Imaging Journeys of Recovery and Learning: A Participatory Arts-Based Inquiry

Abstract

The relationship between processes of mental health recovery and lifelong learning is an area of increasing international interest. Experiences of transformation, positive effects on self-esteem, self-insight, and empowerment have been identified regarding both endeavors. Recognition of these benefits has stimulated collaborative development of educational programs in personal development, self-efficacy, and recovery principles. The importance of evaluating this educational provision has been emphasized; however, there has been little detailed exploration of students’ experiences and perceptions of recovery and learning in the context of recovery education programs. In this article, we present a participatory arts-based inquiry with 14 women, including mental health service users, who undertook a recovery training program to support their roles as mental health support workers in Ireland. Participatory visual analysis revealed three recurring themes; the interrelatedness of learning and recovery journeys, knowledge as a source of stability and rescue and the need for resilience in learning and recovery.

Keywords

Recovery learning participatory arts-based inquiry narrative co-production lifelong learning knowledge training education lived experience health users’ experiences recovery college experiential mental health and illness mental health support workers mental health nursing resilience interdisciplinary team qualitative Ireland

Introduction

In recent years, an increasing commitment to the principles of recovery in mental health practice, education, and research has been observed internationally (Happell, 2008; Moran & Russo-Netzer, 2015; Perkins, Repper, Rinaldi, & Brown, 2012; Ramon, Healy, & Renouf, 2007). The concept of mental health recovery has been variously explained and understood. Warner (2004) advances two definitions: first, a long-standing characterization, predicated on the biomedical knowledge and expertise of psychiatric service providers of successful treatment of symptoms. This construction foregrounds clinical or complete recovery and is embedded in customary biomedical knowledge and theories of causation and treatment. Here, mental disorder is considered as brain disease/illness amenable to pharmacological intervention, which resolves the biological abnormality. This model and its attendant epistemology has shaped and privileged Western knowledge and treatment approaches regarding mental disorder for the past 50 years. However, biomedical definitions and constructions of mental distress have been challenged in recent years as being reductionist and exclusive of psychosocial influences such as race, culture, gender, and living environment (Deacon, 2013; Lafrance & McKenzie-Mohr, 2013).

The second, more phenomenologically informed definition of mental health recovery offered by Warner (2004) regards mental health recovery as a unique, experiential journey which does not necessarily result in reversion to a pre “illness” state. Similarly, Davidson and Roe (2007, p. 460) claim that “like mental illness itself, the notion of recovery represents a multidimensional set of phenomena.” This individualized and process based conceptualization has its origins in survivor/recovery movements in the United States in the 1980s and the 1990s in the United Kingdom (Anthony, 1993; Chamberlin, 1988; Deegan, 1988; Young & Ensing, 1999). Mental health recovery movements challenged existing biomedical formulations of mental disorder and recovery; placing increased value on experiential knowledge (Boardman, 2017). Experiential knowledge occurs when personal lived experiences are translated into insights that enable the person to cope more effectively with illness or distress (Blume, 2017). Blume (2017, p. 97) further asserts that when experiential knowledge of mental distress, psychiatric treatment, and effective recovery strategies is shared through personal accounts and narratives, “the communal body of knowledge exceeds the boundaries of individual experiences.” Thus, experiential knowledge is foundational to the ethos and approaches of the mental health recovery movement. Blume (2017, p. 94) posits that experiential knowledge differs from medical knowledge in that “it is holistic and total, rather than being divided into specialized segments as medical knowledge is.”

The work of the recovery movement in facilitating pluralistic and participatory approaches to knowledge generation and care provision has challenged taken for granted, homogeneous knowledge constructions and theories concerning mental distress and recovery trajectories (Davidson, 2016; Ramon et al., 2007). These diverse perspectives concerning recovery have subsequently influenced mental health policy, practice, and education. For example, theories concerning lifelong learning have been useful for conceptualizing mental health recovery. The relationships between processes of lifelong learning and mental health recovery have been explored, particularly in terms of transformative experiential learning, development of self-esteem, self-insight, and empowerment (Hammond, 2004). Griffiths and Ryan (2008, p. 51) go further in regarding the experience of mental health problems and recovery as embedded in lifelong learning in that “human experience involves constant, simultaneous engagement with various forms of recovery and ongoing learning.” Internationally, researchers and policy makers advocate using formal learning processes and frameworks to promote mental health recovery as well as increasing the inclusion of those with mental health issues in mainstream formal lifelong learning provision (Ramon, Griffiths, Nieminen, Pedersen, & Dawson, 2011).

