The Arts in Psychotherapy 72 (2021) 101748

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The Arts in Psychotherapy

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Research Article

Exploring the role and impact of visual art groups with multiple
stakeholders in recovery-oriented mental health services
Tríona McCaffrey a, *, Paula Higgins b, Heidi Morrison c, Siobh´an Nelligan a, Aoife Clancy a,
Pui Sze Cheung a, Sin´ead Moloney d
a
Irish World Academy of Music and Dance, University of Limerick, Ireland
b
Highfield Healthcare, Dublin, Ireland
c
Soearth Projects, Kildare, Ireland
d
Novas, Dublin, Ireland

ARTICLEINFO
ABSTRACT
Keywords:
Visual art This arts-based study explored the role and impact of visual art in supporting collaborative working between
Mental health recovery service users and staff in a recovery-oriented mental health service in Ireland. A total of two service users
Co-production and five staff members took part in three visual art focus groups led by a qualified art therapist. Afterwards,
Arts-based research service user and staff experiences of focus group participation was investigated through individual semi-
structured interviews that were analyzed using Thematic Content Analysis. Three original artworks were
created in three focus groups, each of which represented how stakeholders wished their recovery-oriented
service to develop in future. Analysis of interviews describing experiences of working with fellow mental
health stakeholders in the focus groups
revealed five common themes including: ‘Group art-marking engenders collaboration’, ‘The physicality of
being in the art-making space evokes sensory experience’, ‘Group art-making can offer a sense of
liberation’, ‘Group art-making raises questions about self-revelation’ and ‘Group art-making enables an
atmosphere of equitity’. Findings suggest that when facilitated by an art therapist, group visual art making
can offer stakeholders a
creative, liberating and equitable environment that can foster the concept of co-production that is foundational
to effective recovery-oriented working in mental health.

Mental health recovery

The concept of recovery first emerged in the early 1990s and has
since gained increasing traction in contemporary mental health care
(Slade et al., 2014). Recovery is conceptualised as a journey toward a
satisfying, meaningful and rewarding life, characterised by discovering
a new sense of identity and purpose irrespective of clinical diagnoses
or mental health symptoms (Spandler, Secker, Kent, Hacking, &
Shenton, 2007). The recovery vision has influenced the design and
delivery of health care systems, policies and practices internationally
which has led
to an “ongoing process of mental health reform” (Shera & Ramon,
2013, p.17). Met with numerous implementation challenges, the
biggest bar-
rier to realization of recovery-oriented practice is that the original ethos
and design of most modern health systems align with a traditional
medical model of practice whereby the expert opinion of clinicians
dominates over lived expertise of service users. In contrast to this, a
recovery-oriented approach calls for equitable and reciprocal
relationships between service user, staff, and carer stakeholders (Rob-
erts & Boardman, 2014). Therefore, implementation of a recovery-
oriented approach demands a marked shift in the design and delivery
of mental healthcare systems.
Shared understanding and collaboration between all mental health
stakeholders has become paramount for developing recovery-oriented
services (Borg & Kristiansen, 2004; Holwerda, Fokkens, Engbers, &
Brouwer, 2016). The principle of ‘co-production’ is central to this and
involves multiple stakeholders working together to achieve their
desired outcome in an enterprise or project (Health Service
Executive, 2018).
Co-production automatically engenders ‘shared decision-making’ that
requires a mutual partnership between those who use and those who
provide health services (Davidson, Tondora, Pavlo, & Stanhope,
2017). Such processes are central in supporting stakeholders to feel
respected and valued in a collaborative process while also instilling
confidence in
one’s ability to meaningfully contribute to the design and delivery of
service provision. This can foster healthy relationships between
multiple
 * Corresponding author at: Irish World Academy of Music and Dance, University of Limerick, V94 DK18, Ireland.
E-mail address: triona.mccaffrey@ul.ie (T. McCaffrey).

https://doi.org/10.1016/j.aip.2020.101748
Received 30 June 2020; Received in revised form 8 December 2020; Accepted 8 December 2020
Available online 16 December 2020
0197-4556/© 2021 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
T. McCaffrey et al. The Arts in Psychotherapy 72 (2021) 101748
offers a means of investigating complex topics in a peer-supported
stakeholders to establish a bedrock upon which recovery-oriented ser-
vices can develop (Spandler & Stickley, 2011).

