Mental health recovery and arts engagement

Purpose – Arts and cultural activities have been illustrated to be beneficial for mental health service users. The purpose of this paper is to explore the benefits of museum visits and engage in arts activities for mental health service users. Design/methodology/approach – Semi-structured interviews were conducted with 17 mental health service users in Denmark. A thematic approach was used to analyse the data and theoretical lens of sociological theories of institutional logics was employed to explore the findings. Findings – These benefits are perceived to include empowerment and meaning in life, which are two of the core principles of recovery; arts engagement can, therefore, be a useful tool in recovery. The findings also show that the experience of visiting a museum was not always positive and depended upon the interaction with the museum educators. Originality/value – The service users identified arts engagement as creating meaning in life and empowerment, which are two element in the conceptual framework, CHIME (an acronym for: Connectedness, Hope and optimism, Identity, Meaning in life and Empowerment), that describes the human process of recovery. The findings also highlighted that if museums want to engage positively with people with mental health problems and contribute to their recovery then the training of staff and the improvement of institutional approaches to support working with vulnerable people are essential.


Background
By supporting individuals to feel more in control of their own mental health, the recovery approach is consistent with the social model of health which attempts to address the broader influences on health, including social, cultural, economic and environmental factors (Higgins, 2008).To address the whole person requires an approach that recognises that the person is an understanding body, rather than just a physiological body, and that perceptions and social experiences are integrated as a whole.The dualistic division of body and mind is reflected throughout the health system (Mehta, 2011), not only in terms of how service users are treated medically and personally, but also in the architecture, economics, technologies and the organisation of healthcare practices.If recovery is to be understood from a holistic perspective, where the person's unique story is at the core, then a critical view of the dominant biomedical model is needed.The biomedical model is often described as methodically reductionist, where larger parts are separated into smaller components to be studied individually (Marcum, 2008).The essential concept of the biomedical model is that human beings are best understood by separating the spiritual and mental from the physical, and then increasingly moving in closer and focusing on smaller and smaller organic parts, ending with the function of just one cell.The recovery approach attempts to include the psychological, spiritual and social aspects of an individual, and the approach is focused on the active involvement of mental health service users where their voices are heard, rather than just assumed, by healthcare providers.
In a systematic review and narrative synthesis on personal recovery in mental health, attempting to identity the human processes of recovery, Leamy et al. (2011) describe part of their findings as CHIME (an acronym for: Connectedness, Hope and optimism, Identity, Meaning in life and Empowerment) and is the first and only systematic review and narrative synthesis on the meaning of personal recovery.This conceptual framework, which includes 13 characteristics of the recovery journey, five recovery processes comprising CHIME, and a recovery stage description mapping onto a transtheoretical model of change, sought to inform some of the gaps in previous understandings of the stages and processes of recovery.The 13 characteristics identified dimensions which capture experience and complexity of recovery (see Leamy et al., 2011, for details of the study) and the findings claim to be able to contribute to the development of a measure of personal recovery, "providing a foundation for developing standardised recovery" (Leamy et al., 2011, p. 450).The implications for research and practice, apart from a better comprehension of the identified process and stages, are the provision of a coding framework providing keywords for use in secondary research, such as in the study on which this paper is based and offering the opportunity to link recovery to arts practice.
Service users have described how arts engagement has supported their recovery; for example, Parr's (2012) study illustrates that mental health service users who regularly participated in arts groups/activities experienced a sense of belonging that fosters positive emotion and self-esteem.Parr (2012) emphasises the importance of arts in community mental health settings not being "open to clinical interpretation" (p.11).This non-clinical approach strengthens and fosters the development of identity and a sense of belonging.The notion of identity is also explored in Daykin et al. (2010), who suggest that engaging in arts activities provides service users with access to a variety of new identities and is able to depart from the "stigmatised" or relatively powerlessness of the "patient"; this was reinforced by giving service users a new voice to provide their opinions or speak about their experiences.
Other benefits of participating in the arts projects were described in terms of giving purpose, meaning and hope, increased confidence, a sense of achievement, pride and satisfaction, as well as confidence and self-esteem and the ability to rebuild an identity beyond that of being a "service user" (Secker et al., 2007).While these findings are difficult to standardise and measure, they are probably the most important outcomes for the participants.Spandler et al. (2007) suggest that having access to participation in arts projects may be an important element of recovery for mental health service users that find themselves "caught up in a cycle of hopelessness and despair" (p.78).
There is a distinction to be drawn between arts encounters and arts making, as they entail different experiences and cognitive/emotional processes.This paper is concerned with both; however, it primarily explores arts making, but also addresses arts encounters at museums as a source of recovery, and explores the connections between engagement in arts activities and recovery.It aims to highlight the benefits and challenges for mental health service users engaging in arts activities and to understand some of the issues that may occur in practice in the interdisciplinary field of arts and health.The study draws on an institutional logic perspective (Thornton and Ocasio, 1999) which understands institutional logics to be embedded in institutions as socially constructed historical patterns of practice, assumptions, beliefs and values.

