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Art in the community for potentially vulnerable mental health groups

Elaine Argyle
Department of Sociological Studies, University of Shefeld, Shefeld, UK, and

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Received July 2004 Accepted April 2005

Gillie Bolton
English Department, Kings College London University, London, UK
Abstract
Purpose Drawing on literature and the evaluation of a UK community Arts in Health project, this article aims rst to demonstrate that, in spite of the common association in mental health practice between art and the use of psychotherapeutic techniques, involvement in art creation can, in itself, have a sustained and positive impact on the mental and social wellbeing of participants and, second, to give an analysis of the different forms of arts involvement in health. Design/methodology/approach A qualitative evaluation of a successful process-based arts in health-care provision to existing vulnerable mental health community groups is discussed. Findings While the implementation of traditional forms of art therapy tends to be the preserve of those with specialist training, process-orientated art for health projects have been found to be more versatile and are developments in which many practitioners potentially play an important part. Arts in Health provision in a community setting can offer positive health benets, and aid health promotion. Practical implications More widespread, sustained funding and further evaluation and research for this accessible, cost-effective means of health promotion in a community setting are needed. Originality/value Arts in Health, in institutions (such as prison and hospital) as well as community, is a rapidly expanding, successful and attractive, yet severely under-funded provision. Descriptive in-depth evaluations and critical analyses of the eld, such as that presented here, need to be made available in order to develop the eld practically and theoretically. Keywords Mental health services, Arts, Community work (social welfare), Group work Paper type Research paper

Introduction
Knowledge is limited. Imagination encircles the world (Albert Einstein, 1929).

Art the use of the imagination that magical quality which marks us out as different from all other living beings, can help achieve increases in communication, self-understanding and well-being (Calman, 2000; DLima, 2004; Haldane and Loppert, 1999; Graham Pole, 2000; Staricoff, 2004; White, 2004; NHS Estates, 2002); alleviate stress and anxiety (Bolton, 1999; Staricoff, 2004) and can have signicant therapeutic
Health Education Vol. 105 No. 5, 2005 pp. 340-354 q Emerald Group Publishing Limited 0965-4283 DOI 10.1108/09654280510617178

The authors would like to thank Rotherham Health Authority and Rotherham Metropolitan Borough Council who funded the community Arts in Health project, Ruth Fletcher-Brown (Rotherham HA Health Promotion) and Trevor Kippax (Rotherham Community Arts Unit) who were responsible for initiating and organising the project.

effects (Help the Hospices, 2005). This power of the imagination and art has been known about and harnessed for thousands of years, and due to trends towards more holistic modes of practice (Department of Health, 1999), art is used increasingly in healthcare and community settings (Haldane and Loppert, 1999; Philipp, 2002; Everitt and Hamilton, 2003; White, 2004; NHS Estates, 2002). The arts can be used as a direct agent for helping patients and practitioners to reect effectively upon experiences, express damaging memories, thoughts and emotions, and facilitate helpful feelings and states of mind, to bring about a greater state of well-being (Kirklin and Richardson, 2003; Everitt and Hamilton, 2003). Well-being rather than health as the latter is often considered to be a purely physical state like a smoothly-running car. Well-being is a state of acceptance with what is in mind, body and spirit. One can be ill, yet in a state of well-being. Staricoff (2004) has outlined evidence on the value of the arts and humanities in: . inducing positive psychological and psychological changes in clinical outcomes; . reducing drug consumption; . shortening length of stay in hospital; . increasing job satisfaction; . promoting better doctor-patient relationships; and . developing health practitioners empathy across gender and cultural diversity. The arts offered in a social community setting (Lewis, 2001) can increase community relationships, which in turn further increases well-being and potentially improves health. Visual arts skills can help mental health users towards increased personal expressiveness and agency over their lives (Malley et al., 2002). Communal activities and social capital are decreasing in our society, leading to mental ill health, and increased pressure on primary care services (Walker and Walker, 1997). This is exacerbated by community care policy, which places emphasis on individuals rather than contexts (Phillips, 2001). There is a growing recognition that community art projects can help reverse this worrying trend (White, 2004). So much so that the editor of the British Medical Journal recently recommended that 0.5 per cent of the NHS budget should be diverted to spending on the arts (Smith, 2002). Arts in health has been described as creative activities that aim to improve individual/community health and healthcare delivery using arts based approaches, and that seek to enhance the healthcare environment through provision of artworks or performances (White, 2002, p. 11). It is therefore a broad umbrella covering active participation in creative activities (such as dancing), and more passive audience or viewer activities (such as paintings hung on hospital walls). It is helpful to consider process based and product based forms of arts provision in more detail: Process-based doing it The practice of an art, such as painting (Petrone, 1999; McNiff, 1994), writing (Bolton, 1999; Killick and Allan, 2000), music (Pavlicevic, 2005; Robertson, 1996; Aldridge, 2000), dance (Cook et al., 2003), drama (Snow et al., 2003), performing arts (Sands, 2002), can be therapeutically powerful. It can enable the expression of the otherwise inexpressible, and the experience of cognitive, emotional, and spiritual areas to which people otherwise have no access (Bolton, 1999). The arts can also be soothing and

