Creative Practice as Mutual Recovery
Connecting Communities for Mental Health and Well-Being
When considering the attributes modern-day healthcare is frequently accused of lacking, it is all too easy to overlook one of the most precious of all: humanity. The nascent discipline of health humanities aims to address this critical shortcoming.
Professor Paul Crawford, who led the development of the fast-growing and global field of health humanities, provides the following definition:
"Health Humanities champions the application of the arts and humanities in interdisciplinary research, education and social action to inform and transform health and social care, health or well-being. It aims to be inclusive of viewpoints and contributions from within and beyond medicine; value the experiences and resources of the public; explore diverse approaches to achieving, maintaining or recovering quality of life; and strives for demonstrable impacts, not least in providing new evidence and insights for the education or practices of those planning, organising or working for the health of any population."
Central to the health humanities discipline is the notion of mutual recovery – the idea that the sharing of creative practice and resources can promote resilience in mental health and well-being among professionals, informal carers and service users. This concept is emerging at a time when the burden of mental health remains considerable and a renewed emphasis on biomedical and neuro-scientific solutions is accompanied by little confidence of success.
At present, according to some studies, mental health problems affect as many as one in three and constitutes the second-greatest health burden after cardiovascular disease.
Current community care approaches continue to deliver mixed results, with social isolation and exclusion still growing. There are mounting fears service users' trust is being undermined and that the public is becoming increasingly skeptical about the effectiveness of mental health services.
In the face of these challenges, the role and potential benefits of mutual recovery offer a new and valuable research theme. Crucially, they provide fertile ground for innovation, involvement and impact.
Creative Practice as Mutual Recovery (CPMR) is a highly collaborative programme funded by the Arts and Humanities Research Council (grant number AH/K003364/1). It aimed to examine how creative practice in the arts and humanities can promote the kinds of connectedness and reciprocity that support 'mutual recovery' in terms of mental health and well-being. Please click here to read the CPMR Final Report.
Creative practice could be a powerful tool for bringing together people with mental health needs, informal carers and health, social care and education personnel, to connect in a mutual or reciprocal fashion to enhance mental health and well-being.
The CPMR programme marks a radical shift in vision that could generate new pathways for transforming these discrete groups of people into egalitarian, appreciative and substantively connected communities – resilient communities of mutual hope, compassion and solidarity.
The programme’s ﬁndings have been comprehensively published in peer-reviewed publications in relevant journals, books, conferences, exhibitions and workshops with a linked archive at the Health Humanities website.
The CPMR programme has led to multiple, high proﬁle and diverse impacts, resulting from the programme’s activities in the UK and overseas, delivering accessible creative products available to the public in ﬁlms, plays, ﬁction, events, symposia, websites and exhibitions. The programme has driven new and evolving research with more than £3m additional funding. It also contributes ongoing non-academic community and clinical initiatives for advancing mental health and well-being. Please click here to read the comprehensive CPMR Impact Statement.
The CPMR programme included 10 core projects funded by the grant, with an additional 4 projects being developed between 2013 and 2018.
Below are summaries from all the completed projects within the programme, achieving peer-reviewed, published findings and multiple impacts. A PhD project, by Emma Joyes, on creative practice as mutual recovery in a forensic mental health setting is still ongoing, with completion expected later in 2018.
Capoeira for Self and Society
Project Lead: Jordan, M.
Researchers: Wright, E.J., Purser, A., Grundy, A., Joyes, E., Wright, N. and Manning, N.
The Capoeira for Self and Society project set out to consider how this Brazilian martial art, game and dance form might facilitate connectedness amongst newly-recruited persons in an unfamiliar social setting, plus any other ramiﬁcations of involvement.
A beginners’ capoeira course was provided free of charge for participants in a dance school in a city in the West Midlands of England.
Members of the research team attended these capoeira sessions to collect qualitative overt non-participant observation data. In addition, interviews were also conducted with participants at the end of the course.
From observations of 13 free classes and interviews conducted with two participant groupings — capoeira students and capoeira course leaders — capoeira was highlighted as an enjoyable and supportive group endeavour. It included elements of social play, self-development, community-building, and beneﬁts for self that transcend the boundaries of the class. Capoeira can be argued to facilitate mutuality and egoism concurrently.
Further, capoeiristas can enact and experience—some mode of—escapism via capoeira, whereby a new place and novel pursuit can facilitate hedonistic diversion from the mundane.
Capoeira, therefore, appears to provide adventure and liberation into a relatively unburdened part of, or place in, social life—at least for the participants in this study.
In summary this research suggests that modified capoeira for beginners can be beneficial for both the new capoeiristas themselves and for positive community action during and beyond class.
Project Team: Argyle, E., Bywater, S., Jon, S., Pick, J., Duncan, K., Mattias, O., Dalby, D., Barker, A., MacDonald, K. and Avery, S.
The Clay Transformations (CT) project comprised of numerous interacting strands over the last five years. The project emerged from anecdotal clinical reflection, where practitioners noted how effective clay seemed to be as an adjunct to psychotherapeutic practice.
The first strand of the CT research sought to make sense of playing with clay as task absorption and how this might be understood regarding psychosocial tendencies. Working with research psychologists, laboratory conditions were established to test the hypothesis that playing with clay was functional as an immersive activity whereby subjects would become relaxed, less inhibited and therefore more amenable to talking therapy.
The clay play, involving sentence completion tasks, was set alongside controlled experiments involving drawing, maths and playing with Lego. The research concluded that clay had a positive effect on reducing social inhibition compared to maths and drawing but was no more effective than playing with Lego.
The first stage of the project demonstrated there was a viable weave between science and the arts. The laboratory research did confirm that playing with clay had some effective qualities in terms of bringing about an experience of task immersion, yet the way in which clay worked needed further investigation.
A second strand of activity was led by two practitioners and involved clay workshops in a local secondary school. In the group there were six participants aged 13 or 14, from diverse backgrounds. The clay workshops involved elements of clay modelling, and participants learned sculpting skills.
Over the course of the workshops the practitioners noted elements of group cohesion and peer exchange emerging, and that the sessions were enthusiastically received by participants.
