Personal narrative
Living and working in East London, in the UK, it is hard for me to ignore the influence of Walthamstow’s William Morris, the nineteenth-century social pioneer and founder of the Arts and Crafts Movement. Morris has easily outlived the mark made by Walthamstow’s other famous residents – the 1990s boy band East 17. Importantly, Morris’ principles still inspire occupational therapy collaborations with the arts today.
Morris highlights a yearning for freedom that I feel is one of three great motivators alongside empathy and creativity. These notions are all emotive, distinctly human and sadly not always extended towards those people with, or recovering from, mental health difficulties. This can be a source of frustration and a breeding ground for occupational alienation, injustice and deprivation. Our liberty is realised in the ideal of social inclusion: equity, allowance and recognition for all. William Morris was an enthusiastic advocate for fair treatment, better living conditions and the acknowledgment of craftsmanship. He promoted both individualism and collective advantages against soul-less mass production of furnishings, preferring imaginative design. Given his views, it is ironic that his designs have been widely reproduced since his death, although that may reflect their enduring attraction rather than his political opinions.
I consider that empathy is the keenest of driving forces. We all have our mental health alongside our physical and spiritual well-being. However, one in four people will have a mental health problem during their lifetime and most of us will experience, at the very least, the effects of stress, bereavement and anxiety. Fascinated by my own ever-changing emotional state, my work has evolved to a passionate moral support for those much ridiculed and marginalised by society. This has been influenced by working in mental health, over the past 10 years, in psychiatric accident and emergency; acute, low secure and long-stay inpatient units, day hospital and community services.
My third motivator is a strong belief in universal creativity. People are not only occupational beings but also creative beings. Everyday human traits such as problem solving, resourcefulness, invention and flexibility are just as creative as painting, composing music or writing poems. But as occupational therapists how can we truly harness creativity?
Having the opportunity to explore new ground in a practice development occupational therapy post, much of my current work with the arts was founded by the desire to uncover a vehicle for service users to move away from institutions, and their often accompanied staid thinking, to experience greater acceptance in mainstream life. Art has proved a valuable means for this. The success of this approach resulted in the change of my post to focus on leading occupational therapy for the arts and rehabilitation.
Innovation never ceases to amaze the world, but individuals’ endeavours can be hidden from view by a lack of access to the elite arts world. For individuals with mental health problems, occupational disruption is caused by clinical symptoms, financial hardship, poor confidence, and resistance resulting from years of invaded privacy and depersonalisation. Yet, mental illness is often linked to the genius of artistic expression as illustrated by the composer Ludwig Van Beethoven, postimpressionist painter Vincent Van Gogh, writer Virginia Woolf and more recently actor Spike Milligan. As Edvard Munch the creator of the painting, The Scream, said, ‘Without fear and illness, I could never have accomplished all I have’ (Thinkexist, 2007). Reflecting on the ways we may unwittingly curtail ambition brings about greater understanding of how we can broaden existing opportunities and create new openings for people with mental health problems.
After years of running many different creative sessions, using a variety of media including photography, music, writing, craftwork, art and drama, I wondered why the process sometimes seemed demeaning or even patronising for the participants. So, I looked beyond standard review processes, such as participant questionnaires and discussions because of their limited perspectives. They appeared only to ask if people were satisfied with the sessions they had participated in and this generated new ideas for activities, which I would then incorporate into revised sessions. I began to believe that this was tokenistic to client-centred practice, because such a task-orientated approach sets boundaries and limits the realm of possibilities for individuals. Most disturbingly, I recognised I could be perpetuating occupational alienation.
Occupational alienation is addressed more fully in Chapter 7, but it contains elements of isolation, frustration and estrangement leading to a feeling that engagement in occupation does not meet the individual’s needs (Wilcock, 1998a). This internal response to activity as an unrewarding experience led me to ask why people went to creative groups. Through detailed discussions, clients identified a range of reasons as to why they attended, including to:
- relieve boredom;
- find respite;
- demonstrate a willingness to get better;
- show progress;
- accelerate the chance of discharge;
- change their mood;
- be with like-minded people;
- find a means of expression.
