There is growing evidence of the contribution participatory arts practice may make towards mental health recovery. The purpose of this paper is to examine this phenomenon by critically reviewing the relevant literature in the light of the CHIME theoretical framework that identifies the components and processes of mental health recovery.
Using a critical realist review method, the study draws upon foundational social and psychological theories offering an analysis of the identified mental health recovery processes in relation to participatory arts activities for people that use mental health services.
This review identifies themes that permeate the categories of CHIME and are widely delivered by participatory arts in mental health projects. These themes define the essence of a recovery approach of care and are delivered, sometimes uniquely, through arts in mental health work.
Whilst mental health outcomes are frequently sought in participatory arts projects, there is sparse theoretical evidence to under-pin such work. This review provides potential recovery outcomes through a theoretical inquiry into participatory arts and psychosocial theories.
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There is growing evidence of the contribution participatory arts practice may make towards mental health recovery. This paper examines this phenomenon by critically reviewing the relevant literature in the light of a theoretical framework that identifies the components and processes of recovery (Leamy et al., 2011) which will be referred to as the CHIME framework. A recently published article (Stickley et al., 2018) has already made this theoretical connection, but through complementary methodologies. In this paper, we offer a conceptual, critical review of the potential for participatory arts to contribute to mental health recovery by using the CHIME framework (Leamy et al., 2011). The review draws upon the methodology of the critical realist review. In this review, we are defining recovery as referring to “personal recovery” as opposed to “clinical recovery” (Slade et al., 2012). Furthermore, the focus of the study is upon published research directly related to group-based arts activities amongst people who use mental health services. These are usually conducted in community settings and designed for mental health outcomes.
Critical realist review method
A recovery approach of care and participatory arts in mental health care are open and complex systems of social science where many variables and fluid factors may come into play. A growing body of evidence has developed around recovery and participatory arts in mental health work, but there is also recognition that there is always more knowledge that can be discovered and explored (Bhaskar, 2008). A critical realist review methodology was chosen as it is helps to discover new ideas, potential new theories and allows the beginning of a critical inquiry without quite knowing where it might end (Edgley et al., 2014). This study examines published research evidence on participatory arts and mental health and is led by the knowledge revealed by that inquiry; it has a focus on evidence addressing people in their social world, and the meaning ascribed to these social practices (Robson, 2002; Bryman, 2004; Bowling, 2009).
Leamy et al. (2011) identified that no systematic review and narrative synthesis had previously taken place to establish an evidence-based conceptual framework of recovery in mental health. At the time of their study, government policy frameworks were calling for mental health care to be focussed on a recovery approach to care, however, it was becoming increasingly accepted that the concept of recovery had not been clearly defined (Cleary and Dowling 2009; Department of Health, 2010). Recovery appeared to have different meanings to different people, at different times, and in reaction to different situations (Lester and Gask, 2006; Buchanan-Barker and Barker, 2008). Pilgrim (2008) highlighted the tensions that might develop in the understanding of recovery between biomedical psychiatrists vs social psychiatrists vs dissenting service users. Mind (2008) was concerned that the term recovery was being embraced by mental health services without the necessary organisational transformation taking place for it to actually be delivered; this has been further highlighted by international experts on recovery (Slade et al., 2014). Positive indications were clear that holistic mental health services should not just concentrate on the amelioration of illness symptoms, but also on other factors impacting on mental health conditions (Craig, 2008). There was also a central tenet that people have a right to build new lives for themselves regardless of mental health difficulties (Shepherd et al., 2008). Accordingly, Leamy et al. (2011) undertook a systematic review and narrative synthesis of literature around a recovery approach, identifying the components and processes of personal recovery and illustrating five dimensions of recovery through the CHIME acronym: connectedness, hope and optimism about the future, identity, meaning in life and empowerment. Each of these dimensions included dominant themes identified through the review as well as sub-categories. Since that time, CHIME has been tested to ensure its validity and implemented as a theoretical framework (Bird et al., 2014; Scottish Recovery Network Briefing Paper, 2015; Stickley et al., 2016).
