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Journal of Psychiatric and Mental Health Nursing, 2007, 14, 783790

Experiences and constructions of art: a narrative-discourse analysis


T. S T I C K L E Y 1 m a d i p n d i p c o u n s r m n , A . H U I 2 m n u r s s c i r h ( m h ) , J. MORGAN3 mnurssci rh(mh) & G. BERTRAM1 mn rn(mh)
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Lecturer in Mental Health, University of Nottingham, 2Staff Nurse, Nottinghamshire Healthcare NHS Trust, and Student Nurse, University of Nottingham, Nottingham, UK

Correspondence: T. Stickley School of Nursing Faculty of Medicine and Health Sciences University of Nottingham Duncan MacMillan House Porchester Road Mapperley Nottingham UK E-mail: theo.stickley@ nottingham.ac.uk

STICKLEY T., HUI A., MORGAN J. & BERTRAM G. (2007) Journal of Psychiatric and Mental Health Nursing 14, 783790 Experiences and constructions of art: a narrative-discourse analysis A narrative-discourse analysis was conducted to study the narratives of mental health service users talking about their engagement with art. The sample was drawn from a group of people who had attended arts workshops organized by a mental health service provider. Eleven people were interviewed and were asked to tell the story of their involvement in art and its signicance to their lives. The data were analysed using a discourse analysis approach. Art is constructed as therapeutic within an illness repertoire. Emotions are inseparable from creative expression and identity claims are made in relation to being an artist. Keywords: art, creativity, discourse analysis, mental health, narrative
Accepted for publication: 8 August 2007

Introduction
In the UK, engagement with the arts is acknowledged as one of the ways that people who use mental health services might be socially included (SEU 2004). Furthermore, there is widespread consensus that art is good for people for personal benets, such as raising self-esteem and increased self-expression (Dissanayake 1995, Backos & Pagon 1999, Creek 2002, Schmid 2005), and for social benets, notably social role and community engagement (Hacking et al. 2006, Parr 2006a). This paper reports upon the ndings of a research project that sought to elicit mental health service users views of how engagement in arts activities might be good for them. Eleven people who use mental health services were identied to participate in this study, following their attendance at arts workshops organized by a mental health trust in the UK. In the UK, the Arts Council England, in partnership with the Department of Health, has developed a framework for the arts and health (Arts Council England 2007), and there is increasing interest in arts pro 2007 The Authors. Journal compilation 2007 Blackwell Publishing Ltd

vision for people who use mental health services (Staricoff 2004, Hacking et al. 2006). In most countries, mental health nurses form the largest contingent of the mental health workforce and may need to further develop creative approaches in care.

