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Using arts to enhance mental healthcare environments: Findings from

qualitative research

Article  in  Arts & Health · March 2010

DOI: 10.1080/17533010903031408

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 Using Arts to Enhance Mental Healthcare Environments: Findings from
Qualitative Research

Norma Daykin, Ellie Byrne, Tony Soteriou, Susan O’Connor with Jane Willis.

Arts and Health: An International Journal for Research, Policy and Practice.
2 (1):33-46.

Please cite the published version:

http://www.tandfonline.com/doi/abs/10.1080/17533010903031408

Corresponding Author

Norma Daykin
Professor of Arts in Health.
University of the West of England, Bristol,
BS16 1DD
Tel. 0117 328 8474
Email: norma.daykin@uwe.ac.uk

Co-authors and collaborators

Ellie Byrne
Research Associate
Cardiff Institute for Society, Health and Ethics
53 Park Place
Cardiff
CF10 3AT
Tel. 029 20870296
E-mail: ByrneE@cardiff.ac.uk

Dr Tony Soteriou
Director of Research Avon and Wiltshire Mental Health Partnership NHS Trust,
Hillview Lodge, Combe Park, Bath BA1 3NG,
Tel. 01225 826423,
Email: tony.soteriou@awp.nhs.uk.

Dr Susan O’Connor
Department of Health New Horizons Programme Lead and Consultant Psychiatrist,
Avon and Wiltshire Mental Health Partnership NHS Trust, Jenner House Langley
Park Chippenham SN15 1GG.
Tel. 01249 468075

1
Email: susan.o’connor@awp.nhs.uk

Biographies

Norma Daykin is a social scientist and musician with over twenty years experience of
research in healthcare services. Her current interests are in creativity and wellbeing;
and the development of arts-based methodologies.

Ellie Byrne was the Research Associate for the project and continues to work in
Public Health research. Her current projects explore the impact of complex health
interventions and the use of photography in research.

Tony Soteriou is Director of Research for Avon and Wiltshire Mental Health
Partnership NHS Trust, with 14 years experience of undertaking and supporting
research in the NHS.

Susan O’Connor is a consultant psychiatrist and was for nine years Executive Medical
Director of AWP. In this role she clinically led several large modernisation projects
including an £80 million PFI Scheme to develop improved NHS inpatient and
community services.

Jane Willis has been a key player in the arts in health field for many years. She set up
Willis Newson, an arts and wellbeing development agency, in 2001 after seven years
at Barts and The London NHS Trust where she founded Vital Arts and led its
development into a thriving hospital arts programme.

2
 Using Arts to Enhance Mental Healthcare Environments: Findings from
Qualitative Research

Norma Daykin, Ellie Byrne, Tony Soteriou, Susan O’Connor with Jane Willis.

Abstract

This paper reports on a qualitative study of the subjective impact of a visual arts
project in a Mental Health NHS Trust in England. A qualitative approach was adopted
including documentary analysis, focus groups, and over 50 in-depth interviews.

Arts were found to help shape healing environments through four processes:
modernisation; enhancing valued features; diminishing negative aspects; and creating
opportunities for service users and staff.

Responses to the artworks were diverse, and modernisation was sometimes perceived
as diminishing staff and service users’ control over the environment. Arts seemed to
be strongly valued when they enhanced control and enabled service users to affirm
non- stigmatised identities.

Arts projects in similar settings are likely to face complex issues of control, identity
and stake. A key challenge is balancing ‘prestige’ with ‘authenticity’. While
consensus may be difficult to achieve, the study points towards the high value
stakeholders place on arts in these settings.

Keywords

Arts, environment, mental health, participation, qualitative research

3
 Using Arts to Enhance Mental Healthcare Environments: Findings from
Qualitative Research

Norma Daykin, Ellie Byrne, Tony Soteriou and Susan O’Connor with Jane Willis,
Mark Palmer, Nola Davis and Joanna Espiner