Leamy et al. (2011) divided the connectedness theme into four sub-categories: peer support, relationships, support from others and being part of the community. Participation in a group can foster a sense of belonging for a person, with individuals sensing that they are working together with other group members, in doing so they develop positive self-concepts (Tajfel and Turner, 1979). They have become part of a group in which they belong and are relevant to them and their life, with positive interactions between the person and the rest of the group promoting unity and social coherence (Turner and Oakes, 1986). An arts environment can be conducive to participants gaining a sense of social belonging, emotional value, confidence, unity and friendship, an environment that fosters peer support (Stickley and Hui, 2012).
Public showing of art or performance is particularly important as a vehicle towards social inclusion, with arts projects for minority or marginalised groups producing public artworks, which affirm their history and place within the community (Parr, 2008). Van Lith et al. (2013) found that social inclusion and belonging were promoted in a variety of different ways, by improvement in interactions with others, greater understanding of social norms, and an increased sense of social wellbeing and acceptance. The same researchers previously emphasised the importance of arts facilitators having the necessary experience, knowledge, skills and competencies to effectively deliver arts projects (Van Lith et al., 2009). Participants in a study by Van Lith et al. (2013) described benefits in regaining a sense of purpose from being involved with arts-based work, as an alternative focus to their mental health problems. This was exemplified by being involved in exhibitions, which led to an associated positive outlook into the future and beyond mental health difficulties. Facilitators also recognised the importance to participants of being in a safe environment where they could experiment freely and be trusted and respected, describing the importance of transforming through overcoming artistic problems and experiencing the pleasure of completion.
Hope and optimism about the future
Leamy et al. (2011) broke down “hope and optimism about the future” into the following sub-categories: belief in the possibility of recovery, motivation to change, hope–inspiring relationships, positive thinking and valuing success and having dreams and aspirations.
Participation with group arts activities can help to reverse a process of developed hopelessness that can take place when a person experiences prolonged mental health problems; this can allow people to think positively about their future artistic development, and help to promote hope and optimism (Secker et al., 2007; Stickley and Hui, 2012). The arts can be a conduit to the re-establishment of a sense of purpose and hope to a person’s life, with successful engagement in arts activities leading to improved hope in regards to educational and employment opportunities (Lloyd et al., 2007; Spandler et al., 2007). Sapouna and Pamer (2016) describe participants as developing a sense of worth, value and hope through participation in an arts project and the benefits they perceive through working towards an end-goal. They acknowledge that there may be frustrations and difficulties on the way, but this may add to the sense of achievement on completion, with some people describing making positive plans for expanded further arts interest in the future. Spandler et al. (2007) identified that one of the most important contributions of arts projects to peoples’ mental health is in counteracting a sense of hopelessness associated with mental distress. They found that participants described the motivation to attend as rekindling hope and giving people inspiration for the future. They describe the importance of having an alternative image as an artist in allowing people to renegotiate relationships leading to the development of more positive relationships, which allow them to develop a more positive outlook for the future.
Within the CHIME acronym, Leamy et al. (2011) break down the identity category into the following elements: dimensions of identity, rebuilding/redefining positive sense of self and overcoming stigma. The concept of identity is complicated, with different theories developed and a lack of agreement on how identity should be defined; it can be approached from two perspectives, the perspective of self-identity and the perspective of social identity (Kunnen et al., 2001). Amongst theories of self-identity, Freud (1923) and Erikson (1959) viewed the development of identity taking place chronologically through childhood with problems or conflicts around personality or identity arising through not successfully completing stages of development. Social identity theory emphasises the importance of group membership and of participating in a group in which a person feels that they belong (Tajfel and Turner, 1979). A person’s social identity develops by a process of self and societal definition and is responsive to the society in which the person lives (McDougall, 1927; Sokol 2009). For a group to be of benefit to a person’s self-identity, people need to feel safe within the group. When a group provides members with strong and reliable relationships, positive group involvement can foster feelings of social unity and coherence for members (Turner and Oakes, 1986; Fiske, 2004).