Recognition of these often-parallel journeys of recovery and learning has stimulated the collaborative development of educational and training programs in personal development, self-efficacy, and recovery principles. These programs attract participants from a range of contexts including service users/mental health practitioners who share common interests and knowledge concerning mental health recovery. The underpinning philosophy and practice of many recovery-oriented programs is that of coproduction, defined by Slay and Stephens (2013, p. 3) as “a relationship where professionals and citizens share power to deliver support together, recognizing that both partners have vital contributions to make in order to improve quality of life for people and communities.” Examples of recovery programs include recovery colleges involving interdisciplinary/service user participation using an educational paradigm (McGregor, Repper, & Brown, 2014; Zabel, Donegan, Lawrence, & French, 2016), recovery-orientated employment apprenticeships (Sapani, 2015), and Wellness Recovery Action Plan programs (Higgins et al., 2012).

Study Background

Mental Health policy and service provision in Ireland, as in other countries, have been engaging for several years with the imperatives of embedding recovery informed frameworks and practices into mental health care and education. Accordingly, a collaborative group of service providers, service users and training organizations in Dublin, Ireland, developed an educational program in Mental Health Studies and Recovery, based on the principles of coproduction defined by Slay and Stephens (2013) and focusing on various aspects of mental health, treatment/support approaches, recovery, and personal development. The program was designed and delivered by the collaborative group and was based on the lived experiences of mental health practitioners and service users. Working with this model of coproduction and codelivery served to contextualize recovery concepts in educational practice. Davidson (2005) asserts that mixed training groups comprising service users, carers, and statutory and voluntary staff encourage participation and shared learning and have the potential to break down taken for granted, stereotypical views about the nature and prevalence of mental health problems and recovery. Applicants to the Recovery program were not required to specify whether they were current/previous mental service users, and statutory or voluntary workers. In addition, the program philosophy of coproduction prioritized a common interest in recovery, working organically with the range of experiences and perceptions that emerged rather than segregating applicants into categories based on roles or experiences. Three people disclosed self-experience of mental health difficulties; however, this rate may have been higher when possible nondisclosure was taken into account. Thus, the class cohort consisted of a mix of students with a wide range of experiences, abilities/needs, knowledge, and perspectives.

The importance of evaluating recovery education and training initiatives has been emphasized in the literature (Newman-Taylor, Stone, Valentine, Hooks, & Sault, 2016) and the educational standards and provision of this program were evaluated using traditional mixed methodology. However, Higgins et al. (2012) and Zabel et al. (2016) highlight the lack of research focus regarding the lived learning experiences of recovery education approaches from student participant perspectives. Similarly, Jacobs, Munro, Taylor, and Griffiths (2017, p. 59) urge researchers to “conduct studies among consumers, carers and service users to explore their own personal meaning and perspectives of the concept of mental health recovery.” Therefore, this article concerns a participatory research study, conducted with 14 women of varying ages and backgrounds, including current/former mental health service users, who undertook the recovery program described above to support their roles as mental health support workers in community mental health services in Ireland. The study was carried out in the context of the overall recovery program evaluation. Narrative and participatory arts-based inquiry methods were used to examine the participants’ experiences of learning and their perceptions of mental health recovery while undertaking the recovery program.

Method

Research Design

A narrative research design was used given that the study involved an exploration of how participants made sense of lived experiences through configuring and sharing life stories in a social context (Murray, 2002). Spector-Mersel and Knaifel (2017, p. 1) consider narrative research on mental health recovery as involving “two sister paradigms.” Mental health recovery involves reflection and sharing of life stories just as narrative research explores the processes of meaning making through story formation and story sharing.

Research Methodology

A pre-program VARK learning style assessment (Fleming, n.d.) revealed that a high percentage of this student cohort learned most effectively through visual and kinaesthetic modes. Therefore, given the participants’ preferred learning styles, as well as researcher commitment to the approach, arts-based research inquiry was considered an appropriate means of exploring the participants’ perceptions and experiences while undertaking the program. Arts-based inquiry is situated within the narrative research paradigm (Casey, Proudfoot, & Corbally, 2016; Leitch, 2006) in that the creation of art draws on personal experience and life history and the art produced tells stories about these lived experiences. Arts-based research approaches use visual, dramatic, and poetic practices as means of inquiry in themselves as well as providing divergent ways of interpreting and re-presenting human experience (Eisner, 2002). According to Elliott (2011, p. 97) “Art is a neuronarrative archive of liminal experience, holding up a mirror to both subjective and objective features of the experience, allowing us to revisit it, speak about it, and learn from it.”