Arts-based approaches to recovery

There is a growing body of evidence to support the utilization of

arts- based initiatives in modern mental health provision (Fancourt &
Finn, 2019; Oren, Orkibi, Elefant, & Salomon-Gimmon, 2019). This
brings credence to the idea that participation in creative activity can
lead to positive mental health outcomes due to the capacity of the arts
to pro- mote self-expression by breaking down communicational
barriers and expressing difficult emotional experiences (Devlin, 2010).
A key focus of related research has been on the role of arts-based
programmes in fostering mental health recovery due to the holistic,
collaborative and person-centred environments they offer (Gallagher,
2007). It is sug- gested that participatory arts-based activity naturally
aligns with a recovery-oriented way of working where factors such as
empowerment, connection, control, fulfilment, agency and hope are
nurtured (Van Lith, Fenner, & Schofield, 2011).
Visual art is one of an array of arts-based approaches utilized in
mental healthcare. It provides a means of improving psychological
well- being, primarily due to its distinct ability to offer a means of
commu- nication beyond use of words. Visual art can play an
important role in fostering emotional expression, communication and
social connection among people with mental health conditions (Fenner,
Ryan, Latai, & Percival, 2018). Participants of visual art programmes
have reported how their involvement therein can support social
belonging and improved psychological well-being due to the ability of
art-making to challenge ideas of illness or limitation (Saavedra, Arias,
Crawford, & P´erez, 2018). Lipe et al. (2012) proposed that group visual
art processes are particularly conducive to a recovery-oriented way of
working because of the collaborative, reflective and shared
experiences they can provide.
Visual art processes have predominantly been employed in mental
health settings to support service users’ well-being and recovery with
limited attention given to the opportunities that such shared processes
may offer service users and staff alike. Fenner et al. (2018) offers once
such example, including both perspectives of service users and staff in
a visual art programme. However, staff reflections on involvement
were focussed on their perceptions about what the creative activity
offered service users rather than on their own personal experiences.
Through a conceptual analysis it was posited that group art-marking
has the po- tential to be a powerful tool for establishing common
ground and connection between those present, which in turn can
nurture ‘mutual
recovery’ in ways that offer “new opportunities to build egalitarian,
appreciative and substantively connected communities” (Crawford,
Lewis, Brown, & Manning, 2013, p.55). While this position is certainly
plausible, no study to date has considered the role of a shared visual
art making to encourage collaboration between service users and staff
in a recovery-oriented context. This arts-based study addressed this
knowl- edge gap by inviting such mental health stakeholders to
participate in a series of visual art focus groups facilitated by a
qualified art therapist in which stakeholders were asked to envisage
how they wished their recovery-oriented service to develop in the
future. At the conclusion of the focus groups, stakeholders were asked
to individually consider their personal experience of participating in the
visual art group process.

Method

Research approach

Focus groups and semi-structured individual interviews were

employed to explore the potential role and impact of visual art-making
to promote collaboration among service users and staff, hereafter
referred to as ‘mental health stakeholders’. The focus group method

