Level-Up

Listening to the voices of

service users: messages
from an arts based
initiative delivered in an
in-patient mental health
setting
Jez Buffin
School of Social Work
University of Central Lancashire
August 2011

Acknowledgements

Most importantly the author would like to thank the participants in the Level-Up programme for
allowing the sessions in which they took part to be observed and for agreeing to allow copies of
the work that they produced to be used in this report.
The author would also like to thank the staff of the Level-Up programme and the staff of the
in-patient unit where the work took place, without whom the programme could not have been
delivered.

Introduction

Level-Up is an arts based initiative

run as a partnership between
Alison (Artists living in situations
of need) and the Mental Health
Equality Team. Funded by Central
Lancashire Primary Care Trust
the project uses an arts based
methodology to encourage
people with mental health
problems to tell their stories and
ascribe meaning to significant
life events. A range of different
mediums are used including
painting, poetry, creative writing,
modelling, photography and
computer design. Used as part of
an assessment the methodology
can help to shed light on what
is important to individual
clients and service users. When
looked at collectively these
individual stories also start to
tell a story about what life is like
for people living with mental
health conditions and about the
synergies and tensions between
the worlds of service users on the
one hand and service providers
on the other.
12 sessions were delivered over
a 6 week period to patients on
an-patient facility in Central
Lancashire over the summer of
2011.
6 of the sessions were observed
by the author in order to capture
the life of the project and to
identify and reflect back to the
Level-Up team and the hospital
ward staff some of the learning
from the project. The author
explained verbally to participants
what his role was. Ward staff
assisted the author to gain
permission from participants to
use material gathered from the
observations (including pieces
of art work) in this report. A
draft version of the report was
shown to participants in order
to help them to understand
how the material that had been

Context and
challenges

gathered would be used. Not all

participants consented and so not
all material has been included.

The sessions

Previously the Level-Up

programme has been provided in
a range of community settings,
but this was the first time that
it had been provided in an inpatient setting. This presented
the team with a number of
challenges:

A typical session lasted about an

hour and a half. The first session
was henna based. It began with
an explanation of henna design,
a discussion of how symbols are
often used in design and of how
we can often ascribe meaning to
symbols. Tattoos, for example,
are permanent and are often
used to make statements about
things that are very important to
people. The group were asked to
think about the kinds of tattoos
that they might design for
themselves. As people began to
discuss and draw the team made
good use of the opportunity to
draw out lots of key issues. It
was attended by 7 people, 2
males and 5 females, although
not all participants stayed for
all of the session: people tended
to drift in and out. Subsequent
sessions built on the work of
earlier sessions. They were all
attended by similar numbers
of people, although the make
up of individual participants
tended to vary. Some participants
who had attended previous
sessions would work on things
they had done earlier, whereas
other new participants would
work on things for the first
time. There was a core groups
of individuals who tended to
attend most sessions but others
came and went as new people
were admitted and others were
moved on or discharged. The
door to all sessions was always
open and there was an informal
atmosphere that allowed people
from the ward to wander in
and have a look at what was
going on. At points this could
be slightly distracting, but it also
allowed people to come and go
as they pleased.

Patients in in-patent settings

tend to be more unwell and
sometimes have trouble
concentrating and remaining
focused. Not all participants
were able to attend all
sessions, sometimes because
they were unwell and some
had made attempts to self
harm in between sessions.
Often patients are aware of
the problems they have with
concentrating. In one session
for example, one of the
participants who was asked to
join a group activity asked to
be left to get on with her own
thing:
I never last long. Let me do
my thing.

Patients tend to be moved on as

quickly as possible. Admissions
are often short so they tend to
be in out more quickly. This
poses a challenge in terms of
building up a relationship and a
rapport.
There is a high turn-over
of ward staff which makes
partnership working between
the Level-Up team and ward
staff difficult. This may have
been the explanation behind
why in session 5 a number of
participants had been told that
this would be their last session.
This caused visible distress to a
number of participants.