Previously struggling to engage and speak in the classroom, the children became playful, excited, engaged, and sociable in the workshops. It was noteworthy that even though English was not the first language of the participants, the clay appeared to offer a trans-linguistic medium for effective peer exchange.
The third strand of the CT project involved running a course of weekly workshops over an eight-week period. A total of 42 participants took part in the workshops and mixed methods were used to evaluate their impact. It is noteworthy that there was a 31 per cent rate of attrition. For those that did engage in the workshops, it was found their social and psychological well-being improved significantly.
The reasons for the high attrition rate are subject to some speculation. On reflection, it might be the case that, while working with artists has significant value, some participants with greater mental health difficulties require mental health professionals to support them when participating in such workshops. The other possibility is that clay as a medium is not suitable for all people.
Two exhibitions were mounted after the completion of the workshops. The first took place at the Institute of Mental Health. The second exhibition took place at the Apsidal Gallery at Rufford Abbey Country Park and was part of the globally renowned Earth & Fire International Ceramics Fair.
The fourth strand involved the use of clay in an educational setting. One session involved a day’s workshop with 22 first- and second- year trainee counsellors. In another session, a clay workshop was delivered as part of a team-building activity for a group of social work practitioners working with ‘looked after’ children.
The workshops used a combination of free-play and group sculpting activities. During the workshops, participants’ workshop experiences were captured through audio-recorded focus group feedback sessions, and via a photographic archive of the sculpts produced.
Not all the participants found working with clay enjoyable, and some found it a challenge. These insights have been helpful to understanding the way clay works, and how resistant qualities of coldness and muddiness can evoke a range of negative emotions. It is these qualities that make clay an evocative and transformative medium for exchange.
In conclusion, clay works as a neutral medium for aiding and facilitating communication skills and offers a three-dimensional form of expression. By reducing the mutual gaze between the therapist and client, working with clay emphasises imagination and voice, as participants become immersed in the process. Clay has ‘therapeutic grab and mash’ properties, providing a potential catharsis for people who are otherwise increasingly absorbed by techno-virtual cultures.
Comedy and Mutual Recovery
Project Lead: Winship, G.
Researcher: Baker, A.
The Comedy and Mutual Recovery work-stream was an addition to the Clay Transformations (CT) project, deploying a similar approach. It was a pilot programme and involved stand-up comedy workshops for 10 participants in recovery. Like the CT workshops, the stand-up comedy workshops were run by a professional with no input from mental health professionals.
The workshops involved elements of processes strongly resembling therapeutic community practice insofar as participants worked in collaboration, initially sharing their story and then working together to develop a short stand-up routine. The workshops culminated in the participants presenting their routine to their peers, with four involved in a public evening performance.
The following tools of evaluation were deployed in the comedy workshop project:
- The Warwick-Edinburgh Mental Well-being Scale
- The Rosenberg Self- Esteem Scale
- The General Self-Efficacy Scale
- The Life Orientation Test-Revised
- Eco-Mapping tool
The results showed favourable findings on three positive outcome measures: psychological well-being, self-esteem and self-efficacy. The participants’ number of social relationships and the strength of those relationships decreased following the intervention. However, the relationships were more mutual and were characterised by less conflict following the workshop.
The small sample limited the generalisation within this study, but the methods for data collection were found to be feasible. The preliminary findings point to a new hypothesis about mutual recovery — that successful recovery might be characterised by a smaller social network, with stronger mutual bonds.
One of the follow-through aspects of the comedy research has been to inform a new conceptual framework for understanding the transactions of humour in mutually beneficial encounters in planned environments. This has been called; ‘the 3Hs: Hope, Home and Humour’, and has informed a new policy initiative for working in prisons.
Many thanks to Elaine Argyle, Sandy Bywater, Stephen Jon, Joe Pick, Kate Duncan, Oliver Mattias, Diane Dalby, Alex Barker, Kirsty MacDonald, for their contributions and assistance within the Clay Transformations and Comedy in Recovery projects.
Creative Art Gallery Workshops (Spain)
Project Lead: Saavedra, J.
Project Team: Arias-Sánchez, S., Murvartian, L., Galván, B., Vallecillo, N. and Luisa Galán, M.
The Creative Art Gallery Workshops project was led by Seville University, and held at the Contemporary Art Centre of Andalusia (CAAC), Spain, in partnership with the Andalusian Health Service and the Andalusian Public Foundation for Social Integration of the People with Mental Disorders (FAISEM).
The project aimed to assess the impact of creative workshop participation on the psychological well-being, social connectivity and subjective experience of people with severe mental illness (SMI), as well as engage the healthcare professionals accompanying them.
“... I am more tolerant now. And being in a group and all that…you end up making friendships with people.”
The project included narrative interviews and pre- and post- tests designed to assess psychological well-being (Warwick-Edinburgh Mental Well-being Scale) and social inclusion (social inclusion questionnaire, Secker) in workshop participants.
In total, 19 people were interviewed, including users (n=11) with different levels of previous workshop participation, keyworkers (n=6), the art facilitator responsible for the workshops and the clinical psychologist overseeing the project. In addition, 4 psychology students participated as observer-participants in each workshop and in the group discussions that were held at the end of the workshops.
"I feel better… I see that my problem has affected many people and I must see it more naturally. Do not ‘stagnate’ into the disease and do not let the people I relate with to do so.”
The project found:
- A significant increase in psychological well-being after workshop participation. No differences were found between-subjects when looking at the outcomes of previous workshop experiences.
- Regarding social isolation, there were no main differences between pre- and post- test scorings, or between participants with varying experience attending the workshops.
- With regards to social relationships, there was an increase in social relationships only for participants who enjoyed low and medium previous experience groups.
- In relation to social acceptance, the results pointed out significantly higher post-test scores for all groups, independent of their previous experience with a large size effect. This was the most significant result – a high increment of social acceptance after workshop participation.