2
T. McCaffrey et al.
engage-
environment (McDaid, 2009), where flexibility can exist so that new ment with the hospital’s creative arts programme. Information about
ideas can emerge (Doody, Slevin, & Taggart, 2013). In this study, diagnosis was not sought from service users within the focus group
visual art was employed as an arts-based method of data collection sessions as doing so would imply different treatment of mental health
and as a possible means to support collaboration between focus stakeholders. All participants were reminded that their participation
group partici- pants. This data collection method was chosen because was voluntary and written consent for study involvement was obtained.
of its capacity to aid insight and offer a forum through which
individuals could relay their personal views (Finley, 2008). The final Procedure
artworks created were consid-
ered as standalone artefacts of ‘presentational’ or ‘symbolized’ forms The aims of this study were
of knowing as advocated in arts-based research (Liamputtong & to consider how visual art: a) can
Rumbold, be used as a data collection
2008). method in response to the
In addition to involvement in the focus groups, participants were question of how mental health
invited to complete a short semi-structured interview in order to gain stakeholders wish their recovery-
insight into their views of the visual art process. These provided a oriented service to develop in
way of future and, b) can be utilized to
honouring participants’ individual experiences while also offering a encourage collaboration
space to be heard and valued (Furness, Armitage, & Pitt, 2011). between stakeholders in a
The-
recovery-oriented mental health
matic Content Analysis (TCA) of these interviews offered an inductive setting. Participants were invited
approach that seemed epistemologically congruent to exploration of a to partake in at least one of three
topic about which little is known (Braun & Clarke, 2006). This meant ninety-minute visual art focus
that identified themes were strongly linked to the data rather than groups over a three-week period
specific questions asked of participants. Therefore data would not in which they were asked to
have consider how they wished their
to “fit into any pre-existing coding frame or the researcher’s analytic recovery-oriented service to
preconceptions” (Braun & Clarke, 2006, p.83).
develop. Average focus group
The lead researcher (author 1) is a music therapist who has previ- attendance varied from three to
ously worked in recovery-oriented mental health services in Ireland four participants. All focus
and had experience of using songwriting and visual art as a means of groups took place at the hospital
inquiry in mental health research. This experience provided insight and were facilitated by a
into— the potential of these arts-based methods to offer a creative and qualified art therapist (author 3)
inclusive way of engaging participants in the process of inquiry. who had experience of working
Alongside the lead researcher, the research team comprised two in mental health settings. In
creative arts pro- gramme co-ordinators (one of whom was a study this study, visual art was used
gatekeeper), art therapist, music therapist, Nurse Practice as a data
Coordinator, Programme Manager and Head of Department for
collection method and
Wellness and Recovery, service user panel member and Chair of the
participants’ experiences of
Consumer Council, in addition to a Professional Lead in Allied Health
using this were
as an external advisor. Regular research meetings took place among
explored. While this study was
this team over the course of this research. Ethical approval was
not designed as an art therapy
granted from the relevant Hospital Research Ethics Committee.
inter- vention the decision that
the focus groups be facilitated by
Participants and recruitment
a qualified art therapist was
paramount. Such facilitation
This study was carried out in conjunction with the ‘Twilight Pro-
allowed for negotiation of any
gramme’, a creative art and arts therapy programme at St. Patrick’s
potential imbalance of power
University Hospital, a not-for-profit, independent mental health
dynamics between service users
service.
and staff. It also ensured
A multifaceted recruitment campaign took place over a four-week
adequate skill to support difficult
period at the hospital. Both in-patient and out-patient service users
or sensitive issues that might
and clinical staff were invited to participate in a series of three
have arisen therein. A variety of
visual art or three songwriting focus groups to investigate how
art materials were made
these arts-based methods might be used to promote collaboration
available at the beginning of
between multiple mental health stakeholders. The findings of the
each focus-group, including a flip
songwriting focus groups are detailed in a separate publication
chart, large sheets of paper, and
(citation removed to ensure anonymous review). Service users were
a selection of pencils, chalks,
notified about the study through provision of hard-copy information
pastels, paints, and crayons. A
sheets that were circulated through
semi-directive approach was
the hospital’s therapeutic activity programmes and support groups.
adopted by the facilitator whom
Clinical staff members were emailed an electronic copy of the
at the start of each group
recruit- ment poster and information sheet. Hard-copy information
encouraged discussion about
was distributed at multi-disciplinary team meetings and placed in
the
staff rooms.
research question. A ‘brain-
All potential participants were invited to contact the research gate-
storming wall’ was also
keeper by phone, email or in person. Seven individuals including five
allied health professionals, one inpatient and one outpatient service introduced as a
space upon which participants
user were recruited, each of whom were female and had previous
3
The Arts in Psychotherapy 72 (2021) 101748
could pin up meaningful words or
images from magazines to inform
the shared creative process.
Following dis- cussion at the end
of the first focus group, the
facilitator introduced additional
structure in subsequent focus
groups by offering a suggestion
of a theme that participants could
use to guide the art-making
process. Each focus group ended
with group reflection about the
art-making process and the
artworks created, each of which
was digitally photographed.
Six participants agreed to a
short follow-up individual
interview in which they were
asked about their experiences of
participating in the visual art
focus groups. One participant
declined to do so for health
reasons. The lead investigator
carried out semi-structured
interviews of
10 30 min duration with each
participant. These took place in
person at the hospital or by
phone to accommodate differing
patient status and working
schedules. An interview schedule
was followed as featured in Table
1.
Table 1
Interview Schedule.
Interview Schedule
1 Can you tell me about your
immediate thoughts about taking
part in the visual art focus
group(s)?
2 What was your experience of taking
part in the visual art focus group(s)?
3 The purpose of the groups was to
answer a question about service
development, what was your
experience of using visual art for
the purposes of answering this
question about how you wish this
service to develop?
4 Did you feel that your thoughts
and ideas were listened to and
included in creation of the
artworks?
5 What was your experience of
using visual art for the
purposes of encouraging
collaboration between focus
group participants?
