The power of the arts

Art bridges the gap between mental illness as disease and mental illness as an integral part of the human experience, in a way that science cannot. Artists of all shapes and forms have tapped into their own mental suffering to find creative power. Artistic representations of mental illness can increase understanding and empathy for those who are ill, and the act of making art has been incorporated into the therapeutic process as art therapy. Right now, we seem to be on the cusp of a shift. Art and science are moving closer together in new ways, in a quest to throw light on some of humanity's biggest questions, including mental health. In this article we explore how this shift is shaping mental health research and practice.

Art as therapy

Within treatment paradigms, art therapy has long played a part, and the evidence base shows there is much support for the use of art in therapeutic settings. In the 1940s an early and far-sighted push by Edward Adamson pioneered the use of art as therapy, bringing it into hospitals. It was while working on this programme that Adamson was handed a set of drawings by a patient at the 960-bed residential psychiatric facility in Netherne. The patient had created the drawings using burnt matches, as he did not have a pencil. Adamson realised the power of art in the therapeutic process, and began campaigning for the use of art as therapy in mental health. Indeed, he has the distinction of being the first artist employed by the NHS, and in the intervening years the evidence has built that art therapy can improve mental health outcomes. This work continues today, not only in mental health treatment environments, but also in physical health and in hospices – see the excellent paintingsinhospitals.org.uk.

Adamson built up an extraordinary collection of art by patients, now housed at the Wellcome Collection, parts of which are currently being exhibited at Birkbeck. In the same vein, the Bethlem Museum of the Mind has art displayed alongside artefacts from Bedlam in days gone by. It is a small, local museum, but it is respected and well known, and was shortlisted for Museum of the Year in 2016. Sitting right underneath the museum, and attracting its fair share of the visiting public, is the Bethlem Gallery, which displays art created by patients currently being treated for mental illness at the Bethlem Hospital.

Others have expanded the range of artistic endeavours that can be used therapeutically. For example, the Alchemy Project is a dance collaboration between Dance United and the Maudsley's early intervention in psychosis team. It has demonstrated significant improvements in mental wellbeing. A recent review (Scope et al., 2017) identified outcomes from art therapy for service users, including improved relationships; gaining perspective; personal achievement and empowerment; relaxation; and crucially, an understanding of illness, self and future. Although the cost-effectiveness of art therapy remains uncertain (Uttley et al., 2015), this is almost impossible to quantify – what is the value of the pieces created by those receiving art therapy, which can be so powerful and illuminating?

Art to raise awareness

Working on the basis that the first step to engage the public is to forge connections with those not suffering from mental illness, in recent decades art has been harnessed in awareness-raising programmes as a way of reaching out and engendering empathy. Academics and clinicians actively seek out artists for collaborations to find new ways to reach the wider public, but also clinical populations, carers and policy makers. For example, in the Maudsley mental health hospital the corridors are given over to installations of art by patients, and photographic documentation of artistic projects including patients.

This has been taken further through immersive multimedia installations, which can convey something of the experiences of mental illness. A recent installation at Copeland Park in Peckham, southeast London saw a collaboration between Dr Helen Fisher, MQ Fellow at the Institute of Psychiatry, Psychology and Neuroscience; Creative Director Rich Maskey, representatives from Voice Collective; and mental health campaigner Jonny Benjamin MBE. It asked the question 'How "normal" do you think you are?', and recreated two key aspects of psychotic experiences: audio hallucinations and paranoia. The audience were given audio guides before walking through rooms to view the art. The audio guides were linked to out-of-sight actors, who were observing the visitors through CCTV. The actors spoke to each visitor: 'Touch the painting. Go on. No one's looking… Touch the woman next to you, smile at her.' The voices created a sense of paranoia as the visitors realised they were being watched. Were the voices in the headphones, or in the head? Why was it so compelling to obey the voices? How much more compelling must it be for those who feel as though those voices live alongside them in their heads. This small, bespoke exhibition drew much attention, and was covered by Claudia Hammond for the BBC World Service.

