Background
Recovery-oriented service provision is a direction for mental health services across Western nations and is mandated throughout Australia. At organisational and individual levels, recovery-oriented service provision enhances recovery processes for people diagnosed with enduring mental illness [
1]. Psychiatric rehabilitation incorporates principles of recovery to support people to pursue meaningful lives [
2]. Art-based rehabilitation programs support the recovery journeys of people with enduring mental health issues in inpatient and community settings [
3]. In Australia, recovery is defined as “being able to create and live a meaningful and contributing life in a community of choice with or without the presence of mental health issues” [
1].
In Victoria, Australia, care provision for a small percentage of people with enduring psychiatric illness and psychosocial disability is on an involuntary basis in secure extended care units (SECU). Involuntary residency in a SECU can span months and years, despite assessment, treatment, and recovery-oriented rehabilitation programs [
4]. Data on SECU recovery-oriented rehabilitation outcomes are sparse. Consumers of rural mental health services are particularly disadvantaged by inconsistent access to evidence-based programs, distance to programs, poorer health, and social isolation [
4,
5]. This article addresses the research question: Is there a role for the creative arts in the delivery of recovery-oriented psychiatric rehabilitation for people with enduring mental health issues and significant psychosocial disability detained in a secure extended care facility? The experiences of consumers, and the views of nurse managers and an art therapist on the “Making Precious Things” project, a recovery-oriented psychiatric rehabilitation art therapy program delivered in a rural Australian SECU, are described to address the research question.
Recovery
Varied notions of recovery exist across stakeholder groups in mental health services [
6]. “Recovery in” [
7], locates consumer/survivor/ex-patient definitions within a social model of disability, and preferences personal recovery and the pursuit of human rights and citizenship. Survivors of mental health services consider themselves experts on their recovery needs and position themselves at the centre of their treatment, exercising their right to personal choice, self-determination, and participation. “Recovery from” [
7], focuses on biomedical classifications, treating disease, eliminating symptoms, and reducing medical disability. With treatment frameworks for delivering paternalistic interventions if the disease process is so disabling that the person is an unable to live independently in the community [
6]. Focussed on individual pathology, cure and remission, recovery from is not concerned with addressing broader social agendas of social justice and stigma [
8].
Recovery-oriented psychiatric rehabilitation
Recovery is a personal journey of hope, empowerment, connection with peers and the community, developing an identity beyond illness, and living a meaningful life [
9]. Recovery-oriented psychiatric rehabilitation offers a long-term model for people to support their pursuit of meaningful community roles, combining treatment and rehabilitation in “an active process of self-agency” [
8]. Recovery-oriented rehabilitation practice requires clinicians to develop working relationships that place consumers at the centre of care [
10], with clinicians using interventions to support the identification of strengths and self-determined goals [
2]. Evidence-based interventions include supported housing, employment and education, peer support, residential and group programs, including therapeutic modalities [
8] with art therapy becoming recognised [
11].
Art participation in mental health recovery
Qualitative research indicates that creative art programs can support recovery in people with enduring mental health issues [
3,
12]. A study in a psychiatric inpatient setting in the United Kingdom (GB) interviewed 11 consumers, and using a narrative analysis approach, reported that art participation provided people with a therapeutic and creative social environment, and improved confidence, a sense of self, and hope [
12]. Another study that interviewed 35 participants from six art participation projects across GB, as part of a larger case study examining the use of art participation in mental health recovery, concluded that art participation contributed to combatting stigma, provided peer support, and opportunities for an identity beyond that of mental illness [
13].
In a critical analysis of the mental health literature spanning 1987 to 2011, van Lith et al. identified a range of benefits stemming from art participation across clinical, personal, functional, social, occupational, and environmental dimensions of recovery [
3]. However, randomised controlled trials (RCT) investigating the benefits of art therapy for people living with schizophrenia have found minimal improvements [
14,
15]. A Cochrane review concluded that establishing benefits in this population required more research [
16]. Despite this gap in evidence, guidelines for the treatment of schizophrenia recommend the use of art therapy in clinical settings [
17].
