousness (Jorm & Griffiths 2008). Arguably, deinstitutionalization has perpetuated such stigma, as those with mental illness are more likely to be superficially in contact with the general public, but often without the opportunity of generating better understanding or knowledge about those with mental illness (Dickerson et al. 2002). The effects of stigma have made it difficult for people with a mental illness to obtain employment, find adequate housing, and become truly integrated in the community in which they reside (Thornicroft et al. 2009). Stigma associated with mental illness has been identified as reducing help-seeking behaviours, particularly in teenagers and young adults (Yap et al. 2011). Self-stigma, in particular, appears to be indicated in avoiding psychological interventions, poor follow up, and lack of treatment adherence (Fung et al. 2008). Goffman (1968, p. 3) identified stigma as an ‘attribute that is deeply discrediting’ and that results in the person holding it ‘different from others and of a less desirable kind’. Within mental health contexts, the reduction of stigma and the promotion of mental health are both corner stones to Australian mental health policy (Commonwealth of Australia 1996). Unlike physical illness, mental illness is often perceived as personal weakness, rather than an illness that is beyond the person’s control, and can often lead to bullying and harassment of the individual, particularly among the adolescent community (Corrigan & Watson 2007). Fear of being labelled as a person with a mental illness, and not being able to cope, can have a profound effect on the young adult, who might consider taking their life as a result of continued abuse (Department of Health 2011). Research has highlighted that much of the stigma that young people face comes from those who ironically represent potential support at a time of need, including friends, siblings, and parents (Department of Health 2011). The prospect of being stigmatized might be greater within smaller rural communities, where people and families are more readily known (Nicolson 2008). The fear of being labelled, ridiculed, avoided, or even abandoned looms large for many consumers, particularly those undergoing the transition from childhood to adulthood (Lau et al. 2012). Mental illness is often as devastating for the family as it is for the person affected. Family schedules, social life, and finances are often disrupted as a result. Compounding the problem for many families is the perception that they are somehow to blame for the person’s condition (Gray et al. 2010). The stigma associated with mental illness can be, in some instances, more
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acutely felt by families supporting a person with a mental illness as it can for the sufferer themselves (Robinson et al. 2012). Preoccupation with the problem in the family and feelings of guilt and shame can lead to the family isolating themselves from the larger community (Department of Health 2011).
ART Given the entrenched position of stigma within our communities towards mental illness (Mendoza et al. 2013), the need for mainstream policy responses to mitigate such negative perceptions is evident. Initiatives to reduce stigma predominantly seek to portray positive and rounded messages about consumers and the contribution they make to society (New South Wales Community Advisory Group 2008). Additionally, stigma-reduction programmes seek to encourage dialogue and wider understanding of mental health issues (Suicide Prevention Australia 2010). However, there is also opportunity for communities to initiate more creative and localized responses to the problem of stigma, with art being identified within the context of this study as a promising medium through which to communicate (Department of Health 2009; Lamont et al. 2009). Art is a well-established medium that has been predominantly used as a psychotherapeutic approach within the context of mental health treatment (British Association of Art Therapists 2010). Community-based arts projects are, by comparison, not a formal psychological intervention, but rather seek to creatively encourage people to engage with art, with the aim of maintaining mental well-being and enhancing artistic and social skills (Meeson 2012). The majority of studies on community art focus on the impact of participation upon the mental health consumer. Hacking et al. (2008) conducted a 2-year evaluation of participatory art projects, and identified improved selfesteem and confidence as the most common benefits to the mental health consumer. Empowerment, social inclusion, assertiveness, greater ability to regulate anxiety, and enhanced physical, social, and psychological well-being are further identified benefits of community-based art (Greaves & Farbus 2006; Spandler et al. 2007; Teall et al. 2006). However, Leckey (2011), in a systemic review of art projects, found little cohesive terminology towards key artistic constructs being measured, and a weak evidence base for its symptomatic efficacy due primarily to a lack of randomized, control studies utilizing established measures for specific mental illnesses. Nonetheless, Leckey (2011) acknowledged that evidence for art programmes © 2014 Australian College of Mental Health Nurses Inc.
