Little is known about the benefits of arts on prescription for mental health clients. This study found it provided peer support and a sense of vocation
Theodore Stickley, PhD, MA, PGCHE, Dip Couns, Dip Nurs, RMN, is associate professor of mental health, School of Nursing, University of Nottingham.
Stickley T (2010) Does prescribing participation in arts help to promote recovery for mental health clients? Nursing Times; 106: 18, early online publication.
Background Although recovery has become the focus of mental health policy in the UK, few models of practice show how mental health nurses may promote recovery through participatory arts.
Aim To explore the experiences of people who engaged with an arts on prescription programme.
Method This study used narrative inquiry and participants were interviewed three times over one year.
Results and discussion Participants clearly benefited from the programme, especially in terms of having a “safe place” to come to, from making new friends and experiencing peer support. It also enabled some to access education and voluntary work.
Conclusion Engaging with community based arts activities may provide opportunities for clients to make friends, become more socially engaged and have a greater sense of belonging.
Keywords: Mental health, Recovery, Arts on prescription
- This article has been double-blind peer reviewed
- The closure of asylums and day services means the need for a “safe place” for some people should not be ignored.
- Arts activities alone are not necessarily curative. It is the significance of good therapeutic relationships that facilitates recovery.
- Facilitating social networks and friendships may be one of the most important things mental health nurses can do for clients.
- Mental health promotion should involve providing new opportunities for people to become less dependent on statutory services.
Mental health nurses’ role has increasingly involved mental health promotion since the introduction of the National Service Framework for Mental Health (Department of Health, 1999).
In the subsequent decade, many and varied mental health promotion projects have been implemented in the UK. The principles of recovery have become enshrined in policy, including endorsement in the chief nursing officer’s review of mental health nursing (DH, 2006).
This article reports some of the research findings from qualitative interviews with six participants of an arts on prescription programme. A full description of the programme, Art in Mind, can be found in Stickley and Duncan (2007). It focuses on community development by helping clients to work together as artists, for example, sharing studio spaces. All participants use or have used mental health services.
While much research has explored the efficacy of professionally led arts groups (for example, Greaves and Farbus, 2006), there is little on the benefits of community arts, in spite of policy support (DH, 2007).
The arts may be significant for promoting recovery and have been recognised in New Horizons (DH, 2010). Furthermore, the benefits of community arts to mental health are reported in a study (Anglia Ruskin University/UCLan Research Team, 2007) commissioned by the government in response to the Social Exclusion Unit’s (2004) report. The study explored participatory arts and mental health work in England with people aged 16-65.
Results showed significant improvements in empowerment, mental health and social inclusion. Improvements in empowerment and mental health were greater for those identified with “clinically significant” mental health problems at baseline and those who did not report a recent new stress in their lives at follow up than in the comparative groups.
There was a significant decrease in the proportion of participants identified as frequent and regular service users, but no change in medication use or use of specific services, other than a decrease in overnight stays. While there were no differences in occupational or educational activity, one third thought their involvement had increased future employment and education opportunities.
The concept of social capital has been applied to community arts development. For example, in a community arts programme promoting mental health, Parr (2006) found that for many, arts activities provided stability and contributed to social wellbeing in terms of forming and sustaining relationships with other participants.
While research on the arts and community engagement might be in its infancy, examining research on the relationship between arts and health offers useful insights. Staricoff (2004) examined health and medical literature from 1990 to 2004 to explore the relationship of the arts to health and healthcare, and their influence and effects on health. Although the review did not seek to be the definitive evidence base for arts in health interventions, it provided the most comprehensive review of the literature to date, and identified that many areas remained for further exploration.
While a number of community based participation projects have been evaluated, the Health Development Agency (2000) concluded it was not possible to give exact details of specific improvements resulting from such projects, particularly as so few directly provide information on health, or social matters related to health, based on formal measurement instruments.