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calming, and offer gentle physical activity distracting from pain and anxiety (Graham Pole, 2000). The very act of creativity also tends to increase self-condence, feelings of self-worth, motivation for life (DLima, 2004; Calman, 2000). Art can also be an unparalleled form of communication (Charon, 2000a). Art is not seen as just a route to enabling communication between practitioner and patient, but as therapeutic in itself. A reliance on word-based therapy can marginalise the therapeutic value of performing the artwork itself (Maclagan, 1989; Matarasso, 1997). Matarasso (1997) reported nearly half of participants in his survey feeling better or healthier having been involved in an arts activity. White (2004) reports a structured creative arts activity, which resulted in fewer re-admissions to psychiatric hospitals than a control group. Commonly perceived benets of arts activities are that they are non-medicalised, non-judgemental, and person-centred (White, 2004). In medicine and healthcare people become patients (Smith, 2002); in arts in health projects people become artists. Participants make their own choices, and remain in control of their activity and level of psychological and social involvement. Practice in the arts can encourage self-motivation, and self-care. They encourage community collaborative work the work is more like a conversation (Everett and Hamilton, 2003), and people only participate because they want to. Perhaps most importantly they are enjoyable and fun. Playfulness not only creates social and psychological bonds between people, it can enable healing exploration and expression of deeper levels of experience, knowledge, memories and ideas. Product-based experiencing it Concerts, literature, artworks can be experienced for healthful benet. Artistic products have helped people understand and perceive better, probably as long as people have been able to think and feel in the way we think of as human. Art products can take an audience away from painful, depressing, grieving or humdrum concerns, actions and feelings, and can enable reexive thinking about the self and personal and social situations (Kenyon, 2003; Staricoff and Loppert, 2003; Duncan, 2003). To be classed as art, a piece of music, sculpture, poetry has to be of a quality to transport the audience perhaps from a state of anxiety by encouraging deep, often critical, engagement. Music is rhythmical like the heartbeat, soothing, exhilarating, or a mode of communication (Schatzberger, 2001, Pavlicevic, 2005); ction and drama have the power of narrative, plot and characterisation enabling readers to inhabit the ctional world, to empathise with the characters, and roam in unfamiliar landscapes (Bolton, 1999; Harris, 2003; Sampson, 2004). Poetry takes readers sharply to the heart of something vital, and can therefore have great emotional or insightful impact (Bolton, 1999; Mazza, 2003; Fox, 2003). A painting can tell things about the personal or everyday world which might never otherwise be perceived, or be restful and calming (Kenyon, 2003; Padeld, 2003; Higgs, 2003). Art is also intensely educational. Literature is full of detail about the way people live in unfamiliar cultures, about suffering, healing, medical practices: every aspect of life (Charon, 2000b; Salinsky, 2002; 2004; Evans, 2003). Art and popular culture can inform about how emotions work on people, how people think and communicate, how they relate to others. Much of this learning can also be therapeutic. The line between therapy and education can narrow to non-existence.