Participant recruitment
The volunteering participants (nine females and eight males, ranging in age between 30 and 55 years old) were all attending an arts workshop or a vocational education course for adults with various special needs at the Hans Knudsen Instituttet (HKI) in Denmark from where they were recruited.The recruitment of participants was conducted by staff at HKI and the researcher, PAGE 158 j THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE j VOL. 13 NO. 3 2018   Downloaded by Aalborg Universitet At 03:57 27 July 2018 (PT) information meetings and information sheets about the study were provided and there were opportunities to ask questions.Furthermore, written information was handed out with information about their role in the study and how the data would be collected, stored and analysed.

Data collection
The participants went on visits to four museums in Copenhagen and engaged in a guided tour around the museums followed by a creative workshop where they produced their own paintings and sculptures (only two museums provided the creative workshop).In this way, the participants were both "viewers" and "makers" in terms the arts engagements.One-to-one semi-structured interviews were conducted to elicit in-depth personal experiences.The interviews were recorded and varied in length.The interviews were transcribed and translated into English.All transcriptions were approved by the participants.

Data analysis
Braun and Clark's ( 2006) six-phase framework for the thematic approach was used for data analysis, and is as follows: familiarisation with the data; generating initial codes; searching for themes; reviewing themes; defining and naming themes; producing the report.The analysis process was conducted in consultation with supervisors in order to ensure rigour.The study was part of a PhD research project at the University of Nottingham and was approved by the Research Ethics Committee at the Faculty of Medicine & Health Sciences.

Findings
The findings include the themes "empowerment" and "meaning in life" as well as statements to illustrate some of the service users' experiences and understandings.These subthemes emerged under the two themes: disconnecting dialogues between service users and museum educators; and being self-experts in arts engagement.

Empowerment
The study shows that accessing cultural institutions can support feelings of empowerment for service users.The empowerment of mental health service users can include a higher degree of individual empowerment, a stronger sense of belonging to the community, development of, and participation in, the activities.When asked about visiting a museum, it was commented on as being inspirational, useful and positive as part of a recovery for mental health service users.The service users found museums to be places where they found stimulation and a place for learning, relaxation and wellbeing: Museums are very important […] important for people from the hospital who have been through crises, for inspiration […] if they spent their time on creativity, then museum and galleries are a good idea […] It makes my life better […] I gained inspiration from the visits (Lotte).
Lotte sees museums as places for both visual learning, stimulation of new ideas for her own artwork and as a source for gaining new knowledge.
Karsten explains how he uses museums for relaxation and how wandering around the museum creates an inner space of calmness: I generally get stressed quickly.So this is relaxing just to walk around and look at things […] For example, in museums that we have been to […] you could walk around have a look and stay in your own world and think a little about the displays.And try to get some inspiration (Karsten).
Jens suggests that for him visiting a museum can create a new life perspective and it improves his sense of wellbeing: The service users commented on the values that they attach to engaging in arts activities and beyond, creating a sense of empowerment; and when asked about the significance of "doing art", several service users described engagement in arts activities as a form of play and something that they associated with a child-like way of being: I think the closest you can compare it to is when you were a kid and you were playing.Yes, because within myself I call it playing.For it is a game and I think that it is one of the healthiest things we can do in life is to play (Lillian).
Rikke comments about being transported into a different world where new things are possible.Positive associations are made between play and arts engagement and Henriette also makes a link to the aspect of self-development that is involved: This association with play and childhood appeared to create a feeling of reconnection with innocence and/or a situation where spontaneity was possible, which the services users referred to as being positive.It is most likely a state of being that is difficult to access for individuals with mental health problems, which makes arts engagements even more significant in terms of therapeutic values and feelings of empowerment.
The findings in this study also illustrate that there was awkward communication between the service users and the museum educators, resulting in an off-putting experience for some of the service users.
Lotte was particularly alert to the way in which communication was conducted and felt that the approach to the group was limited to a level which was not stimulating or inspiring.Having come to the museum expecting to learn and gain knowledge, the level of dialogue was, in some instances, disappointing and upsetting: Sometimes I got a little angry at the educators because I think they talk down to me, right?So when you see an angry mask and the question is, what does the mask look like?Well […] yes, we are not that medicated (Lotte).
Lotte suggests that the dumbed-down approach made her feel angry and patronized and while museum/gallery visits can be beneficial to mental health service users, the overall comments from the service users in the study suggest that it depends on the facilitation of the visit.