6 In your opinion, did the visual art
method encourage collaboration
T. McCaffrey et al.
between focus group
participants?
7 Do you think there are
advantages to using visual
art in working with fellow
stakeholders?
8 Do you think there are
disadvantages to using visual
art in working with fellow
stakeholders?
9 Do you have any recommendations
of how these visual art focus groups
could be
Data analysis
Similar to treatment of arts-
based materials in previous
studies (McCaffrey & Edwards,
2015), the artworks were
reflected on in terms of what
participants were
communicating about their
wishes for future development
of their recovery-oriented
service. They were not
subjected to analysis per se but
rather used as standalone
artefacts that could aid insight
(Schenstead, 2012) and access
aspects of human experience in
an immediate and creative
manner (McCaffrey & Edwards,
2015). To further address the
question of stakeholder wishes
for development of recovery-
oriented services, the focus-
groups were transcribed
verbatim and a summary of
each artwork was extracted
from the written tran- scripts.
Six interview recordings were
transcribed verbatim with pseu-
donyms assigned to each
participant and all personally
identifying information removed.
Transcripts were analyzed
using TCA which involved six
steps of: 1) familiarising oneself
with the data; 2) generating
initial codes; 3) searching for
themes; 4) reviewing themes; 5)
defining and naming themes; 6)
producing the report (Braun &
Clarke, 2006).
A systematic approach to
analysis was employed
whereby authors (5
& 7) read each interview
transcript before individually
generating initial codes. These
codes were pasted into a
master table and colour-coded
to inform the development of
emerging themes across the
data-set. In order to bring
further rigor to the analytic
process, all themes were cross-
checked by authors (1 & 6) with
reference to the original
transcripts. These penultimate
themes were collectively
reviewed by authors (1, 5, 6, 7)
until consensus was reached on
five final themes.
Findings
Visual art findings
Over a series of three visual
art focus groups, three artworks
4
The Arts in Psychotherapy 72 (2021) 101748
were created with input from
seven participants. A short
description of each artwork is
featured below.
At the beginning of the first
focus group the art therapist
presented participants with a
large sheet of blank paper and
an array of art ma- terials.
These were used to create a
design-oriented artwork (Fig. 1)
that features three distinct
contributions including various
elements of rep- resentation
and imagery including a bird,
cracked egg, clock, flowers
and people’s faces. Two of
these contributions fall within
better facilitated in future?
paper that included two faint
circles, the inner representing
recovery, and the outer
representing service
development. This starting-
point aimed to provide a more
contained space for participant
collaboration.
All three participants described
this as an ‘organic’ artwork (Fig.
2) that contained many
intertwining shapes and colours
with different clusters
of design and a stem that
extends beyond the circle
perimeter.
The facilitator began the final
focus group by asking the four
attending participants to consider
the idea of a themed garden that
could reflect their aspirations for
development of their mental
health service. Participants were
asked to consider the type of
plants to include in their garden
and how these would exist
together, or not, in this space.
The final artwork (Fig. 3) has
numerous abstract elements
displayed across the full page.
These are closely spaced
together with pieces of paper,
paint, sticks and string bringing a
and another falls outside what
the group referred to as a
‘blood line’. This was drawn
after completion of each
individual contribution, for the
purpose of
connecting these three varied
representations. This artwork
represents many different ideas
around how participants wish
their recovery- oriented service
to develop.
The facilitator took a slightly
more directive approach at the
beginning of the second focus
group by introducing a large
sheet of
three-dimensional quality to this
colourful artwork that has a
strong sense of energy and
movement.
Interview findings
After the conclusion of the
three focus groups, six of seven
partici- pants described their
experiences of working with
fellow mental health stakeholders
through the medium of visual art.
Analysis of interviews revealed
five common themes including:
‘Group art-marking engenders
collaboration’, ‘The physicality of
being in the art-making space
evokes sensory experience’,
‘Group art-making can offer a
sense of liberation’, ‘Group art-
making raises questions about
self-revelation’ and ‘Group art-
making enables an atmosphere
of equality’ .
Group art-making engenders
collaboration
Participants described that
group art making encouraged co-
operation and collaboration. The
art-making initially provoked open
T. McCaffrey et al.
communication as participants
discussed how to navigate the
creative space together. Alison,
a staff member, described this
initial process;
We had a large white sheet
to begin and trying to think
how do we share this page,
you know, how do we
discuss, do we just go ahead
and take our own space or
do we say divide it up? So
we had lots of different
conversations around that.
using the chalks and pastels. The
The Arts in Psychotherapy 72 (2021) 101748
ment when navigating a space gave her a multi-perspective of
The process of joining lines upon which to work. the task at hand;
and linking spaces facilitated Participants com- mented that
collabo- I think particularly having to
such movement enabled them
ration and active problem- move around and you know
to see their artwork in different
solving among participants. In even some people sat down,
ways, with Amy, a staff
reference to artwork 1, Maura, a and even more people stood
staff member recounted: “we member, explaining how this
up, and we rummaged
had individual pieces of work,
we then joined them all
together and then what
brought us
together was thinking how do
we join them together and we
drew kind of lines that brought
it all together”.
Interviews revealed that
collaborative action could be
spontaneous,
or happen unconsciously, when
participants began to move into
one another’s space on the
page. Jane, a staff member,
described how everyone
attempted to fill in the
uncoloured areas, but
navigated in
unspoken ways around one
another;
There was collaboration
cause we were all drawing
on each other’s bit… I was
colouring any gaps I could
see and then one of them
did mention she felt like
she didn’t notice it but just
unconsciously we started
to move into each other’s
areas… I was gradually
F
moving but I was being
i
gentle about it…. So there g
definitely was .
collaboration, some of it
was conscious, some of it
was unconscious. 2
.
Overall, the art-making
instigated varying collaborative A
actions such as brainstorming, r
t
negotiating space, colouring w
and joining lines. These actions o
were like a dance between r
participants through the art- k
making process.
2
.
The physicality of being in the art-
making space evokes sensory
experience Participants outlined
the physicality of the art-making
process and the accompanying
sensory perceptions it evoked.
This was illustrated in terms of
individual positioning, the
materials used and the trans-
formation of a blank space into
those of substance and colour.
Ruth, a
service user, recalled the “nice
sensation” in her fingers when
large sheets of paper prompted
physical move-
5
 Fig. 3. Artwork 3.