An Arts for Health in the Community project The National Service Framework for Mental Health (Department of Health, 1999) identied a number of groups particularly vulnerable to developing mental health problems. Single parents, homeless people and those involved in substance misuse, for example, have been identied as having a greater propensity to develop mental ill health than other groups. As part of its preventative strategy, the UK government recommends that service intervention should target such groups. With this goal in mind a number of suitable groups in Rotherham, UK were approached and the project discussed with group members. From these negotiations, three groups were eventually selected as being able and willing to take part in the project. It was decided to work with existing groups for a number of reasons. For example, it improved the opportunity to provide a sustainable arts project for the participants as funding would be more easily sought through an organised group and project coordination and monitoring could be more readily facilitated. Following their selection each group was allocated an artist who visited each group for around ten weekly sessions. The three participating groups (1) A single parents support group, a long-established group that aimed to provide social contact and support to its members. It had a stable membership of around ten women all of whom took part in the art project. Their ages ranged from late 20s to late 50s and due to childcare responsibilities, the majority were not in paid employment. (2) A drop-in centre, which provided practical support and counselling to a large and transient membership who experienced a variety of problems including drug and alcohol abuse and homelessness. Of this transient membership three men and three women became regular art project participants, all were unemployed and their ages ranged from early 20s to early 60s. (3) A recently established support group targeted at teenage parents. It aimed to promote members condence and self-awareness, ultimately guiding them into work or further education. It had six regular female attendees all of whom took part in the art project. Approach to evaluation It is important to evaluate the impact of such projects if the availability and sustenance of appropriate levels of investment is to be secured (Health Development Agency, 2000). In view of this, an independent evaluator was appointed and project participants were interviewed during the rst and last art group sessions on their initial expectations and subsequent experiences of their involvement with the use of a semi-structured interview format. A reexive approach was adopted in these interviews in which emergent themes were identied and pursued. From these interviews, full transcripts, eldwork notes and case studies were produced and an ongoing analysis of qualitative material was carried out with the use of the constant comparative method (Bryman, 2001). In order to promote the validity of the data collected, a variety of methods and data sources were also used. One-to-one interviews with group members were complemented by focus groups. Interviews with participating artists and group leaders were also conducted at the beginning and the end of the project. Ethical issues of anonymity, condentiality and informed consent

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were strictly adhered to throughout the eldwork with group participants being given the choice as to whether or not to take part in the project evaluation. All agreed, although some members of the drop-in centre requested that their individual interviews were not tape-recorded. There follows an account of these ndings, including the details of project participants, group decisions and goals, the art group sessions and project outcomes. Problems in evaluating the effectiveness of therapeutic interventions are widely recognised by practitioners due for example to the impact of extraneous variables upon such interventions (Huntington, 1999). As such, it was recognised that any possible benets experienced by participants may have been due to other factors such as the ` che worker throughout the duration of the project and the provision of a cre self-selection of project participants. This is especially the case for the drop-in centre members, only a minority of whom took part in the project. Moreover, few participants at the drop-in centre were willing to have their voices tape-recorded in project evaluation interviews hence the relative scarcity of comments from this group. Further distortion can arise as a result of reactivity or interviewer bias brought about by the presence of the researcher. For, according to phenomenologists, all information gained in interaction situations is highly subjective, inuenced as it is by the respective values and expectations of the participants. For example, Fennell et al. (1988) observe that people in receipt of formal provision are unlikely to express dissatisfaction with this provision due to such things as their sense of loyalty to the staff, or the fear of negative repercussions on their service input if they were to voice any criticisms. This may help to explain the relative scarcity of critical comments from the participants in this project. Greater methodological rigour could have been achieved in the project evaluation through such as the establishment of statistical data indicating the social and psychological well being of participants both before and after the project or through the use of a control group of individuals who chose not to take part in the art activity. Such measures would have provided an objective baseline from which to measure the subsequent impact of the project. They would also have facilitated a greater degree of comparison between the reactions of different participating groups and group members. However, such quantitative methods were thought to be incompatible with the small scale of the project. Thus with the exception of a form eliciting the demographic details of participants, methods used in this evaluation were solely qualitative in their orientation. Moreover, time and resource constraints combined with ethical issues meant that only those participating in the project were included in its evaluation. Findings Issues and anxieties in the lives of group members In spite of the diversity of project participants, common themes and concerns emerged. Financial issues were one such concern with the majority of group members being reliant on state benets:
You just tend to be sat in the house especially if you are a single parent, you are on income support, youve got no money to go anywhere, even say if you just want to walk round town, you cant because you are limited, you havent got the bus fare (single parent group member).