Artistic works of those in treatment can go further than increasing empathy, and can contribute to addressing negative attitudes towards mental health, and the breaking down of stigma. The Koestler Trust, a charity that works with offenders, secure patients and detainees, holds an annual exhibition at London's Southbank Centre, including talks, exhibits and performances; and it is hosted by ex-offenders. This September it will be curated by Antony Gormley. The exhibitions challenge attitudes by illuminating the relationship between mental illness and offending behaviours, and showing work from highly stigmatised groups of people. In the process, attitudes are nudged away from moral censure towards understanding.

The future of arts and mental health

Increasingly we are noting intriguing new developments in art and mental health, with projects moving beyond art therapy and awareness raising. We hear much about social prescribing in mental health, where patients are prescribed exercise, or a class, or a social intervention. Under the umbrella of social prescribing, there is a growing recognition that by prescribing arts and culture we might be able to improve mental health outcomes. Pioneers are piloting work in this area, and measuring results. This work is not taking place just amongst third-party organisations with a link to mental health, it's happening in the NHS itself.

In 2014 NHS commissioners in Gloucestershire and Kent were selected to pilot a structured framework for incorporating arts and culture into health and wellbeing services, including mental health. The three-year programme, funded by Arts Council England, aimed to explore 'the opportunities for using arts and cultural organisations to deliver health and social outcomes'. Gloucestershire CCG has prioritised and funded an innovative and active approach to commissioning the arts and cultural sector to support a range of health and care needs. They piloted a programme of cultural commissioning, in which they piloted 12 'test and learn' feasibility projects, using a co-production model designed and steered by patients, clinicians, artists and commissioners. Their brief to the cultural sector was to work with the CCG to develop innovative offers to meet a range of identified needs that were not currently effectively met by more traditional services, thereby also using the programme to help work towards reducing identified health inequalities. Ellen Rule, Director of Transformation and Service Redesign at NHS Gloucestershire, is clear about the benefits: 'This has challenged me down to my commissioning roots… but it inspired us to see things differently, lose the labels and see the potential of how arts and culture can break into a world where previously there might not have been any other solutions.'

One of the projects involved engaging with young people about their mental health, and determining positive steps they could take to self-manage what might be described as 'low-level' needs to prevent these exacerbating their situation. The Roses Theatre was culturally commissioned to deliver a project called 'Secrets and Lies'. Separate teams worked with boys and with girls to give both an opportunity to explore issues that they may not feel comfortable expressing in front of each other, including pornography, self-harm and family relationships. The boys developed a performance piece in the form of the film, and the girls performed a short acting piece for peers, school staff and commissioners. For the young people involved one clear unintended outcome was that the girls developed a peer-support network through working with each other in the project. For the CCG this project has contributed to the understanding of how to increase a targeted early intervention to young people in a schools context. For the Roses Theatre, the work has informed a successful bid to Children in Need for future work.

Other respected organisations are getting on board with the challenges of harnessing artistic projects to mental health outcomes. Lizzie Raby is a designer and researcher at the Helen Hamlyn Centre for Design at the Royal College of Art. She created some prototype liver models for Alcohol Specialist Nurses within hospitals. The novelty here is that the concept is sensory, and the models are designed to look and feel stiffer as they move from health to fatty then cirrhotic. This tactile component comes into play when patients hold a diseased liver in their hands – the engagement with the materiality of the object disrupts the process of cognitive dissonance that those dependent on alcohol often display. It's hard to give yourself a message that your liver is healthy when you are forced to feel a sclerotic version created by an artist. The liver models themselves would look at home in a Damien Hirst exhibition, and large-scale production has now started by a company more used to creating prosthetic makeup for films such as the Harry Potter series.  

There are also initiatives that prescribe attendance at cultural spaces, such as museums. The 'Who Cares' project in the northwest of England brought together six museums with the Psychosocial Research Unit at the University of Central Lancashire to research the potential of museum collections to improve outcomes for people with mental health issues. South London and Maudsley NHS Foundation Trust ran a similar initiative in their Journeys of Appreciation Programme, in which older adults with mental health problems and dementia visited partner museums and galleries. The Trust reported that it provided a turning point in nurse–patient relationship, and noted the difference the project made both to patients and to staff. Other projects have noted that museum object-handling sessions with patients can bring about decreasing negative emotion; increasing vitality, participation and sense of identity; and enjoyment and positive emotion (Ander et al., 2013).