Traditional occupational therapy creative groups have their value and can lend the means to improve health, rediscover latent talent, continue an existing hobby or find a new one; yet occupational alienation can be present. Considering the complexity of initiative, personal drive and decision making, each of the aforementioned aims, singly or in combination, potentially holds positive and/or negative traits. Being attentive to participants’ motives for engaging in groups is fundamental. If someone is finding involvement in activities anywhere on a scale between uninteresting and soul destroying, this should be investigated to establish the cause, or else there will be the risk of occupational alienation.
To move from running traditional creative groups in the hospital setting, I sought to recognise and showcase the artistic abilities of mental health service users, carers and staff. Hoping to break down some of the barriers that can exist between people, I established a Visual Arts Project in 2003, which is open to all contributions. This was an adjunct to existing occupational therapy services and open to everyone connected with mental health care in the North East London Mental Health Trust (NELMHT). Since April 2006, the project has developed into a budding organisation called thinkarts and its associated reference group Creative Circles. These ventures will be discussed in more detail later.
Occupational potential
Alison Wicks (2001) in a comment paper used an evocative illustration to describe occupational potential; it is worth repeating here.
A clay pot sitting in the sun all day will always be a clay pot. It has to go through the heat of the furnace to become porcelain (Mildred Witte Stouven, cited in Schaef, 1990, March 30). Actually there is nothing wrong with being a clay pot. It is just all of us have the possibility of becoming porcelain. (Schaef, 1990, cited in Wicks, 2001, p. 32)
Creative activities in occupational therapy
The therapeutic use of the arts can be traced back to classical times, for example, Egyptian writings from as long ago as 2000 BC tell of temples where ‘melacholics congregated in large numbers to seek relief… where recreations were instituted’ (Turner et al., 1992, p.12).
In the UK the Arts and Crafts Movement instituted by William Morris and others was part of a wider social reform movement, which, according to Wilcock (2001), included Thomas Carlyle, Robert Owen and Octavia Hill. They were all important in the inception of occupational therapy through their influence on Elizabeth Casson, who was instrumental in the development of occupational therapy including establishing the first school of occupational therapy in the UK (Wilcock, 2002). Holder (2001) suggests the tradition association between activity in occupational therapy and crafts derives from these early influences.
Drake (1999, p. 7) credits Tracy in 1910 as the first person to ‘designate specific crafts for specific needs’. Also at the turn of the twentieth century, Massachusetts-based doctor Herbert James Hall extolled the virtues of occupation for health by ‘…combining aims from medicine, psychiatry, the arts, and social work… where patients became “artisans”, … engaging patients in arts and crafts activities’ (Quiroga, 1995, p. 93 & 94).
Despite the centrality of occupation as treatment, the profession’s historical links to the arts appeared go astray from the 1950s, when there was an identity crisis in the profession as it moved to a more scientific focus to gain more recognition from medicine (Perrin, 2001). In the 1980s, it was acknowledged that creative activities were less valued in treatment programmes (Jungersen, 1981; Swee Hong & Yates, 1995), perhaps suggesting that Western culture favoured cognitive and verbal activities over manual skills. However, the move away from the arts was not to last. Returning to its roots, the profession re-engaged with creative occupations (Perrin, 2001). Other literature, around this time, noted the use of creative occupations in mental health (Craik et al., 1998; Lloyd & Papas, 1999; Griffiths, 2000). The range of creative media used in occupational therapy noted in the literature currently includes digital photography (Fitzgerald, 1999), pottery (Overton Croad, 2002), poetry (Pollard & Steele, 2002) and creative writing (Wood, 2003).
Thus, the profession came full circle with the emergence of occupational science and its emphasis on occupation as central to humans. National occupational therapy associations have moved to define and consolidate their identities based on occupation. Pierce (2003) noted that both the Canadian and the American Association had placed occupation at their philosophical core. The World Federation of Occupational Therapists (WFOT) (2006) definition of occupational therapy emphasises the promotion of health and well-being through occupation, and the WFOT (2002) revision of the curriculum for occupational therapy education placed occupation at the core of professional education.
