Abstract
Recovery as a social justice framework addresses how people who experience mental illness can increase being active agents to assist in improving their quality of life. Similarly, co-operative inquiry challenges the power imbalances that exist among marginalized and vulnerable groups by seeking to create relevant platforms for equality. The intention of this current study was to explore the relationship between art making and the mental health recovery process. This article describes a multi-faceted approach to action research by using the concept of the bricoleur to piece together co-operative inquiry and art-based research with the mental health recovery values. In particular, a relational layer of knowing was brought forward through the making of art-based intersubjective responses of the data collected. By integrating the knowledge gained from this first-second-person relational knowing with the findings from participant interviews, the overall the trustworthiness of the study was enhanced. For this type of co-operative inquiry, trustworthiness was determined by whether engagement in the study led to the development of relationships built on mutual respect and how a shared understanding enabled further validation of the participants' experiences.
Introduction
This article traces the use of co-operative inquiry in bringing forth a relational layer to a study exploring the role of art making in mental health recovery. To begin with, the framework of mental health recovery is introduced, and the use of integrating co-operative inquiry and art-based research methods are explored. Then, the first-person knowledge that I brought to this study is described before detailing how first-second-person knowledge was elicited through the creation of intersubjective responses. To finish, the relational knowing that resulted is further unpacked through an exploration of how the insights elicited shaped the study and shifted my view on this topic of inquiry.
Mental health recovery
The growth of the mental health recovery movement began alongside the feminist, disability and gay rights movements during the 1970s (Crossley, 2004; Sayce, 2000). Pioneer recovery advocates, such as Judy Chamberlin (1990, 1998), used the term ‘recovery’ to emphasize that mental illness was a social disability in which the symptoms were exacerbated by the stigma attached to the illness. There was also a societal expectation that people with mental illness should remain submissive about their livelihood (Chamberlin, 1990, 1998). In Australia, Helen Glover (2005), a mental health survivor and leader in the field, was particularly instrumental in advocating for the promotion of lived experience accounts of mental illness to guide policy and service development. Essentially, these activists were fighting against being regarded as passive recipients of mental health services and working towards being seen as active agents of change through their participation in mental health services.
Through conducting a cultural case study on a mental health service, Myers (2010) described how professionals had skewed the recovery philosophy by promoting North American morals of self-determination and expectations of valued citizenship. Myers (2010) concluded that the recovery movement's philosophy may serve as a corrective to the negative effects of past mental health models, but emphasized a need to ensure its implementation is stress reducing, personally relevant and available in culturally variable ways.
Addressing power imbalances through co-operative inquiry
A major goal of utilizing the co-operative inquiry approach is to empower those with little or no power to control their lives by amplifying their voices and expanding their choices (Park, 1993; Ristock & Pennell, 1996). The co-operative inquiry approach was incorporated into this study because it is fundamentally about the right to speak and be heard (Hall, 1993) and strives to enhance both psychological and political power (Park, 1993). By using this type of inquiry, it was assumed that knowledge is a source of power and that the consumer participants generate important and valid knowledge to this area of inquiry (Whitmore, 1991).
Integrating the recovery values through adopting a co-operative inquiry into the study meant that the participants and I became involved in a continuous process of negotiation and collaboration (Tobin, Chen, & Leathley, 2002). Glover (2005) reminded us that as professionals and researchers we need to let go of urges to become experts, and instead use our expertise to help people who are recovering from mental illness to understand and describe what works for them. In line with this, the co-operative inquiry engages participants throughout the research process in a genuine way (Wallcraft, Schrank, & Amering, 2009), meaning that the amount of collaboration is not as important as the quality of negotiation and engagement throughout the research process.
Integrating co-operative inquiry with art-based research
First-second-person theory within co-operative inquiry foresees the intertwining relationship between the researcher and participant to be one of mutual gain (Chandler & Torbert, 2003; Whitehead & McNiff, 2006). The underlying philosophy stems from Buber's I-Thou relationship (1958), whereby through the sharing of identities and seeing the other as an extension of oneself, the relationship transfers from I-It (object) to I-Thou (subject). In reference to the transcendence that emerges from this relationship, Buber (1958) stated: I do not experience the man (sic) to whom I say Thou. But I take my stand in relation to him, in the sanctity of the primary word. Only when I step out of it do I experience him once more. In the act of experience Thou is far away… no deception penetrates here; here is the cradle of Real Life. (p. 9)
As the primary focus of this current study was to inquire into the nature of art making, it was congruent that art-based research was incorporated into the research methodology. I was interested in looking at art making as the process of turning thoughts into visual form and regarding this as representation of a personally significant feeling. The premise for using art in research is that visual imageries are produced in a particular space and time, and therefore provide a snapshot of that moment in time (Guttmann & Regev, 2004; Rose, 2001). Here a symbolic constructivist approach was adopted, which uses non-routine art-like portrayals (that is, drawings, paintings, mixed media, sculpture, photographs and poetry) to bring forth alternative knowings, beliefs and feelings both conscious and unconscious (Barry, 1996).
