Justifying the arts in health and care in Finland: A discourse analytic inquiry

Arts-based initiatives have been increasingly introduced into elderly care in recent years in Finland. Consequently, there are more and more reports and dissertations that address such initiatives: their rationale, practices and impacts. Located at the interface between arts educational research and cultural health and well-being research, this article explicates the interpretative repertoires and discourses used to justify arts in elderly care in such documents. The article describes the discourse analytic approach used in the study. Text excerpts are introduced to illustrate the key interpretative repertoires and discourses identified from the data, including discourses on (1) physical and mental health, (2) meaningful life, (3) cultural rights, (4) care ethics and (5) employment. It is argued that how the role of the arts in elderly care is articulated depends on the particular interpretative repertoires and discourses that provide justification statements for their argumentative leverage in the contexts where they are addressed. Subjects: Arts; Cultural Studies; Interdisciplinary Language Studies; Aging; Community Social Work


Introduction
Connections between the arts, culture, health and well-being have been recognised for centuries (Belfiore, 2016). In addition to experiential knowledge, today there is a growing body of research available on the impacts of the arts on health and well-being (see e.g.: Clift & Camic, 2016;Gordon-Nesbitt, 2015;Honkasalo, 2013;Lelchuk Staricoff, 2004;Warren, 2008 Kai Lehikoinen is a university lecturer in Performing Arts at the University of the Arts Helsinki, and vice director of the ArtsEqual Research Initiative. His research interests include arts, health and well-being, artistic interventions in organisations and expanded professionalism in the arts and art education. He has recently authored a book on dance analysis, and co-edited a book on artists in organisation development. His current research focuses on dance in elderly care and with asylum seekers.

PUBLIC INTEREST STATEMENT
In Finland, a national action programme on the arts and culture for health and well-being has encouraged artists and arts pedagogues to collaborate with the health and care sector in recent years. Such collaboration has yielded a large number of arts-based initiatives in elderly care. In his article, Dr Kai Lehikoinen from the University of the Arts Helsinki investigates recent reports and dissertations that address such initiatives in order to identify and exemplify how the arts in elderly care have been given justification from a range of perspectives such as physical and mental health, life content, cultural rights, care ethics and employment. The article highlights that justifications for the arts in elderly care are subject to these and other perspectives, and that some justifications are less appropriate than others in particular contexts to get the message across.
The ArtsEqual Research Initiative, a research consortium co-ordinated by the University of the Arts Helsinki, investigates how the arts and arts education can meet the social challenges of the 2020s in Finland. In ArtsEqual, my research team studies the arts in health, welfare and care contexts to explicate how arts-based practices are justified in such environments. We study such practices to identify mechanisms that generate well-being, and also potential mechanisms of inequality that may hinder participation. Located at the interface between arts educational research and cultural health and well-being research, my recent inquiry has focused on arts-based work in elderly care. While my empirical research focuses on the work of dance ambassadors in elderly care, in this article, I have chosen a broader focus and applied discourse analysis to investigate how the use of arts-based approaches in elderly care has been justified in the above-mentioned documents.
In this article, I will first introduce the role of the arts in elderly care. Then, I will explicate the discourse analytic method that I used to investigate the interpretative repertoires and discourses that provided leverage for the justification statements that advocated the arts in elderly care. Next, I will introduce text excerpts from the data to illustrate the key interpretative repertoires and discourses identified from the data. Finally, I will argue that justification statements on the arts in elderly care depend on particular interpretative repertoires and discourses that give them their argumentative leverage in specific contexts.