Background

There is a growing recognition of the value and contribution of arts to enhancing

healthcare environments (Arts Council England & Department of Health, 2007;
Daykin, Byrne, Soteriou & O’Connor, 2008; Devlin & Arneill, 2003; Douglas &
Douglas 2005; Lowson, Beale, Kelly, & Hadfield 2006; Staricoff, 2004; Ulrich &
Gilpin, 2003; Ulrich, Zimring, Quan & Joseph, 2006; Waller & Finn, 2004). Research
has identified impacts of arts within healthcare environments at several levels,
including improvements in physiological indicators of stress such as blood pressure
and reduced anxiety and depression (Staricoff, Duncan, & Wright, 2004; Ulrich,
Simons & Miles, 2003; Ulrich, Simons, Losito, & Fiorito, 1991); and behavioural
changes in clinical settings (Kincaid and Peacock, 2003). Clinical research studies of
arts and arts therapies adopt increasingly robust designs, as is demonstrated in the
recent publication of systematic reviews of therapeutic arts in mental healthcare
(Crawford & Patterson 2007; Gold, Heldal, Dahle & Wigram 2005). As well as
clinical outcomes, many arts projects seek to enhance wellbeing, contributing to
quality of life and satisfaction with care. These aspects are recognised as important by
patients and staff, who value the contribution of arts to increasing wellbeing, reducing
stress and distracting from worries (Staricoff et al 2004). Research is needed in order
to understand these subjective impacts of arts in healthcare settings. Further, policy
makers, practitioners and researchers need to understand process issues that can help
or hinder projects. The recent Kings Fund evaluation of the Enhancing the Healing
Environment Programme has highlighted a number of issues, such as the time needed
for management of complex and sometimes contentious processes such as user
involvement and changes in working practices of staff (Lowson et al 2006).

Findings from a recent review of the literature (Daykin et al. 2008) concurred with the
view of those commentating on arts and health generally that research frameworks for
examining social and subjective impacts of arts are less well developed than those for
evaluating clinical evidence (Angus, 2002; Smith, 2003; White & Angus, 2003).
Rigorous qualitative research is needed to provide information about the experiences
and perceptions of stakeholders in order to underpin successful policy and practice.
Not only can qualitative research provide rich description of experiences and
perspectives, it can develop concepts and frameworks that assist understanding of the
arts in diverse healthcare contexts. This paper reports on a qualitative study of a three
year arts project that sought to enhance patient and staff experiences of mental health

4
care environments.

One area for investigation is whether particular characteristics of artworks can be

identified as suitable in healthcare settings. Research has sought to identify these
characteristics, drawing attention to the healing dimensions of particular kinds of
imagery, such as nature (Ulrich et al. 2003). Several studies have identified the
importance patients place on having a view from a window (Lawson & Phiri, 2003;
Ulrich, 1984; Verderber & Refuerzo, 1999). Beyond this, responses to artworks may
be diverse. While arts projects are generally liked by patients and staff (Scher and
Senior, 2000; Staricoff et al. 2004), reactions to particular pieces can be complex and
unpredictable (Duncan, 2003), with some early evidence that responses in mental
healthcare may be more polarised than in other settings (Chen & Sanoff, 1988). The
question arises of whether factors external to the artwork mediate its effects on
patients and staff in particular contexts. Hence it may not be possible to explain
responses to artworks with reference to the intrinsic characteristics of artworks
themselves, making it difficult to reach consensus about what kinds of artworks to
include in healthcare settings.

This debate has been explored in relation to arts and music. The notion that musical
works have intrinsic meaning has been challenged by sociologists who suggest that
while artworks can not be ‘read’ in reductionist ways, their meanings are nevertheless
situated and contingent, shaped by a combination of forces and the actions of
composers, performers, audiences, critics and funders (DeNora, 2000; Williams 2001).
This suggests that understanding of the roles and perceptions of actors in healthcare
settings is needed in order to explain responses and impacts of art within these
contexts.

Two key issues arise in relation to this discussion. The first is that of control. Several
studies have identified lack of control by patients, an enduring feature of old and new
healthcare settings, as limiting the potential benefits of environmental enhancements
(Duncan, 2003; Lawson & Phiri, 2003). Hence involving service users and staff in the
development of projects is recognised as a key factor underlining good practice
(Lowson et al. 2006). A second issue that has been explored to a lesser extent is that
of identity. In this context, identity is not perceived as a fixed, predetermined category
but something that is relatively fluid and shaped by experiences of participation. A
study of musicians’ wellbeing revealed the way in which the notions of creative
identities that individuals bring to arts processes can both enhance as well as diminish
their experiences of arts (Daykin 2005). A study in cancer care revealed that
participants can re-evaluate these notions of identity through engagement with the arts,
which can offer important resources for positive re-definition (Daykin, McClean &
Bunt & 2006). Similarly, Lane (2005) found that cancer patients benefited from
participation in a hospital arts programme by gaining a sense of empowerment as well
as through the opportunity to experience ‘authenticity’. The notion of identity is also
important in mental healthcare: a key benefit of participation in arts projects is the

5
opportunity for patients, particularly in mental healthcare settings, to re-engage with
alternative identities that are less stigmatised than that of ‘patient’ (Spandler, Secker,
Kent, Hacking & Shenton, 2007). This suggests that as well as increasing
participants’ sense of control over their environments, the success of arts projects may
to some extent depend on their ability to engage with and affirm creative identities of
participants.