Arts-based research methods have been effectively used in evaluation practice in a range of contexts; for example, Cancienne and Snowber (2003), Casey (2009), and Wimpenny and Savin-Baden (2014). Simons and McCormack (2007) argue that arts-based evaluation offers participants’ opportunities to reveal insights that are beyond words, to translate tacit knowledge, thus providing a powerful means of voicing learning perceptions and experiences. Accordingly, these authors recommend the use of arts-based evaluation methods among people who learn in alternative ways, or who may be less verbally articulate. Community involvement in the process of art making can be a means of collective story making and the discovery of new strengths and abilities (Mizock, Russinova, & Shani, 2014; Murray, 2012).

Upon conclusion of their recovery program, participants were facilitated to tell the story of their engagement with learning and recovery using arts-based inquiry methods. This process was participative, in that the participants played an active role in the creation and analysis of the data, following the guidelines for Participatory Visual Research Methodologies (PVRM) as set out by Mitchell, Theron, Stuart, Smith, and Campbell (2011). PVRM involve the use of the visual (photography, video, digital storytelling, drawings) as a participatory methodology. This approach can be best explained as a merging between participatory action research and arts-based research. Mitchell et al. (p. 22) assert that “as with arts-based research, the visual in PVRM can serve as a mode of inquiry, a mode of representation, a mode of dissemination, and a mode of transformation.” The capacity for transformation and narrative configuring of meaning make this approach an attractive one in learning and recovery contexts. PVRM are grounded in community-based research, and like recovery education itself, operate through collaboration and coproduction of knowledge.

Participants and Ethical Considerations

The class cohort (14 students) was invited to participate in the arts-based inquiry concerning their perceptions and experiences of learning and recovery while undertaking the Recovery program. The recruitment process, following PVRM guidelines (Mitchell et al., 2011), involved conducting an introductory information/discussion session with the class cohort as well as providing written information regarding the proposed activity and expectations of participation required. Mitchell et al. (p. 23) recommend issuing “A reassuring invitation to draw” given that potential participants may not feel confident in drawing skills. Participants were reassured that the focus would be on the content, not the quality of their drawing. They were also assured that participation or nonparticipation would have no association or implications regarding their course of study. All 14 students gave written consent to participate and to share their images and comments in subsequent publications and reports. All participants were female; ages ranging from 23 to 56, and all worked as mental health support workers in community mental health services. Three participants had disclosed self-experience of mental health difficulties and all were currently undertaking the Recovery educational program. Throughout their course of study, participants had shared details regarding their personal mental health issues and recovery journeys among the class cohort. A commitment to continued confidentiality regarding potential disclosures during the course of the research was agreed with the group. Participants continued to have access to psychological support services from program staff during the research/evaluation period. Ethical approval for the study was obtained from the University’s ethics committee.

Data Collection

Mitchell et al. (2011, p. 24), in their framework for PVRM, advocate providing guidance to the participants regarding the focus of the art-making activity in the form of a specific prompt as this “provides structure and contributes to richer data generation.” Therefore, for this activity, it was suggested to the participants a week beforehand that they might imagine their experiences of undertaking the program using the mental image of a journey. The use of the journey metaphor was inspired by Morgan’s (1996) image–based research among nursing students, and his suggestion that “as a fundamental archetypal notion, the journey offers diversely satisfying allegories through which we may come to more deeply comprehend our life’s events, drives and experiences” (Morgan, p. 144). Moreover, experiences of recovery and learning are often perceived as lifelong journeys (Droud, Fossey, & Fortune, 2015; O’Grady & Skinner, 2012; Sefton-Green, 2017). Thus, it was hoped that this metaphor would resonate with the participants’ lived experiences and would provide an exploratory framework while still allowing flexibility and freedom for unique responses and perspectives to emerge.

In PVRM, articulation, exploration, and sharing of mental images are facilitated by asking participants to make an external picture or drawing of their mental image, which involves the second recommendation by Mitchell et al. (2011, p. 23); the provision of “A choice of drawing tools” which suit the culture, contexts, and preferences of the participants. A comfortable, spacious room, complete with various art materials was made available to the group. The third recommendation is to follow “a leisurely pace” (Mitchell et al., p. 24). This involves going slowly and giving time for the creative and configuring process to develop. Some participants formed dyads, others preferred to work alone. The participants worked on planning and constructing their art pieces for an hour. This was followed by a group session involving each participant/dyad sharing and explaining their art piece and ensuing group discussion regarding the artwork presented. Totally, 10 art pieces were produced and discussed. With participant consent, this session was recorded and transcribed and the artwork was photographed by the researchers.

