Qualitative findings from a systematic review

This article reports on an investigation of the effects of ‘visual arts’-based programmes on subjective well-being (SWB) outcomes for adults with mental health conditions. In a systematic review, electronic databases were searched for articles published from January 2007 to April 2017. Grey literature completed from January 2014 to April 2017 was also considered. Six published articles of mostly moderate quality and six evaluation reports (grey literature) covering a wide range of visual arts practice, population groups and settings were included. Key themes emerged connected to the concept of ‘bonding’, sense of belonging, appreciation of self-identity and the confidence that engagement in visual arts can facilitate. The overall conclusion supports that visual arts have the potential to enhance the SWB of adults with mental health conditions. The evidence is relatively limited in terms of scope and quality – increased funding across sectors should be secured to support more extensive and long-term research.


INTRODUCTION AND LITERATURE REVIEW
The What Works Centre for Wellbeing (WWCWB) initiative, funded by the Economic and Social Research Council (ESRC), commissioned evidence reviews in key areas, including culture, sport and well-being, the focus of the authorial team's evidence review study programme 2015-19. This systematic review's focus on visual arts was determined as one of the key topics of enquiry following consultation between scholars and stakeholders engaged in artistic and cultural research, policy, commissioning, management, delivery and participation and initiatives. This article reports the qualitative findings of the systematic review from published and unpublished sources concerned with the subjective well-being (SWB) outcomes of engagement with the visual arts for adults with mental health conditions. The literature review following this introduction frames the research questions formulated for the systematic review, and a description of the methods adopted is then provided. Tables and figures presenting full details of the systematic review can be found online (see note 1 ).
The potential for art-based initiatives to promote well-being and mental health is recognized in a growing evidence base (Clift 2012;Clift and Camic 2015;Daykin et al. 2010;Fancourt 2017). A recent inquiry by a UK All-Party Parliamentary Group on Arts, Health and Wellbeing illustrated the meaningful impact that participation in clinical arts interventions and non-clinical participatory arts programmes can have on public health (Gordon-Nesbitt 2017). Visual arts programmes have been shown to enhance well-being and benefit people with a range of mental health conditions (Johansson et al. 2001;Renton et al. 2012;Argyle and Bolton 2005). For individuals, arts participation can help to reduce anxiety and improve mood (Bell and Robins 2007), improve self-esteem and confidence (Stickley and Eades 2013) and contribute to clinical outcomes such as preventing re-admission to psychiatric hospitals (White 2004). A systematic review, although limited by size (six studies), found that arts practice can significantly reduce trauma symptoms in traumatized adults (Schouten et al. 2015). Art participation can also lead to non-clinical benefits fostering skills that lead to increased personal expression and control, reducing stigma by facilitating alternative identities to that of 'patient' and KEYWORDS systematic review visual arts mental health well-being adults bonding belonging self-identity improving community relationships (Hacking et al. 2006;Malley et al. 2002;Daykin et al. 2010;Stickley 2012;White 2004).