Social prescribing is a relatively new model and limited literature addresses its role in primary health care. This method of linking patients in primary care with non medical sources of support in the community (Friedli, 2004) has been used quite widely for people with mild to moderate mental health problems, with a range of positive outcomes. Only a few studies substantiate the effect of social prescribing and the context in which it is most effective (such as Darbishire and Glenister, 1998). Some examples include exercise on prescription, prescription for learning and arts on prescription (SEU, 2004).
Social prescribing schemes work with underrepresented communities as a whole and with disadvantaged and isolated people with severe and enduring mental health problems (Bates, 2002).
The literature shows clearly that research on the arts and health, especially arts on prescription programmes, is in its infancy.
Aim and method
This study aimed to explore the experiences of people who engaged with an arts on prescription programme.
A narrative inquiry was used, which provides a framework for exploring the way in which the “self” is influenced by social conditions, discourses and practices. This interpretive research approach places the text in the broader social context and the person’s life situation and environment are relevant to the understanding of the text (Bryman, 2001). It allows us to enhance understanding by exploring and conveying a full picture of this diverse and multi-faceted reality.
The inquiry was based on in depth interviews about specific aspects of participants’ lives, conducted three times over one year.
The relevant ethics committee granted approval and full consent was obtained from participants before each interview. All names have been changed in this article to protect participants’ confidentiality.
This article presents a snapshot of some findings. A collective narrative is identified between participants, which draws together themes and similarities, summarised in three sections: asylum, voice and vocation.
Descriptions of the arts on prescription programme as providing a psychologically “safe place” featured in a number of narratives.
Participants saw staff as supportive, non-judgemental and accepting, and also viewed fellow participants as supportive. The programme was seen as a place where new friendships could be made; an oasis in a difficult world.
Experiences of schooling featured in the narrative of most interviews, although this subject was not raised by the interviewer. Because of the absence of prompts about school and its subsequent appearance in the text, this was interpreted as a positive transference because participants recalled art lessons at school as enjoyable.
Arts on prescription provided a form of institution for participants. The activities were run on set days for set periods. Similarly, experts led the sessions in the same way that teachers had led lessons in school.
Since staff were almost exclusively female (although there were both male and female sessional facilitators), arts on prescription may be seen as a safe mother figure that facilitated “family” type gatherings of vulnerable people. At these, creative opportunities were offered and participants perceived it as a non-threatening place for social engagement and meaningful activity.
The word “voice” featured periodically throughout the findings as it also does in the narrative inquiry literature. Narrative research encourages people to find and express their voice.
There was a sense throughout the data collection period that people were keen to participate in the study, partly because of a perceived opportunity to express their appreciation of being able to participate in a programme that depends on temporary funding. By giving positive reports of the project, there might be a chance of further funding in the future. Therefore, there is a socio-political motivation to get the message across that the project is working and is of value. Often, participants made comments confirming these motivations before or after the recorder was switched on, creating a feeling of collusion.
Once the recruitment process was complete, it was also noticeable that no one dropped out of the study and a number made positive comments about being involved.
The extent to which participants saw the interview process as providing the opportunity to give voice to their thoughts, feelings and beliefs cannot be measured. However, the notion of voice should not be understated in healthcare, especially in mental health where people’s voices may have been previously ignored (Hurwitz et al, 2004).
For several participants, attendance at the workshops had vocational connotations (see Box 1 for two case studies). For one, the programme and the subsequent drop-in sessions provided a focus for his daily life, without which there was a void. For another, it enabled him to engage with various arts projects and secure voluntary work.
Box 1. Case studies
Eve found understanding and companionship in a “safe place”. She recovered from her breakdown, developed a portfolio of artwork and started a foundation course leading to a fine arts degree.
Although Rupert did not entirely abstain from drug-taking while on the programme, his dependency reduced. He declared that for the first time in his life, he felt a sense of social belonging. He has continued to be involved in numerous projects including acquiring a studio, community theatre, film-making, exhibitions and performances. Becoming an “artist” has given Rupert a much-needed identity.