The ‘I’ position in relation to this study
The ‘I’ in first-person theory refers to self-knowledge (Torbert, 2001) and its influences on the research at hand. It brings to light the role of values (axiology) within the research process and how these are inextricably linked to the researcher's (in this case my own) value system and set of beliefs about the nature of reality (Denzin & Lincoln, 2005). Within the first-person theory framework is the underlying view that to change the attitude of others involves first changing the researcher's own attitude (Chandler & Torbert, 2003; Reason & Torbert, 2001). Therefore, it seems pertinent to present my position at the beginning of this article.
My attitudes to the lives of those with ongoing mental illness have been informed by various experiences of previously living with people in adversity and being influenced by those who have given altruistic support. When I was a child, my family lived next door to a supported residential service for men who had been institutionalized for the majority of their lives, many of whom experienced substance abuse. These men would spend most of their day pacing up and down our street pavement talking to themselves. My parents' small gestures of conversation or a glass of water seemed much appreciated by these men who had few people who cared about their well-being. Even though I was young, these experiences attuned me to the difficulties that many people face as a result of both the socio-cultural and psychological aspects of a mental illness.
In my early 20s, I began working in psychosocial residential rehabilitation services and worked as the sleepover worker five nights a week. Through this work, I spent prolonged amounts of time with the residents and saw various aspects of their lives, not just during their personal crises but when they were enjoying themselves too. Being young and inexperienced, I often felt out of my depth was to how I could reach out to them. Though this experience helped me to gain a better understanding of their lives, I realized a need to conduct this study to authentically come to a place where I felt a co-habitation of their experiences.
Research procedures
Recruitment process
A purposive sampling strategy was used to recruit participants from two psychosocial rehabilitation services in Victoria, Australia. All participants had ongoing and severe levels of mental health issues, including depression, anxiety, borderline personality disorder, schizophrenia, post-traumatic stress disorder, gender identity disorder, bipolar disorder, anorexia nervosa, and drug and alcohol abuse. However, the participants' diagnoses were not specifically identified in the study, but only discussed if the participants mentioned them during the interview. This decision followed the mental health recovery principles that require one to look beyond the diagnosis to focus on the personal growth aspects (Anthony, 1993; Deegan, 1988, 1996).
Participants' demographics.
Engagement and intentionality
Building rapport with the participants was not about becoming their friend, therapist or gaining their trust to divulge anything they wanted to keep private, but instead involved clarifying that they understood the peculiar relationship between a researcher and a participant (Dickson-Swift, James, Kippen, & Liamputtong, 2009; Dickson-Swift, James, & Liamputtong, 2008). Part of building this form of a relationship involved regarding consent as a continuous and contextually bound process of negotiation, making sure to verify that they understood what they had agreed to before each interview (Mitchell & Irvine, 2008; Simons & Usher, 2000).
Establishing this level of rapport went beyond signing a consent form and involved becoming a known face in these art therapy programs (Heron & Reason, 2001; Reason, 2006). In other words, for an authentic relationship to develop I could not just engage with participants; I had to spend time in their world. The previously gained insider knowledge (Heron & Reason, 1997, 2001; Reason & Heron, 1995), I had from working as an art therapist, support worker and researcher in the mental health sector helped me to understand the cultural practices and conduct of this setting.
Collaboration through authentic participation
Data collection involved three rounds of interviews with each participant over a one-year period. The process involved collecting both quantitative and qualitative data concurrently at each of the three interviews for each participant. The interview loosely followed the order: filling out the Recovery Environment Enhancing measure (Ridgway, 2005); then participating in an open-ended conversation on the experience of art making; and finally engaging in symbolic meaning making by reflecting on artworks completed in the previous six months.
