Culture and the arts in mental health innovation: Young people want and need more than ‘traditional’ ‘treatments’

Creative engagement tends to be rewarding and results in skills development. Such enabling solutions foster authentic collaboration and in these ways increase the ownership and sustainability of an individual’s recovery.

i-THRIVE is a national programme of innovation and improvement in child and adolescent mental health. In March 2019, the Greater Manchester GM iTHRIVE Programme Management implementation team appointed me in a role unique to GM, managing the Arts and Mental Innovation Programme.

Why THRIVE?

We know that in current NHS mental health services, 1 in 2 young people will reliably recover. THRIVE is an integrated, person-centred and assets-based model that enables better access to support, improves links between sectors, and promotes a broader, more substantial range of treatment options. At the heart of the THRIVE offer is shared decision-making, and a recognition that to successfully engage young people and families, services must seek to innovatively engage with their interests, and in their language.

Play, creativity and solution-seeking

When an animal engages in disruptive or self-injurious behaviours, we ask, what is wrong with its environment? The language of treatment sets up a perception that services will fix a problem within a person, commonly meaning talking and behavioural therapies, and medication use. Our services are too often geared towards resolving the problem within the child; an approach that can be doomed to fail if the environment is not also subject to change. The THRIVE model shifts the focus from (misrepresented) assumptions that these approaches will eventually lead to improvement, towards recovery models which emphasise the resources available within individuals and their communities.

Why would a clinical psychologist with ‘clinical’ in the title be interested in culture and the arts?

My answer is partly because sometimes focussing on the problem is the problem. Current mental health systems can risk over-medicalising difficulties, when normalising is a powerful process toward recovery. Young people and families can too easily form negative expectations regarding prognosis (the nocebo effect [1]), instead of an experience that enables them to express, feel validated and to engage with professionals about the meaning of their distress. Moreover, hope, or lack of, is the chief predictor of suicide and should be a target of services. Peer groups where the arts unite – for example, choirs, creative writing or dance companies – can foster peer bonds and shared experiences wherein the communicative and connecting properties of arts-led interventions can combat hopelessness, stigma and shame.

It’s also partly because creativity is essential to problem-solving. Creative and playful approaches are age-appropriate: essential to child development, they support learning, collaboration, and identity formation.

Another answer is because there is little doubt that the arts and culture foster key ingredients of positive mental health. Their benefits span all ages, in both preventative and curative capacities, and have been subject to research in fields ranging from medicine, psychology, neuroendocrinology, and trauma, to the wellbeing of the workforce and in public health initiatives.

With regards to psychological intervention, creative approaches can support the first task of engagement. The arts can convey more than language alone and have always been powerful tools toward reflection and communication; tasks critical to the therapeutic encounter. Moreover, studies around the world identify that creative absorption can help soothe, focus or distract. Expressive and reflective options such as song writing and dance performances have clear roles alongside ‘traditional’ services.

Regarding behavioural interventions, creative engagement tends to be rewarding and results in skills development. Such enabling solutions foster authentic collaboration and in these ways increase the ownership and sustainability of an individual’s recovery.

Our journeys toward positive mental health, if we achieve it, require ingredients all demonstrably accessible via cultural activities, which promote connection (attachment and belonging), expression (emotion and mood regulation), absorption and focus (which can support distress tolerance), communication (interpersonal relationships), self-knowledge (reflection and formulation), creative problem-solving (CBT et al.), confidence (self-esteem) and the thing it all ultimately comes down to – and possibly where language is more easily shared – hope.

Differing from the ‘traditional’ approach, both the iTHRIVE model and arts-led options are actively engaging, drawing on strengths. Crucially, resolution is more easily discoverable within the individual, thus ensuring a far better chance of succeeding and sustaining improvements, even once the ‘treatment’ is ceased. Arts-led interventions provide a far more versatile and empowering repertoire than is currently available.

The multi-faceted ways artists can contribute within the healthcare sphere is significant and overlooked. Arts-led methods of engagement can make all the difference; imbuing the therapeutic encounter with art and creativity adds meaning, conveys emotion beyond language, and can be more authentically shaped by the person who is at the heart of quality care.