Although, there is a relative wealth of literature on creative activities and related subjects in occupational therapy, the evidence base of its effectiveness is limited especially, as Lloyd and Papas (1999) highlight, around outcome measurement. Research into the use and efficacy of creative activities was identified in the priority list for occupational therapy in mental health by Fowler Davies and Bannigan (2000) and later by Fowler Davies and Hyde (2002). Although, it did not rate as highly as other issues, it was included.
The art and science of occupation
Through an array of key occupations, people have searched, solved and survived in ever-changing environments, having adapted over time to evolve sophisticated tools for living. There is a fascination with the human capacity to act on their environment, being driven to investigate and create beyond the necessity of survival, for example, earlier cave paintings depicted life at that time but do not appear to have a survival purpose. According to Clapham (1986) the basic needs of the early hunter gatherers were for shelter, warm clothing and tools to get food and water. The occupation of making was vital to providing a home, however temporary, when caves were unavailable, to providing animal skin garments to wear and to construct sharpened materials to catch prey for food. Sadly, for many people in some parts of the world, this focus on occupation for survival persists to the present day.
For other people, making consists of contributing to a larger project such as building bridges, computers, kitchen appliances and fairground attractions as part of their paid employment.
While for another group, their life focus is so remote from occupation in its original meaning that they find ways to include occupation in the everyday life. This is evident, in Western society, in the resurgence of lifestyle programmes on television and in magazines promoting the virtues of cooking, gardening and home decoration. However it is achieved, making remains a core occupation.
Through experimenting with occupations people discover who they are. Occupations extend from babies learning to crawl and adolescents testing their independence to adults maintaining their employment and older adults adjusting their occupations to cope with the participation restrictions of later life. This process is achieved over the life span through testing capabilities physically, emotionally and spiritually, by way of trial and error, boundaries and comfort zones are found.
In occupational terms, Nelson (1998) argues that the occupations that people do are both overt and covert. The establishment of an individual’s identity and their strengthening sense of self is largely a covert experience, nourished by active occupation, worldly exploration, relations with others, socio-cultural and environmental influences. An individual’s sense of self and all that it means is often the springboard for taking opportunities for occupation within the wider environment. These biological attributes in unison with humans’ creative capacity have enabled the occupation of making throughout evolution. As occupational therapists, the enjoyment of delving into the arena of people’s adaptability to their environment is far too tempting an opportunity to miss, the history of humanity holds many mysteries ripe for unfolding. Engagement in occupation, art specifically, offers participants opportunities for social inclusion, occupational balance and promotion of independence. These will be discussed below, as well as highlighting the place of arts in health.
Social inclusion
The thinkarts project builds on the results from Bryant’s (1995) study into long-term, community-based, social contact groups for people with mental health problems. She found that many users preferred these groups to other more formal day care, citing their low-key approach as a reason for this. With its focus away from clinical intervention, thinkarts goes further taking steps to develop community forums called Creative Circles, intended to foster social inclusion. The UK Government’s weighty agenda for social inclusion has meant that there is an expectation that those working in the pubic sector will take up the challenge and work towards social inclusion.
Occupational balance
The concept of health as more than the absence of illness is now well established and links to the heart of occupational therapy through occupation’s intrinsic connection to well-being since ‘man, through the use of his hands as they are energised by mind and will, can influence the state of his own health’ (Reilly, 1962, p. 2). It is with this belief that thinkarts endeavours to provide opportunities for users of mental health services, their carers and staff in the NELMHT to promote occupational balance, which leads to well-being (Wilcock, 1998b). A healthy occupational balance should not just include activities of daily living but the unusual and infrequent events that are part of the fabric of life. The thinkarts project aims to give people a choice to participate in its creative ventures to positively affect occupational satisfaction and improve quality of life, which is in keeping with Wilcock’s (1998b) view that occupational therapists need to develop new skills in new arenas to develop occupational potential.