The arts in elderly care
Arts in elderly care can be understood as a set of cultural practices that are open to multiple and even contradictory interpretations. From a social constructionist perspective, arts in elderly care entail and are informed by multiple realities. Such realities are discursively constructed, and they "compete for truth and legitimacy", as Gail T. Fairhurst and Grant (2010, p. 174) have pointed out in management studies. This kind of ambiguity is rather obvious as one attempts to investigate how the role of the arts in elderly care is addressed from multiple perspectives and social positions.
For example, some artists and arts pedagogues find it genuinely interesting to work at the interface between the arts and elderly care. Such a hybrid context provides for them an opportunity to expand their professionalism in the arts. Meanwhile, there are other artists who criticise such work for instrumentalising art. Also, residents in elderly homes and in home care, for whom artistic initiatives in elderly care are targeted, respond to the arts in multiple ways: some with enthusiasm, others with indifference or even rejection. That is something to be expected because people in their later adulthood are individuals with different backgrounds, interests and tastes-something that service providers may sometimes forget. 1 Care workers can also have different views on the arts in elderly care. Some of them can appreciate arts projects for their positive impacts, not only on the clients but also on their own well-being at work. Others, however, may fear that arts projects interfere with the daily routine, or cause extra work. Likewise, managers in elderly care may see artists, who are often externally funded, as a convenient free resource to activate residents. Yet, many of them may lack a deeper understanding of the value of art for its own sake, or of cultural rights and arts as well-being.
Researchers approach arts in elderly care from a range of positions including, for example, a work research perspective on well-being (Liikanen, 2013), structural concerns regarding funding (Rosenlöf, 2014) or the quality of arts-based work (Huhtinen-Hildén, 2014). Also, many students reflect upon arts in elderly care in their dissertations: not only students in the arts, but also those in health care, social care and youth work. In their writings, their perspectives range from sociocultural animation with drama (Saranpää & Sinisalo, 2010), to music in elderly care (Sillanpää, 2014), to the arts as a means to work with people with memory diseases (Tiihonen, 2013), or from designing an empowering, visual arts-based workshop model (Pinotek, 2012) to the impacts of the social circus on wellbeing services for elderly people (Kuitu, 2013). Such a multiplicity of perspectives, and also the complexity of potential interpretations, calls attention to the plurality of meanings that are ascribed to the arts as different authors justify the role of the arts in elderly care. Hence, with this article, I wish to contribute to the scarce body of research literature on the discourses through which justification for arts in elderly care is sought and stated.

