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:

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.

Comedy and Mutual Recovery

Project Lead: Winship, G.

Researcher: Baker, A.

Baker, A & Winship, G (2016) Recovery is no laughing matter – or is it?

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.

Digital Dialogues

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.

A good number of narratives were generated, and all these stories, along with selected post-project interviews, were analysed and the process evaluated.

Over the period of the intervention, participants’ stories were analysed for indications of:

• Confessional, cathartic content,
• Resilience,
• Mutuality,
• Recovery, and
• Discovery.

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.

A special thanks to StoryWorks UK for their assistance in this project.

Genealogies and Theories of Mutual Recovery

Project Leads: Brown, B. and Manning, N.

Atanasova, D. Koteyko, N. Brown, B. & Crawford, P. (2017) Representations of mental health and arts participation in the national and local British press

Brown, B. (2016) Mutuality in health care: Review, concept analysis and ways forward

Brown, B. (2015) Towards a critical understanding of mutuality in mental health care: Relationships, power and social capital

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.

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. 

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.

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 in Media and Policy

Project Lead: Koteyko, N.

Researcher: Atanasova, D.

Atanasova, D., Koteyko, N., Brown, B. & Crawford, P. (2017). Representations of mental health and arts participation in the national and local British press

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:

1. found that recovery was rarely defined within the analysed policy documents and some conceptualisations of recovery were metaphorical;
2. identified themes of recovery such as ‘arts participation and recovery’, ‘stigma and recovery’, ‘recovery as an assessment criterion for mental health service funding’; and
3. 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.

Acknowledgements

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

Non-Academic

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.

Academic

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).