and came back and you know even when you were looking in other
bags for things you suddenly saw it from another perspective so I It sort of helped loosen things up … you know how could we
think that sort of physicality as well, you know, both the materials think about things differently and one of the things for me was
very much
and the movement and the negotiating, I think that all contributed.
the need to return to a sense of playing with something in order
This back and forth movement of group art-marking created a busy to discover something, and I think it allowed us to do that. There
and dynamic space in which to work. One staff member found this to was a great sense of sort of exploration and play (Amy, staff
be a particularly satisfying experience, reflective of the manner in member)
which she carries out her work at the hospital. However, one service
Particularly striking was how this sense of liberation seemed to
user did share a concern that the physical demands of the group
support a “journey of discovery” for one staff member who described
art-marking
being genuinely curious about what happened in the group art-making
environment may exclude those who “didn’t feel like they could do
process.
anything”.

Group art-making raises questions about self-revelation

Group art-making can offer a sense of liberation
All study participants relayed how the process of group art-making
Participants described art-making as a liberating experience where
spurred them to think about the notion of self-revelation. This theme
exploration was fostered in a non-judgmental environment. This
was most apparent in staff accounts of focus group participation.
enabled participants to freely write, colour and draw in an authentic
Maura, a staff member, explained how the demands of the art-making
manner. Jane, a staff member, explained this sense of freedom as she
process was in stark contrast to the boundaried manner in which she
contributed to the group artwork:
would usually carry out her role in the hospital:
I felt it gave me a lot of space to… be colourful, to be myself …
I felt a bit strange, ahm, as a staff member, ahm, because normally
but also appreciate each other’s talents and strengths. I think
I would be quite boundaried and I, you know, I wouldn’t really be
it’s not taken on, so I really felt much of mine was in that
expressing very much about myself but I felt I was opening up, am,
picture. And I
kind of ideas that I had and sharing them with another staff member
didn’t feel judged … whatever I wrote, or coloured, or stuck, I
and a service user and I just found that strange.
felt I had the freedom to do it.
Alison, another staff member, shared a similar concern about self-
This freedom enabled exploration of the creative space. Art-making
revelation, particularly when working with service users who might
promoted a gentle curiosity among participants as to what they could
feel overshadowed by staff revealing more of themselves than they
achieve, as there was no ‘right’ or ‘wrong’ way to engage in the
usually do in their professional practice. In sharp contrast to this, Ruth,
process.
a
The activity was framed as being fun and playful, an environment in
which participants laughed and connected together while having service user, explained that “by virtue of being in hospital” she had
shared much about herself already and was less concerned about
something specific to focus on:
what The question of self-revelation undoubtedly ignited feelings of
she self-revealed in the focus groups. vulnerability among participants. Such vulnerability was recognised by

Amy, a staff member who said “you have to shed something, you have sensory experience’, ‘Group art-making can offer a sense of liberation’,
to allow yourself to be vulnerable and sometimes that can be a bit of a ‘Group art-making raises questions about self-revelation’ and, ‘Group
challenge you know”. Staff explained that the creative process auto- art- making enables an atmosphere of equality’.
matically required them to open up and reveal more of themselves In this study group art-making, as skilfully facilitated by an art
than
they usually would in their daily practice. Debbie, a staff member,
added that this required “a huge amount of trust … and sensitivity”.

Group art-making enables an atmosphere of equality

Participants explained that within the art-making process they
stood on an equal platform where previous senses of hierarchy or
authority seemed to vanish. Individuals may have entered into the art-
making space as a staff member or service user but, once the process
commenced, they assumed equal positions as fellow human beings.
One service user, Ruth, noted how respective roles seemed to
dissipate,
adding that for her it was about “getting away from the fact that I have
been in hospital”. In Ruth’s view this gave way to a shared sense of
humanity among those present:

It’s nice to meet on equal grounds in the sense the person isn’t,
well the person isn’t ill, if you know what I mean. It’s not a patient
and in those settings, we’re coming together as human beings.

The feeling of equity was also acknowledged by staff. Maura

described an absence of hierarchy in the art-marking space which
served as a way of breaking down barriers and opening possibilities
for open communication among those present:

I felt it was very flat, that there was no, there was no hierarchy,
within that, within the room, do you know…We were all very much
equal whether the service user would feel the same, but I think that
she would, but I definitely felt there was no barriers there or that we
were very open to each other.

This shared feeling of equity among participants appeared to break

down interpersonal barriers and facilitate open discussion. It would
seem that group art-marking presented participants with an opportunity
to ‘step out’ of their respective institutional roles and engage in an ac-
tivity on more common ground.