The arts on prescription group is still changing and those who run it measure its success informally, not so much by continued membership but by people becoming less dependent on the group. The notable success story is Eve, who progressed to a foundation arts course to start a part time fine art degree. Rick progressed to part time voluntary work, while Gill added arts on prescription into her repertoire of interesting activities. Rupert, Rick and Ray all benefitted from attending the activities and subsequently formed theatre groups.
The programme therefore offered opportunities not only to develop artistic skills but also social and vocational activities. It is through these social opportunities and an infrastructure to support them, that people may also take the opportunity to form new social and personal identities as artists.
Arts on prescription provided refuge (asylum) and something meaningful to do for people who have become socially disenfranchised. Those who continue with the programme are perhaps those who years ago would have found a strong sense of identity within the walls of the asylum.
Recently a national move has developed towards closing day centre provision for this group of people in favour of more “socially inclusive” models. Only time will tell if British society has made significant gain or loss for some of its most vulnerable people in the name of social inclusion.
Factors that compound the exclusion of people with mental health problems include the effect of mental health services and those working within them (Repper and Perkins, 2003). Admissions to psychiatric wards may lead to all roles being eroded other than that of “mental patient”. Lengthy and repeated admissions have been found to lead to diminished social networks and increased contacts with professionals and fellow service users (Holmes-Eber and Riger, 1990).
Friendship helps people to develop and sustain personal and social identities. When this is reduced to quasi-friendships of contact with healthcare professionals, people may accept their own identity in relation to statutory healthcare provision.
Sayce (2000) maintained that by not thinking of mental health service users in terms of citizens in the wider community, mental health practitioners condemn them to a marginalised role of outcast. In other words, by maintaining the worker/client relationship, statutory workers may inadvertently reinforce negative stereotypes and challenge the development of personal identities away from the identity of “service user”.
Social inclusion, therefore, is so much more than helping people to integrate into society; it is also about acknowledging the potentially damaging roles of the very people whose role it is to “promote inclusion”.
Social capital and inclusion
Parr (2006) suggested it is perfectly possible for people to attend closed art groups with other service users and feel improved self-esteem and benefit from peer support, but remain isolated from the wider community.
For participants in this study, what is significant is the bonding that people experienced with one another in the arts on prescription programme. Genuine friendships were established and mutual, peer support was apparent.
Only further, longer term research will establish whether people have moved on to full time education or employment.
Deficits in a sense of belonging have been linked to problems in both psychological and social functioning. There are surprisingly few mental health research studies on the psychosocial influences of a sense of belonging although a number of studies exist, mainly in relation to displaced people (for example, Prince and Prince, 2002).
Halpern (2005) identified “group density effect”, in which mental health may improve where people have a sense of belonging in a minority group. It has been argued that this decreases hospital admissions for people with mental health problems (Halpern, 2005). Again, further longitudinal research is needed as membership of a group limited to mental health service users may also increase stigma (Sayce, 2000).
For participants, the arts on prescription programme provided a sense of belonging that would have been seriously lacking for some.
Participants identified a wide range of benefits, including:
- Increased social contact;
- Having a “safe place” to come to;
- A sense of belonging;
- Making new friends;
- Being able to develop an identity as an artist;
- Opportunities for future education and work;
- Increased opportunities for intimate relationships;
- A non-threatening and non-judgemental environment.
Existing research illustrates how engagement with arts activities may enable people with mental health problems to work towards recovery. There is little evidence in the literature of nurses engaging with creative approaches to promote mental health. This study shows not only how mental health nurses may deliver creative solutions for clients’ psychological and social needs but also provides a model for research.
While policies and practices move towards more socially inclusive models of working, clients’ complex needs for safety, belonging, friendship and identity should not be ignored. Community based arts programmes may help to meet some of these needs.
The arts on prescription programme is part of the Art in Mind programme, delivered by City Arts (Nottingham).
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