Background
The great archaeological discoveries of the 20th century have revealed how art was integral to the ordinary life of those in ancient cultures, evidenced largely through the design and production of domestic objects and accounts of life such as cave paintings (Hartt 1976). However, it is thought that these were more likely purely functional (Storr 1988). It has been argued that the arts are biologically evolved propensities of human nature and that their fundamental features helped early humans adapt to their environment and reproduce successfully over generations (Dissanayake 2000). The notions of a work of art and an artist would have been incomprehensible to those living,
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for example, in the Greek or Roman civilization (Storr 1988, Benediktson 2000). In post-Renaissance times, art became the property of those who could commission and afford to buy works created by artists. Matarasso (1997) speculates that art is apparently useless, yet all human societies produce it. Whether through painting, drama, music, dance, storytelling, narrative, humour or play, artistic expression has been considered inseparable from the psyche and often manifested through religious or superstitious beliefs. Artistic creativity has often been associated with both madness and the sublime (Storr 1988, Nettle 2001, Guimn 2006). Mental illness is prevalent in the families of artists, poets and writers. The genetic temperaments and imaginative capacities that lie behind both insanity and creative ability are entwined, and the traits that lie behind insanity, it is asserted, have evolved because they have psychological benets as well as costs (Storr 1988, Nettle 2001). Ideas of the arts being good for us have existed at least since the time of Aristotle. For Aristotle, when listening to music, our souls undergo a change. He does not escape the charge of artistic elitism, however, as he advises that not all music is therapeutic; an instrument such as the ute is vulgar and bets those of lower social classes such as labourers. Plato also differentiated between virtuous music that appeals to the educated and vicious music that appeals to the uneducated. Throughout the centuries since Christ, until the time of the Enlightenment, art was often seen as the property of the church, depicting religious messages through paintings and songs. With the birth of aesthetics, however, in the 18th century, a shift took place in the arts, from the sacred to the secular, and the arts legitimized spiritual expression outside of organized religion. This was reected in the cathedral-like architecture of modern galleries and, in the 19th century, public access to these galleries was seen to be healthy and good for people of all classes (Carey 2005). Art would (in contemporary language) promote social capital by bridging the classes; public viewing of high art would become available to all. As early as 1835 in the UK, a House of Commons select committee advised on the effectiveness of the visual arts to promote the improvement of morals among the lower social orders. The National Gallery was situated in Trafalgar Square so that it was geographically accessible to all classes (social inclusion). Furthermore, to promote genuine inclusion, there was no entrance fee. Whether the morals of the lower social classes that visited such galleries were improved remain to be seen. However, drawing heavily from psychological evidence, Kreitler & Kreitler (1972) assert that art will never improve change in behaviour. Carey (2005, p. 101) insists that The widely shared
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belief that art can instruct the public, and help to attain a better state of affairs, lacks any factual backing. As Secretary of State for Culture, Media and Sport, Chris Smith (Smith 1998) set out to remove the distinctions between high and low art and declare that the arts (not just art) could promote social inclusion. However, he offered no real example of what this might look like in practice, and the social inclusion agenda at that time was barely established. The link between creative expression and psychological well-being was formally recognized early in the 19th century when artistic expressions were used to interpret the unconscious mind. From those early beginnings, there are now many different forms of art being used for therapeutic purposes. In recent times, however, the role of art therapy has been challenged and there is an emerging literature that advocates a move away from using art as therapy, towards a more democratic process that places the healing signicance of creativity away from the therapist and locates the therapeutic efcacy of creative expression within the individual (Boal 1992). Given the historical and integral nature of creativity to well-being, it is odd that creativity has not played a stronger role in the health care agenda in the past. This may be largely due to the contemporary nature of a health care system that is socially constructed in a post-Enlightenment, post-industrial revolution, positivist arena, where science rules. Arguably, progress in terms of technology and materialism has alienated modern humans from the creative drive that helped in the survival of the species. An alienation of a species from the creativity that it needs, on the grounds of progress, might well be described as madness. Thus, the madness evident in modernism, illustrated by Sass (1992), may be a generational response to the insanity of modern society (Laing 1960).

Research process
Service users who had attended arts workshop days were invited to participate in one-to-one qualitative research interviews. Full written information was given to the potential participants, and consent forms were completed by those who wished to take part in the research. Eleven people were interviewed about their stories of engaging with art. It was acknowledged that the sample of people who agreed to be interviewed had an interest in arts activities because of their choice to attend the workshops in the rst place. Each interview lasted about 1 h. The researchers involved in the project were two registered mental health nurses and one student nurse; the interviewers did not know the participants in their capacities as nurses. Ethical approval was obtained from the local National Health
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Service research ethics committee and all names have been changed to ensure condentiality. The interviews were audio-recorded and transcribed verbatim. Participants were asked: Please tell me the story of how art has been signicant to you through out your life, all the events and experiences that have been important to you personally; begin wherever you like, I wont interrupt, and Ill just take some notes for afterwards. Follow-up questions were asked, aiming to invite further narratives on specic aspects of the participants original stories.

How are experiences, both positive and negative, constructed?

Discourse analysis
Discourse analysis is a research method that incorporates many ideas and approaches within the social sciences (Yates 2004). The approach has emerged from a number of disciplines (Wood & Kroger 2000), notably sociology and social psychology. Wetherell et al. (2001) suggest that discourse practices can be positioned under three broad headings: social interaction (conversational analysis); minds, selves and sense-making (discursive psychology); and culture and social relations (post-structuralism, notably the work of Michel Foucault 1926-1984). Potter & Wetherall (2004) would add a further category, that of the sociology of scientic knowledge. All discourse analysis practice focuses upon the use of language. Discourse is said to refer to all written and spoken word (Wood & Kroger 2000). In the latter half of the 20th century, language has come to take on a greater signicance in the world of social science research. Inuenced by linguistic philosophers such as Wittgenstein (1968) and Winch (1958), social constructionism emerged (Berger & Luckman 1966, Gergen 1999). The fusion of narrative approaches and discourse analysis, often referred to as narrative discourse, is largely represented through discursive psychology (e.g. Harr & Gillet 1994, Edwards 1997, Harper 2004). Discursive psychology combines socio-psychological and linguistic approaches with a philosophical component found in the later work of Wittgenstein and the philosophy of ordinary language (Brockmeier 2001).