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having positive outcomes for improved self-esteem, and social interacting is apparent. Hadland and Stickley (2010) recommended that art projects in mental health contexts be distanced from statutory bodies and imbedded within the grassroots of a community. While the impact of the social environment on mental health is well established (Truong & Ma 2006), there is less understanding of the impact of community-based art projects on those receiving the art, as distinct from those creating the art. Certainly, evidence exists that community art projects can act to build community cohesion, as well as social capital (Parr 2006; White 2006). However, the impact of art as a mental health-promotion and stigma-reducing intervention receives little attention in the literature. The exception to this is the use of the arts for mental health promotion within Australian indigenous settings (Nagel et al. 2009). Inequality of citizenship, and not being recognized as an active community member, are two areas whereby those with mental illness are marginalized. Conversely, social inclusion, where it is active and participatory, is seen as a vital response to stigma (Queensland Alliance 2009; Thornicroft et al. 2008). People experiencing mental illness are one of the most stigmatized and marginalized groups in Australian society, which in turn might be acting to delay early help seeking for emerging mental illness (Queensland Alliance 2009). Key recommendations to reduce stigma in the Queensland Alliance (2009) review include interacting with those experiencing mental illness and a creative use of the arts.
for people aged 12–25 years. The service runs a weekly social recovery project during the school term (the art group) attended by approximately 15 Headspace consumers, both male and female. The young people became involved in the art group via referral by Headspace practitioners, including those under the mental health nurse incentive programme that funds credentialed mental health nursing interventions for those with serious mental illnesses (Happell & Palmer 2010). The group’s mental illnesses included depression, anxiety, and personality disorder, as well as bipolar disorder and Asperger’s. The young people painted and drew on canvases with a weekly theme to work towards an exhibition with the common theme of ‘connect, celebrate, grow’. This theme sought to construct a message that challenges the marginalization of those experiencing mental illness, and to communicate the importance of both resilience and hope to achieve recovery (Mizock 2012). The young people in the group generated their paintings through their individual interpretations and personal experiences of this theme. With the support of 12 local merchants, the art created for the exhibition was prominently displayed within commercial retail outlets in late 2012 for approximately 2 months, and was clearly identified as being generated by young consumers of the Headspace mental health service. It was hoped that the artwork would encourage people to hold conversations with friends and family on mental health as a means of challenging the shame often associated with mental illness (Department of Health 2011), and that also inhibits people to seek mental health help (Carr & Halpin 2002).
RESEARCH QUESTION
Qualitative methodology and study design
The aim of this study was to answer the following questions: (i) What, if any, was the impact of the communitybased art (paintings) on individuals’ experiences towards mental health promotion/stigma reduction?; and (ii) What, if any, was the impact of the community-based art (paintings) on individuals’ likelihood of self-initiated helpseeking behaviours for emerging mental illnesses and/or self-initiated behaviours to encourage and protect strong mental health?
This topic of investigation has had little or no research undertaken, and an exploratory approach is hence required to direct larger studies of the phenomenon (Patton 2002). It was for these reasons that a phenomenological approach was used in the gathering and analysis of the data in the form of semistructured interviews and thematic induction. This approach proved useful in exploring the complexities of the topic under investigation, and provided rich data from studying a limited number of cases in depth. The use of thematic analysis meant that the findings were based on the participants’ own understanding and meaning of the phenomenon, as situated and embedded in contexts of their working lives. As such, this study sought to gain a deep and contextualized understanding of the participants’ individual experiences, and subsequently sought emerging shared essences of these experiences, which are then expressed as themes (van Manen 1997).
METHODS Ethics approval for the study was sought and gained through the Southern Cross University ethics committee (Coffs Harbour, NSW, Australia). The art was generated through a group of consumers attending the Headspace service; a non-government, early-intervention mental health and well-being service © 2014 Australian College of Mental Health Nurses Inc.
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Recruitment The study was undertaken in an area of regional Australia that has a comparatively low socioeconomic community profile to most other parts of the country (Australian Bureau of Statistics 2011). Local retailers (banks, cafes, retail shops, and community service organizations) were asked if they would participate in semistructured interviews regarding their observations, interactions, and experiences of the public (patrons) viewing the displayed art, as well as their personal experiences of engaging with the art. Staff from seven of the 12 retail outlets consented to participate in the study. These staff were also the staff in charge of setting up the displays around their central work station, where they could have frequent interaction with the public and the art. All seven participants were female, ranging from 25 to 60 years of age. All had worked in their outlets for at least a period of 1 year.
