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'Getting back to normal': the added value of an art-based programme in promoting 'recovery' for common but chronic mental health problems
Sally Makin and Linda Gask Chronic Illness 2012 8: 64 originally published online 10 October 2011 DOI: 10.1177/1742395311422613 The online version of this article can be found at: http://chi.sagepub.com/content/8/1/64

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Article

Getting back to normal: the added value of an art-based programme in promoting recovery for common but chronic mental health problems
Sally Makin1 and Linda Gask2

Chronic Illness 8(1) 6475 ! The Author(s) 2011 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/1742395311422613 chi.sagepub.com

Abstract Objectives. The aim of this project was to explore the added value of participation in an Arts on Prescription (AoP) programme to aid the process of recovery in people with common but chronic mental health problems that have already undergone a psychological talking-based therapy. Methods. The study utilized qualitative in-depth interviews with 15 clients with persistent anxiety and depression who had attended an AoP service and had previously received psychological therapy. Results and discussion. Attending AoP aided the process of recovery, which was perceived by participants as returning to normality through enjoying life again, returning to previous activities, setting goals and stopping dwelling on the past. Most were positive about the benefits they had previously gained from talking therapies. However, these alone were not perceived as having been sufficient to achieve recovery. The AoP offered some specific opportunities in this regard, mediated by the therapeutic and effect of absorption in an activity, the specific creative potential of art, and the social aspects of attending the programme. Conclusions. For some people who experience persistent or relapsing common mental health problems, participation in an arts-based programme provides added value in aiding recovery in ways not facilitated by talking therapies alone.

Keywords Anxiety, depression, creative therapies, social inclusion, recovery

Received 14 August 2011; accepted: 15 August 2011

Old Age Psychiatry, Manchester Mental Health and Social Care Trust, Manchester Royal Infirmary, Manchester, UK 2 Primary Care Psychiatry, Health Services Research Group, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK

Corresponding author: Linda Gask, Primary Care Psychiatry, Health Services Research Group, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, M13 9PL, UK Email: linda.gask@manchester.ac.uk

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65 have been calls for a more systematic approach to evaluation6 in an arena in which there has been only limited peerreviewed and published research.7 Commentators on the evidence base for arts in health have also noted that there is a pressure for quantitative positivist evaluation in the healthcare eld,8 particularly in the evaluation of newer focused psychological interventions, which may particularly clash with the ideological stance of those involved in creative therapies.9 The practice of an art, such as painting, has the potential for therapeutic power, enabling the expression of cognitive, emotional and spiritual ideas to which people may otherwise have no access. The arts can be soothing and calming, distract from pain and anxiety, and increase self-condence and motivation.6,10 Particularly promoted for people with mental health problems are community-based arts for health projects. These dier from more traditional forms of art therapy, which requires therapists with specialist training, in that they are focused on processactually doing and experiencing the creation of art. There is some evidence that they may have a positive impact on sense of well-being, psychological symptoms, quality of life and recovery from illness.3,11 Arts may be especially helpful for those who nd it hard to express their feelings verbally,8 and can oer ways of dealing with social exclusion.12,13 Arts on Prescription (AoP) is a type of social prescribing in which there is a referral process, whereby health or social care providers refer people to a service or source of support.14 The rst AoP scheme was founded in Stockport in North West England in 1994. In AoP settings, working artists, rather than trained art therapists, engage groups of people in a community setting. There is limited published empirical research specically on AoP,15 but Bungay and Clift have reviewed the available evi-

Background
There is a developing evidence base for the impact of creative arts in healthcare.1 Arts in health have 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 the provision of artworks or performances.2 (p. 11)

This includes literature and writing, theatre and drama, dance, music and visual arts3 and is therefore a broad umbrella covering active participation in creative activities (such as drawing and painting) and more passive audience or viewer activities (such as paintings hung on clinic and hospital walls).The relationship between art and health has a rich and complex history2 and a broad scope incorporating two key dimensions, whether the focus is primarily on engagement with the arts (with an assumption that this carries benets for well-being) or more specically on health improvement (with the assumption that the arts can help to achieve health outcomes).3 The intervention evaluated in this article is concerned with the latter dimension.

Arts, health and mental health

In 2006, the Review of Arts and Health Working Group3 concluded that:
Arts and health are and should be rmly recognised as being, integral to health, healthcare provision and healthcare environments (p. 16).