Analytical approach
A narrative discourse analysis was conducted, studying the stories of 11 mental health service users with regard to their experiences of art. As discourse analysis views language as constitutive of experience as opposed to being reective or representational (Willig 1999), the interrelationships between language and experience is explored by looking at what was being said in what was said. Any rhetoric in themes, ideas and language was examined by investigating variability, constitution and function (Potter & Wetherell 1987). Through studying variability, individual experiences of art were uncovered, so as not to assume all service user perceptions are alike and the same. Similarities and differences between service users were compared with the cultures, ideologies and discourses of the dominant mainstream understanding of art, whereby relationships and interrelationships were uncovered. Greater understanding may also be gained through investigating constructions and functions; unravelling underlying meanings and possible assumptions (Burr 1995); and analysing how experiences are expressed, what purpose this may full and what the role and consequences of this might be. Questions relating to the text were asked throughout the analytical process, in ultimately establishing where the service user discourse lies in relation to art and in responding to the research question posed. The analytical questions were developed and modied while service user narratives were being read, because of the unassuming nature of discourse analysis and the unstructured role of narrative inquiry. Some, more general, analytical questions were initially asked, with questions becoming more detailed and specic once the narratives were read and the analytical process developed. These questions included: How do the individual participants construct the concept of art? How is art used by service users? How do the service users say they experience art? What do participants say about their thoughts, feelings and emotions related to engagement with art?
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Carrying out the analysis


The service user narratives have been wide-ranging and varied in terms of peoples experiences of art. This has presented some challenges in rstly identifying a collective service user discourse and, secondly, in presenting such ndings while maintaining the uniqueness of such individual experiences. For ease of reading, the topics arising from the narratives have been placed under appropriate subheadings and analysed and discussed within this section. This, however, by no means detracts from the interrelatedness of the issues discussed. Neither is this an attempt to categorize and homogenize all service users and their experiences as being one. In this project, we sought to identify, analyse and critique why service users may use art; why art is signicant in peoples lives; and how service users conceptually construct art. The pros and cons of using art will also be uncovered and discussed, alongside
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art as a form of expression and the power of art in creating resistance and achieving freedom.

Producing art has been associated with increased selfesteem (Matarasso 1997, Wilcock 2001), although how sustainable these feelings are is questionable.

Findings
From analysing the discursive narratives of service users, it is apparent how individualized and unique each persons experiences have been in relation to art. Not only has each service user had different experiences of art both during childhood and adulthood, but also the types of art explored have been equally varied, with many art forms mentioned, including visual arts, writing, poetry, music and lyrics. Moreover, the power of art has been a signicant aspect of peoples lives. In the analysed data, art has been described as reecting peoples emotions; providing a sense of achievement, inspirational and motivational; promoting socialization; individuality and hope. All participants saw art as an important part of their lives, with freedom, expression and identity being central themes throughout. These will be discussed in detail in the following.

Distraction/escape
Other reasons why service users have embraced art include
I think its (art) become more important to me more recently while Ive been poorly . . . Its part of the sort of, you know, a distraction . . . Cheers you up . . . Engages you . . . Takes your mind off all the crap thats going on up here (Natalie, p. 1). Whenever something has been too stressful (I) always turn try to do drawing, and painting or sewing . . . (Janet, p. 1).

Art therefore may have a benecial therapeutic effect for some by releasing tension and offering escapism.

Expression
When considering what art actually is and means to people, many may initially think of art from a visual perspective. However, through reading and analysing the service user narratives, the depth and breadth of such a concept become clear, with 30 different forms of art mentioned. It may come as no surprise that the term art was mentioned the most, given the topic of analysis. However, this was closely followed by painting, drawing and music, respectively, in terms of numbers of service users being involved in each type of art. The great variances in the frequencies of the different types of art mentioned may have occurred for several reasons. These may include that services themselves offer limited choices, restricting the types of art service users can become involved in. Alternatively, service users may genuinely have interests in certain types of art more so than others. Thus, these factors need to be taken into consideration, along with issues of nance and funding and the possibilities for change where necessary. As Sarah states,
Art jobs are really hard to nd because you hear about equal ops all the time but there arent equal ops, you know, somebody decides that some subjects are more important than others . . . They seem to just want to repeat the same thing. Cos its easier . . . (Sarah, pp. 4, 7).

