Abstract
Introduction
The attitude of the general population towards mental illness has been considered to be a crucial barrier for individuals suffering from mental illness, in that it may influence their ability to recover and live within a community. In view of this, the World Psychiatric Association, for instance, has been implementing a major international programme aimed at reducing the stigma around and discrimination against schizophrenia (Sartorius, 1997; Thompson et al., 2002).
It has recently been suggested that art created by people with mental illness holds great potential in terms of reducing the stigma of and inducing favourable attitudes towards mental illness among the general public, and enhancing community relationships (Argyle and Bolton, 2005; Lamb, 2009; Lejsted and Nielsen, 2006; Masuda, 2001; Twardzicki, 2008), although the relationship between creativity and mental illness is still unclear (see the review by Waddell, 1998). There has been longstanding interest in the therapeutic role the creative arts may play in helping people adapt to or recover from mental illness (Crawford and Patterson, 2007; Green et al., 1987; Hacking et al., 2006, 2008; Röhricht and Priebe, 2006; Spandler et al., 2007; also see the reviews by Ruddy and Dent-Brown, 2007; Ruddy and Milnes, 2005). Although this process of therapy, rather than the creative works themselves, is the main focus, some corporations and non-profit groups, and other organizations have recently supported projects that raise the visibility of such works and thereby help combat the stigma of mental illness (see the review by Lamb, 2009). For example, the Cunningham Dax Collection (Shrimpton and Hurworth, 2008), based in Victoria, Australia, and BASTA – The Alliance for Mentally Ill People (previously called Bavarian Anti-Stigma Action, see the review by Rüsch et al., 2005), based in Munich, are active in various fields, and organise exhibitions of art by people with mental illness and other cultural activities. Thus, although their activities might have a different orientation, efforts to utilize the art created by people with mental illness to raise the mental health awareness of the public, which are common to both organizations, appear to be fruitful, especially in terms of favourably influencing the attitude of the general public towards them.
However, to the authors’ knowledge, barring two pioneering studies (Shrimpton and Hurworth, 2008; Twardzicki, 2008), there is no evidence to establish the effects of creative works like paintings and performing arts by people with mental illness on the attitudes of the general public towards them. These two studies have involved the analysis of open-questioned questionnaires (i.e. textual data) and implied the effectiveness of these arts on the general public in changing attitudes towards them favourably. However, they have also argued about the subjective interpretation of the content of the open-ended descriptions and have highlighted specific comments as unique or typical of themes.
Furthermore, although some studies have been conducted to assess mental health literacy among the Japanese public (Takeshima et al., 2007), negative attitudes towards people suffering from mental illness have been common among them as well as other populations (e.g., Griffiths et al., 2006). On the other hand, as Crawford and Patterson (2007) argued, the tradition that creative activities and works by people with mental illness have been focused upon as a therapeutic process to express their thoughts, emotions and ideas symbolically is considered to be especially strong in the Far East, including Japan (Spaniol, 2001). Also, there have recently been a number of exhibitions that have displayed artwork created by people suffering from mental illness in Japan. However, no study has examined the attitudes of the general public towards such artwork in Japan.
Therefore, as a preliminary study with a view to examine whether the artwork created by people with mental illness can change the attitude of the general public towards such people, the current study examines the attitudes of the Japanese public towards such artwork after visiting exhibitions showcasing them using textual data as well as a brief closed-ended question. The current study received ethical approval from the National Centre of Neurology and Psychiatry in Tokyo, Japan.
Methods
Participants and procedures
The study involved 951 Japanese visitors attending an art exhibition held at a gallery in Kyoto, Japan. The exhibition was promoted by distributing several hundred flyers, publishing articles in the local newspaper and through TV interviews. The exhibition introduced a total of 107 original creations by Japanese and Australians suffering from mental illness (Cunningham Dax Collection, 2009), including work on paper and canvas as well as several pieces of craftwork. In addition, professional artists had structurally arranged the exhibits in the gallery to enable the visitors to observe the change in expression from several decades ago to the present, according to the characteristics of the artwork (e.g. abstract or non-abstract). These works were displayed from 4 to 22 February 2009.
During the exhibition period, visitors were asked to voluntarily complete a short questionnaire survey on their attitude towards such works. Of the 951 visitors, 277 completed the questionnaire (described below), and 52 returned it without completion. To maintain anonymity, only the participants’ gender and age were recorded (seven categories: 10s, 20s, 30s, 40s, 50s, 60s, and over 70). The participants comprised 126 women and 151 men. Among these, 7 participants (2.5%) belonged to the 10s category, 59 (21.3%) to the 20s, 67 (24.2%) to the 30s, 46 (16.6%) to the 40s, 50 (18.1%) to the 50s, 23 (8.3%) to the 60s, and 25 (9.0%) to the over 70.
Questionnaire
A short questionnaire was designed specifically for this study. The participants first answered a simple closed-ended question (Question A: ‘How do you feel about the exhibition?’), which measured their appreciation for the displayed works on a four-point scale (1 = ‘not interested’, 2 = ‘slightly interested’, 3 = ‘fairly interested’, 4 = ‘very interested’). They were then asked an open-ended question (Question B), that is, to freely describe what they personally found interesting about the exhibition. Since Question B could not be made mandatory, fewer participants answered it (n = 222).
Data analysis
For Question A, a χ 2 test was conducted on the data obtained using SPSS version 15.0 for Windows, with a significance level of p < 0.05.