The last decade saw a rapid development of arts and health projects across the United Kingdom, supported by policy developments.4 However, this was not without its critics citing inadequate evidence and exaggerated claims for the benets of art.5 There

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66 dence, much of which, they note, is qualitative, indicating that participation raises selfesteem, provides a sense of purpose, helps people engage in social relationships and increases sense of empowerment and social inclusion.15,16 A large, multi-project evaluation Invest to Save, which included evaluation of AoP projects, utilizing both qualitative and quantitative methods and conducted in the North West of England has also reported its ndings.17

Chronic Illness 8(1) recovery from depression,22 in the eld of common mental health problems notions of recovery remain remarkably biomedical. In pharmacological trials, recovery is dened in terms of reduction in symptoms rather than improvement in social functioning.23 Allied to this is the view that recovery, although dened in social terms but from the rather narrow economic perspective only of ability to work, can be achieved with a quick x of psychological therapy alone.24

Promoting recovery
There is also growing interest in the link between recovery and involvement in creative activities. Recovery is understood to mean something dierent from sustained remission of symptoms or cure and has been dened by Anthony as a way of living a satisfying, hopeful and contributing life, even with the limitations caused by illness.18 There has been only limited exploration of the utility of the recovery model for people with common mental health problems (though there is increasing evidence of the chronic nature of some common mental health problems19); and little work has been done to fully characterize the process of recovery from these problems, despite the success of this concept in changing the culture in the eld of severe and enduring mental illness (which does not generally include within its denition anxiety and depression), particularly schizophrenia.20 In recent years, recovery has been redened from the traditional sense of cure or absence of symptoms21 to something less quantiable and more attainable for those with persistent mental health problems, encapsulating the return of the ability to function eectively to some degree and the return to activities that would normally be taken for granted. Although some qualitative work has been carried out to characterize the process of

The present study

The call for evidence to inform the quality and cost-eectiveness of services funded from a diminishing healthcare budget is strident. Indeed it seems likely that, in a period of more limited funding in mental health, with a more specic focus on outcomes (usually measured quantitatively),15,25 there will be tight competition for funding between community-based services utilising an artistic medium and healthcare services utilising psychological therapies in the non-pharmacological treatment of common mental health problems. The art-based and psychological therapy literatures have developed in parallel. In practice, some clients will have been in receipt of both of these approaches. How do these dier and potentially complement each other? The aim of this project was to explore the added value of participation in an AoP programme to aid the process of recovery in people with common but chronic mental health problems who have already undergone a psychological talking-based therapy. In order to answer this question, we need to understand how recovery might be conceptualized by those attending the programme. What part did attending the sessions play in the process of recovery? And, how did this process dier from the clients previous experience of treatmentspecically, in this case, psychological or talking therapies?

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67 the 6-month AoP programme, and whom had also been in receipt of some form of psychological therapy within the previous 5 years (and thus were experiencing or had experienced either persistent or recurrent symptoms anxiety and/or depression during that period), was compiled by the mental health worker attached to the project. A total of 16 potential interviewees were approached from this list by the researchers, based upon their gender (in order to achieve a balance of male and female interviewees) and the type of psychological treatment receivedcognitive-behaviour therapy,counselling, guided self-help and/or brief psychological input from a Graduate Mental Health Worker or psychodynamic psychotherapy (or a combination of these)in order to include as wide a range as possible of dierent experiences of talking therapies. Further, interviewees were approached from the remaining clients when two of the original 16 who had initially expressed interest in the study were not willing to participate and one person withdrew permission after the interview, leaving a total of 15 (see Table 1). The interviewees were between the ages of 22 and 62 and all were of White British ethnicity. START gets few ethnic minority

Method
Qualitative in-depth interviews with 15 clients who attended the Time Out AoP service run by START in Salford. Permission to carry out this study was obtained from the University of Manchester Research Ethics Committee.