Challenges of providing recovery-oriented services
Recovery-oriented service provision is difficult in SECU type facilities that are predominately focussed on risk management, protecting the community, and containment [
18,
19]. Many scholars propose transformation in mental health organisations for recovery to become embedded in service provision structures and practices [
20,
21]. According to Pilgrim, coordinated consultation of all stakeholders in a local area can determine their epistemological positions allowing examination of the issues that prevent recovery-oriented practice [
6]. Identifying, articulating, and making space for dialogue about these tensions supports the development of recovery-oriented approaches and contributes to transformation in mental health services [
22]. Understanding the way that a local service makes sense of their epistemological framework underpins the change process [
6].
Whilst consumer participation is mandated in all areas of service provision under policy guided by recovery-oriented principles [
1,
23], services have been slow to demonstrate their uptake of this process [
24] and there is a dearth of literature that examines the experiences of people detained in secure extended care facilities [
4]. This study is unique because it captures the experience of consumers living with enduring mental health issues and significant psychosocial disability detained in a SECU. The views of an art therapist were seen as important to provide insights into the use of art making in recovery-oriented psychiatric rehabilitation. Their perspective has been captured in only a small number of studies [
25].
The views of nurse managers on recovery-oriented psychiatric rehabilitation programs were deemed important given their leadership role in local organisational culture and policy development [
26], which is particularly relevant for consumers detained in secure extended care. However, there is a lack of research that explores their views on recovery-oriented rehabilitation [
27]. The ability of service managers to articulate their vision for recovery-oriented rehabilitation programs can provide the impetus toward evaluating current processes, and where necessary, implementing change processes [
1]. Whilst the Making Precious Things project was conducted in one service, the usefulness of evaluating local recovery-oriented projects for broader learning has been identified [
28-
30].
The making precious things project
The Making Precious Things project was conducted over 20, one hour weekly sessions between January and May 2012. Different visual art forms and media were explored, focussing on the process of creating art. Two art therapists were employed, and the student researcher (ND) attended as an observer and participant. Consumer attendance was voluntary, with five to eight participants (20-40% of unit population), and a core group of three long-term residents. The group had a recovery-oriented rehabilitation focus aimed at creating a safe and respectful space for participants to share stories, make art, and feel valued. Each session involved an introduction to the topic and medium, with art therapists offering therapeutic guidance on subjects that enabled the exploration of identity. The concluding minutes of each session were devoted to group reflection, where personal meaning was drawn from the artworks. A group exhibition celebrated the end of the project, and group members shared their participation through selected artworks with family, carers, and staff.
Discussion
The findings demonstrate that consumer participants found the experience of the Making Precious Things project beneficial. They identified that the program generated relational and participatory skills that enhanced their experience of the inpatient unit as a potential healing community. The process of making artwork conducted in a therapeutic environment encouraged participants to share, cooperate, and feel accepted as equals by others in the group, enabling feelings of safety and relaxation. Feeling comfortable improved participants’ self-confidence and ability to express their emotions in the group, and in their artwork, and discover personal interests and capabilities, which they did not feel was possible in the usual unit milieu. Consumers articulated many ideas to extend the rehabilitation program to support their recovery, despite complex disability and a perceived lack of service provision in this area.
While service managers and the art therapist supported the use of art-based rehabilitation programs in progressing a recovery and rehabilitation approach in clinical service provision, several systemic barriers were identified as obstructing its provision. The predominant organisational culture was characterised by a biomedical framing of recovery, understood as recovery from rather than recovery in mental illness, with responsibility for rehabilitation entrusted to external services. Barriers identified were the historic loss of clinical expertise over time in rehabilitation modalities, poor coordination between clinical and community services, and a culture deficient in recovery-oriented approaches. There was an expressed lack of understanding of recovery-oriented rehabilitation service provision, and minimal funding to support programs focussed on consumer choice, self-determination, and participation.