Data Analysis

In PVRM, involving participants in analysis is vital as meaning is embedded in the art piece, which, like narrative, is created in a particular space and time for an intended audience. Thus, following the PVRM guidelines for “A shared analysis” (Mitchell et al., 2011, p. 25), participants were invited to describe and analyze their art piece; to reflect upon and share what the visual image meant to them, the thought processes involved in constructing the artwork, their use of color and the spatial organization of the art piece. Elliott (2011, p. 98) in using similar participant analysis, observed that

analysis of the art work itself was subsumed into the meaning it had for the artist’s narrative of experience, . . . that by virtue of authorship of the work, and ownership of the experience, the artist held the richest and most meaningful analysis possible.

The shared analytic process also extended to the participant group. They responded to each artwork, analyzing its construction, commenting on the aims of the piece and how it resonated with them and their own perspectives on the experiences/issues conveyed. Mitchell et al. (p. 25) in discussing this collaborative meaning-making process, claim that “when the analysis is shared in this way, valid knowledge production occurs.” These processes of individual and group analysis are evident in the findings section of this article (see analysis of Figures 5 and 7 in particular). Toward the end of the participant discussion session, the overall shared perceptions and experiences among participants were collectively identified and the group was facilitated by the researchers to agree the main themes emerging from their artwork and discussion in relation to recovery and learning.

Elliott (2011, p. 98) reminds us that “every narrative, like every art piece, is only a partial portrait . . . meaning is reconstructed in the interaction and interpretation of storyteller and listener.” Meanings are socially constructed; prevailing social discourses are invariably employed and are often unquestioned as we make sense of human experience. Therefore, it is important to identify broader social constructions, including the interpersonal dynamics of the participant group that may have shaped the art-making/meaning-making process and the participant analysis. To this end, the researchers used an interpretive approach, again informed by the guidelines of Mitchell et al., to examine the artwork in the context of the recorded descriptions and discussions. This involved comparing and contrasting what was being conveyed visually in the images with the transcripts of accompanying individual and collective dialogues concerning learning, recovery and the relationships between these phenomena. The incorporation of this broader, situational analysis enriched and developed the key themes and findings of the participant-led analysis. An example of this wider contextual analysis is evident in the description of the group discussion regarding Figure 7 in the findings section of this article.

Findings

Through art making, participants explored their perceptions of recovery in relation to both their learning and their occupational contexts. Seven art pieces focused on the interaction between recovery and learning and three art pieces were concerned with the relationship between recovery and the participants’ mental health practice contexts. In this article, we examine participants’ experiences and perceptions of recovery and learning; therefore, the seven art pieces/participatory analysis from this area form the basis of the findings. Three of these seven art pieces (Figure 3, 4, and 7) which are particularly illustrative of each theme are presented in more analytic detail. This includes participant and group analysis as well as the wider contextual researcher analysis where relevant. The findings section of the article will conclude with a collaborative reflection on the use and usefulness of arts-based methodology in the study context.

From the PVRM analysis, the following three recurring themes were identified as prevalent in both the artwork and the participant/group contextual discussion:

“Highs and lows”; interrelatedness of learning journeys and recovery journeys

“Knowledge is the string”; knowledge as a source of stability and rescue

“If you fall off you get straight back up”; the need for resilience in learning and recovery

Theme 1: “Highs and Lows”; Interrelatedness of Learning Journeys and Recovery Journeys

It was notable that many participants used their artwork to tell stories of the interrelatedness of personal learning journeys and recovery journeys; there were many references to the “highs and lows” of both learning and recovery processes. Images of movement, particularly “ups and downs” were evident in both the verbalized and visual participant narratives. Nicola’s image of the upward and downward movement of a slide (Figure 1 - The Slide) and Maureen’s sense of being a passenger on a speeding, runaway train (Figure 2 - The Runaway Train) are representative of this perception.

Figure 1.

The slide—Nicola.

Figure 2.

The runaway train—Maureen.

Mary and Kate, in their collaborative art piece (Figure 3 - Highs and Lows), presented and analyzed the highs and lows of learning and recovery in more depth:

Figure 3.

Highs and lows—Mary and Kate.

My journey about Recovery was like . . . the mountains are representing the highs and the lows . . . I also used different media for like . . . different moods I was going through . . . so like the waves and water and that . . . the highs and the lows and rollercoaster journey and eh . . . the sunshine was to represent the . . . like that there is light at the end of it. (Mary)

Mary’s analysis highlights her perception of the mountains and the butterfly with their capacity for upward and downward movement as signifying the “ups and downs” and “highs and lows” commonly associated with mental distress and recovery journeys. In addition, Mary emphasizes the sense of turbulence through her use of words such as “rollercoaster” and the addition of water and waves in the image. The textures and colors (blues, grays) chosen by Mary have culturally received understandings in relation to portrayal of low mood. Similarly, the metaphor of sunshine and the “light at the end of it” communicates a commonly held belief that after suffering there will be hope. Kate’s contribution to the picture was the addition of the butterfly, shedding its cocoon at the top of the mountain:

My aspect was like a caterpillar at the beginning. I was kind of slow and quiet . . . I knew I had a lot to learn . . . so it is like I took the knowledge and . . . eventually . . . as I got better and better . . . I was able to eh . . . leave the safety net . . . and . . . recover . . . and turn into a butterfly . . . and head towards the sun as well. (Kate)

The transformation from caterpillar to butterfly also has shared cultural currency as a symbol of positive change and psychological growth. There is a clear parallel between Kate’s sense of her learning and her recovery journeys. Knowledge is regarded as a requirement for this journey; Kate has “a lot to learn.” Taking the knowledge enables her to “get better and better,” to leave the safety net or cocoon “and . . . recover” transforming into a butterfly heading upward to the sun. The belief in knowledge as a transformative agent in both recovery and learning is a strong feature of many of the visual and oral narratives.

Theme 2 “Knowledge is the String”; Knowledge as a Source of Stability and Rescue

The perception of knowledge as a sustaining element in this challenging journey is also articulated by Jane through her construction of a kite (Figure 4 - The Kite)

Figure 4.

The kite—Jane.

Eh . . . mine is a kite . . . I suppose my view on mental illness was that it was like a string-less kite almost . . . that there was nothing to control it . . . everything was so haphazard . . . you know . . . there was nothing to pull you back down . . . I imagined that . . . when you’re in depression or schizophrenia that . . . that everything’s just gone . . . you either couldn’t fly or . . . you were gone . . . there was no coming back down . . . And now I think that there’s a string on it . . . this is for us in our learning . . . you know, that the knowledge is the string . . . it doesn’t stop you . . . but it kind of stabilises you . . . it kinda grounds you a little bit . . . and that’s what I hope it’s done . . . so that you’re not just . . . so that you have the wherewithal to use it I suppose. . . (Jane)

In the process of constructing and analyzing her artwork, Jane configures and communicates her perspective on mental illness, recovery, learning, and the complex relationship of these experiences to her beliefs about knowledge. Here, unlike the butterfly heading toward the sun in the previous image, flying free is associated with mental distress (schizophrenia or depression) and is an uncontrolled and terrifying prospect; “everything was so haphazard . . . there was nothing to pull you back down.” Jane highlights her estimation of the value of knowledge gained on the Recovery program “. . . this is for us in our learning . . . you know, that the knowledge is the string . . .” Being tethered by the string of knowledge offers rescue from mental chaos and facilitates mental discipline. Acquisition of knowledge provides stability and grounding; “it doesn’t stop you . . . but it kind of stabilizes you . . .”

Similarly, Margaret (Figure 5 - Calming the Scream) created an artwork depicting a mobile phone accompanied by a copy of Munch’s “The Scream.” In her analysis, she reflected on the stabilizing influence of knowledge and support provided by course facilitators and peers via phone calls when she was experiencing distress.

Figure 5.

Calming the scream—Margaret.

Jane and Margaret did not elaborate on the forms of knowledge they were referring to, however in the groups’ analysis of these artworks, participants considered the nature and usefulness of the knowledge they had gained on the program:

Angela:

I’ve worked in mental health services for a long time . . . and you get people relapsing and relapsing again . . . and you kinda begin to think it’s all a bit hopeless . . . but taking this course, you begin to see recovery as a circle . . . not a straight line . . . you know, people move around the circle . . . And sharing the course with service users . . . that has helped me to see that people really can move on.

Yvonne:

It helps you to see recovery as a process and not a cure . . .

Alison:

And to see the person . . . not the mental illness, but the person behind it . . .

It is evident from the findings that, in undertaking the recovery program, participants questioned their prior assumptions and developed their knowledge of recovery as “a process and not a cure.” These new insights are also conveyed through Angela’s depiction of the nonlinearity of recovery and learning journeys (Figure 6 - The Nonlinear Journey).

Figure 6.

The nonlinear journey—Angela.

Angela also identifies that collaborative learning with service users enabled exploration of participants’ lived experiences and as a result developed experiential knowledge. Notably, former illness-dominated frameworks of understanding were challenged with participants seeing “not the mental illness, but the person behind it.” Collaborative learning with service users also exposed participants to alternative possibilities and outcomes, as Angela observes: “sharing the course with service users . . . that has helped me to see that people really can move on.”

Interestingly, Jane’s earlier comments suggest that gaining new insights and developing knowledge in itself is not enough. There needs to be a corresponding ability to apply knowledge; “you have the wherewithal to use it.” Thus, there is a recognition that usefully employing this knowledge involves a shift from cognitive grasp to transformative action.