Promoting independence
Alongside acknowledging people as occupational beings and utilising occupation to improve quality of life, the concepts of independence, occupational satisfaction, community and social inclusion have been the dominating ideals behind thinkarts. In an American position paper, Hinojosa (2002, p. 7) states that an ‘individual’s independence should not be based on pre-established criteria, perception of outside observers, or how independence is accomplished’. Promoting independence is a mainstay of thinkarts. Autonomy has been achieved by being person-centred and supportive yet not taking on a clinical or teacher role.
Mocellin (1995) suggested that occupational therapists should exchange occupation for teaching skills as their focus for intervention; Crabtree (1998) countered this view, stating that such an approach has no roots in occupational therapy, as it neglects context and would limit the profession enormously. Furthermore, Crabtree (1998, p. 505) acknowledges that teaching competence-building interventions is important but that it is not as important as ‘qualities and characteristics that go beyond skills and competence’. The thinkarts project endeavours to emphasise the characteristics that Crabtree promotes – a state of engagement, a sense of actuality, a sense of authorship and a sense of identity (Crabtree, 1998). Everyone is welcome to contribute to thinkarts, no matter their aptitude and there is no predetermined motive to build skills. Contributors have had to take complete responsibility for engaging, and are buoyed up, if need be, by conversations about their involvement. Furthermore, remaining separate from any hospital service has meant not being associated with any clinical team’s identity. Community orientated working and moving away from institutions into the public domain adds to the mainstream characteristic for thinkarts and further develops the arts in health movement.
The arts in health
The Health Education Authority (1999) published a review of good practice in community-based arts projects and interventions which impact on health and well-being. They identified over 200 projects in the UK linked to social or health related issues through intervention in the arts. The thinkarts project follows in this tradition. The Arts Council for England (2002) is involved in ensuring the arts are represented in heath care through a wide range of activities. In addition, there are many other separate arts projects of all different shapes and forms over the country in mental health. These include the START project in Manchester, which employs full-time artists in the occupational therapy-led adult day services, the Bethlem Gallery at the Maudsley Hospital for mental health service users work (Risby & Maddox, 1998), the national Art Works in Mental Health, a partnership of organisations involved in mental health who showcase the creative talents of those with mental health needs, LIME, who work all over health settings in the UK to make the arts a fundamental part of the healing process, and the Arts in Hospital project at Dorset Country Hospital, who borrow contemporary art works to display in public areas. It is against this landscape that thinkarts will be discussed.
Establishing arts projects
The next section of this chapter describes the development of a series of Visual Arts Projects each building on the success of the previous one and each moving further from the confines of hospital services and into the public arena. The impetus for these is based on the themes of occupational science and the practice of occupational therapy, and they will be illustrated in relation to the main themes of the projects.
Financed by the NELMHT charitable fund, a Visual Arts Exhibition was held in 2003 during NHS Week. It involved much partnership working using a new, but as yet unused, ward at Goodmayes Hospital. Practical support was received from a variety of sources and included users of Vocational Rehabilitation and Community Mental Health Teams who helped to set up the exhibition, exercising carpentry, Front of House and interior design skills. Contributors were prepared by being given a detailed fact sheet covering the process, sales options, their rights and the practice development occupational therapist’s responsibilities. On display were a variety of works including a rolling poetry display projected on the wall called Poetry in Motion, sculpture, cartoons, textiles, paintings, photographs and drawings by NELMHT service users, carers and staff of all age groups. Many exhibitors sold items of their work, accepted commissions or were invited to teach their expertise to others. The NELMHT produced their 2003–2004 annual report in the form of a calendar illustrated with a selection of works from the exhibition, for which the artists collected a national award.