Most of them cant pay their bills. Quite a lot are ex-offenders because they have stolen to feed their habit, be it alcohol or drugs (drop-in centre leader).

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Even those with jobs experienced money problems due to low rates of pay, as a child minder said:
I mean Im self-employed but Im on a very low wage and by the time Ive forked out for the things that I need and the mortgage, theres no money left . . . I need to work over 60 hours a week to break even, I work for about 75 a week (single parent group member).

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Much research has highlighted the close relationship between ill health, disability and material deprivation (Palmer et al., 2002). For example, the Black Report (1990) showed that inequalities in the incidence of ill health have been widening since the 1950s and that this trend was principally related to growing material inequalities. In accordance with this, a signicant proportion of participants claimed to suffer from a disability, others experienced long-term health problems with subsequent implications for the quality of their life:
It affects the quality of my life and youve got to be a hundred percent with the children . . . I mean when youre ill and self-employed you dont get paid (single parent group member).

Mental health problems were also an issue for participants. For example, the single parents felt that they were vulnerable to such problems primarily because of the stress they experienced as a result of their childcare role, with many members claiming to have no time to themselves away from their children:
You have your children and you become an adult in an adults world and at night-time, you put your kids to bed and youre either doing housework or making a shopping list and youre just too tired to do anything (single parent group member).

More severe mental health problems were experienced by members of the drop-in centre:
Oh we have a lot of very depressed people. I mean the Samaritans come in here because we have an average of two potential suicides a week, at least (drop-in centre leader).

The presence of social support has been identied by much research as being an important aspect of social capital and a crucial factor in reducing the risk of mental ill health (Brown and Harris, 1978). However, contrary to the mutually supportive portrayals of working-class life traditionally espoused by sociologists (Young and Willmott, 1962), more recent research observes that deprived social groups are less likely to have access to informal support than the better off (Argyle, 2001). This is due for example to geographical mobility serving to undermine this support as well as growing social polarity leading to the further isolation and marginalisation of vulnerable groups (Dorling and Rees, 2003). As such, many participants claimed to lack informal support and experienced stress as a consequence of this:
I had lost both my parents in the space of three months. In the month in between my husband started divorce proceedings, he went off with another woman. It was just too much to cope with on my own because I had no other sort of family (single parent group member).

For the teenage and single parents, this lack of support was exacerbated by the fact that they lacked the practical and emotional support of a partner, while also feeling themselves to be stigmatised and ostracised by the wider community. More overt

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forms of social marginality were apparent amongst members of the drop-in centre, many of whom were homeless:
Quite a lot are suffering from rejection because many have been thrown out of the family home . . . A lot of people have felt that their parents have never loved them; they have perhaps been bullied at school. Some have been sexually and physically abused in the home environment (drop-in centre leader).

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An important alternative source of support can be derived from social groups in the community and their role in providing members with support and a sense of belonging, thus enabling them to cope more effectively with their personal, group or community problems (Doel and Sawdon, 1999). All participants claimed to experience such benets from their group:
This group has been very, very important to my life. Ive had quite a lot of traumas over the last few years and if it hadnt been for coming here and getting adult support, I dont think I would be here, really (single parent group member). Its friendly and very open. And another thing is that you can express your feelings and you know that it stays in this building. It doesnt go anywhere else unless you are comfortable with what you are saying. I think that we are all in the same boat as well. We all had children young so I think that is another reason (teenage parent group member).