 Concerns about patient safety

and risk management means
that there are often restrictions
about what individuals are
allowed to have on the ward.
Not all patients were allowed
off the ward and staff were
concerned that materials left
in the activity room may be
trashed. While these concerns
are understandable for
example, one week a patient
did conceal a hammer from
the workshop and took it
back to her room where she
used it to self harm and in one
instance a canvas that had been
left in the workroom to dry
disappeared between sessions
- such restrictions also made it
difficult to leave materials that
patients could have access to
and use in between sessions.
Risk management often placed
restrictions on activities as
patients needed a level of
supervision that ward staff
were unable to provide.

The skills and

expertise of the
staff

Although Level-Up is an arts

based initiative, the work is often
used as a vehicle to promote
discussion about a broad range
of issues. Often there are
several discussions going on
at the same time. There is a
very personal feeling about the
sessions. For example, at one
point one member of the group
was talking about the meaning
of the hat that she wore which
was covered in badges, while
another talked about his family
and another talked about the
fact that she did not know who
her named nurse was. The
important thing is that the team
create a space for people to talk
about what is important to them.
The conversations were skilfully
handled by the staff team.
They were gentle. People were
encouraged to talk and to focus
on what was important to them,
but they were not forced.
The comings and goings of
individuals both between and
within sessions is a challenge, but

attempts are made to work with

these challenges. A new comer
in session 7 exclaimed that she
felt that she couldnt stay and
participate because the group
was clearly already well formed
and close. Staff spent time
with her to introduce her to the
session and to integrate her and
this was successful. She stayed
until the end and participated
in a group activity and then in
subsequent sessions.
The team showed great respect
for the participants and treated
them with dignity. For example,
when one participant wanted a
drink of water, the team were
quick to get her one. When the
water in the tap turned out to
be warm, they went out of their
way to make sure that she was
fetched a cold drink.
The team are good at going with
the flow. They are not rigidly tied
to a session. They are adaptable
and flexible and well adept at
going with whatever participants
bring. Two participants had been
involved in other forms of art and
had examples to show the team
back on the ward. They were
encouraged to go and get these
and the staff showed a genuine
interest in what they brought
back. Indeed the work that they
brought back was incorporated
in to subsequent sessions and
used as part of the evolving
programme.
At the end of one session the
team had planned to take all
of the work away with them to
scan it in to a computer so that
they could use it for the next
session, but it was clear that one
participant wanted to carry on
working on what she had started
to produce. This was respected
and the team left the work with
her, electing to take a photo
of what she had done instead,
rather than deprive her of the
chance to carry on working on it.
The team are also adept at
facilitating several different
activities to go on at the same
time within the same session.
The fourth session in particular
was marked by participants who

were working on different things

that they had begun in previous
sessions using a variety of
different mediums but also new
members working on things for
the first time.
One participant found it difficult
to join the group. She did not
like the noise and preferred to
work quietly on her own. This
was facilitated.
Showing flexibility and
adaptability was not at the
expense of remaining focussed
and purposeful however.
Despite deviations, the group
retained a focus on the key
tasks - to produce images that
were symbolic and reflective of
their experiences in the hospital
and of the issues that were of
most concern to them. The
sessions are well managed and
the time is used productively.
The team are good at building
a rapport quickly and they use
this very effectively to encourage
participants to open up. Some of
the discussions are intimate and
personal. The discussions are very
human, with staff sharing and
giving of themselves and their
own experiences.

Listening to the voices of service users

The sessions provided opportunities to gain an insight in to the worlds of service users in two distinct
ways. Firstly through the art work itself, much of which was purposefully directed so that it would
reflect patient and service user experiences. Secondly through the incidental conversations that
took place during the sessions themselves, sometimes between Level-Up staff and service users and
sometimes between service users themselves.

The narratives of the

art

One participant designed a tattoo

with the name of his wife and
daughter above his own and the
motto Try harder. It symbolised
the commitment that he felt
towards them and he specifically
linked the words try harder to
trying harder for them.
Another drew a picture with
a bird and a cross. This was a
symbol of her faith and of how
important her faith was to her in
trying to get through.

bars, because she felt that she

was behind bars. The number
3 represented the section that
she was detained under and the
money sign symobolised the fact
that she felt that she needed
money.
This same person also later drew
a large pair of wings with a
heart, and the logo never lose
hope emblazoned across it.
Again it features the number 3,
representing the section that she
was detained under. This time
the number 3 clips the wings
which reflects how she felt about
the section.
Another drew a picture of a
nursing badge with a line crossed
through it. This symbolised the
fact that she did not know who
her named nurse was. This led
on to a discussion about her
frustration about not being
able to get things done and
not knowing who she should
talk to about it. She became
frustrated at this and said that
she took this out on herself which

One drew a large question mark

with different sections broken
down and different images
within it. The question mark
symobolised the uncertainty that
she faced.
I dont know when I am going. I
feel anxious.