Theme 3: “If You Fall Off You Get Straight Back Up”; The Need for Resilience in Learning and Recovery

The work involved in applying knowledge and skill in challenging contexts is further explored by Denise’s in her artwork (Figure 7 - The Show Jumping Course) and in the group response. Denise painted a show jumping course with herself as the horse rider. She animated her presentation of her narrative by moving a small plastic horse around the painting and making clip clop sounds. In reenacting her progress through the virtual show jumping course, she also performed her learning journey on the recovery course.

Figure 7.

The show jumping course—Denise.

I was thinking about the course . . . and I just said “Well . . . I’m to do a journey, sure aren’t I sitting on my horse.” This is me . . . on my horse . . . Rusty. This is the course co-ordinator in the judge’s box; she’s judging the assessments . . . (background laughter). The show jumping course represents this course . . . the Recovery course in here . . . So, you’re really nervous when you come in . . . So I come in on my horse (produces a small plastic horse and moves it around the painting, making clopping sounds) . . . and . . . the first jump is always real easy . . . it’s just a low cross-pole and that gets you going . . . and then I come along to the double here . . . and that’s the homework journal . . . and the thing about the homework journal was, you couldn’t just leave it until the last minute . . . ’cause you’d have forgotten it all . . . and it’s the same with riding . . . you’ve always got to ride forward . . . you can’t just waltz up to it and then go hop . . . and you can’t jump over the first one and stop . . . you can’t lose track of where you’re going . . . and this is the prize . . . my red rosette . . . my QQI award at the end of the day . . . (Denise)

In her analysis of her progression through this educational program, Denise uses a personal narrative that demonstrates her knowledge, skills, and interests. She positions herself as strong and competent “sure aren’t I sitting on my horse.” Denise perceives her journey as involving a progression from initial anxiety through the ups and downs of learning. Each jump represents a learning hurdle; the initial low jump is designed to give confidence while the more difficult double jump symbolizes the homework journal. This continuous piece of work demands a more sustained effort, requiring the stamina and skill to navigate two jumps in quick succession “you couldn’t just leave it until the last minute . . . and it’s the same with riding . . . you’ve always got to ride forward . . . you can’t lose track of where you’re going . . .” Denise articulates the need for focus and resilience in this learning journey. The reward for having the “wherewithal” to use knowledge and skills is “my red rosette . . . my QQI award at the end of the day.” The use of a show jumping metaphor also resonates with Angela’s earlier perceptions of recovery as nonlinear; people moving around a circle, relapsing and recovering; a process that also requires stamina and resilience. In addition, the interrelationship between learning and recovery processes permeates the ensuing group analysis of Denise’s’ artwork.

Lisa:

And I think it also . . . tells about mental difficulties . . . as well, with all the hurdles and setbacks . . .

Mary:

Yea, you often can’t take a breather . . . you’ve got to go straight back at it . . . and if you fall off you get straight back up . . . you know, you never actually take a break or, or . . . give up . . . you always go again . . .

Margaret:

Most of us haven’t studied in years.

Nicola:

And the assessments were a worry.

Lisa:

Sometimes you feel like you’re in the box . . . (pointing to the judge’s box in the picture)

Denise:

(laughing) That’s the boss doing the corrections.

Lisa:

And like the judge’s box . . . it’s like personal recovery . . . you can see that life is going on outside . . . on that suicide watch . . . that’s what it was like . . . in the box.

Throughout the session, the art pieces hold layers of meaning and representation. Perceptions regarding the prescribed learning journey and mental illness/recovery journeys play back and forth, sometimes in parallel, sometimes informing each other, sometimes overshadowing. In the researcher analysis of this artwork in the wider context of its generation, we propose that Lisa is drawn to the image of the box, which, to her, has personal and possibly painful connotations of her experiences of mental distress. Denise’s focus on observation and judgment of learning leads Lisa to reflect upon a time when she was boxed in, gazing at life going on outside, also experiencing being watched and judged.

Reflections on the Use and Usefulness of Arts-Based Methodology

The construction of visual narratives and subsequent analysis by the participants in this study reveals a sophisticated process of configuring meaning. The careful choice and use of metaphors demonstrates reflection and inquiry into learning/recovery experiences and perceptions. In addition, participants reported that the process of art making fostered critical thinking concerning their learning experiences on the program. Denise’s comments about her preference for making images rather than words to configure and represent her perceptions and knowledge is illuminating in this regard