The exhibition attracted an attendance of over 200 people, and their responses to the event were recorded in the visitor’s book. As occupational therapy aims to improve a person’s ability to function, increase health, well-being and quality of life through the purposeful use of activities, the entirely positive anecdotes such as ‘excellent – really enjoyed it, ‘I got so much from this’, ‘inspired me to re-start my art’ and ‘more please’ indicated its therapeutic value. But it was still too contained within the mental health community. So, the following year, a second Visual Arts Exhibition was held in a more public space, a local theatre attracting more volunteers, contributors and a wider audience.
Creative circles
Following the second exhibition, participants felt there needed to be a way to bring people together to share ideas, plan and organise visual arts events – the first thought was to establish a NELMHT Arts Council. However, the name seemed too formal and better suited to a chaired committee. Therefore, many versions later, the name of Creative Circle was agreed upon to promote the notion of equality and shared leadership. The aim of the Creative Circles is to serve as a reference group for all arts activities providing regular feedback and adding a greater element of accountability. In keeping with the aim of inclusively, a logo for this group has been created by a service user and acts as the identification mark on all promotional and advertising flyers and materials. Membership has been drawn from service users, staff and carers with interests and talents in creative pursuits as varied as music, stand-up comedy, poetry reading, amateur dramatics, graphic design, textiles, art and crafts. Meetings are held at community venues such as theatres, town halls and galleries.
To progress from this stage, it was necessary to contend with the concept of outsider art. The term was noted by Roger Cardinal and is applied to the output of people who have no supposed artistic background. As outsider artists have had no conditioning, they show purity of expression. However, the term can be misused or misunderstood, especially by those who use mental health services, who may consider it to be demeaning. As one in four people experience a mental health problem, the term applies to a quarter of all trained or untrained artists, whether they are involved in conventional settings or not. Where would this leave a twenty-first-century dwelling Van Gogh? To remove the straitjackets and labels that exist in both the arts and health, perhaps other terms such as ‘Free Art’ or ‘Open Art’ would be more appropriate terminology to honour those taking their own work beyond traditional routes and enable greater occupational satisfaction (Ede, as cited in O’Reilly et al., 2006).
To move further into the mainstream, the next step was to ascertain whether any London-based arts facilities would like to team up with the NELMHT. The Serpentine Gallery in Kensington Gardens, a famous location in central London, responded positively, and a meeting with their educational programmers resulted in an enthusiastic agreement to work together. Initially project workshops were hosted at the Serpentine Gallery for service users and staff to join with artists to visit their exhibitions regularly, responding to use of the artistic media and to explore ideas related to the display. These also provided forums to discuss future partnership working.
Hearing voices, seeing things
The partnership with the Serpentine Gallery grew from recognising the appetite for creativity in the mental health service user community and the frustrating inability to access the mainstream art world. Over a 3-year period a programme called Hearing Voices, Seeing Things developed with funding from The Big Lottery Fund, Rayne Foundation and Bloomberg, through a series of seven projects involving 150 people.
Adolescents designed images on plates donated by the world famous manufacturers Wedgewood for the grand fete event the Crockery Smash Up with ceramist Karen Densham. Young carers explored their home ground with new eyes in a photographic project called Urban Jungle with Andy Lawson. Hearing Voices Group members informed and contributed to the psychosis experience instillations of Silent Interruptions with Victor Mount. People with dementia created a new alphabet and lyrical works for Reminder with Bob and Roberta Smith. Adults of working age made a radio show in Ha Ha Bonk Telling Stories through Sound Effects with Mel Brimfield and Sally O’Reilly, and they created a theatre-based tableaux with Mandy Lee Jandrell and enjoyed plenty of humour through ‘What’s So Funny?’ with Jessica Voorsanger.
The projects culminated with a month-long Hearing Voices, Seeing Things exhibition at the Serpentine Gallery in autumn 2006. A collection of three posters were created with the London Transport’s art organisation, Platform for Art, to advertise the event and were shown across the London Underground tube network. A book detailing and illustrating each project, with additional contributions from poet and service user John Hegley and psychoanalyst Darian Leader was launched at the exhibition. The exhibition was an opportunity not only for those not directly involved in the projects to celebrate their innovative contribution to the art world, but also, for the viewers to question and challenge their preconceptions about mental health. The exhibition opening night was extremely well attended and generated a great deal of excitement and positive reviews. This approach of working closely with the arts has continued to be developed.