"Yes, I feel more relaxed, I develop more the mind, I collaborate more in group, I have learned new things, and it is a development mentally and physically as well. Positive things, especially positive things … I find myself more excited. As the mind more awake. I am very relaxed in the creative workshops. "
The creative activity made it possible for mental health service users and professional carers to participate in diverse social practices far removed from clinical settings and to help them increase the quantity and quality of their social contacts.
"... It frees my mind from the mental block, it frees me, the things I learn every day ...in each workshop."
Implications from the project for SMI rehabilitation:
- Creative practices can significantly improve social inclusions and well-being in people with severe mental illness.
- Participating in creative workshops helps to elaborate personal meanings and promote recovery.
- Creative practices in mental health services can challenge professional roles and institutional practices.
- Participation of people with and without severe mental illness engaging together in artistic activities can decrease public stigma.
The Creative Art Gallery Workshops Project has led to continued collaboration between the Faculty of Psychology at Seville University, CAAC and FAISEM. The participation from community groups, professionals and service users in creative practices in non-clinical contexts helps reduce public stigma and improve their psychological well-being.
Many thanks to Felipe Vallejo, Sandra Melgar and all the carers and users for their commitment. To the students for their participation in the creation of the Art and Psychology seminars at the Faculty of Psychology in Seville. Also, many thanks to the three institutions who supported the project activities: Contemporary Art Center, the Andalusian Health Services and the Andalusian Public Foundation for Social Integration of the People with Mental Disorders
Project Lead: Wilson, M.
Project Team: Bleakley, A., Allard, J., McKay, J., Lewis,K., Helledd Jones, L. and Liguori, A.
Wilson, M. ‘Some Thoughts on Storytelling, Science and Dealing with a Post-Truth World’, Storytelling, Self and Society, Vol. 12, No.1, Fall 2017
Digital Dialogues was a project that created an online, safe space for stories to be shared between health service providers, health service users, and their informal carers. The research question posed was:
Can digital storytelling afford a network for mutual recovery across mental health service users, carers and doctors?
Underpinning this research question is an understanding that:
- Storytelling as a communicative mode is a form of social engagement that challenges conventional power structures;
- Storytelling is a mode that enables the processing of experience into learning, by enabling the identification of what is significant in any experience and then the communication of that experience to others; and
- Storytelling facilitates self-reflection and self-awareness that can lead to empowerment.
"I'm not sure if this is the kind of response required but, as a traveller myself, I wanted to respond to this story as I empathise with it enormously. Not only can I identify with it, the way it is written makes me want to hear what happens. Go for it whoever you are."
A good number of narratives were generated, and all these stories, along with selected post-project interviews, were analysed and the process evaluated.
“I like this a lot: ‘Just another moment in time that lasts for days, a single moment looms over your life like cold that linger.'"
Over the period of the intervention, participants’ stories were analysed for indications of:
- Confessional, cathartic content,
- Recovery, and
No Time Resides Here. A story written by a Digital Dialogues Service User, based on a visit to 'Grace' on a dementia ward.
Below is a condensed summary of the project’s findings:
- Perhaps the most important ‘finding’ was the fulfilment of the research design intervention: that doctors, patients and carers met in dyads or triads thus challenging conventional structural power relationships. Established roles and hierarchies were suspended for democratic alliance in the spirit of human inquiry.
- There was no evidence of stories changing noticeably in content or style for any one participant over time. The fact no longitudinal effect was found is probably due to a tailing off effect within the project.
- Stories in a personal, confessional genre dominated the kinds of stories told. Such stories were often cathartic, related to childhood memories or previous events.
- Doctors as well as service users produced confessional stories, exposing vulnerabilities. This goes against the grain of the professional distance or veneer typical of medicine, but not necessarily typical of psychiatry.
- Story lines indicated resilience, recovery and discovery but this cannot be attributed to the project intervention.
- There was some scant evidence of mutuality or community building from stories or responses to them within the online platform. This could indicate that the online medium is not effective in facilitating mutuality, or there was not enough input to the platform to create the possibility of dynamic exchange.
- Carers recruited to the project remained silent, forming an ‘absent presence’.
To conclude, simply putting together dyads and triads of doctors, patients and carers, and encouraging them to work together outside of their normal roles, is an important step. This move challenges the conventional power structures that regulate contacts between doctors and patients, and doctors and carers to allow each of them to become ‘citizens’ in a temporary democracy.
Furthermore, stories can offer a medium for confession and catharsis, as well as a medium for the development of resilience, mutuality, recovery and discovery.
"Yet another brilliant story about life and all that makes me laugh."
A special thanks to StoryWorks UK for their assistance in this project.
Flamenco and Kundalini Yoga Workshops
Project Lead: Perez, E.
Researchers: Crepaz-Keay, D., Ball, M., Haslam-Jones, E. and Pickard, D.
The Kundalini Yoga in Children’s Homes Project comprised a feasibility study of mutual recovery through the creative practice of kundalini yoga with children in care, youth practitioners and management.
The findings from the study include:
- Participants found the practice meaningful and experienced benefits on both an individual level and a social level.
“I learnt a lot about myself, I think it’s given me far more focus in what I’m doing, I think reflecting and looking back on it regarding focus; it gave me a lot more focus, not just jobwise but life wise […] I’m happier, I’m certainly happier, and I’m certainly a lot more focused on my health than I was and I say I’m a lot more focused on me than I was.”
- ‘Togetherness’ is a factor that promotes well-being.
“I feel more connected to others. It’s opened my eyes to something new.”
- Embodied practices are more suitable for children and young people who may find talking therapies challenging.
“I mean it. [practicing yoga] did make for a good conversation point because we were all having a good chat about it, what we did there and how, we had a laugh.”
- Ethics for accessing children and young people’s narratives online is a requirement to promote trust in the digital environment.
The initial work introducing Kundalini Yoga in children homes has evolved considerably, with new creative interventions being designed to improve spiritual, physical and emotional well-being combining yoga and flamenco.
This work was presented at the recent 5th International Health Humanities conference, and soon after numerous invitations were received to run workshops among children and young people as well as adults (e.g., AHRC funded project ‘Hungry for words’ lead by Dr Bartel and at the National Trust, The Workhouse in Southwell).
