The art of recovery: outcomes from participatory arts activities for people using mental health services.

Abstract Background: There is a growing evidence base for the use of participatory arts for the purposes of health promotion. In recent years, recovery approaches in mental healthcare have become commonplace in English speaking countries amongst others. There are few studies that bring together these two fields of practice. Aims: The two aims of this study were (a) to investigate the validity of the CHIME framework for characterising the experience of Participatory Arts and (b) to use the CHIME framework to investigate the relationship between participatory arts and mental health recovery. Method: The study employed a two-phase methodology: a rapid review of relevant literature followed by secondary analysis of qualitative data collected from 38 people who use mental health service who took part in participatory arts activities designed to improve mental health. Results: Each of the recovery processes identified by CHIME are present in the qualitative research literature as well as in the data of the secondary analysis. Conclusions: Participatory arts activities produce outcomes which support recovery, specifically including enhancing connectedness and improving hope. They can be recommended to people living with mental health problems.


Introduction
Participatory arts activities are typically facilitated by artists with little or no specific training in psychotherapeutic processes, they are usually unregulated activities, and involve active participation. Activities can span a range of media, including visual arts, singing, music, dance and drama. Participatory arts lie at one end of a spectrum of arts activity, at the other end of which is spectator or receptive art activities. Reviews of the impact on health of arts activities across this spectrum have identified a wide range of benefits for wellbeing and sense of control, social engagement and mortality (McLean et al., 2011;Putland, 2012).
Participatory arts differ from arts therapies, which are practised by trained arts therapists and regulated by professional bodies, such as the British Association of Art Therapy in the UK. Art therapy is now an established approach, recommended for consideration in NICE Guidelines for psychosis especially in relation to negative symptoms (NICE, 2014). More generally, arts therapy has been investigated using randomised controlled trials for older people (Kim, 2013;Rusted et al., 2006) but a recent review identified a paucity of evidence relating to mechanisms of action (Kelly et al., 2015).
There is however strong evidence of a positive effect of arts participation on health and wellbeing. A systematic review including 25 studies identified benefits from participation in music, dance, creative writing, handicraft activities and drama for emotional, social, physical and organisational wellbeing (Jindal-Snape et al., 2014). There is some evidence of specific effects, for example in supporting the development of resilience in young people (Macpherson et al., 2012), especially in relation to enhanced interaction and communication, and community empowerment (Daykin et al., 2008). A review of 31 studies (n ¼ 2040) of participatory arts involving older people identified benefits for mental health, physical wellbeing, community participation and reduced societal stigma (McLean et al., 2011). Guidance based on experience in using art as an approach to reducing health inequities has been published (Ings et al., 2012). Key issues are evaluation, benefits and experience, socio-economic inequality, the quality and integrity of artistic processes (Billington et al., 2012). A mixed-method evaluation concluded that participatory arts can ''expand capabilities for creativity, personal development and being part of a community for everyone involved'' (Lewis et al., 2016). Whilst some of the research reports outcomes of arts interventions for specific conditions, much relates to mental health and wellbeing. However, the evidence base for mental health specific outcomes is limited.
Recovery has become enshrined in contemporary mental health policy and practice in English speaking countries (Slade et al., 2014). A systematic review and narrative synthesis developed a conceptual framework of five core recovery processes: Connectedness, Hope, Identity, Meaning in life and Empowerment (CHIME framework) (Leamy et al., 2011). The two aims of this study were (a) to investigate the validity of the CHIME framework for characterising the experience of Participatory Arts and (b) to use the CHIME framework to investigate the relationship between participatory arts and mental health recovery.
This involved a two-phase research design: a rapid review of relevant literature followed by secondary analysis of qualitative data collected from mental health service users who took part in participatory arts activities designed to improve mental health.

Methods
We first sought to validate and if needed, modify the CHIME framework in relation to participatory arts experiences, by identifying if CHIME spans the full range of experiential benefits (i.e. Phase 1), and then to use this as a deductive coding framework for retrospective re-analysis of an existing qualitative dataset (Phase 2).

Phase one: rapid review
A rapid review of the research literature (Khangura et al., 2012) was conducted to identify qualitative evaluations of participatory art experiences amongst people with mental health problems. Search terms were: qualitative, research, evaluation, participatory arts, groups, art groups, community arts, mental health, mental illness, dance, drama, theatre, music, poetry and writing. These were used to search MEDLINE, CINAHL, EMBASE, ASSIA, PSYCHINFO, Web of Science and the Web of Knowledge and Google Scholar. Studies were excluded which related to art therapy (because it is not participatory in the sense of group and community focus), focussed upon individual's arts practices, and studies that used quantitative methodologies. Included studies were reviewed for the presence of the CHIME recovery processes in participants' reports of benefits experienced from taking part in participatory arts.