Achievement
The majority of service users begin their narratives with either childhood (Barry, Caroline, Jean, Janet, Natalie and Ryan) or teenage (David and Martin) accounts of their artistic experiences before going on to discuss the signicance of art in later life. However, for the time being at least, the focus here will be on the importance of art during the present time in peoples lives in maintaining current perspectives. From a service users perspective, the role and rationale for using art has been that
I found (art) relaxing and calming and quite an achievement to get an end result (Caroline, p. 1). Basically, its been something thats made me want to achieve . . . Show people what I can do . . . Makes me feel good . . . Finding out that I can do something Ive not tried before (Jean, p. 1).

Art then appears to be somewhat of a double-edged sword, presenting as both a challenge and an accomplishment or achievement. The act of doing art may be a challenge in itself, made ever more so by having also to defy the social norms of others perceptions: showing people what I can do. The process and production of an art piece, however, may be something of an achievement, providing a sense of self-satisfaction and making people feel good in gaining an end result. This is very much supported by David, who stated that
Youre producing something thats of value and it lasts . . . and its better than just like a thought trapped inside your head (David, p. 2). 786

When talking about the visual arts, Wendy narrates,


When I thought about visual arts, it felt like it had more passion in, it like embodies me . . . (Wendy, p. 14).

Similarly, on talking about music and lyrics, Jean and David, respectively, express that
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It was an upright piano, totally out of tune but I needed to play, I dont know why, I just needed to play. I suppose I was angry inside, it, you know, all that stuff. Emotions, I didnt know how to express myself . . . (Jean, p. 11). I live to write lyrics, I live to perform music and the art just helps kind of get ideas together for that, really . . . its a visual side to it, theres a kind of subliminal side to it, with the words and the lyrics but then, often they keep them together in an image . . . (David, p. 2).

and frustration . . . and would feed into falling out with everyone in sight, ending up very isolated . . . this is what my manic depressive cycle was all about (Barry, pp. 2, 3).

Spoken about in this way, art represents a mode by which people are able to assimilate, incorporate and exemplify their understandings of themselves and their thoughts, in this way, making things solid and real. With words such as embody and subliminal being used to describe the feelings and emotions evoked by art, undertones of consolidation appear with almost an ethereal, majestic-like quality. These are emotions that seem to be shared between service users, despite the different pathways to art being sought. With art being turned to during times of need, a form of expression is gathered, providing an outlet and heightening the portrayal of the importance of art. Art, as examined within this section, appears to have been alluded to as a form of expression, sometimes being limited by outside inuences, but a very much different and individual experience for all service users involved. Bender & Ewashen (2000) discuss the therapeutic efcacy of creating something in the external world that is rst created in the internal world, thus concretizing inner processes. Where art may offer a form of expression, there may also be a degree of vulnerability accompanying such forms of communication that may be so openly criticized by others, putting into question the impact that art may have on a persons health and well-being. The act of doing art, as well as the emotional expression through art, may be an invaluable source of freedom and expression (Caroline, p. 1); however, other peoples critiques may lead to consequences that are more negative. Barry, in particular, made a rm decision to be no longer involved with the arts because of his personal recognition of the negative impact art was having upon him. Although Barrys experiences have been exceptionally different from those of other service users interviewed, as he himself describes,
I had this craving to be recognized, to be famous and so on . . . a lot of my artistic effort was derived form this same desire to get a lot of attention and in a sense, it was kind of narcissistic . . . that sense of excitement over a long period of time with what youd call mania, would keep me motivated and so on and then the irritation at other people not giving me that attention . . . that irritation would feed into the mania and would create anger
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Perhaps in the same way that this involvement in art was negative for Barry in terms of the desire for attention what it has provided, however, is a sense of recognition for his own needs, identity and sense of self. In this was. Barry was able to break the cycle between the mania and depression, thus overcoming the problems he was experiencing during this time, eventually culminating in a positive outcome through realization.