Using discourse analysis to investigate justifications for the arts in elderly care
Discourses have an important and yet under-researched role to play as we discuss the value of art for society, and also as we introduce the arts, arts education and arts-based services to other fields such as elderly care or, more generally, social work and health care. Drawing from Norman Fairclough (2003) and Bob Jessop (2002), it can be suggested that discourses become strategically important, especially in times of austerity and change, as new initiatives challenge established practices and, therefore, actors are forced to compete to set up new, more advantageous or more economical ways of working. As Finland is currently undergoing a health, social services and regional government reform that is one of the most extensive administrative overhauls in the country's history, the radical shift makes it urgent to investigate how arts-based initiatives in elderly care, and elsewhere in the social and health sectors, are justified. Indeed, the reform may generate not only new windows of opportunity, but also potential threats for the arts sector.
A way to make sense of the different justifications for the arts in elderly care is to use discourse analysis to scrutinise how the value of art is constructed in various justification statements, and to identify particular discourses that provide argumentative leverage for such statements. As there are currently more than a dozen strands of discourse analysis used to study texts and other cultural phenomena, it is beyond the scope of this article to explicate their particularities. 2 It suffices to say that while discourse analysis is not a single method or a coherent practice, I have been drawing primarily from the French philosopher Michel Foucault's (1972Foucault's ( , 1980Foucault's ( , 1981 ideas on discourse and power-knowledge, as I have investigated justification statements on the arts in elderly care as discursively invested texts. Foucault (1972) understands discourses as rather unprecise, historically particular and dynamic areas of knowledge that provide interpretative frames for individuals and communities. Furthermore, discourses are intricately linked to power, as they name things and define reality. Power is "produced from one moment to the next" (Foucault, 1981, p. 93) as it "circulates" (Foucault, 1980, p. 98) in society. It operates through historically particular and culturally specific discourses that people use to construct meanings, generate speech acts, exchange ideas, set up social practices and so on (Mills, 1997). That is, discourses provide what Jonathan Potter and Margaret Wetherell in social psychology (1987, p. 149) term "interpretative repertories" for social interaction.
In my search on discursively constructed interpretative repertoires dealing with the justification of arts-based approaches in elderly care, I used the idea of leverage. The concept of leverage comes from "levour", the Middle-English word for lever: "a bar used for prying or dislodging something, denoting the means of accomplishing a purpose" (Volkema, 2006, p. 3). For Roger J. Volkema in management studies, social leverage has to do with "influencing the behaviour of other parties" (2006, p. 3), but in subtle and not so obvious ways. In his words, a lever "allows one not only to gain advantage, but to do so at a distance" (Volkema, 2006, p. 3). Here, I would like to introduce a Foucauldian perspective, and suggest that argumentative leverages in justification statements on arts in elderly care can be seen as discursive power in action-especially when particular phenomena are ascribed as something inherent to the arts in elderly care, and presented in a favourable light.
In addition to the idea of leverage, I also consulted Teun A. Van Dijk's (2003) and John Wilson's (2003) work on political discourse. As van Dijk notes, political discourse participates "in the enactment, reproduction, and legitimization of power and domination" (2003, p. 360). Thus, I examined the data to see how language and different interpretative repertoires on the arts in elderly care were used "for specific political effect" (Wilson, 2003, p. 410). It needs to be noted that researchers have not reached a consensus on what counts as political discourse. Therefore, in my research the concept of political discourse refers to any discursively constructed meanings that leverage (or undermine) the case for the arts in elderly care.
My data consists of 4 research reports, 7 BA and 1 MA dissertations and 7 project reports that addressed the arts in elderly care in Finland from 2010-2016. As the different disciplines from which the authors addressed their topics were mentioned above, it suffices to say that the arts projects that the reports address range from devised circus and theatre to arts and crafts exhibitions targeted at elderly people, and from co-singing and assisted playing of instruments to dancers and poets visiting nursing homes to co-create with the residents. I used purposeful sampling (Creswell, 1998) to satisfy the saturation criterion, as I analysed the data to identify passages of legitimation or justification from the text. I read the reports several times and treated every passage that attempted to persuade or have an impact as potentially political. I used descriptive coding (Saldaña, 2009, pp. 70-73) with Atlas.ti, a qualitative data analysis software, to create codes and categories to identify different types of interpretative repertoires used in the passages, and in the discourses that operated within them. The coding was very much an interpretative process, which can be described in line with Robert Elliot and Ladislav Timulak (2005, p. 154) as having a "dialogue with the data" (2005, p. 154). As the reports were incredibly rich in their content, the analysis yielded a long list of codes, and in the second phase of the analysis I grouped the codes based on some common denominators that I was able to identify from the passages scrutinised.
Following Michael Billig's (1996, p. 117) idea on justification and criticism as central features in rhetoric, I considered not just the use of words in the passages that I studied but also their argumentative contexts and the specific social context. In addition, I considered "the positions which are being criticized, or against which a justification is being mounted" (Billig, 1996, p. 121), in order to grasp the discursive dynamics that underpin different arguments.

Discussion
The analysis showed that the authors of the documents examined used five broad interpretative repertoires to justify arts in elderly care: physical and mental health, meaningful life, cultural rights, care ethics and employment. Next, I will use excerpts from the data to explicate these repertoires and the discourses that operate within them.