Phase two: qualitative analysis
We used a Qualitative Secondary Analysis (QSA) approach (Heaton, 2004), by pooling data from similar participants who were asked comparable questions to give an ''amplified analysis'' (p. 47). Data were pooled from four previously published narrative studies investigating the experiences of mental health service users participating in community-based arts activities (Stacey & Stickley, 2010;Stickley, 2010;Stickley & Eades, 2013;Stickley & Hui, 2012). Ethical approval was previously obtained for each study. All interviews were conducted with people using mental health services in the East Midlands region in the United Kingdom between 2005 and 2011. Interviews were conducted by four researchers, and the topic guide for each interview focused primarily on experiences in relation to their participation in community-based arts activities. Sessions were led by professional artists using mixed media, but largely visual arts. The pooled dataset comprised transcriptions of 38 qualitative interviews (c.250 000 words).

Analysis
Three QSA analysis stages were implemented. In Stage 1, a researcher not previously involved in the original studies read all transcripts and coded broad categories using the CHIME framework: Connectedness, Hope and Optimism, Identity, Meaning in Life, Empowerment. The coding related to each specific ''unit of talk'' (UOT) (Schiffrin, 1988), where the interviewee spoke about a topic that fitted within the CHIME framework. UOTs vary from a few lines to multiple paragraphs. UOTs were doubly coded if a quote related to more than one CHIME category.
In Stage 2, a different researcher who also had not previously been involved in the original studies then re-coded the data within each category using the published subcategories of CHIME. This entailed systematically working through the entire categorised data set, which not only produced more specific attributes but also acted as a checking process. Again, it was possible for each UOT to fit into more than one sub-category. Some UOT were edited down to include only the most relevant section of a long UOT. Some UOTs were split as part of the quote was best listed under one sub-category and part under another. Maintaining contextual understanding was a priority when deciding whether and what to edit in each UOT. Queries over relevance, meaning or length of quote were identified using comment boxes within the data so that the researchers could address these later in the subsequent stage.
Third, the Principal Investigator (of both this and all the previous studies) read through the results of Stages 1 and 2. Several anomalies were found, and further amendments were made to the coding and distribution of quotes amongst the categories and sub-categories. Once this work was completed, the Principal Investigator and a fourth researcher identified the instances of UOT attributed to each category and sub-category.

Phase one: rapid review
The 17 studies meeting inclusion criteria are characterised in Table 1. This table identifies which of the CHIME categories are present in each of the studies together with themes not identified in the CHIME framework.
The new themes (those additional to CHIME categories) which were most present were ''Confidence building'' (identified in 7 of 17 studies) and ''Self-expression''''' (identified in 6 of 17 studies). No other themes were identified in more than four studies. Confidence building is a component of ''Empowerment'' and Self-expression a component of ''Identity'' in the CHIME framework, so as these two refinements were minor and to preserve comparability we used an un-modified form of the CHIME framework in Phase 2.

Phase 2: qualitative analysis
From the data of 38 participants, a total of 576 Units of Talk (UOT) were coded, comprising: and Empowerment (n ¼ 94). The coding of CHIME and subcategories is shown in Table 2.
Each category is now described in more detail giving examples of quotations that match the sub-categories of the CHIME framework. Pseudonyms are used throughout.

Connectedness
Participatory arts are intrinsically social. Participants had attended groups that were formed for both artistic and social outcomes, with a strong focus on forming connections with others through Peer Support: It's a real support group. . . but, the support that you get in the group off everyone, it's better than your normal support group (Sarah) A goal is the development of Relationships: I've made new friends because I've met other people that are in the same boat like me (Paul) And, just, just making friends, going for coffee with people. . . . . .it's been quite profound in every way really.
And an experience of receiving Support from others: One of the problems which you have as somebody like me is, with my ill health, I become isolated and lonely. So coming to Arts on Prescription has enabled me to do a bit of bonding with my fellow human beings. (Clive) . . . you've got comradeship, you know, and you feel strong cos you're with other people that have got similar experiences so you don't feel like you're the only one in the world that is feeling like you do. That's really important. (Karen) People feel a sense of Being a part of a community They don't ask about your background, they take you at with open arms. (Karen)  Spandler et al. (2007) Mixed, visual arts X X X X Coping, Self-expression Lloyd et al. (2007) Mixed, visual arts X X X X Self-expression Self-discovery Stickley et al. (2007) Mixed, visual arts and movement X X Sense of achievement, Self-expression Stickley (2010) Mixed, visual arts and music X X X (2010)

Hope
The environment of the participatory arts programmes has been very important to the success for the respective projects. This therapeutic atmosphere is largely created by the artists and arts assistants. Participants are encouraged to express themselves and to be creative. The process of these activities in this environment stimulates hopeful feelings and thoughts. Belief in the possibility of recovery

Identity
The concept of identity is central to mental health. For many who have experienced mental health difficulties, they may experience spoiled identities (Goffman, 1963). Participatory arts activities gives opportunities for people to . . .it's given me the confidence. It's made me realise that not everybody is going to think I'm a nutter. (Mick)

Meaning to life
It is apparent that participants found a great deal of meaning in both exercising arts activities and also in the relationships they formed in the process. People valued the sense of doing something worthwhile and of value for self and others.