A paper describing the process to develop the workshop titled ‘Creative Practices as Mutual Recovery: Flamenco-Yoga’ (2017) has been accepted to the Spanish journal ‘Working papers on Culture, Education and Human Development’.
International collaborations have culminated in two journal articles (Saavedra et al., 2017;Saavedra et al 2017) and the possibility to contribute as editor in a special issue of the Journal ‘Arts and Health’. This special issue will be focused on creative practices as mutual recovery and it will feature some of the research work presented at the 5th International Health Humanities conference.
Acknowledgements to be made to Emily Haslam-Jones from Yoga Nova and Diane Pickard from Fiesta Flamenco.
Genealogies and Theories of Mutual Recovery
Project Leads: Brown, B. and Manning, N.
The Genealogies and Theories of Mutual Recovery work package involved investigating: the genealogy, theories and conceptualisation of creative practice as mutual recovery; and the nature, shape and form of communities of recovery.
It considered how communities of recovery are thought of and how they might be connected to promote mental health and well-being. It has traced the origins of the recovery movement and considered how this has shaped the rise of the user movement and other movements in critical psychiatry.
Within this work package it was also considered how notions of community and mutual recovery are understood within nursing and medicine and how they relate to broader structures and processes such as social capital and responsibilisation.
The concept of recovery has predominantly been formulated as being about an individual psychological adaptation to so-called mental illness. In the present day, and in earlier incarnations such as Recovery Inc and Alcoholics Anonymous, the focus has been on individual adaptation and transformation. The overarching notion of ‘illness’ itself is typically not challenged.
Moreover, the focus on the client’s thoughts and actions rather than the therapeutic actions of service providers further individualises and personalises the problems. Rather than encouraging client autonomy, this thrusts responsibility for recovery back upon the client and their thoughts and actions.
"They told me I’d have to take responsibility for myself. Well how can I? You can go home at night but I’m here on a f****** section so how can I do any such thing? I’m not allowed to go home am I?"
Consequently, when recovery programmes are discussed in literature and implemented in practice, they tend to focus on individual factors at the expense of looking at wider patterns of social relationships, opportunity and social inequality which may enforce the invalid role or enable emancipation from it. This impression was sustained in a series of conversations with people who had undergone recovery after a period of mental ill health.
The recovery-oriented activities they described in the context of service delivery were awkward and burdensome, but the social activities – and social capital – they had moved on to in the wider community were described much more favourably. Significant to this latter experience was the ability to contribute something back.
The experience of involvements in amateur dramatics, sport, artistic communities and allotment societies was described in positive terms and participants relished the opportunity to do things with others towards a common goal and feel that they were contributing something, or they had skills valuable to others.
"People think that amateur dramatics is a bit you know arty farty and it all just happens. Well it bloody well doesn’t. There’s a lot of sheer hard graft...Loads of work."
This aspect has also informed work package three: Comparative analysis of multiple narratives of mutual recovery and community building. Here, it was discovered that there is substantial coverage of arts-based initiatives to promote mental health and recovery in the local press in the UK, and these opportunities were described favourably, often in clients’ own words.
Making Music for Mental Health
Project Lead: Williamon, A.
Project Team: Bleakley, A., Allard, J., McKay, J., Lewis, K., Helledd Jones, L. and Liguori, A.
Fancourt D, Perkins R, Ascenso S,Carvalho LA, Steptoe A, & Williamon A (2016), Effects of group drumming interventions on anxiety, depression, social resilience and inflammatory immune response among mental health service users
The Making Music for Mental Health Project examined how group drumming can facilitate mental health recovery among adults with experience of mental and emotional distress based on a series of drumming interventions led by professional and student musicians.
“Look it was nice not to know who was who yeah? So we didn’t have to put a label ‘this one is a therapist, this one is a patient.’”
Adopting a mixed-methods approach, quantitative and qualitative data were collected throughout each intervention using questionnaires, saliva samples to measure stress response and immune function, and interviews.
The research showed that, compared with control activities, 10 weeks of group drumming led to significant improvements in measures of:
- anxiety (by 20%),
- depression (by 38%),
- social resilience (by 23%), and
- well-being (by 16%).
"[Drumming is] a doorway to something (…) somebody has opened a door into an area that you might never have gone into which is really exciting isn´t it? There might be a few more doors out there… (…) who knows, bungee jumping! But hum, it´s that openness and exploring in it."
These findings were maintained at 3 months follow-up, with drumming seen to facilitate positive emotions, increased agency, a sense of accomplishment, task engagement, enhanced self-awareness, and social connections. The mechanisms behind recovery were identified as:
- artistic, due to the communicative and rhythmic nature of drumming;
- social, due to the accepting, safe, and connecting nature of the group; and
- educational, due to the inclusive and free learning environment expedited by expert musical facilitators.
In addition, analyses of immune function (derived from saliva samples taken as part of the research) showed that drumming was also associated with a shift away from an inflammatory immune profile – a finding comparable with results from studies involving anti-depressant medication and psychotherapies.
The project has led to ongoing drumming provision for mental health service users and their carers at community centres in London and has informed drumming and singing interventions offered through a parallel project with older adults (Art for Ages).
“To me it was about bringing myself more to the realm of music and my body! Because it made an impact on my balance you know, and that´s in fact something that I am quite [keen] to continue to keep the balance because I can easily spend too much time in my head."
Additionally, the project has informed an ongoing suite of arts-in-health projects led by the Royal College of Music, including Music and Motherhood (exploring the impact of creative interventions on symptoms of postnatal depression) and HEartS (exploring the health, economic and social impact of the arts).
The research team would like to gratefully acknowledge the Chelsea and Westminster Hospital Foundation Trust and the workshop leaders and assistants who facilitated the drumming workshops.
Musical Jamming (US)
Project Lead: Beresin, E.
Project Team: Callahan, K. and Schlozman, S.