In the mental health sector, participants often commented that engaging in research involves being observed and asked questions, without researchers taking into account the participants' concerns or experiences (Bensimon, Polkinghorne, Bauman, & Vallejo, 2004). Pyett (2002, 2003) suggested that collaboration works most effectively when the knowledge, skills and experience of both parties are equally valued and regarded with respect. In keeping with the co-operative inquiry aspect of this study, participants were asked to review and provide feedback about descriptions of the interviews, which were in the form of collaborative accounts. These were essentially a case synopsis or qualitative description of the interview, where the key aim was to stay true to the participant's words and create an accessible account for review (Sandelowski, 2000). Using collaborative accounts helped to ease concerns of power imbalances, by ensuring I was telling the participants' stories in ways that were acceptable to them and confirming that I had gained consent for what was being revealed (Glover, 2005; Tobin et al., 2002; Wallcraft et al., 2009).
The participants valued the collaborative accounts as a genuine form of feedback and verification of their experiences. For example, I typically received the collaborative accounts back with handwritten notes all over them, usually relating to phrasing or noting that their perception of an experience had changed in some way. I saw the feedback as a sign they wanted to ensure I had heard correctly and to some degree understood them. The feedback also gave authority to the participants, because it was their sharing of experience that contained influence and their authentication that helped to strengthen the study (Park, 1993; Ristock & Pennell, 1996; Whitmore, 1991).
An additional benefit that came out of the collaborative accounts was that they provided a bridge across the interviews, as well as a tangible form of each participant's experience in each session. A few of the participants used these accounts as a means to share their current issues with their psychiatrist, therapist or support worker. For example, two participants used the accounts to reflect on where they had been and as a comparison for their current situation, demonstrating that engaging in research can have benefits beyond the scope of the study (Heron & Reason, 1997, 2001). As one participant stated: ‘I shared these notes with my psychiatrist, and it was like the icing on the cake for what I had already begun to realize’.
Dwelling into the first-second-person relationship through intersubjective responding
Going beyond analyzing for themes
Once the collaborative accounts were written up and had been analyzed for individual themes, the reflexive nature of the process lent itself to a new understanding regarding each individual's experience (Natterson & Friedman, 1995). This meant that to ensure I had understood the first-second-person relationship using an empathetic standpoint (Finlay, 2002a, 2002b), a further analytical step was introduced. First of all, I wanted to know whether the inferences I had constructed out of the data were authentic to the participants' original meanings, and secondly where it placed me in the findings? This line of questioning followed Eisner (1981) when he wrote about indwelling as a form of empathy: ‘to imaginatively participate in the experience of another … it's the content provided by this form of knowing that serves as a major source of understanding’ (p. 6).
I also felt a need to process my internal responses, which I had held onto throughout the study. I would add that when one is studying a topic that is potentially psychologically challenging for the researcher such as mental illness, expressing one's intersubjective responses allows for being fully open to the other whilst being aware of one's own emotional responses. As opposed to thinking that being sensitively moved by the data would obstruct the findings (Mitchell & Irvine, 2008), I saw my feelings as holding valuable insights that could actually enhance the findings.
The creation of intersubjective responses
The activity of creating intersubjective responses involved adopting the artistic style and media preference of the specific participant whose experience I was trying to embody. Although the participants often embraced several styles, these choices were made on the basis of the qualities that lingered after the analysis process for the collaborative accounts. As I was creating, I immersed myself into the three different forms of data that had been collected. Embodiment of the participant's thoughts, feelings and attitudes enabled me to be drawn into the participant's lived experience in an alternative and more expansive way. In turn, my responses enabled a kind of synthesis as well as a more in-depth and informed understanding of the data. I saw that being open and committed to a deep, but unprompted, kind of experience and responding cognitively, sensory, and emotionally was very revealing about myself in relation to the participants (Rumbold, Allen, Alexander, & van Laar, 2008).
For the intersubjective responses to emerge in the form they did, I needed to be attuned to my intuition and to let it guide me. Each participant had a large amount of data that I was processing and only an attitude of complete openness seemed to match the changing nature of this experience. McNiff (1998) suggested that experimentation is the key element for art-based research so that transformative insights not accessed by any other research method can emerge. Hervey (2000) agreed with McNiff and added that to respond creatively, the researcher needs to stay with opposing and contradictory tensions, as this is the very fabric from which a new form can emerge.