Involvement in arts in mental health activities can lead to the discovery of hidden talents and the development of new skills, with people regarding themselves as developing artists with an associated perception of improved identity (Twardzicki, 2008). Parr (2006) describes mental health participants with static or stigmatised identities, developing improved personal and artistic identity through involvement with individual and collective arts projects. Gwinner et al. (2015) found that service user artists valued the freedom of choice of multiple unique artistic identities, describing the stigmatising effect that mental illness and labelling had on their relationships and aspirations for the future, by contrast the arts provide an opportunity to move on to more positive interpretations of self. This rebuilding of a positive identity is especially important for participants whose identity has been significantly affected by mental health difficulties and long-term recipients of mental health services.
Sapouna and Pamer (2016) recognise the importance of the arts in challenging stigma on two levels, from the perspective of mental health professionals recognising participants as individuals beyond their diagnosis to being artists, and the benefits of mental health arts projects in contributing to local communities. Spandler et al. (2007) describe the return to the arts as being central to regaining a person’s sense of self and identity, and through presenting to others it gave participants a positive social context of being involved with meaningful activity as an alternative to the stigma associated with not being in conventional employment.
Meaning in life
Leamy et al. (2011) break down the meaning in life category into the following sub-categories: meaning of mental illness experiences, spirituality, quality of life, meaningful life and social roles and rebuilding life. The question of “what is the meaning of life?” demands philosophical answers and understandings. The Philosopher Frankl (1986) asserts that every life is worth living and should be purposeful that people should set themselves tasks in life through which they can develop experientially and attitudinally. The existentialist view of life is that people can develop their own essence as an individual rather than by categories others use to define them, and that they can define themselves through their actions (Sartre, 1996).
The beliefs that people have around spirituality and religion have important effects on their behaviour and their perception of the world, and gives people meaning to their life (Saucier and Skrzypinska, 2006). Spirituality is an inherent part of being human, it is at the core of existence, is multidimensional and involves the search for meaning to life, whereas religion revolves around a higher being or beings, and is organised with specific practices or rituals (Tanyi, 2002).
A recovery approach of care embraces the notion that everyone needs to have a sense of purpose and meaning to their life, although their ultimate aim might not be achievable, the process of working towards that aim gives the person “purpose and direction” in life (Repper and Perkins, 2003). People inherently seek explanations for what has occurred in their life, be they “physical, medical, social, political, spiritual or philosophical”, or a combination of these elements (Basset and Stickley, 2010).
Participation in the arts can be a powerful transformative tool that can introduce positivity and strength into people’s lives and allow them to overcome adversity (Smith, 2002; Aprill et al., 2006). White (2006) reflects on the processes that arts and health projects go through to create positive social and environmental conditions that can lead to improved physical and mental health. In a later publication, White (2009) asserts that there is qualitative evidence that the arts address all psychological facets including negative feelings, positive feelings, spirituality, religion and personal beliefs.
Gwinner et al. (2015) found that the creation of artworks was part of a significant process of developing new meaning for people, which allowed them to make sense of previous experiences; artistic activity gave people new ideas and led to them living a contributing life on their own terms. Secker et al. (2007) found that the arts supported self-expression which aided recovery, in particular for participants with complex mental health difficulties or who had experienced difficult traumatised backgrounds. They found that by expressing themselves through their art, people developed a greater understanding and sense of their experiences and evolved a new positive relationship with their thoughts and feelings.
Leamy et al. (2011) categorise empowerment under the following headings: personal responsibility, control over life and focussing upon strengths. Empowerment is the process or mechanism by which individuals, groups or communities take control of their own affairs, it also refers to an individuals’ level of self-determination and their democratic influence on the community in which they live (Rappaport, 1987).