More practical support was offered by the drop-in centre:

Very few have relevant life skills. Just simple skills like knowing how to eat a meal, knowing to put rubbish in a bin instead of throwing it on the oor, that kind of thing. Basic life skills we try and teach as we have them in the centre (drop-in centre leader).

Participant choices of arts activity An important factor in promoting the participation and empowerment of group members is to enable them to determine their own goals and actions (Mullender and Ward, 1991). As such, participating groups were not only given the choice as to whether or not they would take part in the art project but also on the type of art they would like to become involved in, with possible options including creative writing, drama, photography and painting and drawing. Following group discussions, all chose the latter option. A number of reasons were given for this. A major factor was that most people acquire experience of drawing and painting during childhood. Many participants wished to further pursue this lost aspect of their past lives:
I mean I used to like drawing when I was at school and at home I used to love drawing and then I got into like knitting and reading and I just never did it no more (single parent group member).

Furthermore, in contrast to other forms of art, painting and drawing was regarded as a versatile medium in which participants would be unlikely to have been perceived as failing:
We decided on drama but then we took into consideration Rachel and Claire because they are quiet and not the outgoing type. So we decided to do drawing and painting and writing if we could get to do all of them. If not we actually decided on painting as the main one (teenage parent group member).

Yes I asked them about creative writing rst of all. But as we have got a lot of illiterate people that had to go out of the window because it excluded quite a few. So we said, well what about art? (drop-in centre leader).

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Exhibiting work produced in traditional art therapy has long been a subject of debate, with some therapists believing that such exhibition creates a misplaced assessment of the aims of the activity. However, others feel that the aesthetic and productive aspects of art and the activity of producing it are highly important within the art therapy process (Byrne, 1978). In accordance with this latter view, all three participating groups maintained that a sense of achievement and creativity with the opportunity to exhibit their work was a further factor inuencing their decision to select painting and drawing as their preferred form of art:
We think art would be best and then perhaps we can put our pictures up on the walls in the centre and say that weve done it (drop-in centre member).

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This clarity of purpose helped participants to envisage the fullment of personal aims and goals (Northern and Kurtland, 2001) thus enhancing their levels of motivation in the project. As such, all groups hoped to exhibit their work in some form, with the single parents aiming to produce a calendar to which each member would contribute a piece of artwork. While the teenage parents group appeared to be quite politicised in their view of the art project, feeling that exhibiting their artwork would enable them to publicise their collective situation and express their feelings of oppression to a wider audience. For the drop-in centre members, their plans for exhibiting were less specic. This could have been attributable to its large, transient and diverse membership, which undermined the possibility of rigid goal setting (Vinter, 1967; 1974). The artists perspectives on the art sessions The three artists taking part in the project saw themselves primarily as artists, not therapists (arts in health, not arts therapy). As such verbal therapy was not practiced within the group sessions with the artwork and the process of creating it being seen as an ends in itself. For example, the artist for the teenage parents group hoped that the work would improve the members condence, help them to relax and give them a break from their children. She thus planned to introduce the group to different types of paint and methods through the use of still life, mask making, glass painting and puppetry:
Its not about nding good artists as such. I dont believe that there is such a thing as bad art. Its just a case of being creative in itself, about taking pleasure in doing it and just relaxing really (teenage parent group artist).

Similar methods and aims were expressed by the artist for the single parents group whose sessions progressed through the stages of basic drawing, basic painting, using a transfer grid and calendar painting, her aims being:
Hopefully to build their condence more than anything. To make them feel good about themselves and basically be individuals rather than mum or whatever other stereotypical label they get (single parent group artist).