Physical and mental health benefits
The analysis showed that many passages that justify the arts in elderly care link to ideas on health and rehabilitation. Such statements tend to construct arts projects as useful due to their positive impacts on physical functionality, agility, vitality, health and longevity. In Excerpt 1, for example, engagement in the arts is constructed as a means to activate the senses, achieve physical activation and engage socially.
In Finland, connections between the arts and health have been high on the agenda due to the national Art and Culture for Well-being 2010-2014-programme. The programme was launched in 2008 as a result of the Policy Programme for Health Promotion that was issued by the Finnish Government in late 2007 (Liikanen, 2010). There is also a growing body of research available on the interaction between arts and health. Therefore, and also because the care sector is to a high degree informed by and organised through discourses on health and medicine, it is hardly surprising that the health impacts of the arts are high on the agenda when the role of the arts is justified in elderly care in Finland today. Hence, from the perspective of the health discourse, the arts are often justified as a means to rehabilitate people in late adulthood, or that arts provide new methods of stimulation for rehabilitation, as indicated in Excerpt 2.
Excerpt 2 shows how the interpretative repertoire, which draws from the health discourse, seeks leverage for justification in the passage not only from medical research but also from brain research. That is, the value of music in elderly care is attached to a range of positive impacts that brain research has shown music to have, not only on brains, but also on how quickly stroke patients recover. This line of reasoning can sometimes resonate with what Albi Odendaal, Sari Levänen and Heidi Westerlund (2016) call "the allure of neuromyths in advocating the arts" because such attempts to justify the arts are often rooted in "undue simplifications of scientific results and offer misinformation about, and misinterpretations of, neuroscientific findings" (2016).
A sub-group in the health discourse informing the interpretative repertoires that many authors use to justify the arts in elderly care, refers to psychological well-being and mental health. In Excerpt 3, a comment from a nurse in an intensified sheltered housing unit exemplifies how the arts, in this case music, is constructed as a means to help elderly people to relax or cope with distress.

New employment opportunities
In one of the passages examined, the idea of work development constitutes an interpretative repertoire that is used to justify the role of the arts in elderly care. This is evident in Excerpt 4, which refers to a development project set up by the Arts Promotion Centre in South-West Finland. In the excerpt, puppetry is described not only as a means for therapy, as in art therapy, but also as a means to develop a new collaborative mode of working at the hybrid interface between the arts and other fields such as psychology.

Excerpt 4
Taiteen edistämiskeskuksen Porin sivutoimipiste on toteuttanut Nukketeatteri terapian maailmassa -hanketta vuodesta 2012 lähtien. Tavoitteena on tutkia nukketeatteritaiteen mahdollisuuksia terapian ja hyvinvointityön alueilla sekä luoda uusia toimintamalleja taideterapeuttisten työmenetelmien kentälle kehittämällä taiteilija-terapeutti työparimenetelmää. Hanke toimii syventävänä koulutuksena nukketeatteritaiteilijoille ja pyrkii avaamaan uusia näkemyksiä terapeuteille ja muille ihmismielen kanssa työskenteleville. Tarkoituksena on edistää taiteilijoiden työllistymistä omassa ammatissaan ja näin kehittää nukketeatteritaiteen mahdollisuuksia hyvinvoinnin lisäämisessä. (Rosenlöf, 2014, p. 38) The branch office of the Arts Promotion Centre in Pori has been undertaking a Puppet theatre in the world of therapy-project since 2012. The aim of the project has been to investigate the potential of the puppetry art in areas of therapy and well-being work, and to generate new approaches for the art therapy field by developing an artist-therapist -partnership method. The project operates as a continuing education for puppeteers and attempts to open up new insights for therapists and other people who work with the human mind. The objective is to promote the employment of artists in their own professions and, thus, develop the opportunities for puppetry to enhance well-being.
A brief reference to new employment opportunities can be identified in Excerpt 4. This intertextual reference links the passage to a more general discussion in the cultural sector about making a living from the arts, and the fact that an interpretative repertoire on getting paid work for artists is often applied to discuss the objectives of arts-based initiatives, in a range of contexts outside traditional arts institutions. While such an interpretative repertoire, which draws from discourses on economy and employment, may have validity for the cultural sector, it hardly provides plausible leverage to justify the arts in elderly care.

Meaningful life
One of the most often-used interpretative repertoires to justify the arts in elderly care draws from concepts of meaningful life. From such a perspective, as seen in Excerpt 5, the value of the arts is located in the meaningful cultural content, and the joy that participation in the arts brings to people in their late adulthood. https://doi.org/10.1080/23311983.2017.1345048
In Excerpt 6, the leverage for arts in elderly care is constructed by combining two interpretative repertoires: one that draws from health discourse with a reference to functionality, while the other links to the idea of meaningful life. However, in the text this meaningfulness is attributed not only to the cultural content but also to the sense of communality to which engagement in the arts contributes.