The literature on recovery indicates that mental health clinicians and service managers are confused by the term and meaning of what working in a recovery orientation entails [
27,
34], exemplified in the findings in this study. Clinicians have to balance competing epistemologies of duty of care and risk management with consumer autonomy and self-determination. Often risk management is more clearly supported by law and service policy and procedures [
34]. Nurse manager participants in this study confirmed that, the predominance of a biomedical model in mental health services perpetuates negative attitudes towards those labelled mentally ill [
35], exemplified by derogatory language used to describe consumers.
A consequence is the overuse of medications in clinical services with an associated decrease in a rehabilitation focus in developing therapeutic relationships with consumers [
36], which encourages the repetition of the historical and cyclical condoning of a culture of coercion in mental health organisations [
37]. This is despite consumer dissatisfaction with current treatments, a desire for more therapy in service provision [
38] and the limited evidence of the efficacy of offering only psychotropic medications long-term [
39]. Balancing different epistemologies is important for the provision of recovery-oriented care. The availability of models that can address social perspectives in mental health care is necessary [
30,
35]. The art therapist’s suggestion that there is less crisis work when staff uses art-based therapeutic techniques in practice supports these contentions.
Current mental health service provision discounts rehabilitation approaches because services emphasise throughput and ignore psychosocial disability, particularly in long stay clinical service populations [
30]. Internationally, deinstitutionalisation has been described as under-servicing people with enduring and complex mental illness [
40]. In Australia, psychiatric rehabilitation services are fragmented across clinical and community domains, with gaps in service provision prominent in rural and remote areas for people with enduring issues [
41]. Despite the evidence of high levels of disability experienced by this population across financial, health, and social and relational areas [
38], little clinical or community care is devoted to this area of practice [
30,
39]. These contentions are supported by the findings in this study. Clinical rehabilitation services are needed to assess causes and levels of psychosocial disability, and provide meaningful activities that are recovery-oriented, which include consumer-defined ambitions, and promote social inclusion [
29,
30]. Clinically relevant evaluation of interventions aimed at minimising the experience of psychosocial disability is essential for developing a locally informed evidence base [
39].
Stigma, coercive practices, and the attitude of clinicians in inpatient services towards consumers are commonly cited issues that prevent a recovery orientation. Consequently, clinicians staffing long-stay inpatient units have little hope for people achieving recovery, and consumers regard these units as boring and dangerous with minimal staff [
36]. The therapeutic relationship is conceptualised as the cornerstone of good psychiatric care [
42], and important for recovery [
43], but not devoid of issues related to power in psychiatric services [
36]. Mental health services should be providing psychosocial interventions that aim to provide meaningful human contact, connectedness, and reciprocal relationships for this population to alleviate the profound existential suffering experienced by social isolation identified in this group [
44]. The art therapist’s identification of the ‘us versus them’ culture and the ability of art-based rehabilitation programs to enhance meaningful connection in this study confirms this, and is consistent with research findings from art therapists and consumer artists [
45].
Art participation programs can alleviate boredom in inpatient units [
12], and assist consumers and staff to form collaborative alliances that moderate collective anxiety, fostering a healing environment [
46,
47]. Quantitative studies that have used methods other than RCT to determine the effects of art participation programs for people with enduring mental health issues have found improvements in mood, wellbeing, relationships, and social inclusion, particularly when art making was experienced as meaningful and engaging [
48,
49]. Qualitative studies consistently support the use of art making and art participation in this cohort to assist in skills development, improve psychological wellness, and promote self-expression and self-discovery [
3,
12,
13]. The findings from this study describing consumers’ experience supports these identified benefits for consumers and staff, especially relational development and the promotion of a healing community. Research involving art therapists supports this finding, and indicates that art making is a healing tool that can promote deep human connections [
25,
45].