Discussion

Over a series of three visual art focus groups facilitated by an art

therapist, seven participants created three original artworks that were
based upon their collective vision for development within their
recovery-oriented mental health service. The visual art process was
employed as a data collection method and the artworks created from
this were regarded as presentational forms of knowledge open to the
inter- pretation of others (Ledger & McCaffrey, 2015). Collective
reflection from our research team acknowledged the abstract nature
of the art- works that were undoubtedly open to multiple
interpretations. In considering the primary research question about
the possible role of visual art in supporting collaborative working
among mental health stakeholders, we reflected upon the artworks
collectively. In doing so, a striking point was noted in terms of the
evolution of the creative process whereby earlier distinct and separate
contributions dissipated into those where no discernment of
individuality can be made. Therefore, these artworks are testament to
the idea that an increased sense of collabo- ration and creativity had
occurred over the course of the focus groups. Follow-up interviews
were carried out to evaluate the role and impact of group visual art
making in fostering collaboration between mental health stakeholder
participants. Analysis of six interviews revealed five themes including:
‘Group art-marking engenders collabo-
ration’, ‘The physicality of being in the art-making space evokes
therapist, was described as a means of engendering collaboration be-
tween mental health stakeholder participants who came together to
consider their idea of recovery-oriented service development. Partici-
pants were not focusing on mental health difficulties in the task,
instead directed efforts towards a meaningful activity which became
the catalyst for problem-solving and co-operation. Participants spoke
of being resourceful in the novel ways they worked with others, as
coming together to make a collective artwork resulted in new ways of
thinking and shared decision-making. Such collaboration aligns with
the princi- ple of co-production in recovery, in which stakeholders
work together to accomplish a task, and each individual contributes in
a valuable way (Clark, 2015). This study highlights that when
sensitively facilitated by an arts therapist, shared art-making can
provide meaningful opportu- nities for fostering healthy relationships
within an interactive and engaging process that has a focus beyond
mental illness or limitation. This can be described as a collaborative
journey whereby more emphasis is placed on the process of
discovery rather than on the artistic outcome (Nadeau, 2008).
Mental health stakeholder participants described that the
physicality of the art-making space evoked sensory experience,
explaining how new perspectives were gained because of physical
movement and re- positioning. Submergence in the art-making space
resulted in connect- ing to the physicality of the experience, but also
connecting to the self and others through a sense of movement. This
supports previous ac- counts of the body-mind connection that the
art-making process can stimulate into ones awareness (Teoli, 2020).
Being in the art-making space was a novel, unstructured experience,
requiring experimentation and self-direction which has also been
noted in previous research (Secker, Heydinrych, Kent, & Keay, 2018).
While the physicality of the art-making space was described in a
positive manner overall, one service user recounted that the physical
demands of this could be too great for an individual experiencing low
mood. This is an important finding to consider when determining the
construct of similar active art-making groups in future. It also
highlights the importance of such group facili- tation by a qualified art
therapist who can simultaneously support varied levels of visual art
art-marking process. These findings resonate with those of previous
studies which highlight that engagement in arts-based methods can
elicit strong emotional responses in a recovery-oriented context and
that participants should be made aware of this at the onset of any such
programme engagement (McCaffrey et al., 2020). They also
corroborate our decision that focus groups be facilitated by a qualified
art therapist who could skilfully support participants when experiencing
such feel- ings of vulnerability while also ensuring a sense of safety
throughout the creative process. With this safeguard in place, we
believe that there is a value in experiencing vulnerability as a shared
quintessential essence of being human. One staff member perceived
vulnerability as a catalyst to
“push things forward” in enhancing stakeholder relationships. This
shows how shared creative processes can disrupt and transform
estab-
lished institutional boundaries in ways that are perceived to enhance
recovery-oriented working (Saavedra et al., 2018).
Study findings revealed that art-making enabled an atmosphere of
equality for collaborative engagement, one that broke down barriers
between stakeholders in mental health. The disbandment of perceived
hierarchical structures allowed group participants to stand on an equal
platform with one another, which enabled open communication. Staff
members reflected that art-making afforded the possibility of moving
away from traditional roles and engaging on a shared common ground
by coming together “as human beings”. This is reflective of previous
experiences of creative-arts approaches in mental health (Cole, Jenef-
sky, Ben-David, & Munson, 2018), where reciprocity, connection and
empathic communication are fostered as central principles of
recovery-oriented working (Roberts & Boardman, 2014). Similar to
previous findings, it was not art-making itself that supported recovery,
rather the collaborative environment it created (Saavedra et al., 2018).
engagement tailored to the presenting needs and abilities of those
present.