Meaningful life and social roles
And you kind of like, meet a group of people that ordinarily you wouldn't, you wouldn't necessarily meet. I think that's good. It, it helps you with your confidence as well. (Sala)

Meaningful life and social goals
I've always considered myself to be an artist but, even when I wasn't working, you know, maybe it's kept me going all these years. (Matt)

Rebuilding life
Art has helped me in lots of ways. (Andy) .

Discussion
This study investigated the validity of the CHIME framework for characterising the experience of Participatory Arts, and then used the framework to investigate the relationship DOI: 10.1080DOI: 10. /09638237.2018 between participatory arts and mental health recovery. The CHIME framework spanned most experiences reported in the 17 studies identified in the rapid review, providing evidence of validity. All five recovery processes were evident in the qualitative accounts of participatory arts experiences, especially enhanced connectedness and increased hope. There are five implications of these findings. First, the rapid review identified a body of evidence about mental health outcomes amongst people using mental health services and engaging in participatory arts activities. Previous literature reviews have focused on arts and health outcomes (Jermyn, 2004;Staricoff, 2004;Stuckey & Nobel, 2010), and the developing evidence base specific to mental health recovery indicates a growing field of investigation. Second, understanding of recovery processes could give more significance to self-expression. Engagement in arts activities promotes and enables self-expression, and our findings suggest that it is a combination of the accepting environment with the opportunity for self-expression that helps to build confidence and to facilitate hope. This links with the focus in the Implementing Recovery through Organisational Change (ImROC) national transformation programme on hope, agency and opportunity (Shepherd et al., 2008). These activities are not delivered in a vacuum, and participants benefit from doing these activities with others. Participatory arts activities are intrinsically social and the social component is of greater importance to participants; the importance of human connectedness is highlighted by the equivalent effects for activity groups and art therapy (Crawford et al., 2010).
Thirdly, the CHIME theme of connectedness was the most frequently coded recovery process, suggesting that participatory arts can be considered as a mental health intervention to promote social inclusion. Reviewed studies identified common factors associated with success in promoting mental health outcomes: being led by professional artists; delivered in community locations; attempting to be nonstigmatising; appearing to have flexibility (following participants interests); promoting social engagement; often involving exhibitions and performances; and delivered for a specific period (although this may be determined by limitations in funding). These common factors provide the starting point for developing interventions which can be subsequently evaluated using evaluation methods that could potentially be drawn from scientific and/or arts methodologies. As policymakers seek to develop programmes of work to deliver recovery-orientated practice, this study argues the case for participatory arts programmes as an approach to deliver socially inclusive, recovery-orientated outcomes.
Finally, given the social and psychological advantages with participatory arts activities, and identifiable structural components, the findings from this study could be used in the development of an evaluation framework. Whilst frameworks exist for Arts and Health interventions (Daykin & Joss, 2016), none exist specifically for participatory arts interventions and mental health. The CHIME framework of recovery processes was found to be a valid approach to characterising outcomes, suggesting that a combination of qualitative investigation of change combined with the use of brief standardised quantitative measures of the five CHIME processes would be a defensible evaluation approach.
The main strength of the study is in investigating a relatively under-researched and potentially important area. The limitations relate to the non-systematic rapid review methodology and the use of secondary and retrospective data to code against the CHIME framework. Deeper understandings of the impact of participatory arts on mental health recovery might involve a prospective and repeatedmeasures design, including standardised measures of recovery processes and a longitudinal diary design (this could be creatively developed) to capture changes in narrative over time. The current study findings indicate that future evaluative research should assess CHIME processes before, during and after experiences of participatory arts, in order to completely understand their impact on recovery processes.

Conclusion
There is evidence of a strong relationship between participatory arts activities and recovery outcomes. The role of human relationships in the practice of community-based participatory group art-making is significant, through both the positive relationship between artist and participant and amongst participants themselves. Because these activities are community-based, participatory arts programmes may be effective in the promotion of social inclusion as indicated by Secker et al. (2009) and in more recent years, others have developed methods for assessing this kind of social recovery (Marino, 2015). As well as promoting recovery and social inclusion, it is observed that participatory arts may also help with selfexpression and confidence building which in turn are empowering and hope-building.