In contrast, the artist for the drop-in centre followed a less prescriptive approach than the other groups. This was due to the nature of the group, with the sporadic attendance

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of the drop-in centre members making the adherence to rigid structures and goals impractical (Vinter, 1967). Initial attendance was also hindered by group members suspicion of strangers, their possible unfamiliarity with modes of creative expression and what the artist felt to be the intrusiveness of centre workers who would sometimes enter art sessions and comment on participants artistic efforts:
Its all about building up a rapport and trust with them because they are very suspicious of new peoples faces (drop-in centre artist).

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The approach of the drop-in centre artist was therefore aimed at building up rapport and trust, publicising the group within the centre and at promoting participants condence, decision-making and group work skills, as well as their spontaneity and creativity:
I think they will gain creativity, self-condence, self-validation and sort of decision making, very simple objectives really. But also working within a group as well (drop-in centre artist).

They were thus given total freedom as to the types of materials used and the materials were left for the participants to use at the end of the project. The success of his approach was indicated in the attendance levels, which after a slow start stabilised to around six regular participants:
As the weeks have progressed and I have become more of a familiar face and the existence of the group has become known, the numbers have picked up (drop-in centre artist).

Organisational problems encountered The major problems associated with the project were organisational. A number of delays were encountered in the process of group selection. For example, a support group for older Asian men was provisionally recruited to the project. They later decided to withdraw due to the aftermath of the terrorist attacks taking place in New York during 2001 for they felt that their main priority during this time was to support each other. Ethnic diversity was therefore not achieved, with the three participating groups having a predominantly white membership. In addition, problems in gaining access to suitable groups meant that the commencement of the art project was delayed. This meant that the sessions were interrupted by the Christmas holiday period, leading to a possible loss of momentum in the work being undertaken. While this interruption did not affect attendance for two of the groups, for the teenage parent group, art sessions prior to Christmas were poorly attended due to the fact that group members had acquired other seasonal commitments:
I think getting them altogether is not easy, especially at this time of the year with shopping and jobs they have got at home. And a lot of them help with childcare within their own families as well and there are a few seasonal jobs that have cropped up (teenage parent group leader).

One of the artists also commented on having to pay for art materials herself before claiming it back:
It would be good in the future for this sort of project to have a budget, a petty cash budget, for equipment (teenage parent group artist).

Finally, it should be recognized that a truly therapeutic experience is one that is sustained and goes beyond immediate and transient distraction (Hilgard et al., 2000). However, the achievement of this sustained impact was undermined by the short-term funding of the project, which meant that art sessions were restricted to around ten weekly sessions. As the single parent group leader said of the art project:
It just seems to have own. Thats a downside really. It hasnt been long enough (single parent group leader).

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Impact of art sessions on group participants In spite of these problems, the project evaluation revealed that group members experienced the art sessions as being therapeutic. For as Dalley (1984) maintains, all stages of art activity can be seen to contribute to an overall therapeutic effect, for art activity is spontaneous, self-motivating and self-sustaining as the person becomes absorbed in what they are doing. Many participants spoke of this therapeutic experience, observing the way in which they found the art sessions relaxing and benecial to their peace of mind. This could in turn be seen to have a positive impact on their mental well-being:
I have found it relaxing because you could get rid of your pent-up emotions by actually channelling it into something (teenage parent group member).

For the teenage and single parent groups this therapeutic experience was facilitated by ` che workers during the period of the arts project: the availability of cre
` che worker is when we are actually doing something (single parent The only time we get a cre group member).

As such, due to their role in society as carers, many women are prevented from recognising their own need for support and time to themselves and are therefore denied possibilities for creative expression outside their nurturing role (Otway, 1993). As the teenage parent group artist observed:
I think that they have improved condence and that they will get an opportunity to have a bit of a break from the children, to relax and just talk among themselves. Its a very relaxed environment so they can chat and that in itself is just a bit of a release. I havent got any big ambitions that they will go into the arts themselves but I think they will believe in themselves a bit more, through doing art (teenage parent group artist).