Setting
The START in Salford project (a charitable organisation that provides arts training and opportunities for people of all ages experiencing mental ill health or social exclusion) is based in Pendleton, Salford, Greater Manchester, and was set up in 1993, where it primarily worked with people with severe mental health problems and psychosis. For the last 5 years, it has been providing a service for people with mild to moderate anxiety and depression, referred (as a form of social prescribing) by their general practitioner (see Box 1)

Recruitment of sample
A list of 28 clients of the project who had recently completed (or almost completed)

Box 1
The Time Out project at START in SALFORD Start Time Out Arts on Prescription service offers up to two sessions weekly, each lasting 2 hours with all materials and equipment provided. Professional artists are there to help as much as members need and will guide them through a series of activities which could include: drawing and painting, pottery, gardening, photography and more. They can try a variety of activities and choose what they like best. Beginners are especially welcome. The project is flexible and can last up to 6 months. Members can explore opportunities in volunteering, leisure interests, employment and education. Or, having enjoyed their 6 months of art sessions they may then decide to join the member-led art group. A mental health worker carries out the initial assessment, and is available for one-to-one counselling when needed. She also runs workshops to promote mental well-being such as relaxation sessions. Additional out-reach art sessions are also organized in local primary care settings, which have also welcomed exhibitions of members work. http://www.startinsalford.org.uk

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Table 1. Demographic characteristics of participants and experiences of talking therapies Interview number 01 02 03 04 05 06 07 09 10 11 12 13 14 15 16 Gender F F F M F F F M M F M M M M F Age 56 46 59 37 22 59 62 39 57 52 40 53 54 45 56 Ethnicity White British White British White British White British White British White British White British White British White British White British White British White British White British White British White British Type of previous treatment Cognitivebehaviour therapy Cognitivebehaviour therapy Cognitivebehaviour therapy Graduate mental health worker* Perinatal service-counselling Graduate mental health worker* Counselling Counselling Graduate mental health worker* Psychodynamic psychotherapy Graduate mental health worker* alcohol team Graduate mental health worker* Cognitive-behaviour therapy, inpatient care Counselling, inpatient care Counselling

*Graduate mental health worker is trained in and provides brief psychological therapy utilising guided self-help.

referrals, which reect the ethnic mix of Salford (predominantly White British). Generally, they were no longer in receipt of any form of psychological therapy although in a minority of cases contact with the psychological therapist was ongoing. All those interviewed described experience of persistent mental health problems, which had only partially, if at all, responded to earlier therapy. All participants provided written consent to be interviewed and every eort was made to ensure that interviewees did not feel coerced in any way to participate.

participants, and how this approach diered from their experience in talking therapies. The interviews lasted between half an hour and an hour and a half and were all audiorecorded and transcribed. The topic guide can be found in Box 2.

Analysis
All participants were sent copies of their interview transcripts for editing and correction so they could be sure that their anonymity had not been compromised in any way. Data was analysed thematically.26 The lead author began coding each interview as it was carried out, with the assistance of MAXQDA2 qualitative software to assist in data handling. Emergent themes were discussed and developing hypotheses explored in subsequent interviews with modication of the interview schedule. All interviews were repeatedly read by both authors. As the project progressed, they met regularly to clarify meaning and to characterize the nature of the experiences that were described by participants, in order to develop a conceptual understanding of emergent themes.

Data collection
Interviews were carried out during the period of May to July 2008 by a medical student researcher trained and supervised by the second author. Interviews were specically concerned with the following topics: the nature of the problems that resulted in referral to the project, views about the project, how the process helped with specic symptoms of anxiety and depression and with the process of recoveryincluding how that was understood by the

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Box 2
1. Nature of problem that resulted in attending the project? (prompts) . Nature of problem . Duration . How aects everyday life 2. Other types of treatment that he/she has received for this? Who from? (prompts) . GP . From Primary Care Mental Health Team . Mental Health Services . Other? What type of treatment? (prompts) . Talking treatment- psychotherapy, counselling, cognitive-behaviour therapy . Medication? . Other? 3. Views about Arts on Prescription? . What have you been doing on programme? . How has this helped- if at all- with symptoms? . How has this helped- if at all- with functioning in everyday life? . How has it helped- if at all- with getting back into work? . What else is involved in recovery? . How else has it helped or denitely not helped? 4. Comparison with previous experience of talking treatments? . How does this approach dier from talking treatment? . What is dierent? What is Arts on Prescription better for? What is talking treatment better for?

Results
The ndings are presented here, in accordance with the key themes that emerged from the analysis. Through an understanding of how participants conceptualized recovery, it was possible to develop an understanding of how attendance at AoP had contributed to this, and then to discern how this experience diered from and/or complimented their previous experience of psychological therapy.