Meaning in life
The findings in the study show that the service users have a comprehensive understanding of the role that the arts and cultural activity have in their lives and this understanding makes them experts on their own engagement in the arts and places them in a position to contribute as an engaged expert in their recovery.
Jan suggested that the engagement in arts creates a relational and focused space where he is able to enter a peaceful and worry-free space, enabling an escape from negative thoughts and patterns: The comments offered by the participating service users show that they are aware of the value that arts and cultural activities can bring to their lives in terms of life quality as well as health and wellbeing.The engagement in art activities is especially connected to its usefulness as part of the recovery approach, where the knowledge and lived experiences of the service users are important.
Having access to arts engagements enables a creative process and a person-centred approach that values the uniqueness of the individual, which is important for the service users in this study.Several service user participants commented on how arts engagement provides meaning in life.Noticeable is the comment offered by a service user describing how the act of drawing was used to make connections and sense of his day: It connects the day […] by summing up what's happened that day and if there is certain things that has made a deep impression on me then I painted it in some funny way (Lasse).
The functionality ascribed to arts in mental health is illustrated by using art to make sense of the day and creating meaning in life as a tool for inspiration and motivation, and feeling good and relaxed, as described in the comments by the service users.Its physical, practical and psychological "doing" is a functionality that had a positive impact on health and wellbeing for the participating service users.
Being able to develop a creative identity and engaging in arts activities has positive wellbeing benefits and provide purpose and/or meaning in life to some service users.This approach emphasises health, wellness and strengths, rather than symptoms such as pathology and deficits, as well as including respecting the expertise gained by the lived experience of the service users.
Additionally, the comment offered by another service user, describing how arts engagement had stopped her suicidal thoughts, further illustrates that engagement in arts has the ability to create meaning in life.Furthermore, it had also helped to create a feeling of worthiness: In this way, engagement in arts can be a vital element in rebuilding life, contributing to survival and providing meaning in life for a service user and as a positive step in the recovery journey.