Art and identity


In studying the narratives of service users, the interrelationships between art, identity and the expressions of such identities become ever clearer. There appears to be a tendency among service users to identify their innate needs for doing art, coupled with some forms of external inuences, sometimes acting as external pressures, creating friction and resistance. Ryan describes art as being
The only thing Ive ever been good at . . . the only sort of thing I had any kind of natural ability with (Ryan, p. 1).

Similarly, other service users identify with this stance, stating


It felt essential to my being . . . its like all those patterns and connections and stuff inside of me, with art, I feel like I can make those connections and say what it is I need to say, and its a bit more instantly available (Wendy, p. 4). I would be constantly doing things to try and get to the art but because I was so young, they didnt understand . . . I would literally just cut things up and they were really naughty behaviours but its only with massive hindsight that, it was the natural artist in me, it was what I did . . . it was totally natural, for me, that was treated as bad behaviour (Sarah, p. 1).

Therefore, there appears to be much emphasis on natural talent and abilities; making connections; and implicitly describing the necessities of art. Furthermore, while the expressions of art by a child are misinterpreted and treated as bad behaviour, as was the case with Sarah, the nurturing of such natural skills, abilities and talents are encouraged.
Art gives me a desire for life . . . I cant think of anything else that I would have wanted and I think the saddest thing of all must be for a person whos depressed, but doesnt have anything like that. And I think, I think thats what we should be trying to do with children, nd out what it is thats special about them, not impose what we want on them but bring it out (Sarah, p. 6). 787

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It has been suggested that alongside identity, the identication of a role is as equally important in understanding ones own being and person, the notions of identity and role are thus seemingly intertwined and interlinked:
It doesnt matter what it is, somebody needs something that theyre good at, that they can call themselves, whether it be football, brick-laying or whatever, you know, it sort of takes your mind off . . . and, doesnt matter what it is, whether its, like I say, football, bricklaying or whatever it is, you need something that you can call yourself. Everybody does, not necessarily just people who are mentally ill, I think, anybody does (Martin, p. 3).

Along with this sense of identity, there is therefore also a sense of ownership and unique relationship with this particular special skill. This role-identity formation may also be central aspects relating to condence, self-esteem and feelings of fullment (Sarah, Caroline, Jean, David, Martin, Wendy), in holding the assurance and conviction to freely express oneself. This form of expression may be through the arts, or as Caroline explains, through her sense and style of dress:
I dont go for the latest fashion just because its in the catalogues or in the shops, because youre going to be restricted . . . so theres no way that I want to look like, you know, every third person on the streets so I use vibrant colours, the art form goes into selecting fabrics, jewellery, making jewellery, decorating something with appliqu, with beading, with sequins, with tassels, you know, the artwork that comes into virtually everything (Caroline, p. 4).

Simultaneously, what is demonstrated here are the unique individualities of peoples work and minds in the creation of such different pieces of work, with an individual sense of ownership and respect that ideas will not be copied. Through such notions, widely different and diverse outcomes may be created. Although a person may have more techniques; not necessarily better ideas but better execution and techniques (David, p. 2), the differences between the technicalities and natural abilities of art are highlighted. Personal identity does not feature strongly in the arts and mental health literature, although social identity through a sense of belonging does (Parr 2006b). Furthermore, the feeling of being accepted increases a sense of identity and gives meaning to life (Spencer & Pahl 2006).

Power of art
The power and inuence of art have so far been discussed in terms of the meaning of art, the uses of art, the positive and negative aspects of art, and the expression of identity through art. Although these are important aspects of art to consider, there are also more hidden subtleties, such as hope, motivation, change and involvement, underlying the service user narratives:
Its something that I can actually focus on that I can do, feel good about you know, and thats a real big change and I actually sort of like feel involved and I feel motivated, you know, that, okay, I dont know were this is going but at least its taking me somewhere . . . and its better than being nowhere (Ryan, p. 2). Im doing new things and combining different things together as well . . . were al sort of bouncing off each the . . . inuences . . . ideas and things, its good (Martin). It gives more appreciation for myself when I see readymade work or somebody elses, how detailed it is, how much effort is actually involved in it . . . it is a constant learning curve and artwork is something that people get together and youve got a common interest that develops socially, moral support . . . and if I didnt have that, then I would be a really bad state (Caroline, p. 3).