Callahan, K. Schlozman, S. Beresin, E. and Crawford, P (2017) The use of music in Mutual Recovery: a qualitative pilot study
Please click here for an example of mutual recovery, by Dr Gene Beresin
The concept of mutual recovery is extremely rare in US health care. When we began our collaboration with Professor Paul Crawford and colleagues in 2013, to our knowledge there were no other groups or academic institutions in the US pursuing these unique ideas in healthcare. Similarly, there were no publications from US authors in which the fundamental concepts of mutual recovery were addressed. To date, this does not appear to have changed, with the exception of the work we have been able to complete.
As we have stated in our review article (accepted, pending revisions for the US journal Psychiatric Services), the reason for the virtual absence of what are clearly extremely compelling concepts is most likely tied to the American system of health care delivery. To the extent that US healthcare is structured much more as a business than health care systems in other developed nations, the notion that the “deliverers” of care could and indeed ought to benefit from providing care is overwhelmingly foreign.
Professionalism in the US is specifically defined as providing care absent of a bidirectional paradigm. In other words, doctors and other clinicians provide care to patients, the patients receive the delivered care, and any mutualism that arises from this transaction is either purely coincidental (the clinician happens to feel rejuvenated by an experience that was coincidentally experienced) or derived from the sense of a duty to the patient performed by definition completely selflessly.
Nevertheless, it is also clear that the benefits of mutual recovery as described in work from the UK and other nations would be of great benefit to health care in the US. Physicians and other clinicians in America are subject to worsening burnout as measured through numerous studies as well as implicitly through increased rates of health care complaints among clinicians, including higher rates of depression and suicide.
To this end, it is very possible that mutual recovery could become a central ingredient to rescuing our badly overburdened and often unsatisfying health care experience. Whether these concepts could translate into US health care was the key question that drove our collaboration. An intensive literature review and a pilot study using qualitative analysis were conducted.
Literature Review: Before embarking on our own study, we decided to research whether there were any US investigations of mutual recovery that had already taken place. Despite an extensive review of US literature, we were not able to find review articles or active studies. There were articles that addressed the recovery movement in mental health care and substance abuse, but these articles were limited to the relatively narrow concept of self-driven recovery among those who suffer from psychiatric illnesses. There were no articles that noted any deliberate or even accidental benefit to the clinician in the delivery of health care outside of the entirely selfless model of clinical work that is a cornerstone of medical professionalism in the US.
We also noted that, while much of the creative endeavours that are characteristic of mutual recovery are present and in fact of increasingly enthusiastic interest in American clinical practice, it is never stated that clinician and patient might bi-directionally benefit from these practices. There is, for example, a quickly expanding body of literature exploring music therapy, but there are no studies or even recommendations about clinicians and patients creating music together. The same is true for art therapy, dramatic therapy, and other similar modes of treatment.
The mutualism of mutual recovery is, as we have said, completely absent from American healthcare. In our review, we discuss why this might be the case and how US medical schools and health care delivery systems could benefit from incorporating Mutual Recovery concepts. This review has been accepted pending some revisions for Psychiatric Services.
Pilot Study: We decided to investigate mutual recovery using the NVivo measurement tool for qualitative analysis, focusing on a musical performance that happened weekly in the Boston area and involved clinicians as well as patients. These patients all carried diagnoses of one or more very severe psychiatric illnesses – most often psychotic disorders – and most of them lived in supervised residential settings. The musical performances were free form and non-prescribed, and patients as well as clinicians were interviewed after the performances.
Through these interviews, we learned that clinicians and patients felt measurably better about their work together, enjoyed both clinical work as well as the work spent creating music, and experienced significant rejuvenation. This work has been favourably reviewed with revisions requested by the Journal of Applied Arts & Health.
In summary, although mutual recovery is still largely unexplored in the US, we hope to change this, and we are grateful for the support from and collaboration with Professor Crawford’s group.
Many thanks to the Massachusetts General Hospital and Harvard Medical School, Department of Psychiatry and the Division of Child and Adolescent Psychiatry.
Mutual Recovery for Older Adults Experiencing Depression (China)
Project Lead: Dai, J
Project Team: Fu, H., Gao, J., Wang, C., Hua, Y., Qian, W., Liu, J. and Wu, L.
Chao, W., Yujie, H., Hua, F.,Longfeng, C., Wen, Q., Junyang, L., Crawford, P. & Junming, D. (2017)Effects of a mutual recovery intervention on mental health in depressed community-dwelling adults: A cluster randomised trial.
The Mutual Recovery in Community Depression for Older Adults Project investigated whether creative practices such as story and music sharing promoted mutual recovery among older adults experiencing depression in Fudong community, Shanghai, China. The study found this approach could effectively improve symptoms of depression, sleep quality and psychological well-being in older community-dwelling adults with depressive symptoms.
Additionally, two publications (listed below), emphasising the importance of social connectedness, were developed and are being used across six communities in the Shanghai district.
Happiness and Well-being Publication
This public, easy-to-read publication, published by the Department of Public Health, Fudan University and Fudong District in 2014, summarises the key evidence from the research. It promotes mutual recovery approaches to dealing with depression and highlights the benefits of health satisfaction and sleep. Case profiles on10 participants present personal statements on the benefits of the creative intervention.
Happy Lifestyle and Well-being Guide
A detailed guide on enhancing happiness and well-being for elderly people with depression, resulting from the project. It was published by the Department of Public Health and Fudan University in 2014. The guide provides an eclectic approach to the management of depression in the community setting and with the support of community members.
Acknowledgements to Chao, W., Yujie, H.,Longfeng, C., Wen, Q., and Junyang, L for their contributions to the project.
Mutual Recovery in Media and Policy
Project Lead: Koteyko, N.
Researcher: Atanasova, D.
The Mutual Recovery in Media and Policy project analysed news articles published in national and local British newspapers between 2007 and 2015 to understand how mental health and arts participation were framed and how the relationships between participants in arts initiatives were conceptualised.
Using corpus-assisted qualitative frame analysis, frames of recovery, stigma and economy were identified.
The recovery frame, which emphasised that mental illness can be treated similarly to physical illness, positioned arts participation as a form of therapy that can complement or substitute medication.
