Keywords

1 Context/Introduction

The right to participate in cultural life and enjoy the arts is enshrined in Article 27 of the 1948, Universal Declaration of Human Rights [1]. In a contemporary context, there is an appreciation that the arts and creative activities can support the development and maintenance of good mental health across the life course. Policies in each of the devolved nations recognise the positive role of culture and the arts in the lives of its citizens and the part that it plays in supporting vibrant and creative communities. More recently, arts and creativity as non-pharmacological interventions in the treatment and management of mental health conditions has received considerable attention. The Department of Health and Arts Council England [2], for example, has highlighted that the arts have an important role to play in the delivery of health care, in promoting social wellbeing and in delivering demonstrable benefits across the life course against a wide range of health priorities. Arguably, older people have been at the vanguard of community arts and crafts through their leadership and participation in the many voluntary organisations, such as the Women’s Institute (WI), which exist at least in part, to support and encourage such activities. However, the involvement of older people in participatory arts in the form of community projects or as interventions in the support, management and treatment of mental or physical health needs has traditionally been less visible [3].

This chapter begins by defining participatory arts and other kinds of arts activity. It briefly considers the role of the arts and creativity in the treatment of mental health conditions with a focus on depression in later life. The chapter then takes a broader perspective and reviews some of the evidence which illustrate the ways in which participatory arts support more generally the promotion of mental health and contribute to developments such as age-friendly cities and places.

2 Defining Terms

Taking part in the arts incorporates a diverse range of activities informed by different theoretical perspectives and with different ambitions in respect of their purpose, process, degrees of participation and outcomes. The Mental Health Foundation [4] identifies various forms of arts engagement which include audience participation, ‘passive’ engagement (e.g. listening to music), doing art and craft through personal hobbies, the arts as therapy and participatory arts. Arts as therapy (e.g. art therapy, music therapy, drama therapy) have been defined as expressive or creative therapy that introduces action to psychotherapy [5]. The British Association of Art Therapy defines its discipline as ‘a form of psychotherapy that uses art media as its primary mode of expression and communication. Within this context, art is not used as a diagnostic tool but as a medium to address emotional issues which may be confusing and distressing [6].

Participatory arts are distinct from other forms of artistic endeavour as they are underpinned by a belief in the right to access culture and the arts, to create environments which give voice and the means of expression to people who often have less power or who are recognised as marginalised people [3]. Participatory art involves people in collaboration with professional artists representing diverse forms of expression, to develop artistic work, which reflects, represents or relates in some way, to participant experience [4].

Participatory art is defined as an emergent research field which is not yet in a position to provide scientific evaluation which can make confident comparisons between art forms or draw conclusions about impact from a number of studies [4, 7]. Nevertheless, there is a growing and often compelling body of literature which supports the view that older people benefit from arts engagement, suggesting positive impact on health and wellbeing and value in supporting the promotion of good mental health and in the management and treatment of a wide range of health contexts.

3 Arts and Creative Interventions with Older People with Depression

It is increasingly accepted that arts engagement with older people can impact positively on health, improve health outcomes, support people to cope with the challenges associated with poor health and provide a means of developing protective resources to combat the risk of mental ill health [8–11]. There is evidence to suggest that older people are more likely to prefer to participate in psychosocial interventions than to use medication to treat depression [4] and some of the evaluations of participatory arts projects appear to corroborate this view by presenting evidence of higher rates of participation amongst older people when compared with participation in more ‘traditional’ interventions [3, 7]. There is too the potential for arts-based interventions to offer opportunities to older people who, across the course of their lives, have experienced inequality of opportunity and who may, as a result, be at particular risk of poor mental health and with limited opportunities to access culture and the arts [7, 12].

Reminiscence with older people has had a lengthy and significant presence in practice with older people. Organisations such as ‘Age Exchange’ started by Pam Schweitzer MBE in 1983 developed ground-breaking participatory theatre linked with reminiscence practice with older people and across generations. Reminiscence has a significant place in therapeutic practice with older people with physical and mental health needs, including people living with depression. A number of studies have concluded that reminiscence can lead to constructive outcomes in the management and treatment of depression evidenced by improvement in symptoms of depression, an increase in wellbeing and growth in confidence [13–15]. Gibson [16], who has researched and written extensively on the use of reminiscence and life story work with older people, cautiously concluded that a combination of talking, reflection, life review and production of a tangible record can have constructive outcomes for older people with depression. At the time of writing, there has not been a systematic review utilising Cochrane standards to assess the impact of reminiscence as an intervention for older people with depression. The waters are further muddied by the potential to conflate different kinds of reminiscence – for example, reminiscence work, reminiscence therapy, life review, life history or life story work – and for reminiscence to become a ‘casual’ activity or form of distraction in collective settings which Organ [3] argues reduces reminiscence to an end in itself and another form of ‘care’.