One section contained a flower

and represented the fact that
it was Spring. Another section
represented her friends. A dot
represented how isolated she
felt. The hill represented the
mountain that she felt had to
climb. Another section contained

left feeling disconnected, out of

place and possibly foolish like a
clown but without the circus.

Im back in hospital because Ive

failed
left behind as the recovery ship
sailed
mistakes Ive made, regrets I regret
most of which I can never forget
I really hate myself so much it hurts
it feels as though my life has no
perks
I get frustrated, angry as well
my life has become a living hell
friends are few and far apart
I need some glue for my broken
heart
led to feelings of anger. This
would lead her to cry. Later she
developed this picture so that
it contained other images too
including a half full bottle and a
broken heart.
One of the participants produced
an image of a dog and cannabis
spliff. This prompted a discussion
about cannabis use with the
participant acknowledging that
his heavy use of cannabis had
perhaps not been helpful or
productive. The session created
space for reflection. It was
important that some boundaries
were put in place around his
cannabis use as over use could
prevent him from getting things
done and could lead to the
creation of dangerous situations
(for example, smoking while at
work). He also acknowledged
how his highs (caused by smoking

up to 15 spliffs in day) led to

periods of lows when he was not
using. He said that he would
include a motto with the image
choose family over drugs.
Another drew a picture of
a spider with heavy stoned
eyes. The spider was smoking
a cannabis spliff but the spliff
was not intended to represent
cannabis it was intended to
represent the effects of the
prescribed medication that he
received which often left him
feeling out of it. He depicted a
spliff because he said that people
would be able to relate to the
effects of this better.
Pictures and paintings were not
the only form of art used. One
participant took the opportunity
to write a poem which describes
how she feels about her illness,
about being in hospital and her
fears about the future. It is full of
negative thoughts and feelings.
She describes how she feels as
though she has failed and made
mistakes. She has regrets and
hates herself. Her life is painful,
a living hell. She has few friends
and few perks. She describes her
heart as broken and she is fearful
that if she lets people in they will
hurt her. Self-harming appears to
be a way of making herself feel
real and her scars are a way of
showing the world her pain. She
does not appear to believe that
she will ever get better and is

Ive shared my corrupt and my pain

Ive struggled in silence and
suffered in vain
Ive let you in, please dont attack
or I fear Ill take a big step back
I hurt myself and break the seal
Its the only thing that makes me
real
suicide and self-harm corrupt my
soul
to feel loved would be my goal
when pain and despair overtake
my fragile heart starts to ache
You do not know Im hurting or tell
that Im in pain
so Ill wear it on my body where no
words need explain
Ive been quite honest, Ive tried my
best
to get these thoughts from off of my
chest
Ive told you my concerns, my fears
and doubts
without having to scream, yell or
even shout
I often ask whats my aim, whats
my purpose
I feel like a clown but without the
circus
will there come a time when Ill be
free
probably not because Ive got BPD
The poem itself was later
animated by the team.

The 7th session was given over mainly to a group activity, encouraging participants to work on two large
shared canvasses, one representing things that were negative about life on the ward and one representing
things that were positive. The paintings were abstract using colour and unrecognisable shapes to
represent each in order to ensure that the ability to draw did not represent a barrier. The 8th session
was used to review the pieces of work and to discuss the key issues that lay behind peoples positive and
negative experiences of life on the ward.

The negative picture

The positive picture

In terms of the artwork itself, the
pieces were received with mixed
feelings:
I dont like either of them.
They are all too much.
For me that one makes me
feel high as a kite. There is
a lot going on. It makes me
feel like I am off my head.
I like that one best. It looks
like something that you
might see in a gallery.