Excerpt 6
Opinnäytetyöstä käy ilmi merkityksellisyyden ja osallisuuden tuntemisen painoarvo vanhukselle, sekä virkistystoiminnan merkitys toimintakyvyn ylläpitäjänä ja yhteisöllisyyden edistäjänä. Taiteella osaltaan, sen tekemisellä ja kokemisella on merkitystä ihmiselle läpi elämänkaaren. (Saarinen, 2015, p. 37) The thesis reveals the meaningfulness and the value of the experience of participation for the old person, and also the significance of recreational activities for maintaining functionality and nurturing of communality. Art for its part, its making and experiencing, has significance for a person throughout their lifespan.

Cultural rights
Besides physical and mental health, joy and social engagement, the arts in elderly care have also been justified by an interpretative repertoire that draws from cultural rights. That is: The rights of people to participate in the arts and culture as well as to develop themselves and their communities through them and the possibility of people to express themselves freely are basic cultural rights safeguarded by the UN Declaration of Human Rights, several human rights conventions that oblige Finland and the Constitution of Finland. (Lehikoinen & Rautiainen, 2016, p. 2) In Excerpt 7, the idea of cultural rights can be seen to underpin references to the availability of cultural services, inclusion and the notion of having one's voice heard.
In the extract, it can be noted how the interpretative repertoire on meaningful life entwines with the interpretative repertoire on cultural rights, which draws its argumentative leverage to justify the arts in elderly care not only from democratic values and ethics, but also from references to the subject's sense of being in the world and having agency. Drawing from Michael Lewis (1990), agency can be understood to refer, in this particular context, to both the opportunity and the ability to act volitionally in society: to plan, initiate, execute and control one's actions in society.

Care ethics
In Excerpt 8, the missing agency can be seen to give leverage to the rhetorical question, which in its particular argumentative context justifies the arts in elderly care as a counterbalance to what is regarded as the social emptiness of nursing homes.

Excerpt 8
Päivien huippuhetkiä on kaksi. Ensimmäinen on se, kun liikuntakykyiset siirretään päivähuoneeseen katsomaan televisiota. Toinen on siirto takaisin sänkyyn radiota kuuntelemaan. Asukkaille taataan ruokaa, lääkkeet ja sänky, mutta riittääkö se meidän mielestämme takaamaan hyvinvoinnin? (Kajantie, 2013, p. 8) There are two highlights in a day. The first one is, when ambulatory residents are moved to the day room to watch television. The second one is the move back to their beds to listen to the radio. The residents are guaranteed to have food, medicines and a bed, but is that enough in our view to ensure well-being?
As the reference to "appreciative dialogical contact" in the excerpt demonstrates, interpretative repertoires that use care ethics as a leverage to justify the arts in elderly care often refer to the innate right for everyone to be acknowledged as a person by the other in the present moment, and to be respected. In my reading, such respectful and acknowledging interaction resonates with the concept of "dignity".