The potential health benefit of older people with mental health needs participating in musical activity has also received significant attention. Although there has been a growth of research reporting on the impact of participation in music, they are of variable quality evidenced by a variety of approaches in operationalising concepts, problematic sample sizes and research design weaknesses [17]. A study to systematically identify and critically appraise existing published research on singing, wellbeing and health [18] yielded analysis of 35 articles which, methodological weaknesses notwithstanding, evidenced benefit for older participants with long-standing psychological distress, including depression. Research focusing on the effects of community choir membership also suggests important benefits for people with long-term mental health needs [19, 20]. Case studies have provided a rich source of qualitative testimony from older participants highlighting improvement in the symptoms of depression and are perceived to give a range of other benefits such as increased social confidence, self-esteem, developing social networks and friendships [21]. The authors reason that ‘people with mental health issues would not continue attending singing groups if they didn’t derive substantial benefits from the experience’. Recently, a pilot randomised control trial compared group singing with usual activities amongst 258 participants aged 60 and over and followed participants up at 3 and 6 months [22]. Findings included a significant positive effect on alleviating loneliness and isolation and statistically significant improvement on ratings of anxiety and depression. Coulton et al. [22] conclude that community singing can have a significantly positive impact for older people living with mental health problems, including depression.

Similar observations about the quality of research in assessing impact of participatory arts are made for other art forms. A Cochrane review of dance movement therapy, for example [23], found that due to the low number of studies, combined with quality of evidence, it was not possible to draw any firm conclusions about the impact of the use of this art form. Moreover, it was not possible to compare dance with other treatments and interventions. Taking methodological weaknesses into consideration, a wealth of qualitative and case study evidence exists which supports the benefit of dance and movement for older people with impact upon physical strength, balance and confidence and emotional wellbeing [24]. In a review of exemplary arts practice, Organ [3] cites the Akademi group which offers dance with older women from a Bangladeshi community in London where opportunities for social participation are circumscribed by gender and cultural norms. Organ comments ‘The very act of coming to the class is crossing borders of participation that they will have seldom transgressed’ [3]. In posing the question ‘is this a good thing?’, she observes that attendance and participation exceeds groups such as physiotherapy and provides considerable emotional benefit to its members.

Arts on prescription schemes provide arts and creative activities for participants who are often experiencing mental health problems or the difficulties associated with social isolation and loneliness. The ‘Good Times’ participatory arts project with Dulwich Picture Gallery was based on GP practices connecting older people who were at risk of or experiencing mental health problems, including depression. Based on a retrospective qualitative evaluation of the project, Harper and Hamblin [7] commented that ‘prescription for art’ led to positive evaluations from professional and family carers who saw a reduction in depressive symptoms from individual older people who took part. Qualitative evaluations from older participants highlighted many social, emotional and psychological benefits to participation. Other projects such as the ‘Arts in Mind’ project (www.nottinghamshire.gov.uk/artsonprescriptioncasestudy.pdf) have demonstrated similar findings [25].

3.1 Social Prescribing and Participatory Arts: Art Lift

In recognition that 30 % of GP consultations are about mental health problems, the ‘Art Lift’ project was developed as a form of social prescribing for people with identified mental health needs or who were at risk of developing mental health needs. Participants took part in 10-week courses with a variety of artists representing different art forms took place over the period 2009/2011 and included 202 participants in the evaluation. Measures included the Warwick-Edinburgh Mental Well-being Scale (WEMWBS), artists’ subjective ratings of participant engagement and the Index of Multiple Deprivation. Both the 7- and 14-item WEMWBS demonstrated statistically significant improvement [7-item (t = −6.049, d.f. = 83, P < 0.001, two tailed) and 14-item (t = −6.961, d.f = 83, P < 0.001, two tailed) scaled]. The evaluation reported high levels of participation in Art Life when compared to other types of referral to schemes such as exercise. The oldest members of the sample had the best participation and completion rates [26].

Overall, the study concluded that the project offered a relevant and effective intervention for people with mental health needs and who were at risk of developing mental health problems [26].

The researchers suggested further longitudinal research in order to assess longer-term impact on mental health. Further research examining cost-effectiveness against uptake, adherence and outcome would also be of benefit [26].

4 Participatory Arts, Ageing and Mental Health Promotion

The World Health Organisation [27] defines mental health as a ‘state of well being in which the individual realises his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his/her community’. Thus good mental health has an intrinsic value as well as contributing to overall health, personal capital, wellbeing and functioning. It is recognised that older people may face particular barriers including isolation, disability and ageism which are of themselves debilitating but also act as barriers to participating in social and creative activities that protect and support good mental health and wellbeing. The value of arts in respect of ageing has tended to focus on health benefits derived from participation for those older people who are using health and social care services [3]. But the importance of all people across the life course having the right to access to art and culture and the general benefit to good mental and physical health, social capital and the sheer enjoyment of being creative must not be overlooked.

A systematic evidence review of participatory art projects for people aged 60 and over identified a number of benefits which, despite the limitations of evidence in this area, are argued to be sufficiently compelling to suggest significant impact on mental and physical wellbeing [4]. Specifically, benefits to the individual highlighted in the review were:

  • Increased confidence and self-esteem

  • Feelings of mastery and accomplishment

  • Positive aspects to identity

  • Counterbalancing challenges to wellbeing associated with experiences of loss and change

  • Increased levels of daily activity

Research exploring various aspects of creativity and ageing has highlighted similar benefit for older citizens across many art forms and means of creative expression.