Discussion
In light of the findings, I discuss some of the core principles of recovery and how they connect to arts practice and engagement under the categories of empowerment and meaning in life, which can be linked to the CHIME framework.Two of the CHIME categories are similar to findings in the study, which are empowerment and creating meaning in life; these themes are also recognised in other studies (see Secker et al., 2007;Spandler et al., 2007).While empowerment has been described as the process of gaining control over one's life and having the ability to influence the structures in which one lives (Segal et al., 1995), creating meaning in life remains more subjective for the individual.
Arguably, the institutional logics of the museums created a relationship of power with the service users and placed the service users in a position of lacking power and voice.If decisions and outcomes are a result of the interplay between an individual and an institutional structure, then such interplay has a powerful function (Friedland and Alford, 1991;Thornton and Ocasio, 1999) and attention should be paid towards the role of the institutions in such interplay.In a mental health context, empowerment refers to the level of choice, influence and control that users of mental health services can exercise over events in their lives.A way towards empowerment is the removal of formal or informal barriers and the transformation of power relations between individuals, communities, services and governments that are rooted in institutional logics.Empowerment is a multidimensional social process through which individuals and groups gain better understanding and control over their lives.Consequently, is it is possible to enable change to the social and political environment to improve health-related life circumstances (Loss and Wiese, 2008).
People with mental health problems have historically lacked a voice and power, and have not been involved in decision making on mental health services; they continue to be at risk of social exclusion and discrimination in all aspects of life (Callard and Rose, 2008).Power is central to the concept of empowerment and a significant part of empowerment is to challenge some of the institutional or structural barriers and/or cultural norms when visiting cultural institutions.For the individual, the empowerment process means overcoming a state of powerlessness and gaining control of one's life (WHO, 2006).The process starts with individually defined needs and ambitions and focuses on the development of capacities and resources that support it.The empowerment of individuals aims to help adopt self-determination and autonomy, exert more influence on social and political decision-making processes, and gain increased self-esteem.Communities and institutions can be a support in this process by establishing social networks and different sorts of social support that can encourage people through difficult transitions and periods of vulnerability in life.Callard and Rose (2008) suggest that policy makers should ensure that people with mental health problems have the power to set their own agendas, make decisions and control resources.For the material, psychosocial, and political empowerment that underpins social wellbeing and equitable health, it is vital for individuals to be included in society.Legislative and policy tools can support the empowerment of service users, including the United Nations Convention for the Rights of People with Disabilities.The European Pact for Mental Health and Wellbeing (2008, p. 3) notes that "people who have experienced mental health problems have valuable expertise and need to play an active role in planning and implementing actions", and calls on policy makers and stakeholders to involve people with mental health problems and their families in relevant decision-making processes.
The findings in this study suggest that mental health service users experience a sense of empowerment by visiting museums/galleries and arts engagement.However, in order to make a shift from empowerment being a service user experience, to an actuality that is embodied in institutional logics and a wider societal approach to mental health, it is necessary to work towards transforming the distribution of power and resources, including the equal distribution of collective power and the empowerment of individuals and groups.
Arguably, the visits to the museums created negative experiences for some of the service servicers, partly because of the unpreparedness of the museum educators, which caused unintentional outcomes; the institutional logics of not training the museum educators got in the way of the intended positive experiences.Staff at cultural institutions need suitable preparation and support when they engage in unfamiliar roles as "a background in the cultural sector is not a preparation for working with mental health-related needs and behaviours" (Froggett and Roy, 2014, p. 25).The barriers created between service users and professionals can prevent an open dialogue and can jeopardise the gaining of valuable information about the individual to support a personal treatment plan.Although a more comprehensive understanding of the recovery practice is on-going, the relationship between professionals and service users plays a critical role (Slade et al., 2012).This further perpetuates the need for awareness training for staff at cultural institutions and can further enhance a positive interaction between service users and professional staff.Furthermore, museums have a history of excluding the representation of stigmatised people in their collections, including homosexuals, bisexuals, transgender and disabled people (Silverman, 2010), neglecting an ethical responsibility to represent cultural diversity.
From an institutional logics perspective, it is about promoting inclusion and the effectiveness of such, resting upon the ability to embrace an "organising principle of programmatic organisational changes" (Sturdy and Grey, 2003) and is, to a certain extent, a function of the organisational actors' "definition of the situation that they habitually project" (Goffman, 1956, p. 77).The norms and values of staff are not automatic products of the responses of an objective institutional or organisational structure (Tlili, 2008), but form part of an organisational reality (Reed and Hughes, 1992) with its own logics (Doolin, 2003).In this way, it is difficult to determine where the lack of inclusive practice is rooted within the institution; however, it seemingly starts where the institution fails to recognise the need for the staff's professional development and training opportunities, as well as a lack of more inclusive operational logics.
Valuing the diversity of the community encourages cultural institutions to attract a different public.The social values and logics of the institutions are reflected in their commitment to diverse audiences, as developing collaborations and programmes requires investment of staff time.Without institutional recognition, such additional investment of time can reflect in the professional behaviour of staff, who might then see the interaction with unfamiliar visitors as an unwelcome distraction from their primary tasks (Froggett and Roy, 2014).
The artistic experience has been compared to "play" by Huizinga (1970) who particularly highlights the fun of playing, asserting: "it is precisely this fun-element that characterises the essence of play" (p.21).In addition, it has roots in the primary part of life, which can also be seen in the animal kingdom.Huizinga (1970) further discusses the positive emotions associated with play as: "[…] play-mood is one of rapture and enthusiasm and is sacred or festive in accordance with this occasion.A feeling of exaltation and tension accompanies the action, mirth and relaxation follow" (pp.154-5).Several service users also commented on the aspects of relaxation and de-stressing when engaged in arts activities.Gadamer (1992) also recognises the relationship between art and play in the playful process of art practice itself.He claims that by participating in play it takes the individuals out of themselves and they become drawn into something much larger than is evident to a subjective consciousness (referring to inner and private experiences).Dissanayake (2002) links play behaviour to making art, and explains that in some African societies there is one word that seems to loosely cover both activities.Despite an understanding of art practice and play as being different in western society, Dissanayake (1992) argues that play is fairly spontaneous, but it also has forms and rules which are similar to arts.Freud (1948) saw play as a way of getting fulfilment, and Bruner (1972) valued play for its ability to help with learning skills and social behaviour.Arguably, through play it is possible to create a positive space, and it was referred to by one service user as like entering "another world" with new things happening which lead to something else.Other comments were made about "getting lost" in the activity, with no worries intruding to be concerned about.
These findings illustrate that engaging in arts activities allows a healthy disconnection from concerns and can combat negative thoughts, resulting in health rewards such as relaxation, entering a flow, and making new connections where none existed before which can empower the individual.The links from engagement in arts activities to the recovery process is found in the distraction from distressing thoughts and being able to escape from an inner world with bad reflections (Colbert et al., 2013).Furthermore, the role of arts and cultural intervention can be that of facilitating a personal journey, as the arts also offers different perspectives on the experiences of people's difficulties (Sixsmith and Kagan, 2005;de Botton and Armstrong, 2013), and provides a platform for reflection.Dissanayake (2002) discusses arts as being functional, which is based on anthropological studies, because of its ability to affect social systems and positions and by "impressing others, illustrating an important myth or precept" (p.61).Making propaganda and the values attached to art suggest that it contributes to "human evolutionary fitness" (Dissanayake, 2002, p. 62) and has survival value, which is noticeable in the service user's comment about how doing arts have helped her combat suicidal thoughts.The recovery approach presents principles that are useful for the relationship between service users, arts and cultural practitioners, and health professionals, as they place the service users at the centre of the activity with the ability to co-direct the journey in a respectful partnership.
The link between arts, health and recovery can be traced back to ancient Greece, where people came from across the country to visit the temples of Asclepius, who was the god of healing (Risse, 1990).Part of the healing process involved a prescription to attend a performance or comedy at the amphitheatre (Chatterjee and Nobel, 2013), and poetry was also used for healing purposes (Belfiore, 2016).This illustrates that the Greeks recognised the impact that arts had on healing and recovery.In terms of using arts in a present day recovery context, arts and health practices appear to seamlessly deliver elements identified in the CHIME framework (Leamy et al., 2011) and can satisfy categories identified in the recovery processes and, given that the right people facilitate the process at the right time, arts participation can make a significant contribution to the recovery process.Although this study only makes connections to two of the CHIME categories, other studies suggest that there are links between all the identified processes of recovery and arts engagement (see: Spandler et al., 2007;Parr, 2012;Torrissen and Stickley, 2017).
As the study has elicited the voices of the service users in relation to how they benefit (or not) from engagement in the arts, and what influences might support or not support this process, the findings provide a contribution to support the use of art in mental health settings as part of a recovery process underpinned by CHIME as a theoretical framework, with consideration to the implications of institutional logics.
Recognising that mental health service users benefit from arts engagement in terms of the CHIME categories identified, arts engagement can arguably play a vital role in the recovery process; it is possible to use arts engagement as a tool in recovery, given that it is placed within a framework, as arts engagement can add something unique to each personal and complex story and each journey, provided that it is facilitated adequately.However, further research is needed to test the claims of the links between CHIME and arts engagement in the arts and health field.