The stigma frame presented arts participation as a mechanism for challenging social conceptions that mentally ill individuals are incapable of productive work.
The economy frame discussed the economic burden of mentally ill individuals and portrayed arts participation as facilitating their return to employment.
Using thematic analysis, which paid attention to the representation of social actors, the project found that service users were identified as the prime beneficiaries of arts initiatives, and arts participation was conceptualised as a way to bring people with mental health issues together. These findings are discussed against existing research on media representations of mental health and the concept of ‘mutual recovery’. Suggestions are made as to how wider concurrent developments in the areas of mental health and the media may account for the uncovered frames and themes.
Little systematic research on recovery messages in the media
While the number of studies on mental health and the media is growing, it was found that the latest major review of this literature examined research published until the end of 2005. Therefore, research on the media depictions of mental health published over the last decade (2006 – 2016) were reviewed.
Among the key findings is that studies predominantly focused on the illness side of mental health by examining the representation of mental illness in general, specific disorders or violent events involving mentally ill individuals. In contrast, few studies engaged in systematic research of mental well-being and recovery messages in the media.
While past research occasionally reported the presence of ‘recovery’ themes in a certain percentage or proportion of the analysed coverage, little was offered in the way of context and description of what those recovery messages entailed.
Recovery messages predominate in UK news content, but the potential of creative practice to advance a mutual model of recovery is underdeveloped
News articles published in national and local British newspapers (2007 – 2015) were reviewed to understand how mental health and arts participation were framed and how the relationships between participants in arts initiatives were conceptualised.
Using corpus-assisted qualitative framing analysis, the ‘recovery’ frame was identified as the most prevalent – an overall positive development that recognises the reality that many people who experience mental health problems can and do make a complete or partial recovery. News articles within this frame emphasised that mental illness can be treated similarly to physical illness and positioned arts participation as a form of therapy that can complement or even substitute medication.
Using qualitative thematic analysis, it was also found that service users were identified as the prime beneficiaries of arts initiatives and arts participation was conceptualised as a way to bring people with mental health issues together. Thus, fully fledged mutuality remains elusive, as the focus within the analysed news coverage was on the segregated recovery of service users through arts participation.
Policy documents on mental health have been the subject of little scholarly scrutiny
The research found that the content of policy documents on mental health has not been researched much overall. Using thematic analysis and discourse analysis techniques, the review:
- found that recovery was rarely defined within the analysed policy documents and some conceptualisations of recovery were metaphorical;
- identified themes of recovery such as ‘arts participation and recovery’, ‘stigma and recovery’, ‘recovery as an assessment criterion for mental health service funding’; and
- found that contrary to the identification of most documents as the outcome of cooperative work, the voice of people with mental health problems was seldom incorporated directly in contrast to the voice of other actors.
Project Team: Spandler, H.,Tew, J., Ecclestone, K., Wallcraft, J., White, C., Croft, H. and Devaney, T.
Lewis, L.,Spandler, H., Tew, J. and Ecclestone, K. with Croft, H. (2016), Mutuality, Well-being and Mental Health Recovery: Exploring the roles of creative arts adult community learning and participatory arts initiatives. Summary Report.
Lewis, L., Spandler, H., Tew, J. and Ecclestone, K. with Croft, H. (2016), Mutuality, Well-being and Mental Health Recovery: Exploring the roles of creative arts adult community learning and participatory arts initiatives. Briefing Paper (long)
The aims of the Mutuality, Well-being and Mental Health Recovery research were, to explore
- the mutual processes through which creative practices in adult community learning (ACL) and mental health participatory arts settings affect well-being and recovery for a range of people involved.
- how the goals of mutuality, well-being and recovery interact with educational goals and traditions in ACL and mental health participatory arts contexts.
The study involved five ACL groups in the West Midlands:
- a women’s jewellery-making learning circle;
- a beginners painting and drawing course;
- a creative writing learning circle;
- a ‘confidence through creativity’ art group, and;
- a ‘reablement’ art course.
It also involved two London-based mental health participatory arts organisations:
- an art studio organisation managed by trained artists and art therapists, called studio managers; and
- a poetry group based at a service user-run arts organisation.
The research methods included participant observation, interviews and focus groups with adult learners/ members/ participants (n=50) and, practitioners and volunteers (n=16). In addition, interviews were conducted with project organisers and managers in the fields of ACL and mental health participatory arts (n=10).
The key findings of the research include:
- Creative arts ACL and participatory arts settings can develop creativity and agency for participants as interrelated relational processes.
"I came for the jewellery but I found a lot more."
"It’s such a great group that it does, sort of, build your spirits, really (...) and you go away a lot happier in your heart than when you came in”
- An approach to participatory arts in which practitioners, volunteers and members engage in creative work together can expand opportunities for creativity, personal development and being part of a community for everyone involved.
“It’s good for me to feel I’m part of this community rather than I’m somebody who runs it.”
"Working with the group enriches my life by opening doors to a deeper understanding of other people whose life is different to my own. It feeds my empathetic qualities and teaches me new life skills."
"I enjoy the company and I also enjoy helping others."
- The sharing of creative practices and products through participation in creative arts community settings can enhance capabilities for well-being for all participants through providing a sense of mutual achievement and enjoyment.
- Mutual processes of ‘recognition’ in creative arts community settings involve valuing people by sharing skills and creative outputs and making humanistic connections through shared creative practice. This can create the relational basis for well-being and recovery.
“I mean I’m an artist, essentially, and I have to look inside of myself, and whatever image arises, I have to create that picture or sculpture or film, but I am also interested in having a connection with the wider world, having something to offer, being part of a community or the wider world, having a value in it, having a place…”
"I think it's generous, you know, when people create together."
- Some of the limiting factors for mutuality in these creative settings revolve around tensions between personal needs for social or creative distancing versus connection to others.
- Professional values and boundaries, organisational responsibilities and practical considerations are challenges to a mutual approach involving benefits for practitioners and other participants from shared creative practice in creative arts ACL and mental health participatory arts settings. There are a range of ways in which practitioners and volunteers negotiate these challenges.