Procedures: Data collection and analysis Semistructured interviews using open-ended questions were used as the data collection in an attempt to capture simple experiences, as well as social processes, that were generated from displaying or viewing the art. As such, data collection focused on the lived experience of the retail outlet staff interacting with the public through the displayed art. The semistructured questions specifically explored if (and how) the art influenced these participants directly, and how the participants’ experiences of the art impacted those members of the public they related with. The audio-recorded interviews were separately listened to by two of the researchers for emerging themes pertaining to the overarching research questions. Findings were then repeatedly explored until a consensus was reached on the emergent themes.
Findings Four key themes emerged from the thematic analysis of the participant interviews: (i) art as a means of engagement; (ii) art as a means of reducing stigma; (iii) art as a language that enables empathic understanding of others’ emotional positioning and (iv) art as encouraging helpseeking behaviours. Theme 1: Art as a means of engagement
A clear theme that emerged from the majority of participant experiences was that the publically-displayed art was a non-threatening medium by which to engage the public and raise awareness of mental health. One participant stated how the viewer (participant) was able to engage and communicate with the art, despite experiencing some of the art as being emotionally challenging:
J. HURLEY ET AL. You can get a picture of the art and what might be behind it, some of it can be a little bit sinister, there could be issues there, but from a distance, it (art) gets the message across. (Participant 1)
Furthermore, the participants reported that both they and the members of the public with whom they engaged with were able to suspend their fear towards those with a mental illness, and thus develop better empathy and understanding. Art could act as a communication conduit between the viewer and the person experiencing mental illness. The lack of physical proximity provided the necessary space and perceived safety for those holding stigmatized views that challenged their own beliefs, rather than being confronted about them by others: The public relate better (on mental illness) to something that is not going to talk back to them (consumers), something that is not going to give them an opinion but lets them form their own opinion. (Participant 5)
Theme 2: Art as a means of reducing stigma
The majority of participants reported that the art had a definite positive impact on themselves and the public observers of the art regarding young people with mental illness, especially in the formation of positive views towards the talents of those young people. These views were openly discussed, with participants experiencing the conversations as bringing mental illness out into the open and growing the public awareness of mental illness at a time and place of the observers choosing: They see the art work and think that is amazing what they have done, and obviously have a better understanding and are more accepting of their (the artists’) illness. (Participant 3) It (the art) opens up a dialogue on mental illness that had not existed before. It is unusual for someone to come in here and talk about mental illness, having mental illness. Art opened a dialogue about mental illness, something I have not had on the shop floor before. (Participant 2)
Theme 3: Art as a language that enables empathic understanding of others’ emotional positioning
Most participants expressed having the capability to experience art as a distinct language and mode of communication. Rather than the young person with a mental illness verbally describing their emotional state, the participants experienced the art works as each being an individualized expression of emotion from the artist to them, the viewer of the art. The unique characteristics of each piece of art were thus a personal message, enabling better understanding of the young people who created it. The © 2014 Australian College of Mental Health Nurses Inc.
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participants reported being able to connect with the mood that the artist was in, the emotions being communicated by the artist, and even that the mental state of the artist could inhibit emotional expression: The style of the art, such as the use of colours (and) rigid or flowing lines, communicated a sense of mental state and personality. (Participant 4) That somebody tries to express feelings, and when they can’t, you can see it, so it’s not necessarily anger or whatever they have feelings of, but they can’t get them out. (Participant 7)
Theme 4: Art as encouraging help-seeking behaviours
The majority of participants identified the art as a potential trigger for initiating help-seeking behaviours, including encouraging the observer to create art themselves as a means for improving mental health. Many participants’ description of their personal experiences, and those expressed to them by members of the public, was that the art was a mechanism to build mental well-being. For some participants, this was about creating their own art. For others, the publically-exhibited art raised awareness that local organizations and groups are active within the community, and that there are tangible and valued outcomes emerging from these groups: People said we can see, we can understand this is a troubled youth. I have a troubled child at home, how do I contact Headspace? Can I get them into some type of programme? Can I get them into an art group for them to be part of so that they can display their problems, and you know, get some relief, find some outlet for their expressions? (Participant 2)
DISCUSSION The findings from this small study suggested that the publically-displayed art triggered positive views towards the young artists with mental illnesses. Additionally, the art appeared to have acted as a form of communication that enabled viewers of the art to emotionally connect with the artist. Given that negative social identities (Bates & Stickley 2013) and marginalization (Department of Health 2011) are key constructs of stigma, these initial findings are suggestive that publically-displayed art might contribute to reducing stigma and social marginalization associated with mental health. Although not reported as a theme, some of the participants believed that an important context was to have the art displayed in a ‘natural setting’, such as a retail outlet, rather than having it as a special exhibition. Through situating the art within the context of mainstream © 2014 Australian College of Mental Health Nurses Inc.