Research Approach and Methodology

The study investigated a three year arts project, ‘Moving On’, supported through the
Private Finance Initiative (PFI), which involves private sector investment in new
National Health Service (NHS) facilities and buildings. It included 36 individual artist
commissions, such as integrated flooring, windows, water features, wall hangings,
textiles and paintings across 16 new mental healthcare units. Each commission was
designed in consultation with service users, staff and other stakeholders, and some
included a participatory element where service users became involved in the
fabrication of the artwork.
The study was a partnership between a University, an NHS Trust and an arts
consultancy organisation. It was supported by a Steering Group which included
service user representation. Ethical approval for the research was obtained from Bath
NHS Ethics Committee and for the University of the West of England, Bristol, Ethics
Committee.

The research sought to explore the subjective impact of the arts project on patients
and staff; hence a qualitative approach was adopted. Further, in order to allow for the
triangulation of findings from different areas a number of different qualitative
methods were used including documentary analysis, interviews and focus groups.

The Documentary Analysis

The documentary analysis encompassed over 400 documents generated by the

Moving On project over a period of four years from June 2002 to August 2006,
including 291 ‘love-hate’ photographs taken by service users and staff. Of these
documents eleven were generic to the project as a whole, including the overall Arts
Strategy. The remainder were local and operational documents of varying levels of
formality, and a stratified random sample of these was drawn up.

Discourse analysis (Carabine, 2001) was adopted for the analysis of the documents
identified. This approach, which can accommodate a wide variety of texts including
visual images, goes beyond ‘face value’ identification of key themes to address
tensions and significant absences. Further, Foucauldian discourse analysis (FDA)
recognises the importance of the social and political context from which documents

6
draw meaning. Within FDA, the word ‘discourse’ has two meanings. As well as a
piece of text or an image, a discourse is a set of words, thoughts and actions
surrounding a particular topic. A key premise is that that knowledge and power are
intimately bound, discursively incorporated into ways of thinking and speaking
through textual representation. Discourse analysis helps to unmask how dominant
groups in society promote their own interests by constructing a fitting version of
reality through texts and images. It also reveals ways in which dominant versions of
reality are challenged. In this study, the adoption of FDA principles meant that the
analysis sought to identify contextual discourses, such as ‘modernisation’, that shaped
the project. These are elaborated in more detail in the results section below.

The Interviews and Focus Groups

Following completion of the documentary analysis, interviews and focus groups took
place between March 2006 and May 2007. This phase of data collection took place
across four adult facilities selected to reflect different types of service as well as
geographical locations. They included a rehabilitation unit, medium secure services,
an older adult acute ward and a large campus-style hospital catering for a range of
service users. Hence the scope of the project offered an opportunity to explore the role
of arts in a number of different contexts and with a wide range of service users and
staff.

The majority of the interviews were undertaken by EB, while ND led the focus groups
with EB. There were 55 qualitative interviews with service users (26), staff (18),
carers (3) and other stakeholders and artists (8). Three focus groups with service users
took place; two with inpatients and one with an established user reference group.
Participants were recruited from each of the sites within the three localities, either
directly or with the help of key staff such as service user involvement workers. Each
interview was based on a topic guide but was semi-structured; this allowed
participants to talk in depth about a specific issue if they wanted to. A topic guide was
also used for the focus groups, and in addition these used a photo-elicitation method
using images of the artworks to prompt responses.

The interviews and focus groups were tape-recorded and the data were transcribed
and imported into Nvivo 7™, a software package for analysing qualitative data. The
data analysis was guided by principles and procedures from constructivist grounded
theory (Charmaz, 2000; Strauss & Corbin, 1994). The data analysis was iterative and
began with ND and EB each coding and comparing analysis of segments of data in
order to validate the development of a coding frame. This validation exercise was
repeated several times as new themes emerged and was further supported by critical
reading and coding by members of the project steering group1.

1 We are particularly grateful to Mark Palmer for his input into this phase of the research.

7
 Results and Discussion

Findings from the Documentary Analysis

The documentary analysis identified a number of contextual discourses that shaped

the Moving On project, two of which are discussed here. The first of these is
‘modernisation,’ described by the Department of Health as follows:

The NHS modernisation programme is the largest and most systematic quality
improvement effort anywhere in the world. Since 2001 over 150,000 NHS
staff have been engaged in the work of the Modernisation Agency. This has
brought great benefits to patients as redesigned services and new ways of
working have led to better quality, quicker access and improved outcomes.
(Department of Health, 2007).