Gradually the participants

began to impute meaning to
the pictures and this lead to a
discussion about what was good
and what was bad about living
on the ward. The group re-called
that when they had painted the
positive picture they had started
off by trying to find something
that represented the privacy of
their rooms.
Yes, and the circle represents
your room and the arrow is
like people coming in to it.
The lack of privacy.

A number of people talked about

how the ward made them feel
safe.
It makes me feel secure in
here. It makes me feel safe.
Not necessarily from myself,
but from the world.

For others, this was not just about

keeping them safe, but also
others:
Its a lot safer in here. You
dont know what will
happen. Sometimes its
like people are deliberately
trying to wind you
up. Trying to make you
retaliate. You want to
bloody murder them. Its
like they want you to get a
life sentence.

Key to a positive experience for

people on the ward was their
interaction with staff. Some
staff seemed to be attentive and
considerate (which was a positive)
but others were less so.

You get people from

all walks of life. People
who are here to do a job
and people who are here
because they care.
There are people in here
that get a kick out of saying
no to you. No, you cant
go and have a cigarette.
Well why not? Its no skin
off their face.
There are some people in
here that like restraining
you.

Good staff were seen as those

who had time for you.
If I was a mental health
worker I would re-assure
people more. It happens
in here sometimes but not
a lot. I have a lot of ups
and downs. If someone reassures me it makes me feel
relaxed.

Talking about the token system

that operated for people who
wanted to go and get a drink,
one participant recanted how
some members of staff would
simply say, Ive run out, whereas
others would immediately go and
get some more.
Pursuing a theme around
conversations and inter-actions
with staff one person said:

Some members of the group

blamed staff for the lack of
activities.
They are all lazy buggers.

Others however, recognised the

different pressures that staff were
under.

There is more talk among

ourselves than there is with
staff.

I can see it from the other

side too. Staff are tied up
all day completing CPAs.

It would be good to
have more therapeutic
engagement. Whether its
just talking to you.

You go and ask them for

something but then they
say , In a bit, Ive got to
do my CPAs first. And in
order to do that they have
got to find a computer first
which often takes them off
the ward.

A lot of time was spent discussing

how boring and tedious much of
the time on the ward was.
You sleep to make time
pass.
The evenings are long. They
are long, long evenings.
Its just some structure
to the day that you
want. Doing something
constructive.
At home I would go to the
gym from 8.00-9.30. Go
home, eat, watch a bit of TV
and before you know it, it is
midnight.
It gets boring after tea.
Its like groundhog day in
here. You wake up, wait
for breakfast, wait for the
group to start, then you
wait for lunch and have
your medication. If youre
not involved in any of the
off ward groups in the
afternoon then all you do
is wait for tea and wait for
the soaps.

All day nurses are filling out

reports, things for tribunals,
admissions, discharges,
care plans and on top of
that they have to attend
meetings.

These discussions show how

important the relationships that
patients have with staff are
and how even seemingly little
things, such as whether you are
able to get a token for a drink
or whether you can go out for a
cigarette when you want to can
make a huge difference to how
people feel about life on the
ward. Boredom and the lack of
activities was a major theme.

The narratives of the

conversations
Sometimes the things that people
talked about incidentally gave
key insights in to what life on the
ward is like. As the comments
below suggest, sometimes people
had very different experiences
and feelings about life on the
ward. During a discussion about
the experience of being on the
ward one commented that:
My time in here has been
peaceful

This was quickly and

contemptuously challenged by
another patient:
Peaceful! Peaceful!
Mine has been a fucking
nightmare!

Boredom, powerlessness and the

lack of respect shown by staff
towards patients all featured
significantly. The general sense
was of a poverty of existence as
illustrated by the quotes below.
One participant said excitedly as
the pencils were given out at the
start of the session:
I dont think we have had
a sharpened pencil since I
come in here.

Another who was clearly very

interested in painting was given
a supply of various resources
that she could use in between
sessions to carry on her work
(for example, some acrylic paints
and a canvas). She beamed and
danced around excitedly:
Its like all my Christmass
have come together.