Returning to normality
It was particularly striking how many participants described persistent problems with

social functioning, in terms of an inability to go out and re-engage with everyday life prior to beginning to attend the programme. Many described long-standing diculties with making relationships and coming to terms with loss, particularly through bereavement. The concept of recovery as used in the literature referred to above was not at all familiar to any of the participants in the early interviews, so it was necessary to translate this in subsequent interviews into an equivalent concept; to this end getting better was found to be the simplest explanation of the term. Some participants said that getting better for them meant getting on with life; to stop dwelling on past experiences and to

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70 move forward, enabling them to do things for themselves:

What does getting better mean? Getting back to what we used to be like. Getting back to what we used to do. I mean, when I was [depressed] I didnt watch TV, DVDs, play computer games, read . . . I never did anything, I didnt even date . . . I lost all them and thats all the stu I used to do (participant 4).

Chronic Illness 8(1) enabling them to understand their own thoughts and to change the way they were thinking about things:
It was good for making me focus on things I was doing that were negative, and how to focus on things that were positive and how to maintain a consistent routine as well. I mean just to see where I was going wrong with things, see how I was looking at things in negative ways (participant 2cognitivebehaviour therapy).

For others, it was important to be able to set goals and to be able to reach them, with a sense of moving forward:
looking as though I can go out and I can set goals and I can make them goals . . . me being happy rather than just stuck in a rut (participant 5).

A sense of achieving insight from talking about the past was perceived as an important benet from counselling and more insightoriented therapies:
There was a lot of things that I discovered about myself, masses of things that I discovered about myself which I should have learned when I was younger (participant 11dynamic psychotherapy).

And it was quite simply feeling normal:

I know it sounds daft, but feeling normal . . . its not feeling tired, achy, sad . . . . So feeling normal is getting up in the morning going, Oh, right, yes, new day. Get ready, have a shower, brush your teeth, clean up quick so you can get out (participant 16).

The condentiality of the one-to-one therapeutic relationship was particularly valued:

Its good because youre speaking one to one, and its condential. When theres other people it can be, you know if they are going to say anything outside, or if you bump into them again and they hold it against you and things like that (participant 15counselling, also inpatient care).

Thus, there was a sense of wanting to get back to a life where it was possible to achieve things that had previously been taken for granted, but which was also enjoyable, hopeful and productive. For some, but not all, this also meant being hopeful about returning to work but this was only one aspect of normality and seen as an ultimate rather than a more immediate goal, which was unsurprising given the chronicity of some problems that were described.

However, these alone were not perceived as having being sucient to always help participants to achieve what they considered to be returning to normality.

The contribution of AoP to returning to normality

Three themes emerged from the data in relation to how attending AoP specically contributed to a sense of being able to return to a sense of normality: the therapeutic and eect of absorption in an activity, the specic creative potential of art and the social aspects of attending the programme.

The specific benefits of talking therapy

Most of the participants were positive about the benets they had previously gained from talking therapies. Some particularly like the non-judgemental stance taken by the therapist and the reassurance received from them. Cognitive approaches were helpful for

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something thats sad and depressing. I mean, if I drew you a picture now of a dark castle on a stormy night, what does that tell you about my state of mind? It means Im depressed. If I draw something like a nice, sunny landscape with sheep and cows and that . . . you know, thats basically what it is (participant 4).

Absorption in activity. Most participants

talked about how the arts helped to keep their mind busy. This helped people by keeping them occupied and preventing boredom and by taking their mind o things and getting you doing things. Participating in the classes gave them something to focus on, giving them a way of dealing with distress and helping to stop ruminating on negative thoughts and also to relax:
Well its a few hours where your mind is occupied and absorbed by what youre doing at the Arts centre, so it takes your mind o reality for a while (participant 14).

This feeling might carry over into everyday life:

it takes you away from yourself, youre thinking about something else . . . Theres many a morning after Ive left here when its nished, at 12.30 . . . youre going home with a buzz, that was alright, that felt good, that lasted all day (participant 13).

But for most, it was important in terms of its contribution to a sense of tangible achievement, producing a product of a piece of art and thus resulted in increase in condence and self-esteem. Many participants reported how participation in the arts sessions had increased their condence. Achievement played an important partparticipants often surprised themselves with what they were able to achieve artistically, creating and producing something tangible, which led to increased condence in their own abilities and selfworth.
it started out just doing a little bit of art but the condence spreads to other areas in your life, like I say, doing things, talking to people, not being frightened to have a go. Like I say its aected quite a wide range, I think (participant 16).