The documents position ‘Moving On’ as part of this agenda, which encapsulates a
number of themes including the concerns of the evidence based design movement to
ensure that healthcare environments maximise positive outcomes, avoid negative
impacts and the associated costs of poor design.

A second discourse is that of ‘participation’, described by the Department of Health in

terms of a Government commitment to:

…. empowering both individuals and communities so that they can play a

greater role in shaping health and social care services.
(Department of Health 2008).

Patient and public involvement, described as a response to feedback from citizens as

well as underpinning improved service delivery, has been a key policy thrust in the
UK since the 1990s (Baggot, 2005; Crawford, Rutter, Manley, Weaver & Bhui et al.
2002; Daykin, Evans, Petsoulas & Sayer, 2007). Within mental health services,
participation relates to broader issues of empowerment and rights (Truman & Raine
2002). The Moving On project was designed to involve service users at a number of
levels and the documents suggest that it would have been unthinkable to introduce
arts without attempting to engage service users in participation.

The analysis of the documents reveals the way in which these discourses shaped the
project, sometimes creating vision and at other times introducing difficulties. For
example, notions of ‘modernisation’ and ‘participation’ were sometimes in tension;
this played itself out as a conflict between ‘prestige’ and ‘authenticity’. The former
was felt to be favoured by the funding structure of the project, since funds were
available at the outset for capital investment while additional fund raising was needed
to support participatory projects. Once established, this tension was perpetuated at key
points in the projects’ development. Hence a particular group of stakeholders, those

8
favouring ‘service user art’ over high calibre, ‘professional art’ entered the
consultation process from a position of contestation.

While the healthcare staff leading the project created many opportunities for service
user participation, they found it difficult to meet the expectations of this group.
Tensions arose around specific decisions, for example, the selection of artists. While
service users were involved in the selection process, meeting notes reveal a sense of
dissatisfaction that ‘service user artists’ were not prioritised for the project.

The artists were also affected by this tension. On the one hand they were expected to
produce high quality ‘prestigious’ artworks; on the other hand they were required to
elicit and respond to feedback from service users. They needed to negotiate their way
carefully between these positions.

Findings from the interviews and focus groups

The main themes emerging from the analysis of the interview and focus group data
are presented here. The data are discussed in relation to three headings: benefits of
arts, limits of arts and service user participation.

The benefits of arts

The analysis identified four levels at which arts were seen as contributing positively
on the environment, creating benefits for service users and staff. First, arts were seen
as supporting modern, well designed environments. Many participants had recently
moved from old, deteriorating buildings to the new modern facilities. The accounts
from service users, staff and stakeholders all suggest that the artworks made an
important contribution, adding brightness, ambience, space and identity, and creating
an ‘up to date’ feel:

Yea its lovely I mean its quite unusual I think all the sculptures and artwork
around the place are unusual but its um it just gives a feel of being a bit more
modern and a bit more up to date …I quite like it.
(Stakeholder 05)

A particular issue for service users and staff was that of privacy and in general, the
new environments were seen by some service users as offering more privacy than the
old ones:

I: And what do you think of the actual buildings?

…
R: Well I think it’s fantastic … there just comes a time when you’ve
got to chill out and if you can’t chill out in your room and you’ve
got to be on the ward all day, it’s very, very discomforting at

9
 times
I: So you’ve got more access to your bedroom here?
R: Yea, yea and I think that’s an important part yeah.
(Service user 21)

Another concern was maintenance, and it was important that the artworks were robust
enough to withstand the challenges of the healthcare environment. While some staff
voiced concern about particular commissions that were not working properly a few
months after installation, in general, this aspect of the project was viewed as
successful:

R: tree of light (………..) moving wildly with the very strong winds that
we’ve just had and it took on another dimension
I: Really I haven’t seen it moving, I’ve seen it (……….)
R: Its wild you know, it really moves wonderfully and it’s obviously
very robust
(Stakeholder 01)

In summary, the notion of ‘fitness for purpose’ can be used to encapsulate these
responses to the physical environment:

I think it’s very fit for the purpose. I think it’s a fairly attractive … I hope…
it’s shaking down… and it’s settling down and being of benefit to everybody.
(Service User 13)

The accounts reveal a second level at which arts can contribute: that of enhancing
valued aspects of health care environments. The data strongly suggest that one such
aspect is nature. In the old, rural facilities, service users and staff had free access to
woodlands. While not all respondents enjoyed nature, with some portraying nature as
threatening and dangerous, most placed a high value on being able to encounter
animals and wildlife:

I: Are there any bits of XX that you particularly like?