One patient talked about how he

had gone out for a walk in the
garden area for an hour one day
and that while he was out all his
stuff had been moved to make
room for another patient. He was
only gone an hour and even then
was only in the garden, but no one
had come to talk to him first. This
had left him feeling very angry.
Another talked about the story
of her admission to the ward and
of how she now felt trapped.
She was admitted as a voluntary
patient but now wanted to leave.
Staff had told her that if she
tried to leave they would section
her however. She maintained
that she was an adult and that
as long as she could understand
the advice that she was given
and make sense of it she should
be free to take or leave it and to
take her own decisions. As it was
she now felt tricked and trapped.
Things are likely to take a
long time to get sorted.

One talked about how the needs

of staff seemed to come before
his own. One day when nothing
had been going on for ages
suddenly lots all happened at the
same time. He had visitors and
the doctor arrived to do a ward
round. He got told off for being
disruptive as the doctor was a
very busy man. He protested that
he hadnt done it on purpose.
A number of patients talked
about the boredom of their
existence. During one session a
participant asked if the materials
that she was using could be left
behind for her to continue to
work with in the afternoon.
It will give me something to
do for the rest of the day.

Several members of the group

commented that some activities
had been organised one
weekend that coincided with a
visit from the Mental Health Act
Commission. Normally nothing
happened at the weekend.

Group dynamics

In the situation of the group

a number of dynamics were
observable. There was clearly
an element of mutual support
as is illustrated by the discussion
below in which one patient talks
about her anxieties about going
home:
I have concerns about
going home. Learning to
budget and maybe going
too quickly and not being
able to cope. Should I just
go do you think? Or should
I leave gradually?

Another patient responded to

her, advising her that she should
take the advice of the ward staff:
Listen to the doctors. They
know what they are talking
about.

The above discussion took place

while the first patient was
drawing a picture to represent
the uncertainty that she faced.
Part of the picture was a dollar
($) sign to represent her concerns
about money. The second patient
with whom she was talking
commented on her work:
Its good you put that dollar
sign ($). You talk about
money a lot.

The first patient came back:

Do I?

Further evidence of the

supportive relationships that
can develop within the group
emerged between two of the
women who worked together
on a laptop, manipulating
images that they had produced
previously by hand in a computer
programme.

One said of the other:

You helped me on the
computer. I couldnt have
done it without you.

Later this same patient drew

a picture of the woman about
whom she had made the
above comment. Her friend
was represented as my ray of
sunshine.
In other sessions individual
patients were sometimes less well
and were looked after by other
patients who were less ill and
who would go and sit with them
or ask how they were.
There was sometimes conflict
within the group, but this
was always well handled and
managed, sometimes by staff,
sometimes by other members of
the group.
One participant had her phone
on and it kept going off. She
was challenged by another
participant:
Put your phone on silent
will you its annoying me.

During the introduction to

the first session one of the
participants spent quite a bit of
time talking about henna and
its use. The discussion moved on
to Arabic, the use of Arabic, and
how to spell different words in
Arabic. This conversation risked
alienating other participants who
were excluded from it. The LevelUp team allowed some space
for discussion but also skilfully
brought the focus back around to
the work.
In one session a participant got
up and started banging away on
the piano at one point. Other
group members asked him to
stop. One participant started
to draw on his arm. One of the
Level-Up team asked him to
stop and he did. In another the
session, one of the participants
became frustrated at the

difficulty that he was having

drawing, feeling that he needed
more attention and help. This
was quickly spotted and remedied
and additional assistance was
given.

How the activity

was received by
participants

It is clear from the comments

below that the participants
valued the session. On a couple
of occasions the Level-Up team
were late getting started. On
both occasions they were greeted
by one participant with:
Come on I want to get
started. Where have you
been. Ive been waiting for
you.

Others commented on things

they had got out of the sessions,
often involving learning about
themselves:
I like having our work on
the wall out there. Ive just
seen it. It makes me feel
proud.
I have really enjoyed it and
got a lot from it.
I have realised that you
dont always have to stay in
straight lines - in art or life.
Youve all been great.
Since coming here...I didnt
know that I had a talent
for art. I didnt think I was
any good. But it has given
me inspiration I have just
been drawing and drawing.
I cant believe the immense
talent that I have got, its
awesome.
You are easy going. Not
judging. Not laughing. You
are encouraging. You can
do it.