Dress sense, style, identity and the arts may therefore be perceived as forms of resistance to and non-compliance with social norms; asserting an individual stance through non-conformity. In this way, a unique individuality may be maintained and displayed in everyday life, especially since it is through general appearance that statements and judgements may be made. In likening fashion to school uniforms, Caroline may be perceived to be creating greater resistance particularly towards systems of authority, such as those of the schooling and educational system with its hierarchical nature in this way, offering alternatives. Her use of vibrant colours may also be a reection of personality, mood, artistic culture and inuences. A unique sense of individuality is further recognized through Davids narrative:
Its like, say, one of my paintings . . . you know, Dali probably didnt do that painting in his whole life because if he had then I wouldnt have been able to do that painting so the painting is mine (David, p. 3).

Through comparing his work with that of Salvador Dalis, David is heightening the importance of his own work.
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There is the suggestion that art can therefore take people to other places whether metaphorically or literally. Perhaps what this suggests is that art physically removes people from isolation, uniting them through organized arts activities (Hacking et al. 2005; Greaves & Farbus 2006, Parr 2006a). Moreover, art may offer escapism, in more of a metaphorical sense, with individuals not knowing where thoughts and ideas will lead and thus not knowing how the nal piece of art will end up looking, in this way, creating
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a sense of mystery and adventure. Art in a metaphorical sense may therefore offer hope, as Caroline describes:
If I couldnt cope with that, then I sort of thought, well, put it aside, leave it, because eventually, however, long it takes, ngers crossed, hopefully, that I will be able to get back to it (Caroline, p. 4).

Art thereby offers a sense of hope that she will overcome her problems; that she will be able to focus and concentrate again; that she will feel better once more; and that she will be able to resume the artwork that is important to her and that she so enjoys. There is a sense of mutual appreciation and respect that appears to accompany artists and their artwork alongside the audiences that they capture:
If a well-tuned artist is tuned into what their audience and what the world needs adds on, a well-tuned artist can actually make a real contribution . . . what the artist is doing is valuing and expressing something about other people (Barry, p. 3).

This expression is a form of respect and acceptance through another part of the persons being; art may be more acceptable within a society where mental health problems are not acceptable. This may also highlight the reciprocal nature of art, which relays to others what others can relate to and nds a connection between people with mental health problems and those without, by including them within and as part of society. Art may therefore also offer a form of social inclusion in terms of engendering a sense of belonging to other creative people (HDA 2000, Hacking et al. 2005, 2006, Parr 2006b).

of the lack of social role and recognition of mental patients in Western society, these kinds of feelings may be considered transcendent or redemptive (Barker 1998). What cannot be asserted, however, is how long these feelings may endure. In the course of mental health nursing practice, there may be few opportunities for the nurse to facilitate engagement in artistic activities. However, given the hopeful and healing nature of artistic expression, it is recommended that nurses develop ways to promote creative expression for the personal and social benet of those with whom they work. Whether working in inpatient or community settings, nurses may easily promote creative expression whether individually or collectively. Furthermore, opportunities need to be developed away from statutory settings to help people develop community arts activities to engender a sense of social integration. Given the fragmented nature of mental health problems, the identity claims that people attach to being identied as an artist is of great signicance. Furthermore, we would encourage greater attention to researching the meaning of artistic expression and the possible social benets in the lives of people who experience mental distress.

Acknowledgment
This research study was funded by the Nottinghamshire Healthcare NHS Trust.

Conclusion
The personal and social benets of the arts have been identied in this study. They include identity claims, role, the power of art for healing and inspiring hope, and art as a medium for uniting people. As people were recruited to the study through statutory mental health services, there is the possibility that the research process contributed to the co-construction of the illness narratives. This may have been intensied with the researchers also being perceived as mental health professionals. Art is constructed as an enabler to strengthen identity. While there are numerous claims in the health literature that arts can strengthen communities (Greaves & Farbus 2006, Parr 2006b), there are fewer claims that participation in the arts can strengthen identity. This study reveals the hopeful nature of artistic expression. The production of artwork inevitably attracts praise and recognition. For some, they are able to call themselves an artist. Participatory art therefore may promote feelings of self-worth and a sense of social role (Jermyn 2004, Greaves & Farbus 2006, Parr 2006b). In the light
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