R: The woods.
I: The woods? There’s woods sort of all the way round isn’t there? And
what is it about the woods that appeals to you
R: Squirrels and…
I: Oh really?
R: Yes.
I: So you get to see the squirrels?
R Yeah, they run all over.
I: Wow, are there any other animals that you see?
R: Deer
(Service User 07)

10
Respondents often commented on the therapeutic aspects of nature. Some of
these garden and outdoor areas had been lost in the transition to new facilities,
where the gardens were more enclosed:

I: And what do you think of the garden? Do you like it? Do you think it’s
been designed well?
R: No… Too many bushes out there… too many trees… and you can’t
really… like… I don’t know… kick a ball around, if you’ve got one or
something like that.
(Service User 30)

Careful landscaping was identified as mitigating this loss of nature. Successful

artworks, sometimes made with materials that evoked the old environments, also
worked to create a sense of ‘nature’ in the new environments.

Oh with seating as well….it looks like well all natural wood or whatever but I
think that’s ……it looks great, kind of handmade, hand done, a bit more effort
put into it rather than a sort of real institution look. It’s a bit more sort of
home-grown as it were.
(Stakeholder 06)

In summary, the accounts reveal the contribution of arts in reinforcing positive

aspects of the environment, reinforcing findings from other studies about the
importance of nature and its association with healing.

Thirdly, arts were identified as reducing or minimising negative aspects of the

environment. One such aspect is institutionalisation, a notion that was applied both to
internal and external environments. Institutional internal environments were described
as ‘dull’, ‘boring’ and ‘uninspiring’:

I think it feels dull. It feels like a prison… it’s typical of that type of institution.
Really dull and boring and it made me feel depressed just being in the place.
… Um, reminds me of mm a throw back of, um reminds me of sort of church
youth club, you know? …. That’s the only impressions I’m left with. I didn’t
feel that it was necessarily comfortable or inspiring or anything else.
(Carer 01)

Accounts of institutionalisation alluded to functional as well as aesthetic qualities,

hence institutional environments were seen as those that seemed to facilitate staff
work and clinical practices rather than support patients. For example, it was suggested
that the organisation of old sleeping and recreation facilities served to allow
maximum observation of patients by staff rather than facilitate relaxation. There was a

11
general sense that the artworks contributed a reduced sense of institutionalisation in
the new environments.

So I think they will look beautiful, actually, and I think they will take that sort
of stark, slightly clinical building edge off completely, really. Yes
(Service user 13)

Some staff spoke passionately about the power that art has to change the atmosphere
of a space:

I think its nice if you go into any place and … there is a picture or there are
pictures arranged on the wall, it immediately brings life, it brings colour, it
brings perspective, it brings depth, it brings something to look at and dream
and imagine around. They can evoke feelings, emotions, it can evoke
memories, which is why sometimes images are important, you don’t want
unhappy memories um it can bring pleasure and to thinking that much art,
much, much art is very beautiful and beauty in itself can bring pleasure
(Staff member 10)

One of the aims of Moving On was to reduce the stigma associated with mental health
and mental health care environments. The following comment by a stakeholder shows
how the artworks were perceived as helping to challenge stigma:

Um it creates a very, very different atmosphere. You go to secure services and

your first impression is this amazing depth of blue glazing, your first
impression is not a big fence and that it’s a secure unit. Or you go to say XXX
and your first impression is the blue sky fence it’s very different and it
challenges what you think about mental health, it’s good
(Stakeholder 05)

In summary, the accounts reveal that the arts were generally perceived as successful
in mitigating negative aspects of the environment including institutionalisation and
stigma.

Finally, the arts were seen as enhancing the environment by providing opportunities
for service users and staff. The older external environments had offered many
opportunities, such as free use of large gardens:

Well we were encouraged to walk the mile, it's a mile all the way round and
we are encouraged by physio to walk early in the morning and then go to gym.
(Service user 07)

12
Since the new environments did not offer the same access to open outdoor spaces, it
was important that their design created opportunities for relaxation, peace and
tranquillity:

R: I suppose it’s sort of like… gives you more of a wellbeing… that’s

basically it, really.
I: How would you say that piece… that sculpture there… has an effect on
your wellbeing?
R: Sort of like a… it’s tranquil… sort of thing… peaceful… apart from the
traffic.
SU11

Another opportunity was that of engagement. Successful artworks also provided

interest and stimulation in otherwise dull indoor environments dominated by TV. As
well as relaxation, many of the artworks encouraged reflection and interest. Some
service users related strongly to particular pieces:

I: Right. Sounds like this one’s had the most impact on you?
R: Yes, because I could relate to it, really. Relate to it.
I: That’s interesting. What do you mean, how can you relate to it?
R: Well, really, I thought if I had the opportunity, if I was to do
anything like that, it would have been something abstract, along
those lines.
SU02

For these respondents, the artworks seemed to provide a resource for the articulation
of personal identity. Hence they seemed to enjoy speaking about the arts, not as
‘patients’, but as ‘critics’, ‘experts’ and ‘artists’.