In addition to providing distraction to them and allowing relaxation, doing something also gave participants a purpose, a structure for their day and a reason to get up in the morning and leave their home, helping to increase their motivation.
Well its something to get up for, isnt it? Oh yes, Im going to go there and do that today (participant 1). It made me more focused on what I was doing. I started to organise myself better. Create a routine, rather than just drifting through the day (participant 2).

Company and support. The social aspect

of the programme appears to be very important for all of the participants. Almost everyone said they had made friends, and highlighted this as an important part of the programme. A number of these people saw the friends they had made in the classes outside of START. Meeting other people was a very important aspect of the sessions, allowing participants to have someone to talk to and someone to listen to their problems, which was seen as being very helpful. These people might be the mental health worker, others who were experiencing similar problems:
I think being able to come here and speak to people who obviously have probably been

Creativity. Creating art was seen to be therapeutic and relaxing, providing some participants with a way of expressing themselves and reecting their state of mind:
How does it feel to paint a nice picture?Cause Im doing something thats nice and its beautiful. Im not doing

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through the same thing as what Ive been through . . . And I think if you make friends with people and you chat to them and you listen to them and they listen to you, I think youre helping each other along, you know (participant 6).

Chronic Illness 8(1)

that. . . . I just wanted the more social side and nobody to sit there and say You need to think about your past or anything like that. I just wanted more to focus more on what was coming rather than whats been (participant 5perinatal service and counselling).

A number of participants talked about how being in the classes allowed them to be themselves. Sessions provided a non-threatening and non-competitive environment where people felt they were accepted and could relax, something which may not be possible at home. It seemed important, however, that talking was something that participants did not feel obliged to do:
I come in here and if I choose to talk to somebody I can (participant 11). Unless you wanted to speak to her, [mental health worker] she wouldnt dig (participant 12).

Participants commented on how they liked that the programme was practical and constructive providing participants with new interests and skills and aiding them to return to activities. This made them feel that they were doing something worthwhile that was actively helping them move forward in their lives, thus restoring more sense of hope:
I think also with talking therapies, particularly with counsellingyou could talk about the man in the moon if you wanted to . . . its something to get up for, isnt it?. Oh yes, Im going to go there and do that today and Yes I want to nish that painting so Ill do a bit now (participant 1).

So, being able to relax and enjoy life again, a sense of achievement resulting in increased condence and self-esteem, and an opportunity to re-engage with the social world again can be seen as the mediating factors by which attending AoP contributed to a sense of getting back to normal.

Doing not talking: Added value of attending AoP

A recurring theme was the need to build on what had been gained in psychological therapy, by having an opportunity to (and being motivated to) re-engage with life.
My psychologist referred me, because I was stuck in the house really for quite long (participant 15).

Indeed, an important aspect of the programme appeared to be its role as a stepping stone to other activities. Most participants discussed how it had helped them to get back into education, voluntary work or even, for a few, eventually paid work, giving them a greater sense of meaning and direction in their lives. Thus, talking therapy and attending AoP could be seen as complementary, playing a dierent role. Indeed, AoP did not seem to be seen as therapy in quite the same way as psychological treatment. It was perceived as action or doing rather than talking:
discussing and talking about your condition, gives you a bit more understanding. And as I said she [psychologist] came up with suggestions that helped and the Arts on Prescription isnt to do with your illness, its to do with an activity. So as long as youve got the ability to do the activity thats all the tutors are interested in, theyre not interested in what your condition is, whereas youre talking about yourself and your

However, talking therapy did not specically facilitate social interaction or necessarily focus on the future:
it was just like Right sit here and spill your life out, really. Its like; I dont want to do

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condition with psychotherapy . . . theyre both valuable in their own rights, and theres not one better than the other (participant 14).

73 depression which is echoed in the discoveries that our participants described in their achievement in acquiring or developing artistic skills that they had never known they might possess, leading them to imagine a dierent narrative for their future lives. However, it is interesting that several of our participants also emphasized their goal as being a return to employment, echoing the narrower way in which recovery has been viewed in recent policy on psychological therapy.24

Discussion Summary of key findings

For people with common and chronic mental health problems of depression and anxiety, an arts-based therapeutic programme aided the process of recovery, characterized as returning to normality, through enjoying life again, returning to previous activities, setting goals and stopping dwelling on the past. Most of the participants were positive about the benets they had previously gained from talking therapies. However, these alone were insufcient to help them to achieve recovery. Attendance at the AoP Programme was seen as oering some specic opportunities in this regard, mediated by the therapeutic and eect of absorption in an activity, the specic creative potential of art and the social aspects of attending the programme.