It is understood that long-term treatment by mental health services can lead to people experiencing a lack of control over their lives, combined with helplessness and dependency, and that recognising and being honest about “power differentials” is important within mental health settings (Jacobson and Greenley, 2001; Repper and Perkins, 2003). Organisational change is essential in implementing a recovery model of care in services, with the use of language paramount, some service users experience a history of being defined by deficits associated with medical labels, instead of a more positive dialogue emphasising the possibility of growth and personal development (Shepherd et al., 2009; Pilgrim, 2008). Many mental health professionals have a poor understanding of power relationships and have a corresponding lack of clarity of what empowerment might involve (Masterson and Owen, 2006). Participation in arts projects can support empowerment through five processes, “getting motivated and expressing self, connecting with abilities, rebuilding identities, and expanding horizons” (Spandler et al., 2007, p. 18). Spandler et al. (2007) highlight the connection between the inspiring nature of the arts and motivation, the particular benefit of increased self-expression for people with complex mental health issues, improvements in self-worth through displaying artworks, and the expansion of horizons through confidence to take on new challenges. Sagan (2012) identifies the transformational, positive empowerment that occurs through the development of a new identity of being an artist and the disempowerment that can result from the interpretational nature of traditional art therapy (quite different in nature to participatory arts) and its focus on negative thoughts. Lawthom et al. (2007) point out the importance of arts participation for people from deprived backgrounds in the strengthening of their ability to overcome life’s challenges and enjoy a more rewarding life, they suggest that this could affect longer-term socio-cultural change or transformation. Hacking et al. (2008) found the most significant positive outcome for participants engaging in arts activities was improved empowerment in terms of “self-worth, self-efficacy, positive outlook, and mutual aid” (p. 643).
This review has used the CHIME framework to explore how participatory arts activities may promote mental health recovery. By participating in such activities, people connect with one another and form significant positive relationships that inspire hope. By developing new abilities and strengths, participatory arts activities can break down barriers between service users, professionals and family members. Thus, more relationships that are positive emerge leading to a positive individual and social identity, a stronger sense of belonging, and improved self-efficacy. Membership of an arts group, with resulting creative artworks, can foster positive social unity, an important aspect in increasing social capital and social inclusion. People experience “safe” environments where difference is welcomed and embraced and they may be used as an opportunity for marginalised and vulnerable groups to produce artworks and activity that promote better understanding within the wider community.
Hope and optimism are an important component of recovery, with the development of optimism commonly seen within participatory arts involvement in the context of the opportunity for people to create new artworks and to exhibit, display or perform them in the public domain. This is exemplified by the recognition of the greater benefits of tailor made, unique, goals-orientated arts projects. When artists are working towards a specific event, they develop a common goal with associated group and individual optimism, followed by pride in achievement. Engagement with arts activities is an ideal opportunity for positive change to be experienced in people’s lives, with associated optimism for health professionals involved, and family, friends and carers. The arts offer people a conduit for increased hope in other areas of their lives, including mental health, and support the development of increased positivity in relationships with associated optimism for the future.
Participation in group arts activities is important in developing a positive self and group identity, outside of clinically imposed diagnosis and treatment identities. By being an artist, a mental health service user is perceived differently by mental health professionals, family, friends and carers and the public; with this new perception the arts can play a significant role in challenging stigma associated with mental illness. The development, through arts participation, of positive self-identity promotes positive social identity with an associated sense of belongingness, safety and optimism of increased group and individual strength in overcoming adversity.
There are crucial areas in which the arts can contribute to the “meaning in life” dimension of recovery. The arts are unique in the opportunity they offer for self-expression and for people to develop their own narratives about their lives. Artists can feel safe to explore their life history and redefine as they wish; they can analyse their experiences of mental distress and use this as a catharsis for change, potentially embracing spiritual beliefs and using their imagination creatively. Through individual and group artistic work, people can reclaim their right to create their own positive narratives about life, challenging negative narratives told, or written, by others about them. It is important that these positive narratives are performed or exhibited in the public domain where they can instigate positive social change and address stigma around mental health. The arts have the power to challenge negative stereotypes of mental health of other marginalised groups such as members of the black and minority ethnic, lesbian, gay, bisexual and transgender, refugees and homeless communities. Participatory arts may address stigma and instigate social change through accepting and embracing that which people cannot change, whilst striving through collective action, to change that which they can.
This study validates the evidence for the mental health benefits of participatory arts activity identified by Stickley et al. (2018) and by the articles considered in this critical review. Mental health recovery needs to be defined by individuals, and participating in arts activities enables not only the expression of that definition, but recovery itself.
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About the authors
Tim Sayers is Arts in Mental Health Co-ordinator at the Leicestershire Partnership NHS Trust, Leicester, UK.
Theodore Stickley is Associate Professor at the School of Health Sciences, University of Nottingham, Nottingham, UK.