Authentic co-production: Invisible Dust, “Whenever you add another dimension which is the artistic input that this brings, it’s quite clear that both sides learn from each other and of course then the product at the end is much, much better.” http://invisibledust.com/education/exhale-schools-project/

From fixing to engaging: alternative methods and evidence models

When commissioning this piece, editor Emma Eager asked, “I wonder if the framing moved from ‘fixing’ people to engaging them in finding their own solutions, would a shift in what constitutes acceptable models of evidence follow?” This appears apparent in Finland, where the Government’s Key Project aims to embed the arts and culture into healthcare, following swift action on syntheses of longitudinal evidence. [2]

In an interview about learning, Bill Gates uses the term “meta-skill” to refer to areas such as self-image and resilience. While there are multiple well-designed studies on specific impacts of the arts,[3] this term hints at some of the difficulties associated with evaluating arts-led interventions using ‘traditional’ accepted research methods. For example, we know that music uniquely engages the whole brain, supports learning and cognition, and can be used to reduce stress and boost mood. Such effects are far-reaching and RCT frameworks are not designed to detect non-specificity of action – or at least are limited to a core set of outcomes rather than a nuanced and interconnected whole. Service provision therefore suffers from a lack of critical, joined up consideration of the ample evidence base. [4]

As well as considering how using creative methods might enhance recovery rates in existing services, we might usefully consider how a broader clinical offer can support wider access. There is clear demand for safe alternatives that do not carry harm or ‘side effects’, as associated with pharmacological options. Medication is also highly costly: from R&D through to prescription, the need to manage ‘side effects’ of psychiatric medication, and the disempowering effects of gloomy prognoses. The arts in various forms have been shown to achieve comparable and favourable efficacy without these deleterious effects.

When young people are being manipulated into addictive phone use, and commercial interests advance medication to cure social ills, culture can offer a meaningful and fun alternative. High distress levels among the young are an indicator that all is not well and, where possible, we would do well to resist the idea that such expression means they are mentally ill. Cultural and arts-led interventions can help meet the requirement to connect, to express, to find meaning and develop resilience. Culture reflects and expresses society’s needs in ways that unite us, and we are demonstrably far worse off without them.

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Practice examples

42^nd Street, Manchester, and The Horsfall
http://42ndstreet.org.uk/
http://42ndstreet.org.uk/horsfall/

Lime Arts, Manchester Children’s Hospital
Artist in Residence using print-making to engage with children and young people on the acute mental health ward: http://limeart.org/

Madhlo Youth Zone, Oldham
https://www.mahdloyz.org/

The Warren Project, Hull – whose Three Minute Heroes project is being implemented across GM
http://thewarren.org/
http://threeminuteheroes.com/

For the views of young people in Greater Manchester, check out this 5-minute video from Modify Productions: https://youtu.be/8NZRTa_iSmM

Notes

[1] The nocebo effect is akin to the self-fulfilling prophecy where a person brings negative expectations to a prognosis or treatment resulting in negative consequences. See Taylor, K. (2018) Art Thou Well? Creative Devolution of Mental Health in Greater Manchester, 43. One of the insights within this report concerns the role the arts can play in alleviating the nocebo effect.

[2] See Gordon-Nesbitt, R. (2015) Exploring the Longitudinal Relationship Between Arts Engagement and Health. Published by Arts for Health at Manchester Metropolitan University.

[3] See, for example, the work of Daisy Fancourt and Rosie Perkins, UCL, UK; Vagnoli, Caprilli, Robiglio & Messeri. (2005) Clown Doctors as a Treatment for Preoperative Anxiety in Children: A Randomized, Prospective Study. Pediatrics. Oct 2005, VOL 116/ISSUE4; Crone, Sumner, Bake, Loughren, Hughes, & James, D. (2018) ‘Artlift’ arts-on-referral intervention in UK primary care: updated findings from an ongoing observational study. European Journal of Public Health, cky021, https://doi.org/10.1093/eurpub/cky021

[4] See Van der Kolk, B. (2014) The Body Keeps the Score: Brain, Mind, and Body in the Healing of Trauma.

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Kat began work as a psychology researcher in 2005 at the University of Manchester, before joining the Spectrum Centre for Mental Health Research at Lancaster University. In 2010, Kat began clinical psychology doctoral training, where her research into extremes of mood continued and her journey into creativity, arts and health started. Upon qualifying, Kat took a three-year post with the pioneering Arts for Health at MMU, on the innovative mixed-methods research programme, Dementia and Imagination. Kat now works clinically in Children’s Services (Lancaster & Morecambe CAMHS) alongside her GM iTHRIVE arts innovation role, which was developed as a result of a 2017 Churchill Fellowship.