I mean I would have spent days . . . weeks . . . just like today, I would have gone on with this forever if you’d let me at it. I’m not the academic sort . . . The last time we had a project to do, I thought “Feck this project . . . what am I going to do now?” I did it completely differently . . . I mean it wasn’t just a wordy thing that I handed up . . . I handed up a big flow chart instead . . . so I made up my own . . . I made it something I want to do . . . I’m not going to be sitting down at a computer . . . typing it all in words, cause that’s not me . . . So now I have a plan . . . I’ll do some of this . . . I know what I’m going to do. (Denise)

For people like Denise who construct experience and knowledge visually and performatively, many current education curricula with their emphasis on “prosaic consciousness” (Mair, 1989, p. 63) may be experienced as frustrating and restricting. Opportunities to engage in alternative modes of meaning making and articulation of knowledge are essential. Furthermore, conveying (and in Denise’s case performing) these subjective understandings through art making, resonates strongly with other learners and opens space for signifying metaphors to be examined and developed through participatory inquiry:

Denise:

Anybody have any questions before I go?

Unidentified Voices:

It was brilliant . . .

Yea,

it showed the journey really well . . .

Yes

. . . super . . .

Maureen:

You’re telling your story . . . and I’ve learned more about you . . . than in the whole time of the course . . . than . . . I can ever imagine . . . the way it tells your story . . .

Discussion

The participants’ oral and visual narratives demonstrate their experiences of learning and recovery as being interrelated. The highs and lows of both processes are described interchangeably whether through images of positive upward transformation in mental health and learning; the mountains, the butterfly, the show jumping course, or the distressing points portrayed by the downward slide, the runaway train or the chaotic untethered kite. Respondents in Hammond’s (2004) study concerning lifelong learning among adults used similar up and down metaphors to describe their experiences in returning to formal learning.

The concept of transformation, evident here, is prevalent in literature concerning the recovery process. This is viewed as a reconfiguring of self from an illness-dominated identity through finding meaning, gaining knowledge, and achieving a sense of purpose and hope in the experience of mental distress (Jacobs et al., 2017). Kate’s visualization of the caterpillar leaving the cocoon and transforming to a butterfly also resonates with the work of Karp (1994) and Mancini (2007) who advance the notion of a psychological low point as a turning point, wherein the person realizes and accepts that their own coping mechanisms are failing and that they need to learn new strategies of self-care.

The recovery process, therefore, involves a subjective transformation; leaving the cocoon of illness defined identity and shaping a new identity. Transformative recovery has also been consistently associated with learning and growth (Ellison, Belanger, Niles, Evans, & Bauer, 2018; Zabel et al., 2016). Studies from the domain of transformative learning in education also posit the notion that growth and change come from discomfort. Nemec (2012) claims that learners frequently seek education and training because of a sense that their current way to know the world no longer works. As a result, the learner critically examines personal assumptions, beliefs, and knowledge. Nemec (2012, p. 478) refers to this developing disequilibrium as the person’s “growing edge.” Regarding these synergies, Ryan, Ramon, and Greacen (2012) advocate that the interrelationship between lifelong learning and recovery in mental health should be considered as a new paradigm with attendant theory and practice development.

The value of knowledge as a supportive and transformative agent is a strong and recurring feature of the participant narratives. Kate “takes the knowledge” which enables her to transform into a butterfly and head toward the sun. For Jane “knowledge is the string” which “tethers” the runaway kite, offering stability and grounding in a chaotic world. Denise uses her embodied knowledge and skill to navigate and endure the rigors of the show jumping course. Veseth, Binder, Borg, and Davidson (2012, p. 119), in exploring processes of recovery among people with bipolar disorder discuss the participants “finding something to hang onto when the world is spinning around.” Similarly, a study by McEvoy, Schauman, Mansell, and Morri (2012) proposes that recovery is associated with having a greater sense of balance and control particularly in navigating mental health issues and pursuing personal goals. For many this sense of control is achieved through acquiring knowledge and through appreciating the value of their own experiential knowledge. A participant in Jackson’s (2006, p. 51) study asserts that gaining knowledge about personal mental health issues provides “a way of taking control over something which previously controlled me completely.” In many studies, self-knowledge and self-empowerment are identified as important factors in both lifelong learning and recovery from mental distress (Ryan et al., 2012). In our study, increased knowledge about the nature of recovery, gained through undertaking the program is identified by Alison, Angela, and Yvonne. This is in keeping with research by Higgins et al. (2012) which found that knowledge accrued was valued for improved understanding/empathy concerning recovery, increased practice efficacy and personal security and legitimacy. Participants in our study value knowledge as a supportive and stabilizing force. Perceptions of the benefits of knowledge acquisition have also been identified by other mental health recovery researchers; for example, Hammond (2004) observed that participants valued knowledge for career advancement and participants in studies by Ryan et al. (2012) and Zabel et al. (2016) perceived knowledge as instrumental for changing life and gaining employment.