Study participants also revealed that they experienced a sense of
liberation throughout the group art-making process. They recounted
being enabled to freely write, colour and draw in a non-judgemental
environment where there was no right or wrong way to contribute
artistically. Key to this feeling of liberation, was the idea that art-making
was a process rather than being outcome driven. This enhanced
partic-
ipants’ playfulness and exploration, phenomena associated with
increased feelings of well-being also described by participants in other
art-making studies (Secker et al., 2018). Perhaps it is not surprising
that these experiences of liberation and playfulness in the art-marking
pro-
cess seemed to facilitate participants’ curiosity and access to new parts
of the self as previously reported by Lloyd, Wong, and Petchkovsky
(2007). One staff member recounted her involvement in the focus
groups as a “journey of discovery”, a metaphor often cited when
describing service user experiences of recovery. Findings from this
study
illustrate that staff can also embark upon a journey of personal
discovery within a creative recovery-oriented process tactfully
facilitated by a qualified art therapist.
All mental health stakeholder participants reflected on the notion of
self-revelation. Engagement in group art-making triggered many
thoughts in terms of roles and boundaries which were described quite
differently by service users and staff. One service user recalled that
because of previous hospitalization for her mental health condition,
she
felt that she had “nothing to hide” in terms of self-revelation within the
focus groups. However, while acknowledging the value of the shared
artistic process, staff members found participation challenging due to
the unfamiliar mode of self-expression and associated interpersonal
challenges. Subsequently, feelings of vulnerability arose and many
questions were sparked in terms of staffs’ professional boundaries in
the
Two main limitations arose over the course of this study. Although
equal numbers of service users and staff were targeted during recruit-
ment, the final study included two service users and five staff stake-
holders. Furthermore, all study participants were female so there was
no representation of male perspectives in this research. We
recommend that future research address these issues by giving further
consideration to
ways of supporting service user and mixed-gender study engagement.
The development of recovery-oriented services requires careful
consideration of the ways in which multiple stakeholders in mental
health can collaborate to achieve successful outcomes. Undoubtedly,
this a lofty task that requires a fundamental shift from traditional ways of
working to those where fellow human beings can come together on
equal and common ground. Such sentiment was central to this study
that sought to explore a creative yet somewhat unfamiliar approach to
sup- porting collaboration and equitable relationships between
stakeholders in mental health services. This research has illustrated
that visual art making has a promising role to play in supporting such
recovery- oriented working between service users and staff. It also
highlights the important role of the facilitating art therapist in providing
an open and supportive environment in which co-production could
occur. We conclude that arts therapists have opportunities to use group
art-making not only in the promotion of wellness among service users
but also at an organizational level. This in turn can nurture a healthy
foundation for co-production as a concept that supports the delivery of
recovery- oriented mental health services.
Acknowledgements
We wish to thank each of the seven service users and staff of St
Patrick’s University Hospital who participated in this research.
Thanks are also due to Mary O’Hora (Administrator of SUAS
Consumer Coun-
cil), Brendan Ruddy (Service User Representative of SUAS Consumer
Council), Edel Fortune (Programme Manager) and Adam Kavanagh
(Nurse Practice Development Co-ordinator) for their support of this
project. Hearty thanks also to Stephen Sandford (Lead for Allied
Health Professionals, East London NHS Foundation Trust) for his
inspiring words and encouragement along the way. This research did
not receive
any specific grant from funding agencies in the public, commercial, or
not-for-profit sectors.
References
Borg, M., & Kristiansen, K. (2004). Recovery-oriented professionals: Helping
relationships in mental health services. Journal of Mental Health, 13(5), 493–505.
https://doi.org/10.1080/09638230400006809
Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative
Research in Psychology, 3(2), 77–101. https://doi.org/10.1191/1478088706qp063oa
Clark, M. (2015). Co-production in mental health care. Mental Health Review Journal, 20
(4), 213–219. https://doi.org/10.1108/MHRJ-10-2015-0030
Cole, A., Jenefsky, N., Ben-David, S., & Munson, M. R. (2018). Feeling connected and
understood: The role of creative arts in engaging young adults in their mental health
services. Social Work With Groups, 41(1–2), 6–20. https://doi.org/10.1080/
01609513.2016.1258619
Crawford, P., Lewis, L., Brown, B., & Manning, N. (2013). Creative practice as mutual
recovery in mental health. Mental Health Review Journal, 18(2), 55–64. https://doi.
org/10.1108/mhrj-11-2012-0031
Davidson, L., Tondora, J., Pavlo, A., & Stanhope, V. (2017). Shared decision making
within the context of recovery-oriented care. The Mental Health Review, 22(3),
179–190. https://doi.org/10.1108/MHRJ-01-2017-0007
Devlin, P. (2010). Restoring the Balance: The effects of arts participation on wellbeing and
health. UK: Voluntary Arts England.
Doody, O., Slevin, E., & Taggart, L. (2013). Focus group interviews in nursing research:
Part 1. The British Journal of Nursing, 22, 16–19. https://doi.org/10.12968/
bjon.2013.22.1.16
Fancourt, D., & Finn, S. (2019). What is the evidence on the role of the arts in improving
health and well-being? A scoping review (Health Evidence Network (HEN) synthesis