In summary, the results point towards the opportunities afforded by arts within the
health care environment. One of these is the opportunity to re-establish and affirm a
non stigmatised identity, a significant issue in mental health services.

Limits of art

Some limits of art also emerged from the data. The research identified several levels
at which the role of art may be limited or constrained. Criticisms of the artworks were
often addressed at the characteristics of the artworks themselves, with some
participants reacting strongly against particular pieces. However, there was no overall
consensus about suitable or unsuitable characteristics of artworks, and even in relation
to the popular theme of nature.

13
Other identified limits related to the structural aspects of the environment rather than
the artworks themselves. Hence the introduction of artworks was sometimes
insufficient to address challenges of particular environments:

I think there’s also a hell of lot room for improvement still and it’s not just
about the artwork, its about the whole environment you know which is just the
whole look of the whole place. I mean you can’t just have a building with two
blocks of art and say well this is a really nice homely environment…
(Staff member 14)

These challenges included non visual aspects of the environment. Sounds that service
users seemed to miss in the new settings were those they associated with nature, such
as birdsong. While there was a reduction in annoying sounds such as doors banging
and staff voices amplified by echoing corridors, in the new more urban environments
account had to be taken of new sounds such as the continuous background hum of
traffic.

Other responses to arts seemed mediated by contextual and situational factors,

including roles, identities and control. For example, not all staff appreciated the
changes:

I: And do you feel that the … arts strategy has made that contribution?
R: I don’t see how it has, no, … what we’ve got is three pieces of art, one
that’s appalling and two that are ok… placed on clinical white walls. Well
if we think about how we use art at home and how we use art to create an
environment which is ourselves we aim to create a mood or a theme in a
room and we’d do that by way of colour and fabric and texture, so we
would then be looking at what we’ve got to say well how can we, that
hasn’t been done. Well I don’t think it’s been done
(Staff member 15)

For some staff, and the introduction of the artworks may have reduced their sense of
control over the environment. They seemed to reassert control by adding what were
described as ‘homely’ touches.

The issue of control also emerged in service users’ accounts. A small group of service
users who identified strongly as ‘artists’ were, as has been discussed, vocally critical
of some of the artworks. The issue of control also emerged more generally as
mediating service users’ responses. For example, the accounts reveal that access to the
opportunities afforded by the artworks was contingent upon the day to day
management practices that shaped behaviour in the new environments. Hence some
indoor commissions were described as ‘wasted’ in settings that were not seen as well
utilised. Likewise, service users’ access to some of the beautiful outdoor installations
was limited:

14
 … only allowed out in the garden once every hour on the half-hour for a
cigarette… whereas in the other hospital there was a smoking room like this
where you could sit and chat or you could go out… you had garden access all
day.
(Service users 33)

In summary, while the art works were generally valued by service users and staff,
some limitations were identified. It was difficult to attribute these to the specific
characteristics of the artworks: rather they seemed to be a function of structural
features of the environment as well as mediated by participants’ experiences and
enactment of roles, identities and control.

Service user participation

These findings are reinforced in accounts relating to service user participation. These
reflect the range of experiences within the project on a continuum from service users’
engagement in arts processes through to their involvement at the strategic level of
decision making. Participation in arts processes was almost universally rewarding,
even for those service users who were critical of some aspects of the project. Service
users enjoyed many aspects of this, such as having the opportunity to work with
professional artists, collaborating successfully with others and having a visible
influence on the shaping of the aesthetic environment. While some artists found the
requirement for consultation with service users challenging, they responded positively
and many service users felt that their contributions had really made a difference:

R: Well, she … said: “These are the designs I thought of.” So she put them on the
table and she said: “Just help yourselves and I’ll give you pens and you can
draw round them or about them, or cross them out and do your own design.”
I: So you could amend them?
R: Yes, that’s right. And that was really good. … . She said, “so this is of
common consent… yes… We’re working in these parameters,” which was really
wonderful… you know… because instead of … you doing your own thing she
really integrated everything….
(Service user 22)