Lessons to be
learned

It is clear from the above that

the sessions have been effective
at providing insights and
understanding in to the lives of
individual service users as well as
to life on the ward. The sessions
have enabled participants to
describe things that are of
significance to them and have
clearly been both valued and
enjoyed. As outlined in the
introduction, one of the purposes
for observing the sessions was to
capture the life of the project and
to identify and reflect back to the
Level-Up team and the hospital
ward staff some of the learning
from the project.

Lessons for ward

staff and managers

It is clear from the group session

that focussed on the negative
and positive aspects of life on
the ward that the quality of
relationships with staff are an
important factor in determining
how individuals experience life on
the ward. Under the stresses of a
heavy work load it must be easy
for staff to dismiss small patient
requests such as for a token
to get a drink from a machine
as low priority. Seen from the
perspective of the service user
however and in the context of
being bored and powerless, how
such a request is responded to
can have a significant impact
on an individuals experience.
The message for ward staff and
managers is to remember that
little things are important. For
patients it can often feel that
the ward is organised around
the needs of the staff and the
hospital, rather than around
their needs. Examples of this can
be seen from the patient who
found that his room had been
re-organised to make room for
another patient without any
discussion. The patient who felt
that he was told off for having
visitors at the time of the ward
round is another example. One
patient had to leave the session
one week because she was
shaking too much. This was a

consequence of her medication

which she had been given just
before the session started. She
was frustrated as she could not
manage to complete the delicate
work that she wanted to. She
was upset that staff had not been
able to give her her medication
later, after the session.
While it is acknowledged that
staff are working in difficult and
challenging circumstances and
that they have a duty to ensure
patient safety and to manage
risk, such procedures can often
seem at odds with the notions
of a patient centred service.
The flexibility of the Level-Up
team being able to respond
to the interests and ideas of
the participants was in sharp
contrast to the inflexibility of
ward based risk management
strategies. Nowhere was this
more evident than when the
Level-Up team left resources such
as paints and canvases behind
for patients to use in between
sessions as it became apparent
that they would not be able to
gain access to them due to the
lack of staff available to provide
supervision.
The one thing that patients on
the ward seem to have lots of is
time, but it was commented often
how unproductively that time is
used. Boredom was a significant
feature of peoples lives on the
ward as they reported them. Staff
resources and the use thereof is
clearly a significant barrier here,
particularly in the evenings and
at the weekends. That said, it is
clear from observations that many
of the service users are themselves
extremely resourceful. It is easy to
see the label of a service user and
to fail to see the talents and lives
that people have that go much
broader than this. Thought could
be given to how to encourage
service users to do more for
themselves, both individually and
collectively. It is clear that bonds
often quite strong ones do exist
between service users and that
this often leads to them looking
out for one another. Such bonds
could be directed towards selfhelp and mutual support.

Lessons for Level-Up

The sessions are clearly enjoyed
and productive. The team
should first and foremost hear
the message of success. There
is lots in what they do that is
to be commended. They are
hard working, flexible, sensitive,
caring and creative. They have a
successful formula that can easily
be replicated in other settings.
The lessons identified should be
read in the context of this.

Lots of information was

generated in the sessions about
what is important to people,
what they made of their
experiences and how they viewed
life on the ward. There are
clearly potential lessons for ward
staff and managers, but in order

for these lessons to be heard and

learned it is important that the
team develop a mechanism to
feedback such outcomes to staff
and managers. Currently such
links as do exist appear to be of
a largely operational manner
that is, in order to facilitate the
sessions to happen.
The team need to think more
about the process for feeding
back the contents of the sessions
in order to try to help improve
experiences for service users. It
is hoped that this report might
provide one such vehicle to allow
this to happen.
A number of patients were
discharged from the ward before
the programme was completed.

Although arrangements were

made with one patient who had
been discharged to maintain
contact with the team and to
continue to work on what he had
started in a community setting
he had not taken this offer
up at the time of writing. It is
suggested that more could be
done to facilitate the transition
from in-patient to community
settings, perhaps arranging to
meet individuals at home in the
first instance and to accompany
them in the service for the first
time. Mobile phones and
text messaging may be other
mechanisms for promoting
contact outside of the ward
setting.