report 67). Retrieved from: Copenhagen: WHO Regional Office for Europe https
://www.ncbi.nlm.nih.gov/books/NBK553773.
Fenner, P., Ryan, B., Latai, L., & Percival, S. (2018). Art making and the promotion of
wellbeing in Samoa – Participants’ lived experience of a recovery oriented
intervention. Arts & Health, 10(2), 124–137. https://doi.org/10.1080/
17533015.2017.1334677
Finley, S. (2008). Arts-based research. In J. G. Knowles, & A. L. Cole (Eds.), Handbook of arts in
qualitative research: Perspectives, methodologies, examples, & issues (pp. 71–82). London:
Sage.
Furness, P. J., Armitage, H., & Pitt, R. (2011). An evaluation of practice-based
interprofessional education initiatives involving service users. Journal of
Interprofessional Care, 25(1), 46–52. https://doi.org/10.3109/
13561820.2010.497748
Gallagher, A. (2007). The role of the arts in mental health nursing: Emperor’s new
suit or magicpill? Journal of Psychiatric and Mental Health Nursing, 14(4), 424–429.
https:// doi.org/10.1111/j.1365-2850.2007.01096.x
Health Service Executive. (2018). Co-production in practice guidance document: 2018
–2020. Dublin: HSE.
Holwerda, A., Fokkens, A. S., Engbers, C., & Brouwer, S. (2016). Collaboration between
mental health and employment services to support employment of individuals
with mental disorders. Disability and Rehabilitation, 38(13), 1250–1256.
https://doi.org/ 10.3109/09638288.2015.1076075
Ledger, A., & McCaffrey, T. (2015). Performative, arts-based, or arts-informed?
Reflectionson the development of arts-based research in music therapy. Journal
of Music Therapy, 52(4), 441–456. https://doi.org/10.1093/jmt/thv013
Liamputtong, P., & Rumbold, J. (2008). Knowing differently: Setting the scene. In
P. Liamputtong, & J. Rumbold (Eds.), Knowing differently: Arts-based and collaborative
research methods (pp. 1–23). New York: Nova Science.
Lipe, A. W., Ward, K. C., Watson, A. T., Manley, K., Keen, R., Kelly, J., et al. (2012).
The effects of an arts intervention program in a community mental health setting:
Acollaborative approach. The Arts in Psychotherapy, 39(1), 25–30. https://doi.org/
10.1016/j.aip.2011.11.002
Lloyd, C., Wong, S. R., & Petchkovsky, L. (2007). Art and recovery in mental health: A
qualitative investigation. The British Journal of Occupational Therapy, 70, 207–214.
https://doi.org/10.1177/030802260707000505
McCaffrey, T., & Edwards, J. (2015). Meeting art with art: Arts based methods enhance
researcher reflexivity in research with mental health service users. Journal of
Music Therapy, 52(4), 515–532. https://doi.org/10.1093/jmt/thv016
McCaffrey, T., Higgins, P., Monahan, C., Moloney, S., Nelligan, S., Clancy, A., et al.
(2020). Exploring the role and impact of group songwriting with multiple
stakeholders in recovery-oriented mental health services. Nordic Journal of Music
Therapy, 29, 1–20. https://doi.org/10.1080/08098131.2020.1771755
McDaid, S. (2009). An equality of condition framework for user involvement in mental
health policy and planning: Evidence from participatory action research. Disability
&
Society, 24, 461–474. https://doi.org/10.1080/09687590902879064
Nadeau, R. (2008). Using the visual arts to expand personal creativity. In B. Warren
(Ed.), Using the creative arts in therapy and healthcare (pp. 43–63). East Sussex, UK:
Routledge.
Oren, R., Orkibi, H., Elefant, C., & Salomon-Gimmon, M. (2019). Arts-based psychiatric
rehabilitation programs in the community: Perceptions of healthcare professionals.
Psychiatric Rehabilitation Journal, 42(1), 41–47. https://doi.org/10.1037/
prj0000325
Roberts, G., & Boardman, J. (2014). Becoming a recovery-oriented practitioner.
Advances in Psychiatric Treatment, 20(1), 37–47.
https://doi.org/10.1192/apt.bp.112.010652
Saavedra, J., Arias, S., Crawford, P., & P´erez, E. (2018). Impact of creative workshops
for people with severe mental health problems: Art as a means of recovery. Arts &
Health, 10(3), 241–256. https://doi.org/10.1080/17533015.2017.1381130
Schenstead, A. (2012). The timelessness of arts-based research: Looking back
upon a
heuristic self-study and the arts-based reflexivity data analysis method. Voices A
World Forum for Music Therapy, 12(1). https://doi.org/10.15845/voices.v12i1.589
Secker, J., Heydinrych, K., Kent, L., & Keay, J. (2018). Why art? Exploring the
contribution to mental well-being of the creative aspects and processes of visual
art-
making in an arts and mental health course. Arts & Health, 10(1), 72–84.
https://doi. org/10.1080/17533015.2017.1326389
Shera, W., & Ramon, S. (2013). Challenges in the implementation of recovery-oriented
mental health policies and services. International Journal of Mental Health, 42(2-3),
17–42. https://doi.org/10.2753/IMH0020-7411420202
Slade, M., Amering, M., Farkas, M., Hamilton, B., O’Hagan, M., Panther, G., et al. (2014).
Uses and abuses of recovery: Implementing recovery-oriented practices in mental
health systems. World Psychiatry : Official Journal of the World Psychiatric Association
(WPA), 13(1), 12–20. https://doi.org/10.1002/wps.20084
Spandler, H., & Stickley, T. (2011). No hope without compassion: The importance of
compassion in recovery-focused mental health services. Journal of Mental Health, 20
(6), 555–566. https://doi.org/10.3109/09638237.2011.583949
Spandler, H., Secker, J., Kent, L., Hacking, S., & Shenton, J. (2007). Catching life: The
contribution of arts initiatives to recovery approaches in mental health. Journal of
Psychiatric and Mental Health Nursing, 14(8), 791–799. https://doi.org/10.1111/
j.1365-2850.2007.01174.x
Teoli, L. (2020). Art therapists’ perceptions of what happens when they create art
alongside their clients in the practice of group therapy. The Arts in Psychotherapy,
68, Article 101645. https://doi.org/10.1016/j.aip.2020.101645
Van Lith, T., Fenner, P., & Schofield, M. (2011). The lived experience of art making as a
companion to the mental health recovery process. Disability and Rehabilitation, 33(8),
652–660. https://doi.org/10.3109/09638288.2010.505998