Engagement at the strategic level of decision making engendered mixed responses

from service users. While this form of participation could be meaningful and positive,
leading to a sense of being able to influence decisions and help to shape the healthcare
environment, participation at this level was often challenging for service users. One
challenge was the relatively formal, professionalised culture of meetings and
discussions:

15
 … her exact words were, we need a service user, that’s brave enough to speak
up at these meetings, and they are very official and they can be intimidating,
and there were quite a few times I felt intimidated with the Directors … you
know and even though I appreciate architecture, I can’t understand the
technical conversations about what went on you know
(Service user U05)

The accounts also reveal some particularly contentious issues and areas of
disagreement. The tension between ‘prestige’ and ‘authenticity’ identified in the
documentary analysis also emerged strongly in accounts of participation. As was
suggested earlier, a group of service users and staff who aligned themselves to
‘authenticity’ and the support of ‘service user art’ described themselves as being at a
disadvantage from the beginning of the consultation process. In focus groups service
users described themselves as being continually ‘overruled’ by staff in decision
making processes about the selection of artists and the choice of commissions. In
these group discussions the importance of artistic identity to service users emerged
even more strongly, reinforced by peer support. Hence for this group, a key
opportunity afforded by the arts project, that of asserting and reinforcing non-
stigmatised identity, seemed to be missed and was not successfully compensated by
inclusion in strategic decision making processes.

This tension between ‘prestige’ and ‘authenticity’ did not just influence accounts of
the implementation process. It also seemed to influence subjective responses to the
artworks themselves:

… patients’ art work was missing… I just feel that the quality of the
people that come and use the service was missing from those areas.
So I guess for people who don’t have… or don’t feel they have a
connection to art… perhaps it feels a bit alienating that there are big,
expensive things here that were commissioned or happened as part
of the new build and they don’t feel that they have been part of that
process, whereas with service users’ work… they can relate to that…
I think that feels more personal.
(Staff member 19)

In summary, the data suggest that in this mental health setting, participation in the arts
project was a key issue. In many instances, participation enhanced service users’
sense of control as well as providing positive experiences of communication and
collaboration. Participation also allowed service users to experience and articulate
alternative identities to that of patient, such as that of ‘artist’. For some, however, this
promise of participation was not fully realised. A core group of service user/artists
and their supporters felt disadvantaged by what they saw as financial and business
agenda that not only pre-empted processes of consultation, but devalued their
identities and diminished their control.

16
 Conclusions and implications

The study sought to investigate the subjective impact of arts on patients and staff in
mental healthcare settings. The results concur with previous studies in demonstrating
the value of arts in these settings. In addition, the findings also highlight the specific
contribution that arts can make to mental healthcare environments. These impacts
seem to operate at four levels: the creation of modern, ‘fit for purpose’ environments;
reinforcing positive aspects and diminishing negative aspects of the environment; and
providing a range of opportunities for service users and staff.

The research has identified other limitations and challenges for arts in healthcare.
Hence the introduction of artworks is not sufficient to overcome some functional
issues and visual arts cannot easily compensate for qualities of the aural environment
that service users and staff find difficult. Further, day to day management practices
can mean that the potential benefits of arts are not always realised. Finally, the
introduction of artworks can also be seen as problematic by some staff, who may not
welcome being faced with additional challenges of management and maintenance

The research sheds light on some key questions, exploring diverse responses and
questioning whether particular characteristics of successful artworks in healthcare
settings can be identified. The study concurs to some extent with previous studies in
finding support for specific aesthetic qualities. These include references to nature and
locality; the use of colour, light and shape to create non institutional imagery; and the
avoidance of specific references that might evoke negative associations and memories.
However, the study also highlights the contingency of responses to artworks in
healthcare settings, particularly in mental healthcare. Hence the research suggests that
responses to artworks in these settings are influenced by a complex interplay of forces
including aesthetics, control, identities and power relationships.

The issue of control seems particularly important. Service users and staff who
experienced a sense of control during the project’s implementation were generally
supportive of the artworks, regardless of their characteristics, sometimes accepting
some quite ‘abstract’ pieces. Service users who participated in arts processes gained a
sense of control over their environment and expressed real satisfaction at being able,
with the support of skilled artists, to make a visible difference. A sense of diminished
control seemed to influence criticisms, not just of the individual artworks but of the
arts strategy itself. Staff and service users also sought to reassert control where this
was felt to be diminished, adding their own decorative touches to the new
environments and advocating alternative discourses to that of ‘prestige’ such as
‘homeliness’ and ‘authenticity’. Service users had fewer opportunities to assert day to
day control, and their access to the artworks and the environments being controlled by
staff through management practices sometimes dictated by clinical priorities.