Conclusion
The findings show that engagement in arts can create a sense of meaning, purpose in life and empowerment, which are part of the conceptual framework, CHIME, which describes the human process of recovery.Diversifying the demographic profile requires cultural institutions to become sensitive to a diversity of needs, which requires that the relational skills of staff are developed within a framework with planning and support.In this way, interdisciplinary collaborations between health and the arts can promote recovery, given that the professionals involved understand recovery and, as a minimum, have basic mental health awareness.
Visiting a gallery[…]  well, seeing things in a new perspective and things like that […] It opens my eyes for different perspectives in life or something.Something you would not have got elsewhere.It improves my wellbeing being there, yes.It really does ( Jens).
You enter another world […] It's a fairy tale world.New things happen […] and then you get somewhere else (Rikke).Yes, on the one hand, I thought I went back to childhood, right?On the other hand, it was self-development nevertheless, right.Yes.Yes.Like if you take a swing or something on a playground.Yes […] Yes, it is positive to play (Henriette).

[
Being] relaxed, quiet […] and peaceful […] and also focused […] I think of something else when I draw ( Jan).
PAGE 160 j THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE j VOL. 13 NO. 3 2018 Downloaded by Aalborg Universitet At 03:57 27 July 2018 (PT) PAGE 162 j THE JOURNAL OF MENTAL HEALTH TRAINING, EDUCATION AND PRACTICE j VOL. 13 NO. 3 2018 Downloaded by Aalborg Universitet At 03:57 27 July 2018 (PT) Yeah, I would have committed suicide if I had not had it.I would have […] it gives me […] I feel that I am worth something, that is what it gives me […] (Lotte).