Once I had completed each of the responses, I realized that I had embraced Gendlin's (1962) use of felt sense to make meaning and created a form of Heron and Reason's (1997) presentational knowing. That is, I accessed my experiencing of the data, which at the time was pre-conceptual and experiential, to create a presentational response (Gendlin, 1961). The response was also produced with a reliance on a tacit attunement. As Polanyi (1966) stated, when we indwell the focus is not just on the tangible qualities, but also on the visceral ways of knowing that allow us to achieve an inclusive sense of the phenomena.
More recently, Lett (2001) developed an integrated conceptualization of the intersubjective response of the researcher. He noted that intersubjective responses honor the shared journey between researcher and participant by creating a filtered space. Lett (2001) noted: ‘[the space] is like a framed window, or a slice of the life sphere of shared experience, jointly indwelled, in which there is a mutual sense of understanding that can be trusted’ (p. 334). In other words, the I-Thou relationship is given a space to be experienced, the felt meanings are amplified and tangled together to create a telling of the participant's experiences from the understanding of the researcher. Through applying an empathetic attitude to my reflections, the process of responding intersubjectively gave me an emerging knowledge of the lived experience for each participant in an imaginative mode (Willis, 2001).
Importantly, there was an aesthetic element to creating the intersubjective response that I had not previously considered. Hervey (2000) defined aesthetics as ‘the discriminating appreciation of qualities reflected in form’ (p. 72). The configuration of the various important features being integrated harmoniously into the response meant I was also attentive to how forms and shapes connect (Hervey, 2000). At the same time, I was working with improvisation to enrich my propositional knowing with presentational and experiential forms of knowing (Heron & Reason, 1997).
My intention was to treat each of the participant's data without any judgment or pre-conceived conceptualizations (Lett, 2001). I remained aware that my emotions were only one of the many means to question, shape, extend and filter my intuition, but that it might provide some unforeseen insights (Lett, 2001). Interestingly, I found that the experience of creating the intersubjective responses was quite different in the case of each participant, even though I went about the process in the same way. My experiences seemed to depend heavily on my emotional response to engaging with that participant. I did not see this as a bias towards certain participants, but more an attempt to be honest with the process.
Accounts of the intersubjective responses
The following section briefly describes my reflections after the making of the intersubjective responses for Alex, Kathryn and Sam.
Alex
I saw that Alex was using art making to work through his identity, and in particular evolve his own spiritual beliefs to create a sense of equilibrium within himself. As he did not trust those in the mental health system, Alex tried to seek guidance by exploring these issues through his own art making. As I was creating this intersubjective response (Figure 1), I felt like I was purging my most immediate thoughts and as a result felt a sense of chaos and ambiguity. In particular, I was thinking about how Alex noted that recovery was ‘metaphorically bloody’, but art making enabled the chaos within to be pulled out and pulled apart. At the same time, I resonated with how Alex saw art making as very sacred and private in his life. I also felt wary of sharing this piece with others in fear of judgment. This caution was made valid when I noted others' emotional responses at their first glance of my artwork. Alex also noted that the art making process did not censor his thoughts; instead it allowed them to flow freely. As a consequence, the phrase that came to as conveying the role of art making for Alex was ‘Catharsis: The removal of overwhelming content’.
Intersubjective response for Alex.
Kathryn
Kathryn made art prolifically during her hospitalizations during the study, and her artworks became a representation of the crises that she was working through. By depicting her distress through imagery, Kathryn was able to gradually understand and finally come to a certain degree of resolution. More important to her than being able to differentiate between what was real and what was imaginary in her crises, was the coming to a sense of peace within. For me, an important part of understanding Kathryn was that her family did not want her to acknowledge her Aboriginal ancestry. As a consequence, Kathryn stated that even though she felt an innate connection and sense of personal healing in nature, she did not have the right to claim this part of her identity.
As I carefully applied layers of paint to create the intersubjective response (Figure 2), I felt a sense of lightness and serenity. I noted the change between thinking about luminosity and comfort, as I was cutting out the circle for the sun, compared to feeling grounded by roughly ripping up brown pieces of paper to create the ground. I added the black footprints at the end because I felt a need to acknowledge Kathryn's heritage and her deep sense of spirituality that was integral to her recovery. Through making the response, I understood that the role of art making for Kathryn was a ‘Companion: The existence of a guide to travel along with’.