In addition to the therapeutic benets of the art process itself, was its role in allowing participants to acquire and develop skills in art. Thus, although initial levels of artistic condence and competence varied between different groups and participants, this acquisition of skills could itself be considered therapeutic, having a positive impact on participants self-condence and esteem:
As individuals weve developed skills that we didnt know we had in the rst place (drop-in centre member).

Moreover, while the art sessions were primarily concerned not with the quality of the work but with the therapeutic value of producing it, when work becomes the focus of praise and enthusiasm, this can itself be therapeutic (Dalley, 1984). As such, the positive impact of the arts project was further facilitated by the sense of achievement

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that participants experienced in having created something tangible and valued by the group. As a single parent said of her contribution to the calendar which the group had collectively produced:
I keep looking at it over there and I cant believe that Ive done it. So just signing my name on the bottom and being able to say I did that . . . I was really proud (single parent group member).

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This sense of achievement was most clearly apparent amongst the single parents group whose sessions were consistently well attended throughout the duration of the project. This success may have partly been attributable to the nature of the art sessions, which were clearly structured to the nal goal of producing a calendar. It may also have been due to the tightly-knit and long-established nature of the group, members relatively high levels of artistic condence and their good relationship with the artist who was known to the group prior to the commencement of the project. In such therapeutic activities, therapist and participant variables interact with intervention methods, making it difcult to assess which are related to a successful outcome (Hilgard et al., 2000). Previous research has observed the way in which art carried out within groups rather than with individuals can be advantageous to the art activity, serving to facilitate the acquisition of artistic skills in a cost effective way (Liebmann, 1989). The ndings of this research would further suggest that the use of art with an already established group can also have a positive impact on the workings of the group itself. For example, it served to promote participants sense of belonging, group cohesion and collective esteem, characteristics which have been found to be a major curative factors in group work (Yalom, 1995; Doel and Sawdon, 1999). Moreover, in spite of the dichotomy commonly drawn between activity and verbally oriented group work (Finlay, 1999), it also served to enhance the communication between group members. For example, as the drop-in centre artist observed:
The very nature of being in a group proves they have a willingness to share and join in and I think that will be good for the individuals themselves (drop-in centre artist).

Similarly, the single parent group spoke of the way in which the art project helped to promote group cohesion, not only through their common purpose and goal of producing a calendar but also through its role in facilitating interaction between group members. This, in turn, helped to overcome the selectivity and anonymity of interaction, which can often develop in larger groups (Vinter, 1967):
When youre all sat as a group doing something, you go home warm, thinking theres people out there that care whether youre dead or alive [. . .]. Weve all done brilliant pieces of work havent we and as a group weve interacted with each other, havent we, mixing colours and all that sort of thing (single parent group member).

In spite of the limited duration of this project, its perceived benets were not simply conned to experiences within the art sessions, with many participants further continuing their artwork either within or outside the group:
Some of the members have actually purchased some paints and done their own paintings because they nd it so relaxing (single parent group leader).