- In ACL and participatory arts settings, educational and mental health and well-being goals may be viewed as complementary and there can be similarities and overlaps between educational processes and therapeutic ones. Nevertheless, tensions between these goals may arise. In ACL contexts, an explicit focus on well-being aims may risk overshadowing educational objectives.
For the third sector organisations who collaborated in the research, there are four main areas of impact:
- Supporting and informing the development of practice, provision and evaluation strategy.
- Professional development for members involved in conducting the study.
- Valuing and supporting participants – benefits for participants arising from infusing mutuality into the research methodology.
- Inspiring and informing further work.
Many thanks to the third sector organisations who collaborated in this research and to all the participants who gave their time and insights by taking part in interviews/focus groups and the staff members who facilitated the fieldwork. We are also grateful to those in the study settings for accommodating the participant observation, and to those who agreed to have their art-work appear in this digital report.
If you are interested in reproducing the project artwork displayed, please contact Lydia.firstname.lastname@example.org
The Birth Project
Project Lead: Hogan, S.
Project Team: McCloskey, P., Phillips, K., Baker, C., Cornish, S., Watts, L., Joyes, E. and Gibson, D.
Births can be traumatic for all involved. Hospital protocols, coupled with the unpredictability of giving birth itself, can override what women want and expect in terms of a birth experience, leaving some women frankly in shock, which can then have a knock-on effect on infant development. The Birth Project uses the arts to explore this complex and emotive field.
Throughout the course of the research, parents and birth workers have been given the opportunity to explore their experiences of compassion fatigue, stress, birth suffering and post-natal readjustments using the arts (drawing and painting, photography, photo-diaries and art elicitation in participatory arts community workshops), primarily through art-making and the elucidation of the art works produced.
The aim of this study was to use the arts to interrogate birth discourses, challenge embedded assumptions, and in the process, stimulate mutual recovery between all those who have experienced and been affected by birth.
Researchers worked in collaboration with women (n=16), midwives (n=7) and a birth worker, using a range of qualitative visual methods to produce knowledge and understanding of birth experiences from different perspectives.
Workshop Series 1: Mothers Make Art
Within this workshop, eight women, from a diverse community in Sheffield, attended a three-hour weekly workshop over a 12-week period. The first six sessions were consisted of a group discussion about art and cultural meaning, a discussion of birth and early parenting experience, and then creation of art using every day, domestic objects (such as cling film and paper towels). The remaining six sessions involved the women working on their own projects, related to their birth experiences and early parenting.
The workshop supported the women to develop their own artwork to be shown at an exhibition. The art produced was diverse, some chose film, others photography, sculpture, installation, and digital media.
“Helped me enormously work through my own issues – issues I wasn’t necessarily aware existed!”
Workshop Series 2: Art Elicitation Group
Within this workshop, eight women, from Sheffield and the East Midlands, attended a three-hour weekly workshop over a 12-week period. This was an art elicitation group explicitly for those who felt that they would like to work in a more intensive and therapeutic way with self-acknowledged unresolved birth issues. Themes were offered as a starting point and were introduced through story-telling, poetry, guided imagery, and provision of artists’ images.
The structure of the group included consideration of women going back into their ‘everyday worlds’ and resuming the care of their children and other responsibilities, where debriefing at the end of each workshops was completed. Over the weeks the women worked on several individual pieces of art, using art therapy techniques, which responded to the themes set by the facilitator.
“I was able to share ‘moments’ of empathy. I felt able to express myself freely, cry very early on. We all shared the intense, powerful experience of being mothers, in a creative environment. Time and space to talk about me. Emotional and liberating. I felt supported and cared for. I have never felt silly.”
Workshop Series 3: Birth Professions Make Art
This workshop was attended by midwives (n=7) and a birth worker and involved drawing on techniques from art therapy over a 12-week period. Participants were invited to reflect on what it feels like to be a midwife (or a birthing professional).
Birth professionals found the arts useful as an analytic tool for helping them to think about their practice. They found engaging in a supportive art group experience allowed them to reflect ‘holistically’ on their practice.
"I thought that it was very striking to hear the mothers talk of their guilt surrounding difficult births; they often blamed themselves for complications that had arose. It also made me realise how important it is to give the mother as much control as possible; many spoke of feeling powerless and pressurised into doing things the 'right' way."
Below are the findings for the Birth Project:
- Art elicitation workshops can increase participants’ awareness and understanding of their birth experiences.
- It is less the actual intervention itself in childbirth, rather the quality of the engagement between health professionals and the birthing mother which is of crucial importance to the well-being of the mother during the birth experience.
- Image-making and reflection can validate difficult birth experiences and mediate stress.
- Supportive art group experiences can help mothers in the transition to new motherhood.
- Supportive art group experiences increase confidence and self-esteem.
- The overall experience of being in the groups greatly enhanced the women’s sense of well-being.
- Birth professionals found the arts useful as an analytic tool for helping them to think about their practice.
- Birth professionals found that engaging in a supportive art group experiences allowed them to reflect ‘holistically’.
The Birth Project used the Warwick Edinburgh Mental Well-being Scale (WEMWBS) and the Secker scale 2 to measure the well-being of workshop participants. Both these scales are now widely used, and this therefore increases the comparability of this research.
Most participants attended the weekly three-hour workshops over the course of 12-weeks. A total of 16 mothers completed measures of mental well-being and social inclusion at the first and last workshops, finding their scores increased. The analysis shows improvement in self-reported measures across most fields and an extremely noteworthy increase in the overall WEMWBS scores for both interventions.
The participants’ comments indicated increased social support, confidence, motivation and mental well-being, in addition to decreased social isolation. Despite the small sample sizes, the initial results provide promising evidence of gains in mental well-being and social inclusion. The question of longer-term benefits beyond the duration of the workshops remains, but these results tentatively add further support to the use of participatory arts in promoting mental health and well-being for new mothers.
Findings from a preliminary analysis based on both groups with mothers would appear to support existing research that it is the quality of care and the nature of the relationship between the care provider and the women that is of crucial importance for the women’s birthing experiences, no matter where the birth takes place.