17
These micro level tensions and experiences of control were to some extent supported
by macro level tensions. Hence discourses such as ‘modernisation’ and
‘participation,’ while sometimes at odds, are both important within the mental health
policy context. On the one hand, ‘modernisation’ gives rise to concerns for quality,
prestige, longevity and the need for ‘high calibre art’. On the other hand,
‘participation’ values processes and experiences of consultation and empowerment.
Perspectives on participation seemed to operate on a continuum from service user
engagement in artistic processes facilitated by artists to the notion that service users
should be prioritised as ‘authentic’ artists. Where participation fell short of this ideal,
the project gave rise to disappointment and frustration.

A related issue to control is that of identity. Participation in arts processes as well as

the strategic development of the project seemed to give service users access to a range
of identities other than the stigmatised and relatively powerless one of ‘patient’. The
research process reinforced this, allowing service users to speak with the voice of
‘critic’, ‘artist’ or ‘expert’ about their experiences and opinions. Focus groups in
particular seemed to have this effect, with the group discussion allowing service users
to validate each others’ statements, opinions and standpoints. During these
discussions, prompted by photo-elicitation, service users encouraged each other to
show examples of their own art to the group. It was when these diverse identities were
invoked that service users spoke most passionately about the arts, revealing the strong
sense of stake that some service users invested in art.

The study has implications for the development of similar arts projects in mental
health settings. It suggests that in these settings arts need to address both aesthetic and
political concerns if they are to be successful. As well as the qualities of artworks,
experiences of control and the impact of participation on the roles and identities of
staff and service users are key elements to consider in the planning of arts
interventions. Tensions between ‘prestige’ and ‘authenticity’ may be embedded in the
broader context and may therefore be difficult to eliminate at the local level. This
means that consensus about arts in mental healthcare may be difficult to achieve.
However, the study demonstrates the wide ranging benefits of arts, suggesting that
policy makers and practitioners may need to be prepared to accept and accommodate
diverse views in order to realise these benefits for the majority of service users and
staff. At the same time, arts initiatives need to include genuine opportunities for
participation if they are to be successful in enhancing mental healthcare environments.

The provision of meaningful opportunities for service user participation in creative

activity is not the only prerequisite for success. Other issues are the need for clear
expectations about the roles of key partners (including public and private investors,
managers, care staff, artists, arts therapists and service users) and the need to consider
the meaning and goals of consultation and involvement

18
The study also points towards some implications for research. It demonstrates the
value of qualitative research in informing practice and policy development in
particular contexts. It also highlights the value of particular methodological
approaches such as group based and arts based methods, which can stimulate
expression of perspectives and views that might not emerge from one to one
interviews. Similarly, discourse and documentary analysis added to the research by
allowing the inclusion of contextual and policy issues within the analysis. This is
important to recognise since some achievements may be beyond the scope of local
arts project. The research points towards the benefits of using mixed methodologies,
allowing triangulation and helping to overcome some of the drawbacks of single
methods.

A key question is whether these findings can be generalised beyond the study.
Qualitative research is necessarily situated, but this does not mean that its results can
never be applied beyond a specific case. While the study was influenced by the
organisational context of a NHS mental healthcare trust in England, it drew on
extensive data including accounts of over 50 mental health service users and staff
from a range of care settings. It is likely that some of the findings are applicable to
similar groups elsewhere. The analysis draws attention to the influence of a range of
discourses, some of which frame the international context of arts in healthcare.
Further context specific research is needed to explore the subjective impact of arts and
the process issues that underline the successful development of arts for health activity
in a range of settings.

Acknowledgements

We would like to acknowledge the reviewers of an earlier draft of this paper who
gave valuable feedback and encouragement.

We are grateful to the many participants who gave their time to the study and to the
NHS occupational and arts therapy staff who helped to facilitate the research in
practice settings.

The research was a collaboration between UWE, Bristol, Avon and Wiltshire Mental
Health Partnership NHS Trust and Willis Newson Arts Consultants. The Steering
Group included Dr Mark Palmer, a digital artist and lecturer in the Bristol Institute of
Technology, UWE, Bristol; Nola Davis, who as a service user representative, made an

19
invaluable contribution at all stages; and arts consultants Jane Willis and Joanna
Espiner.

The research was generously funded by the Estates and Facilities Division of the
Department of Health. Responsibility for the views expressed within it lies with the
authors and does not necessarily reflect the views of the Department of Health.

20
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