The contribution of art to the recovery process. The role of arts in enhancing selfesteem has been recognised in many areas of mental healthcare8: by creating something individuals can boost their own self-esteem, which may in turn help to improve their mood. Additionally, being able to express ones state of feeling in paintings may not only be calming and relaxing but also help an individual to understand themselves and their state of minda nding also supported by previous research in this eld.6,10 Our themes are very similar to those of Spandler and her colleagues11 and those benets described for other evaluations of AoP programmes.15 The perceived importance of social interaction also raises the question of whether it was the art classes that participants were involved in, the engagement with a class regardless of the art content or just the opportunity to have time out from their everyday lives and meeting with others in a similar situation that were the primary factors in bringing about a positive experience. Could this have been achieved in a day centre environment without specic engagement in creative work? There are indications that the art played an important role in terms of supporting people. Firstly, the importance of the end products that were produced in the sessions, the visible art works, was emphasized in terms of the feelings of pride in their achievementswhich is also

Relevance to the published literature The meaning of recovery in this context. As we discussed earlier, the meaning of recovery remains unclear in relation to people with common mental health problems given that the literature has thus far focused on the experience of people with more chronic and severe mental health problems.20,21 Our ndings clearly echo those of Ridge and Ziebland22 who found that some of the people with depression who they interviewed wanted to feel normal or human again and enjoy life . . . . They also noted, however, that others wanted more than this, and grappled with narratives about their longer term prognosis. They describe a process of insight into unknown qualities of self that potentially lie beyond

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74 supported by a recent study of the meaning of art to people who use mental health services.10 Learning new skills and the achievement of producing something appeared to be important steps towards rebuilding condence and belief in participants own abilities.

Chronic Illness 8(1) as complementary, and for many, AoP did not seem to be seen as therapy in quite the same way as psychological treatment. There was no relationship with a specic therapist. The emphasis was on activity and enjoyment, with opportunity for improving social interaction. It was perceived quite simply as action or doing rather than talking.

The added value of an arts programme.

Our study adds to the published literature by delineating the specic ways in which an AoP can add value by aiding recovery for people with chronic common mental health problems who have previously experienced psychological therapies. This has not, to our knowledge, been previously explored and was not considered by Spandler et al.11 Previous research specically evaluating AoP programmes15 has also not considered this question, yet, as we have noted earlier, it seems important to ask questions about the specic role of such programmes in the light of the current emphasis on targeting psychological therapy for funding through the Improving Access to Psychological Therapies initiative27 and the changing policy context in the United Kingdom, with the potential risk to funding for both Arts and Social Prescribing initiatives.15,28 Many participants were continuing to struggle with social isolation and exclusion. They described a sense of building on what had been gained in psychological therapy, by having an opportunity to (and being motivated to) re-engage with life. Part of the social aspect of attending the programme was having someone to talk tobut this was very much under the control of the participant with no sense of any obligation to talk, either to fellow attendees or the mental health worker. Making friends and creating a social network is clearly impossible to directly achieve from a one-to-one intervention (although it may be a goal of the therapy)and is not generally encouraged in group psychotherapy. Talking therapy and attending AoP could be seen

Limitations of the study

Due to time constraints, the sample size was relatively small. It was only possible to interview participants who found the project helpful in some waypeople who do not nd the AoP useful did not continue to attend the sessions and could therefore not be interviewed. The sample from which the interviewees were selected was drawn up by the project mental health worker and those people who were approached and were willing to talk may have particularly positive experiences. This may have led to an underrepresentation of the negative aspects of AoP. We were also unable to specically report in detail here on other treatment received as this was not the focus of our study, but it does seem likely from our interviews that additional treatments such as medication also played a part, for some participants, in achieving recovery. It is also possible that people who did not attend the arts programme had recovered as a result of talking therapy alone, such that they did not need to attend an additional treatment programme such as this one; but for those who attended there did appear to be an added benet in terms of recovery. Completing 15 interviews was enough to reach a saturation of themes in relation to the arts programme but not for the very varied experiences of talking therapy (which we did not report in detail here) as there are many dierent types of talking treatments available.

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Conclusion
For some people who experience persistent or relapsing common mental health problems, participation in an arts-based programme may provide added value in aiding recovery in ways not facilitated by talking therapies alone. Funding
This research received no specic grant from any funding agency in the public, commercial, or notfor-prot sectors.

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