Excerpt 9
Kulttuurilla ja taiteella, sekä arvostavalla dialogisella kohtaamisella on merkitystä myöhäisiän hyvinvoinnille. Tärkeintä on löytää aikaa, jotta ikäihmisten sosiaaliset tarpeet tulisivat huomatuksi. Palvelutalossa asuville vanhuksille tulisi tarjota mielekäs arki. Yhteisöllisyys ja osallisuus tuovat turvaa ja mielekkyyttä myöhäisikään. (Sillanpää, 2014, p. 27) Culture and arts, as well as appreciative dialogical contact, have significance for well-being in later adulthood. It is most important to find time so that the social needs of elderly people are recognised. Elderly people who live in nursing homes ought to be offered a meaningful daily life. Communality and participation bring security and meaningfulness to later adulthood.
In Excerpt 9, the comment on the importance of "finding time" to recognise "the social needs of elderly people" and the plea for "meaningful daily life" suggest the use of an interpretative repertoire that gains its leverage from references to dignity. Dignity can be understood as a social construct that, according to Arthur Caplan in medical ethics: refers to the status conferred by those who are moral agents on others-both autonomous and not. It consists of a set of obligations, duties and restrictions on how others and even other objects may be treated by moral agents. There is no inherent property that confers dignity on a human being-it is a social and cultural decision to confer this status … as part of membership in a moral community. (Caplan, 2003) While some scholars value the concept of dignity, critics claim that it is an "empty slogan" (Holmerová et al., 2007;Horton, 2004;Marmot, 2004) that can be reduced to a discussion on autonomy and respect for individuals. 3 Acknowledging these debates, and for want of a better word, I use the concept of dignity, in this article, to identify the interpretative repertoire on arts in elderly care that gains its leverage from references to mindful and respectful attention in social interaction with others.
In Excerpt 9, the comments that refer to dignity can also be seen to carry connotations of care work in the social sector as a dehumanising practice. The excerpt can be read to suggest that in care work there is often no time to recognise the needs of individual clients, and no interest in organising their daily routines in ways that bring meaning to the lives of the clients through participation and a sense of communality. In my reading, the negative connotations in the excerpt resonate with the idea of "clinical gaze", which according to Foucault (1973) separates the individual's identity from his or her body, as the focus is on knowing the illness rather than the individual. Here, however, the extract seems to suggest a sort of institutionalised "care gaze" that is informed by new public management, which has shifted the focus from the individual to efficient care work practices.
As the excerpt shows, by marking present practices in care work with a negative value (dehumanising practice), and marking the arts and culture in elderly care with a positive value (dignifying practice), a stark contrast is created between care work and the arts in order to gain further leverage to justify the role of the arts in elderly care. Such contrasting rhetoric is highly political, and also problematic, because in social reality organisations in elderly care, their work processes, work ethics and also resources vary, which all contribute to the quality of care. Also, there is no certainty that dignity is an integral component of all arts projects in elderly care, albeit such an approach would, without doubt, be desirable.
As the excerpts above suggest, the value of the arts can be justified from a number of perspectives, and with a range of interpretative repertoires and discourses that provide leverage to justify the role of the arts in elderly care. While some justification statements refer to health benefits, meaningful life and cultural rights, others go further and highlight multi-professional collaboration between the arts and care work. Such collaboration may provide new employment opportunities for artists and arts educators, but, by the same token, it demands a repositioning outside the traditional boundaries of art as an autonomous field. Such repositioning suggests an expanded professionalism in the arts, where the artist or arts educator enters a hybrid new field at the interface between the arts and some other professional field such as elderly care. Drawing from Homi K. Bhabha's (1994; see also Rutherford, 1990) idea of "third space", it can be suggested in such hybrid space, the old rhetoric and the old rules of the free artist do not necessarily apply as such.

Conclusions
In this article, I have examined discursively constructed interpretative repertoires that are used in a number of documents to justify the role of the arts in elderly care. As political discourse, such repertoires are used to induce political effects-that is, they advocate for the role of the arts in elderly care. Through critical scrutiny, and with the help of discourse theory, I have pointed out that justification statements for the arts in elderly care constitute a complex set of socially constructed and discursively invested texts.
Based on my analysis, I have argued that the arts in elderly care are justified from a number of social positions. Further, interpretative repertoires, which are informed by discourses on physical and mental health, meaningful life, cultural rights, care ethics and employment, for example, participate in providing argumentative leverage for a range of justification statements that are used in the documents studied. In addition, I have shown that how the role of the arts in elderly care is articulated and justified depends a great deal on the particular discourses that provide the justification statements, and their argumentative leverage in the contexts where they are discussed. I have also pointed out that some discourse types, such as the employment discourse, may be less appropriate than others in advocating for the arts in elderly care.
Nevertheless, arts in health and care do provide new employment opportunities for artists and arts educators. Such opportunities in hybrid contexts call for new principles of practice that need to be negotiated in multi-professional collaboration. This is something to be acknowledged in institutions of higher arts education as they prepare future artists, arts educators and artist-researchers to boost the development of and catalyse new social innovations in this emerging niche.