In the United Kingdom, mental health conditions represent almost 50 per cent of all morbidity in people younger than 65 years (Uttley et al. 2015). Whilst mental health problems account for a high degree of sickness, the NHS budget to treat them is relatively modest, and the costs (from unemployment, sick leave and crime) and the impact of mental illness on an individual and community level are significant. The Organisation for Economic Co-operation and Development (OECD) estimated that in 2015 mental health problems cost the UK economy approximately £80 billion (Naylor et al. 2016). Therefore, the NHS has come under increasing pressure to initiate cost-effective alternatives to better manage the needs of people suffering from mental health conditions (Uttley et al. 2015). It is increasingly recognized that visual arts projects can reduce the burden on the NHS, and Argyle and Bolton (2005) highlighted the relatively low cost of administering a simple activity such as a drawing group, which can have highly valuable outcomes for people and communities. However, programmes, such as Arts on Prescription, have lacked long-term funding due to difficulties in evaluating their impact on well-being, especially in the long-term; thus, Goulding (2014) claims that they require clear policy support from the Department of Health and the continued development of quantitative and qualitative evaluation measures.
Previous evidence reviews have focused on: the well-being and mental health benefits of arts attendance and participation (Toma et al. 2014); the clinical and cost-effectiveness of art therapy for those with non-psychotic mental health conditions (Uttley et al. 2015); the well-being outcomes of participatory arts for older adults (Castora-Binkley et al. 2010); the therapeutic benefits of creative activities on mental well-being (Leckey 2011); the impact of art, design and the environment in mental healthcare settings (Daykin et al. 2008); and improvements in mental well-being for adults with chronic mental health problems through art-based group participation (Williams et al. 2019). A Norwegian evidence review on the use of arts programmes for mental health and well-being within 'health settings' (Jensen and Bonde 2018) identified positive well-being outcomes for participants involved in visual/creative art programmes. Jensen and Bonde (2018) found arts programmes to be holistic, non-medical, and importantly, low-cost, with a high potential for promoting public well-being and mental health. However, as Leckey (2011) has pointed out, a substantial degree of evidence in this area lacks reliability and validity, in part due to indistinct clarity on key terms, such as 'mental health' and 'wellbeing'. Whilst visual arts programmes are increasingly understood as a public health resource supporting health and well-being, there needs to be a higher level of robust and critical evidence of their effectiveness, outcomes and real costs (Public Health England 2016).
The focus of this systematic review was to identify the 'SWB' outcomes from engagement with the visual arts. Thomson and Chatterjee (2014) confirmed the value of basic measures in museum-based, arts-viewing contexts though their data-collection lacked longitudinal dimensions. Measures of SWB are at the core of the Office of National Statistics (ONS) framework for understanding national well-being. There is no single measure of SWB, but the literature points to three principal components: evaluation (life satisfaction), experience (momentary mood) and eudaemonia (purpose) (Dolan and Metcalfe 2012). Some consider the emergence of SWB measures as the most feasible alternative to calculating national well-being by GDP since measuring GDP 'misses out on so much of what makes life worth living' (O'Donnell et al. 2014: 13). SWB describes well-being in terms of the positive and negative feelings arising from what individuals do, and how they think of their lives. SWB, measured by life satisfaction, worthwhileness, happiness and anxiety, has been included in UK population surveys conducted by the ONS since 2011. The SWB focus of this systematic review was established via collaborative engagement with UK-wide stakeholders representing policy bodies, commissioning agencies, service delivery organizations and researchers from academic and non-academic institutions.