4.1 Participatory Arts Research Projects Funded by the New Dynamics of Ageing Research Programme

4.1.1 Example One

The ‘Ages and Stages’ project included as one of its research aims, addressing the relationship between older people’s involvement in theatre and drama and continued social engagement in later life. The research project demonstrated impact for older participants in enhanced self-esteem and self-confidence through participation in theatre and drama and crucially challenged a stereotype that creativity declines with age [28].

4.1.2 Example Two

The ‘Music for Life’ research project aimed to explore the ways in which participation in creative music making could enhance the lives of older people and to explore the potential impact on wellbeing [29].

Results found that participants experienced enhanced wellbeing and quality of life as well as benefitting from acquiring new skills and enjoying social and community activities and the relationships that developed from those activities. In terms of perceived emotional health benefits, findings included improved mental health for participants experiencing mental health problems and emotional distress (e.g. associated with loss and bereavement) and that participation in music making may act as a protective factor against depression [29].

4.1.3 Example Three

The ‘Look at Me’ research project focused on visual representations of ageing women and included in its aims enabling women from different settings to create their own images of ageing supported by participatory visual methods. The research findings highlighted that the participatory process gave women a sense of solidarity and ownership of the process. Crucially the research challenged stereotypes of ageing women and impacted on participant wellbeing [30].

The importance of accessing culture and the arts as part of social participation is highlighted in the World Health Organisation’s Age-Friendly Cities movement which aims to promote active ageing in cities and to optimise opportunities for health, participation and security [31]. Removing barriers to the social participation of older people in the life of the city is vital to the wellbeing of older citizens and to the development of the city [32].

4.2 Manchester, UK

Manchester was the first city in the UK to become a member of the WHO network of age-friendly cities after establishing a ‘valuing older people’ programme to improve services and opportunities for older residents in Manchester. Since 2007 a key activity has been to work with older citizens and cultural providers to make sure that Manchester’s cultural offer is available to older people in the city and to address or remove the barriers that they may face [32].

A network of over 100 voluntary cultural champions act as ambassadors to:

  • Inform older people’s networks and communities within Manchester about the variety of cultural events taking place in the city throughout the year

  • Encourage older people’s networks to attend and try out a variety of cultural events taking place in the city throughout the year [32]

In partnership with a range of arts and cultural providers in the city, a comprehensive cultural offer is available to older citizens. For example:

  • Theatre and performance

    • Developmental projects

    • Intergenerational performance

  • Music

    • Club nights

    • Dance workshops

    • Live music

    • The development of the Golden Voices Choir

    • Outreach work ‘Musicians on Call’

  • Museums and galleries

    • Arts led workshops

    • Adult learning programmes

    • Living history performance

    • Outreach work [32]

5 Discussion

This chapter has briefly reviewed some of the many developments currently taking place in the field of participatory arts with older people. The potential for the arts to impact positively on alleviating the distress associated with mental health problems, emotional distress and isolation is clearly very significant. Taking a wider perspective, arts and culture has always had a vitally important role to play in promoting mental health across the life course and contributing to developing and sustaining vibrant and creative communities. And of course, enjoying the arts or immersing oneself in creative activity, however defined, is important in and of itself. Organ [3] argues that the joy, personal accomplishment, challenge and benefit that individual people derive from doing art or creative activity means that we must be critical of a direction of travel which places an emphasis on health outcomes as the main justification for arts activity. Examples such as the cultural offer in Manchester show how barriers to older peoples’ participation in the arts may be reduced. Such developments add value and benefit to the lives of older citizens and contribute to the development of inclusive practice in supporting older people to participate in the city.

The place of participatory arts in ameliorating the experience of older people living with depression or other mental health problems remains an important element of participatory arts. In order to consider the kinds of arts intervention that work most effectively with particular populations, there is a need to continue to develop research which addresses some of the methodological challenges that have hitherto affected the confidence with which impact can be claimed. Nevertheless, qualitative evidence in the form of the voice of older people and their lived experience is and should remain a central part of evaluation. This is especially important as older people with the most complex needs are also most likely to experience significant marginalisation. This is important not only in order to properly involve older people but also ensure that the kinds of opportunities that are offered are acceptable and appropriate for those people and status as adults. As Organ comments, ‘activities that are reminiscent of playschool, sing-alongs, waving parachutes, visiting clowns, making pictures out of pasta are not associated with a sense of agency in the world. For adults fearing a loss of dignity, uncertainty with strangers, lacking a sense of autonomy, child-like activities can feel very uncomfortable, patronising and plain weird. They can be awkward and uncomfortable reminders of our diminished status and threatened dignity’ [3]. Participating in the arts and creativity should provide every opportunity to reaffirm and validate participants’ status as adults regardless of the complexity of their needs.

6 Questions for Reflection

  • How could social prescribing support the work of primary care in their practice with older people?

  • How do projects such as participatory arts fit with the GP commitment to biopsychosocial care and support for individual patients and local communities?

  • What role should primary care have in supporting wider developments in mental health promotion such as supporting the development of age-friendly communities?