Intersubjective response for Kathryn.
Sam
Sam viewed her artworks as portraits of her experience. She saw that the qualities of art making provided access to her current emotions and the ability to listen to her current state. This was particularly important as Sam's moods quickly fluctuated, often putting her in a suicidal state. Although Sam had come to regard this as a continuous and ever-changing cycle, it still completely consumed her.
The idea behind my intersubjective response (Figure 3) came from Sam's explanation that Borderline Personality Disorder was like constantly trying to strip away the masks, only to never find the one true mask. I initially drew a series of faces to represent this constant theme in Sam's art making, but then decided to cut them in half, as this seemed more reminiscent of her journey.
Intersubjective response for Sam.
As I pasted the faces onto the page, I saw that this left large white spaces; there was no continuity. I contemplated about how in many ways this was the way Sam's life was; dramatic shifts in mood and then great slumps into despair. She could not turn to others for confirmation of her feelings, as other's views seemed to make her more uncertain about herself. Consequently, I filled in the blank spaces by scribbling with charcoal; they were like these spirals down into darkness. But upon later reflection, I saw that the spirals also enabled one to move out of their darkness by providing a way out.
Upon further reflection, I also thought about the corresponding changes in her art style throughout the study. Sam had developed various approaches to assist in changing her state as well as providing her with various means to excel. Therefore, I saw the role art making provided for Sam was ‘Adaptation: The continuous modification to fit a certain purpose’.
How the insights elicited shaped the study
The intention of this article was to demonstrate the application of the mental health recovery values in a co-operative inquiry. In particular, the first-second-person relationship was experienced empathetically through art-based research. The benefits of this approach to the research outcomes could be seen on various levels. The trustworthiness of the overall study was enhanced as the intersubjective responses further verified my findings and brought forward a shared knowledge about my perceptions taken from the participants' experiences.
The impact of continuously asking for feedback on the analyzed data did not translate to overt comments of ‘thank you for trying to understand me’, but rather relationships built on mutual respect. For example, I have since seen many of the participants at art exhibition opening nights. We happily engaged in conversations around the current art exhibition. There was no discussion about the study and instead they wanted to share with me present and future plans for their art making. I took this as a sign that what they wanted to say had been communicated, heard, and they had moved on.
I am uncertain as to how the majority of the participants' viewed the intersubjective responses in relation to their recovery process. I sent each of the art-based responses with a personalized letter stating my intentions and the insights that were evoked about their art making by engaging intersubjectively. I thanked them for their participation and asked that they send back any feedback. Paul wrote me a letter back stating: What you sent me gives me direction and confirms the decisions I have been making. I now see the distinctions in my art that you recognized. I am glad that I took part in this study as I see things about my art that I didn't see before.
As this study was conducted for my doctoral thesis, I took the lead in its design. So, although the study did not embrace the co-operative inquiry to its full potential, it did as far as possible within these constraints. To further explore the knowledge that can be gained by the researcher and co-researcher relationship within a mental health service, future research might benefit from implementing intersubjective responses during several phases of the research cycle.
To finish… Shifting my view in relation to the study
A creative synthesis of how I came to be evoked by the participants' experiences can be seen in the artwork I created towards the end of the study (Figure 4). I was perplexed with what to do with this artwork and the insights revealed, and so took it to my peer research group for advice. They all viewed the photo of the artwork with great interest, and responded to it strongly, eager to engage with what had been evoked for them. As they spoke we recorded key words that came to them, and these included sorrow, passion, complexity, seeing the spirit, softness, lightness and grace.
Creative synthesis.
I talked to the group about seeing the image in the artwork as a large wound being opened up. A former palliative care nurse, expressed a very different perception of a wound, explaining to me how the uncovering of a wound can provide physical relief, and exposure to oxygen can aid in the healing process. For her, the seeping out was like irrigating the wound with water to cleanse out the debris and allow the body to begin healing itself.
My peer researchers' insights helped me to realize that the role of art making in the recovery process is like the constant flowing of water, cleansing out and creating space for a renewed sense of self. This additional knowledge about the study added a third person (Torbert, 2001) layer to the first-second-person knowledge already gained, providing a richer and fuller perspective to the study. Art making offered unique and transformative experiences for the participants in this study. What I came to know and experience through meeting the I-Thou in the intersubjective responses made me closer, just for a brief moment, in coming to know the other.