The art therapists’ emphasis on the importance of the process of art making in a safe environment in supporting recovery, is documented in literature from art therapists [
25,
50]. The addition of an exhibition and consumers’ description of feeling proud of the exhibited art works indicates that the product is also important, and flexibility is necessary in art-based programs to enhance both process and product outcomes [
51]. The focus of the art therapist in facilitating the development of life skills, emotional expression, personal strengths, self-discovery and a renewed sense of self is generally consistent with literature from other art therapists [
25,
45,
50], although differences exist mainly in the depth of information reported. For example, art therapists have reported that art-based practice induces a meditative state [
25], whereas consumers in this study report feeling relaxed and motivated during the art making process. This difference may be because funding restraints limited the duration of sessions and the length of the program, and the focus of this study differed.
In a Korean study, psychiatrists were reported to undervalue the benefits of art therapy for people living with psychosocial disabilities [
52], which may explain the findings in this study where art therapy was not usually included in inpatient services dominated by a biomedical model. For these reason, evaluation of rehabilitation programs can contribute towards developing a recovery orientation in services when consumer voices are incorporated into the range of stakeholders that inform organisational development and service provision. Reorienting resources towards evidenced-based recovery-oriented approaches needs to be based on rigorous evaluation of existing local programs. Consumer lived experience perspectives need to drive the transformation rather than continuing paternalistic clinician driven non-evidenced based programs [
28]. Governance and transparency about the organisational approach is a key indicator of recovery-oriented systems [
39]. These important factors are recognised and confirmed in this study.
Limitations of the study
The results of this study are not generalisable given the small sample, qualitative design, and local area and conditions. Although data saturation was achieved, interviewing different or more participants may have changed the results. The presence of three researchers in the focus group may have influenced consumer participants’ comments towards the positive. While the art therapist’s views were important in this study, it is acknowledged that they may have had a bias towards the positive effects of art therapy. Whilst the study has limitations, description of the local experiences enhances the transferability of findings to other similar areas of practice. Using a small sample in qualitative research can provide in-depth subjective meaning to be derived [
53], exemplified in the rich description of the experience of art participation and barriers to psychiatric rehabilitation in this study.
Conclusions and implications for practice
This study is unique because it captures the experience of consumers living with enduring mental health issues detained in a SECU, a stakeholder group not well represented in literature. Many competing forces bind mental health services, and groups with the least power are often excluded from organisational decision-making. Transforming mental health services towards a recovery orientation requires commitment from service providers and their leaders, in developing evidence-based programs that are inclusive of consumer voices. Consumers, managers, and outsider perspectives can assist with understanding how art-based recovery-oriented psychiatric rehabilitation is practiced in mental health services. By understanding the tensions in a local service that prevent a recovery orientation, appropriate action and research can be undertaken to improve service provision in this important area.
This study supports the utility of recovery-oriented art-based rehabilitation programs in secure extended care facilities to ameliorate psychosocial disabilities and support a recovery orientation in clinical mental health service provision. Mental health services need to redirect funding away from an acute crisis focus to balance the services offered to people living with enduring issues. Art participation psychiatric rehabilitation programs that are based on rigorous local evaluation and consumer perspectives should be included into a recovery-oriented service. Support from organisations is necessary for these evaluations to be worthwhile [
49]. Introducing art-based rehabilitation services into clinical practice with consumer perspectives prominent in service provision have the momentum to drive organisational culture change towards a recovery orientation.
Competing interests
The authors declare that they have no competing interests.
Authors’ contributions
ND, AK, and SK all contributed towards the conception and design of this study. Data were collected by all of the authors, and analysed by SK and ND, while all three authors deliberated on the final interpretation. All authors contributed towards the preparation of the manuscript and have read and approved the final draft.
(1) ND Registered Nurse and Research PhD Candidate at La Trobe Rural Health School, La Trobe University, Bendigo, Australia. (2) Professor AK Registered Nurse, Midwife, PhD, Professor of Rural and Regional Nursing, La Trobe Rural Health School, La Trobe University, Bendigo, Australia. (3) SK Psychiatric Nurse Consultant, MNsg, Research PhD Candidate, Psychiatric Services Professional Development Unit, Bendigo Health, Bendigo, Australia.