Again, this process was most apparent in the single parents group, with the group artist agreeing to continue providing art sessions for the group at a reduced fee. Nevertheless, all participating group leaders were investigating ways in which art activities could be further pursued within the group after the project had nished. Conclusion The art project participants found art creation therapeutic and relaxing, while the acquisition of skills and sense of achievement served to promote feelings of condence and self-esteem. Social relationships between members of the groups were strengthened; this was valuable as these groups existed before the project, and continued afterwards: a vital community enhancement. Such group relations can be important factors in promoting mental wellbeing. A further community value is that the artists became involved with community groups with whom they might otherwise have no contact. These multiple benets to be gained from art activities suggest the need for more widespread and sustained funding for this accessible, versatile and cost-effective means of community health promotion (Staricoff, 2004). There is a pressing need for effective evaluation and research. The project reported in this paper was small and inexpensive (as most are), and only used one of the kinds of art involvement outlined at the start of this paper, and only a small range of arts practices. A practical involvement in the arts can offer a wide range of benets to vulnerable or sick people. This is true of both arts therapies and arts in health, as dened above. Arts as facilitated by artists themselves, with no overt therapeutic input, can be powerfully healing. With very little money, people and communities can be supported towards not just a greater measure of sanity, but also increased health and well-being.
Web sites National Network for the Arts in Health, www.nnah.org.uk Centre for Arts and Humanities in Healthcare and Medicine, www.dur.ac.uk/cahhm The MAP Foundation, www.mapfoundation.org Rosettalife, www.rosettalife.org Lapidus, www.lapidus.org.uk References Aldridge, D. (Ed.) (2000), Music Therapy in Dementia Care, Jessica Kingsley Publishers, London. Argyle, E. (2001), Poverty, disability and the role of older carers, Disability and Society, Vol. 16 No. 4, pp. 585-95. Bolton, G. (1999), The Therapeutic Potential of Creative Writing: Writing Myself, Jessica Kingsley Publishers, London. Brown, G. and Harris, T. (1978), Social Origins of Depression: A Study of Psychiatric Disorder in Women, Tavistock, London. Bryman, A. (2001), Social Research Methods, Oxford University Press, Oxford. Byrne, P. (1978), The meaning of art in art and psychopathology, Inscape, Vol. 3 No. 1, pp. 13-20. Calman, K. (2000), A Study of Story Telling: Humour and Learning in Medicine, The Nufeld Trust, London.

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Charon, R. (2000a), Informed consent: the imperative and the therapeutic dividend of showing patients what we write about them, paper presented at the Narrative Matters: Personal Stories and the Making of Health Policy Conference, Airlie, VA, March. Charon, R. (2000b), Literature and medicine: origins and destinies, Academic Medicine, Vol. 75, pp. 23-7.

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Smith, R. (2002), Spend (slightly) less on health and more on the arts, British Medical Journal, Vol. 325, pp. 1432-3, available at: www.bmj.com (accessed 8 April 2005). Snow, S., Damico, M. and Tanguay, D. (2003), Therapeutic theatre and wellbeing, Arts in Psychotherapy, Vol. 30 No. 2, pp. 73-82. Staricoff, R. (2004), Arts in Health: A Review of the Medical Literature, Arts Council England, London. Staricoff, R. and Loppert, S. (2003), Integrating the arts into health care: can we affect clinical outcomes?, in Kirklin, D. and Richardson, R. (Eds), The Healing Environment: Without and within, Royal College of Physicians, London. Vinter, E. (1974), Programme activities: an analysis of their effects on participant behaviour, in Glasser, P., Savri, R. and Vinter, R. (Eds), Individual Change through Small Groups, The Free Press, New York, NY. Vinter, R. (1967), Readings in Groupwork Practice, Campus Publications, Ann Arbor, MI. Walker, A. and Walker, C. (Eds) (1997), Britain Divided: The Growth of Social Exclusion in the 1980s and 1990s, CPAG, London. White, M. (2002), Determined to Dialogue: A Survey of Arts in Health in the North and Yorkshire, Centre for Arts and Humanities in Health Care and Medicine, Durham. White, M. (2004), Arts in mental health for social inclusion: towards a framework for programme evaluation, in Cowling, J. (Ed.), For Arts Sake: Society and the Arts in the 21st Century, Institute of Public Policy Research, London. Yalom, I. (1995), The Theory and Practice of Group Psychotherapy, 4th ed., Basic Books, New York, NY. Young, M. and Willmott, P. (1962), Family and Kinship in East London, Penguin, Harmondsworth. Further reading Huxley, P.J. (1997), Arts on Prescription, Stockport NHS Trust, Stockport. Payne, A. (1993), Handbook of Enquiry in the Arts Therapies: One River, Many Currents, Jessica Kingsley, London. Petrone, M.A. (2003), The Emotional Cancer Journey, MAP Foundation, London. Townsend, P., Davidson, N. and Whitehead, M. (1992), Inequalities in Health: The Black Report and The Health Divide, Penguin Books, London. Wolton, R. (2002), Our Lives, Our Group: The Thursday Club Book, Shefeld Womens Cultural Club, Shefeld.