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daily community life, the artwork reached a greater proportion of the community, and was arguably normalized and communicating the necessary social inclusion needed to reduce stigma (Queensland Alliance 2009). While art has long been recognized as a major contributor to the physical and aesthetic quality of neighbourhoods and communities (Thiele & Marsden 2003), there is comparatively little research on how art that has been created by consumers impacts on the observer of that art. However, a broader view of art as a means of intervention and public engagement is emerging internationally as part of health-promotion activity and social networking (World Health Organization 2010). This goes beyond the traditional view of art as pieces of work and visual assets of communities, but engenders art as a means of strengthening community identity and social capital (Commonwealth of Australia 2004). Art, as described in the present study, provides a system of communication in which the young people could not only express themselves, but more importantly, be potentially understood and accepted as contributing to their community. The connectedness that enabled this understanding and acceptance of the young artists is suggestive of increased empathy. Burnard (1988) highlighted that empathy is a skill that enables understanding towards another on a level that explores the very drivers of that person’s behaviours, with art, as reported on in the present study, being highly effective in communicating deep understanding. Additionally, the construct of empathy is widely understood as moving beyond understanding another’s feelings to also being non-judgmental (Wiseman 1996). Non-judgmental understanding seemingly represents a powerful tool against the stereotyping and prejudice that drives stigma towards those with mental illness (Corrigan et al. 2003). Art, when used in this way, can be seen as a public health intervention. Public health works to promote healthy behaviour and respond to health concerns in populations and communities (Linsley et al. 2011). Mental illness remains stigmatized and difficult to access. One of the challenges of health and social care professionals is to devise strategies to engage with communities and deliver health initiatives within limited resources. Increasingly, alternative models of community engagement are being developed in the field of mental health that challenge the way in which consumers access services. Art can be seen as a valid intervention for engaging with the public, as one commentator put it: We must remember that art is present in all cultures, all communities, art is not an ‘extra’, instead art is a universal
424 trait of human culture. In providing public health programs to communities it only makes sense to incorporate art into services. (Speak Art Loud 2010)
This study reinforced the role that art can and does play in promoting dialogue on mental health and illness. Art acquires meaning, in part from the context in which it was undertaken and the setting in which it is displayed (Freeland 2001). Additionally, this and other studies (Parr 2006; Staricoff 2006; Stickley et al. 2007) add to the growing body of literature that participation in the arts and crafts can be beneficial for consumers of mental health services, particularly in the context of reducing stigma and social exclusion. This latter point is particularly important for MHN, whose practice has historically been associated with containment, and who struggle to create ways by which to fully engage with promoting social inclusion and community participation (Australian College of Mental Health Nursing 2013), and who have an identity that has been associated with stigma (Halter 2008). We recommend that the role of art for health-promotion strategies be systematically investigated by MHN in partnership with art organizations.
STUDY LIMITATIONS As with any qualitative study, the findings from this research could not be generalized to other people or other settings, and might be unique to the relatively few people that took part in the interviews. That is not to say that the study itself is flawed, but might need adaptation if applied to another setting. What the study does allow is an insight into the topic area that could act as indicator for future research.
ACKNOWLEDGEMENT We acknowledge and thank the Australian College of Mental Health Nursing for the 2012 Partnership in Wellbeing Award, which funded the running of the art group, but not any aspect of the research or this paper.
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