Crucially, arts and culture programmes are difficult to evaluate, at least using traditional evaluation methods. Most projects are generated locally, and evaluation is often an afterthought, with no agreed method of evaluation. We were unable to find any reviews specifically of cultural prescribing, but in a recent review of social prescribing Bickerdike et al. (2017) identified evaluations of 15 small-scale projects, three of which were cultural. They reported that projects often use multiple interventions, so there is little direct line of sight to outcomes, and commented that 'most evaluations have presented positive conclusions, generating a moment for social prescribing which does not appear to be warranted'. However, by their own admission the studies they considered were limited by both design and reporting, as well as a lack of standardised and validated measuring tools in design and reporting.  

Absence of evidence is not evidence of absence, but as social prescribing grows as a discipline, and cultural prescribing grows within it, there is a need for proper evaluation to have evidence for what works, and what is cost-effective. One problem is that traditional evaluation methods may not always be appropriate. As the 2016 annual Social Prescribing Network Conference noted, the first barrier to growing the evidence base is the lack of an agreed definition of what social prescribing is, and the same applies to this new wave of cultural prescribing – should it include everything from exposure to large-scale civic artworks, through museum attendance, to immersive therapeutic spaces, to art therapy, to being prescribed a single cultural output such as a book or a piece of music?

And as with social prescribing, the outcome measures in cultural prescribing are varied, and it may be difficult to capture benefits using purely quantitative data. These barriers to growing the evidence base stem from a lack of research and evaluation methodology around cultural interventions and prescribing. Many projects do not have academic partners to help in the design and measurement, which means data on what works cannot be easily generalised. Further, if evaluation is small-scale, then that may to some extent reflect that engagement with the arts in a therapeutic context generally involves small numbers (O'Neill, 2010).

Things appear to be changing, however. Gladwell famously talks of a Tipping Point in his book of the same name, and the dots are beginning to join up in the UK with some high-level converts, as evidenced by the formation of the National Alliance for Arts, Health and Wellbeing , linked to an All Party Parliamentary Group for Arts, Health and Wellbeing, and the more specialist National Alliance for Museums, Health and Wellbeing. The All Party Parliamentary Group is carrying out a two-year Arts, Health and Wellbeing Inquiry in collaboration with King's College London and in partnership with Guy's and St Thomas' Charity and the Royal Society for Public Health. These initiatives have been set up to look at health and wellbeing across the spectrum of health care, but mental health forms a large part of the remit.

Although it has long been known that the arts could play a positive role in health outcomes, it seems to have taken longer for health care to see the possibilities beyond art therapy and awareness raising. The initiatives described here are exciting not only in and of themselves, but also because they point to something in the zeitgeist, as it is recognised more and more that the power of the arts can be utilised in new ways. We believe these are genuinely exciting times for the arts and mental health, and look forward to reviewing developments for The Psychologist in the future.

- Image: Martin Birch, White cat face on red. Credit: Adamson Collection/ Wellcome Trust.

Key sources

Ander, E.E., Thomson, L.J.M., Blair, K. et al. (2013). Using museum objects to improve wellbeing in mental health service users and neurological rehabilitation clients. British Journal of Occupational Therapy, 76(5), 208–216.
Bickerdike, L., Booth, A., Wilson, P.M. et al. (2017). Social prescribing: Less rhetoric and more reality. BMJ Open, 7:e013384.
O'Neill, M. (2010). Cultural attendance and public mental health – from research to practice. Journal of Public Mental Health, 9(4), 22–29.
Scope, A., Uttley, L. & Sutton, A. (2017). A qualitative systematic review of service user and service provider perspectives on the acceptability, relative benefits, and potential harms of art therapy for people with non-psychotic mental health disorders. Psychology and Psychotherapy, 90(1), 25–43.
Uttley, L., Stevenson, M., Scope, A. et al. (2015). The clinical and cost effectiveness of group art therapy for people with non-psychotic mental health disorders. BMC Psychiatry, 7(15), 151.