The thinkarts project and vocational opportunities
As a result of these initiatives and increased interest, it was necessary to create an umbrella organisation to further this work and encourage arts-related events, projects, voluntary and freelancing opportunities for people who have experienced mental ill health. Recognising the talent and expertise of mental health service users, alongside the barriers often experienced by individuals when accessing the world of art and business, thinkarts was founded in April 2006. Thinkarts endeavours to decrease exclusion by developing healthy and mutually beneficial partnerships with organisations in the wider community. Currently affiliated to the NELMHT, the organisation is working towards becoming an independent social enterprise.
Prior to, and throughout, thinkarts’ lifetime, service users have sought out opportunities to be involved in arts work, providing the inspiration, energy and ideas for projects, shaping the way forward to where we are today. Through thinkarts, individuals are forming a collective able to respond to requests from the community, spanning user groups to commercial businesses, education facilities to charities, for artworks and activities, for example, producing logos and advertising, or using skills to run sessions for local community groups.
The thinkarts project can be a learning ground providing work experience opportunities for those who are seeking employment or fulfilling their vocational needs outside paid work. It caters to all people irrespective of their work status or current activities. This is particularly important as the National Institute for Mental Health in England (NIMHE) (2003) suggests that over half a million people with mental health problems are not seeking work or are considered to be permanently sick. As the UK Government’s ambition is to achieve social inclusion, addressing the issue of unemployment is imperative. In the UK, occupational therapists appear to have neglected the vocational aspect of the profession in recent years and have focused on other aspects of rehabilitation. Further, exploration of this is found in Chapter 10.
With funding from Capital Volunteering, London’s pilot organisation to increase volunteering opportunities in mental health, thinkarts’ members of all ages and backgrounds have benefited from being involved as volunteers or participants in a wide variety of activities. These have included organising and invigilating Paint the Town Red, a World Mental Health Art Exhibition, teaching pastel and batik workshops, responding to graphic design commissions,; enjoying sessions with poets and craft specialists, assembling and rotating the Poems in the Waiting Room collection across clinic reception areas, building the thinkarts Web site and producing regular newsletters. It is hoped that the ‘thinkarts newsletter’ will become a glossy magazine that will continue to be free to service users and voluntary organisation on subscription, but will be sold externally through art galleries and bookshops.
Members have the opportunity to progress from volunteering to being paid either as freelancers or via permitted earnings, therefore protecting their benefit status. Some of the specific paid roles currently filled are events photographers, report writers, interviewers, publication layout specialists, carpenters and Web site developers. As illustrated, thinkarts is in a position to provide a wealth of opportunities for those who gain enjoyment and improved occupational wellbeing from engaging in creative pursuits.
Case Study 9.1 Pete’s narrative
I am a long-term mental health service user and have problems with my moods and depression for which I take mood stabilisers and anti-depressants when needed. I attend a day centre for people with mental health problems for 2 days per week doing pottery and art therapy. The art therapist there put me in touch with thinkarts.
I am very interested in graphics especially computer art; so thinkarts commissioned me to do several pieces of work: firstly, a board game called ‘Well-Travelled’ created as an accompaniment for NELMHT’s annual report, and postcard flyers and ten-way markers for a mile-long walking circuit at Goodmayes Hospital. I have also been involved with thinkarts Web presence and am currently developing an events calendar for the site.
This has been a real lifesaver for me, as I felt that my artwork had no value and was going nowhere. Doing work with and for thinkarts has made me feel a lot better about myself, and my feelings of self-worth have been raised a few notches. I have been to workshops and visits arranged by thinkarts, which have motivated me to leave my flat and get some much-needed personal interaction. It has helped me gain confidence in dealing with people and my surrounding milieu.
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