It would also seem art groups are a valuable resource for women to make sense of, and understand their birthing experiences, as they potentially build self-awareness and self-confidence through the sharing of experience in the process of art-making.
An exhibition of the workshop artwork was held at The Circle, Sheffield, in 2014. A further exhibition took place as part of a showcase event, in April 2015, at the University of Derby’s Enterprise Centre.
Many thanks to the workshop leaders and mutual recovery event facilitators: Shelagh Cornish, Deborah Gibson, Marian Liebmann, and Lisa Watts, and also the current researchers Emma Joyes and Kate Phillips. Eve Wood of Sheffield Vision has exercised huge amounts of patience in dealing with my editorial requests in my role as executive producer of the film series. Last, but not least, Dr Charlie Baker has been a critical friend throughout this project.
Conclusions and Recommendations
Creative arts initiatives can be an effective way of meeting growing calls for a shift of emphasis in mental health services provision towards social perspectives, a community development approach and of enhancing relationships and social support in the context of the well-being agenda. An adequate grasp of mutuality and social relationships is also important in addressing recent policy initiatives around loneliness.
Two key benefits of the diverse set of shared creative practices in this programme of research were identified in the findings. First, they can help people recover mental health and well-being together – ‘mutual recovery.’ Second, they can increase social connectedness within and between not just groups of people with experience of mental health issues, but also informal or family carers and health, social care, education and arts practitioners.
Both targeted and mainstream creative arts initiatives have a role in supporting mental health and well-being. There is also an important place for women-centred creative arts provision which facilitates the development of peer learning and support systems.
To achieve mutual benefits for practitioners and other participants from shared creative arts in Adult Community Learning (ACL) and mental health participatory arts settings, practitioners and volunteers should be supported to negotiate the challenges involved. In these settings, it is also important to recognise the resources within user groups which can support educational and mental health and well-being objectives. However, staff facilitation remains important.
The importance of relationships and social support to well-being and recovery means that continuity and stability of provision of creative arts ACL and participatory arts initiatives is necessary for maintaining outcomes in these domains.
The contribution of creative arts to recovery was particularly well presented in local media. However, the concept of mutual recovery between different groups remains elusive, with news coverage focusing on the recovery of service users through arts participation where they recover 'together', but together with other service users, not alongside practitioners and family carers. It is hoped that in future the media will capture and represent more of the growing number of creative initiatives that bring together all these groups.
Contrary to the identification of most policy documents on recovery as the outcome of cooperative work, the voice of people with mental health issues was seldom incorporated directly.
We did find some instances where a creative practice either did not suit some individuals, did not clearly promote ‘mutual recovery’ or became difficult to engage with. We learned that: while benefiting many participants, clay modelling did not suit everybody due to its qualities of coldness and muddiness; creative arts community initiatives often need to achieve a balance between self-directed and collective practice/learning, and ‘mutuality’ should not be expected or forced upon participants; it is often better for well-being aims to remain implicit in ACL settings; the extent to which online storytelling can promote mutuality or connectivity remains uncertain; professional roles and organisational responsibilities sometimes limited or acted as a barrier to practitioners participating in shared creative practice; people with serious mental health issues may struggle to remain engaged without direct mental health professional support.
We would recommend that health, social care, education and arts organisations consider: promoting more shared creative practices to benefit the mental health and well-being of all communities that they serve, including practitioners and family carers; and developing strategies for how ‘mutual recovery’ opportunities can be maximised to enhance their environments in feasible and innovative ways. In addition, we would encourage professionals in these organisations to consider the benefits of engaging in shared creative practices with their peers, other professionals and non-professionals, not least people with experience of mental health difficulties and their family carers.
Further research is required on how other kinds of creative practice not investigated in this study might promote ‘mutual recovery’ of mental health and well-being. This will address not only the challenge of connected communities, but also enable us to consider a variety of related policy challenges concerned with well-being and social relationships. The need to enhance social capital, promote active citizenship and the amelioration of loneliness can all be addressed via these kinds of activities, so we anticipate a lively role for the health humanities in years to come.
We are grateful to the Arts and Humanities Research Council for funding this programme of research: ‘Creative Practice as Mutual Recovery: Connecting Communities for Mental Health and Well-being’ (Grant numbers: AH/K003364/1; AH/J011630/1).
We would also like to thank our project partners and collaborators, supporting organisations and the many individuals who have offered their advice and encouragement. In particular, we are grateful to: Dr David Crepaz-Keay, Tony Devaney and Debbie Butler for their guidance on Patient and Public Involvement; to Ruth Simmonds for supporting the digital showcase report; and Professor Tess Jones (University of Denver), Professor Niels Buus (University of Sydney) and Professor Andrea Charise (University of Toronto) for being such helpful and critical friends on the Advisory Board. We are also very grateful to Jamie Crawford for editing this report.
Finally, we would like to thank the large number of people who took part in the various projects and all those who agreed to have their art work appear in this digital presentation. We hope that you continue to beneﬁt from being part of creative communities who recover mental health and well-being together.
Project Partners and Collaborators
AIMS (Association for Improvements in Midwifery Services), D.R.E.A.M., Derbyshire Healthcare NHS Foundation Trust, Eventus, FAISEM, Fiesta Flamenco, Mental Health Foundation, National Service Users Network, Nottingham City Council, Nottingham Contemporary, Nottinghamshire Healthcare NHS Trust, OppNet National Institutes of Health (US), Science Museum Group, Shefﬁeld Vision, Sure Search Mental Health Network, Workers’ Educational Association, and Yoga Nova.
Centre for Mental Health (UK), De Montfort University (UK), University of Derby (UK), Fudan University (China), Harvard University (US), Institute of Mental Health (UK), Institute of Psychiatry (UK), King’s College London (UK), Loughborough University (UK), Queen Mary University London (UK), Royal College of Music (UK), University of Birmingham (UK), University of Denver (US), University of Nottingham (UK), University of Seville (Spain), University of Shefﬁeld (UK), University of Sydney (Australia), University of Toronto (Canada), and University of Wolverhampton (UK).