For Question B, word frequency analysis (e.g. Fujigaki and Nagata, 1998; Kreis and Gorman, 1997; Yamauchi et al., in press) was used to obtain characteristic and meaningful words that were considered to represent the visitors’ attitudes towards the arts from textual data. In other words, as compared to previous studies using textual data on the attitudes of the general public towards the artwork by people with mental illness (e.g. Shrimpton and Hurworth, 2008), the current study examined the attitudes using a more empirical method, namely, calculating the frequencies of occurrences of characteristic words.
First, an electronic database of the questionnaire was created. The database was protected by passwords that were known only by the first author. Second, words were extracted using SPSS Text Analysis for Surveys version 3.0 for Windows. Third, the words that were considered to represent the visitors’ attitudes towards the art were identified by manual inspection. The information that could identify specific individuals and artworks was eliminated. Irrelevant words such as conjunctions were also deleted, retaining only essential words that represented the participants’ attitudes towards the art. Furthermore, synonymous words were not counted separately. The data was analysed twice by the first author who referred to the original textual database and discussed the material with the sixth author. Finally, for the remaining words, the total frequency of the appearance of each word was counted. Subsequently, to present an overview of the characteristics of the most frequently identified words that were considered to represent visitors’ attitudes towards the artwork, the ten most frequently used words for Question B were listed.
Results
With regard to Question A, 146 participants (52.7%) felt ‘very interested’, 94 (33.9%) ‘fairly interested’, 34 (12.3%) ‘slightly interested’, and only 3 (1.1%) felt ‘not interested’. The χ 2 test revealed that the strongly or fairly impressed respondents were much higher in number than those who were unimpressed by the artwork at a significance level of p < 0.001. In addition, whereas Kruskal-Wallis test revealed no differences between the age groups with regard to the central tendency of the ratings for Question A, Mann-Whitney test revealed that the ratings for women were significantly higher than those for men (z = 2.50, p < 0.05).
With regard to Question B, word frequency analysis identified a total of 1,150 words. The list of the 10 most frequently written words that were considered to represent the visitors’ attitudes towards the artwork are presented in Table 1. Although some words listed had neutral nuances, the frequencies of the words with fairly positive nuances, like ‘good’, ‘colourful’, ‘powerful’ and ‘great’, were high. By contrast, words that were considered to have negative nuances did not appear frequently.
Frequencies of the words extracted from visitors’ descriptions of their attitudes towards the creative works by people with mental illness (N = 222)
Discussion
Creative activities and works by people suffering from mental illness have been focused upon as a therapeutic process to express their thoughts and emotions. However, results of the current study indicate that approximately 87% of the participants were strongly or fairly impressed with the arts created by the people with mental illness, and only 1% were unimpressed. Moreover, the word frequency analysis recurrently identified some words with positive nuances, such as ‘good’, ‘powerful’ and ‘great’, suggesting generally positive and empathetic reactions towards the artworks displayed and an acknowledgement of their aesthetic value as well as the artists’ talent. For instance, 15 participants described the work as ‘understandable’, which seemed to indicate their sympathy towards people with mental illness. Therefore, although it is possible that both the quality and number of works displayed and the differences in the impact of each artwork can influence visitors’ attitudes, projects like the art exhibition in the present study could help create a favourable attitude towards the art and people with mental illness. However, the attitudes of the visitors towards the artwork may be determined by how they are presented (Koh and Shrimpton, manuscript in preparation). Thus, the findings of the current study may reflect the nature of the exhibition (i.e. structural and characteristic display of the exhibits produced over the past several decades); this might provide the visitors with opportunities to appreciate the artworks in depth. Also, the role of art in Japanese culture may be a reason why consumer art exhibition appears to be a useful way of reaching the general public in the current study.
The findings of this cross-sectional study are preliminary. The assessment of the attitudes was fairly rudimentary, and their ratings were not well established and were carried out at a certain point of time immediately after the visit to the exhibition; thus, the questionnaire used in the current study does not reflect the attitude change of the visitors. Furthermore, as Pinfold et al. (2003) argued, owing to the nature of textual analysis, the attitudes of a study’s participants expressed in written form may not translate into any enduring behavioural attitudes. Also, with regard to the validity of a textual analysis, it is possible that the procedure of this analysis can be affected by an observational bias, although in the current study, the words were identified with reference to the original textual data and its context.
Limitations
The current study has some limitations with regard to the interpretation of results. First, the effects of potential confounding factors, such as previous visits to exhibitions and previous contact with people with mental illness, were not controlled for. There have recently been a number of exhibitions that presented the creative arts by people with mental illness in Japan. However, unpublished data indicated that, out of 43 visitors attending the exhibition where the current study was being conducted, 27 (65.1%) had never visited any other exhibition or similar activities. Second, the response rate is low and the findings of the current study might be affected by selection bias. Finally, participation in the current study was restricted to Japanese people; therefore, the applicability of the findings to a population with a different cultural background should be considered. For instance, it is possible that in other populations, an approach using artwork may be associated with the public showing more favourable attitudes towards people with mental illness than the Japanese public.
Conclusion
Although the current study poses some limitations, to the authors’ knowledge, this is the first study examining the attitude of the Japanese public towards the visual arts created by people with mental illness by using textual data and conducting word frequency analysis. The findings of this study suggest that the Japanese public generally have positive and empathetic attitudes towards artwork by people with mental illness. Future studies should use a more sophisticated assessment tool, namely a questionnaire directly evaluating attitudes towards people with mental health problems, and a procedure with both pre- and post-project assessment in order to test the effects of consumer arts on attitude changes in the general public and to examine whether these attitude changes can be sustained for months or years.
Footnotes
Acknowledgements
The authors would like to thank Nobuo Oda, Ken-ichi Higashino, and the staff at the Department of Mental Health Policy and Evaluation, National Institute of Mental Health, National Centre of Neurology and Psychiatry for their help in data collection.