Here, Jane proposes that it is not enough to have the knowledge; having the “wherewithal” to use it is also important; that is being sufficiently mentally well and having support and confidence to transform knowledge into action. This ability to use embodied knowledge and lived experience to support resilience is further developed in Denise’s visual narrative which powerfully reenacts the hurdles and setbacks encountered in adult learning. This image resonates strongly with other participants’ lived challenges in learning and mental health. Lisa’s experiences during mental distress, of being confined and judged within the box, are juxtaposed with Denise’s engagement in goal-directed activity outside the box. This brings to mind Hammond’s (2004) assertion that in the learning and recovery process there is an expansion from looking inward to looking outward, which positively affects mental health and ability to cope with challenges.

The power and affordances of participatory arts-based inquiry identified in this study support the findings of similar education and evaluation research (Cancienne & Snowber, 2003; Casey, 2009; Simons & McCormack, 2007). The personally and socially transformative potential of collective art making, evident here, has also been observed by Murray and Crummett (2010) who call for the processes and impacts of this approach to be described and theorized to a greater extent. Interestingly, the contribution of art-making processes in supporting recovery in mental health practice contexts have also been identified (Greenwood, Leach, Lucock, & Noble, 2008; Van Lith, Fenner, & Schofield, 2011). In the study by Van Lith et al., (p. 652), participants encountered art making as an innovative and strengths-based method, “a transformative activity which enabled them to take greater control of their lives, resulting in feeling stronger, more confident, and more capable of driving their journey of recovery.”

Conclusion

A major conclusion from the study findings is that learning and mental health recovery are interrelated and interdependent processes. This accords with research findings already cited in this article and extends these by illuminating some of the shared characteristics of this complex interface, for example the fluid and dynamic nature of learning and recovery, both consisting of ups and downs, highs and lows, which correlate with personal growth and transformation. The requirement for a level of focus and resilience in undertaking and navigating both endeavors also surfaced through the artwork and attendant discussions, with an emerging realization among participants of the circularity, not linearity of both learning and recovery. What is also striking is the participants’ perceptions concerning the value of experiential knowledge as a sustaining force and a bolstering influence in learning and recovery journeys. PVRM proved to be a rich vehicle for participants to individually and collectively configure and analyze these complex and subjective experiences. The arts intervention and inquiry were valued by participants and contribute more nuanced perspectives to the existing research in this area.

Relevance for Mental Health Practice

Nemec (2012, p. 479) contends that those working in psychiatric rehabilitation, recovery-oriented services, and person-centered planning are in the “transformative learning business.” Therefore, it is incumbent upon educational and mental health service practitioners to appreciate and foster the relationships between recovery and lifelong learning. This can be achieved through collaborative learning provision such as recovery colleges/courses and bespoke training/development opportunities. In addition, it is important to recognize that significant lifelong learning occurs in any strengths-based supportive intervention where an individual develops self-knowledge concerning their unique experiences of mental distress and uses this knowledge to gain personal control and mastery (Lakeman, 2010). Thus, all mental health practitioners have an important part to play in co-producing knowledge with service users/helpers concerning the nature of mental distress and helpful approaches in recovery. While this study contributes perspectives concerning the processes of learning among participants, additional research is recommended to clarify further the forms of knowledge that are most useful and valued in the context of recovery education programs.

The study participants’ learning journeys, like mental health recovery journeys, are multidimensional and complex. We contend, and concur with other writers, that pedagogical approaches in recovery programs need to be flexible and sensitive to the diverse learning needs and styles of a range of participants. The lived experience and knowledge that participants bring to such programs as service users/service providers must also find expression and dialogue. Pedagogical frameworks and practices employed in curriculum design and delivery also need to be capable of not just accommodating diversity but of productively using it in teaching and learning interventions. Ongoing scrutiny of pedagogical processes and practice is required to guard against adopting taken-for-granted approaches and discourses that maintain power differentials, constrain alternative perspectives, and stifle the coproduction of knowledge. This article argues that narrative and arts-based inquiry in learning and recovery contexts offer opportunities for engaging productively with plurality, collaborative meaning making, and democratic knowledge production that work to transform human experience.

Footnotes

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iD

Briege Casey

Author Biographies

Briege Casey is an assistant professor at the School of Nursing and Human Sciences, Dublin City University. Her teaching and research interests focus on mental health, marginalisation, and arts and health in practice, research and education.

Margaret Webb is the general manager of EVE; a range of governement funded community services providing recovery-orientated programmes for adults who experience mental health difficulties in Dublin, Ireland. She is a psychologist and has practice and research interests in rehabilitation, recovery and quality of life assessment in relation to mental health.

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