RESEARCH QUESTIONS
The two research questions, from the literature review and dialogue with the stakeholders, defining the scope of the review, were as follows: 1. What are the SWB outcomes of engaging with (taking part in, performing and viewing) visual arts for adults (of 'working-age': 15-64 years) with diagnosed mental health conditions? 2. What are the processes by which the SWB outcomes are achieved?

METHODS
The systematic review included searching for and screening peer-reviewed empirical research that examined the relationship between visual arts programmes and SWB in working-age people with diagnosed mental health conditions, published from January 2007 to April 2017. A ten-year publication date range was used as well-being research in the field of visual arts and mental health is relatively new; plus, a ten-year range captures relevant and recent work and reduces the impact of publication lag and theoretically dated research. We also identified systematic reviews for the purposes of handsearching the reference lists. Grey literature, comprising reports and evaluations of programmes conducted and monitored by agencies or institutions in which the programmes took place, which were completed from January 2014 to April 2017, were included alongside the peer-reviewed sources. The protocol for this review is registered on the International Prospective Register of Systematic Reviews (PROSPERO) (registration number: CRD42017061008).
We included studies focusing on adults (of 'working-age': 15-64 years) with a diagnosed mental health condition, but excluded those with dementia. The population included any group or individual taking part in, performing or viewing visual arts, but not as paid professional artists. We included studies from countries economically similar to the United Kingdom (i.e. other high-income countries with similar economic systems). Any study design (qualitative or quantitative) was eligible as long as it presented empirical data and did not have to report the results of a comparator to the intervention. Two independent researchers searched ten electronic databases (PsycInfo, Ovid MEDLINE, Eric, Scopus, PILOTS, CINAHL, the International Index to Performing Arts [IIPA] and the Web of Science indices: Arts and Humanities Citation Index, Social Sciences Citation Index and Science Citation Index) for studies using keywords related to visual arts, mental health and well-being. The search results were split and independently reviewed by teams of two researchers; firstly, via a screening of titles and abstracts, and secondly, by full paper assessment. The full search and screening processes are illustrated in an online source (see note 1 ).
Grey literature was included if it was a final evaluation or report with empirical data, placed the evaluation of visual arts programmes by recognized methods as the central objective and included details of authors (individuals, groups or organizations). The focus was on synthesizing the most recent work in the field to assess contemporary approaches. Pairs of researchers independently extracted data and assessed study quality using standardized forms. Discrepancies were resolved by discussion and consensus. Where agreement could not be reached, a third reviewer considered the paper, and a majority decision was reached. The screening process identified five qualitative studies (four in the United Kingdom, one in Australia) and one mixed methods study (the United States) in the published papers (with 91 participants) and six reports/evaluations in the grey literature that met the inclusion criteria.

QUALITY ASSESSMENT
Quality was assured by judgements on the level of confidence that we have in the reported findings on each of the seven themes. This was achieved by referring to the GRADE/CERQual criteria. Grading of Recommendations, Assessment, Development and Evaluations (GRADE) is a simple and widely used subjective framework for evaluating the quality and reliability of evidence in a research study (Guyatt et al. 2008). Four categories of confidence in the evidence are used in CERQual: high, moderate, low and very low (Lewin et al. 2015). Confidence was decreased if there were serious or very serious limitations in the design or conduct of the study, the evidence was not relevant to the study objectives, the findings/conclusions were not supported by the evidence or the data were of inferior quality and inadequate in supporting the findings. The six published peer-reviewed studies were all judged as of moderate quality. Moderate-quality evidence should not deter policy-makers or detract from the value of these context-specific visual arts programmes. Evidence is defined 'less by its quality, and more by its relevance, applicability or generalisability to a specific context' (Dobrow et al. 2004: 209). The thematic synthesis that follows is based on these six sources and the six evaluation reports within the grey literature that met the inclusion criteria (see Table 1).

THEMATIC SYNTHESIS OF EVIDENCE
Six published and six unpublished qualitative sources were subjected to an inductive analysis in which 111 codes were identified and then recategorized into seven themes (1-7 in the thematic analysis in the following sections). This analysis provides an integrated thematic synthesis of the overall findings from the twelve sources.

Social dimensions and human relationships
'Bonding' was an important theme, as recognized explicitly in two of the studies (Colbert et al. 2013;Stickley and Hui 2012). Participants gained much through forms of renewed association with others. Both studies referenced Robert Putnam's study 'Bowling Alone' (2000) in which he discusses bonding as an exclusive form of social capital, as opposed to 'bridging', which is inclusive across social groupings. Putnam (2000: 23) observed that 'bonding capital bolsters our narrower selves', and for people with mental

Authors and location Date Participants Intervention
Published studies health conditions, the recognition by and respect from others in the bonding dynamic is an important source of self-esteem and growing confidence; the visual arts experiences could reinforce this. The development of 'a general sense of discovery' (Thomas et al. 2011: 432) was central to, and further stimulated by, such bonding processes, as articulated by a participant, Sam: 'it brings out the spirituality in people […] I find that people find themselves: they discover, they explore, they tap into the inside of them and then eventually it comes out on canvas'. Increasing self-confidence within a group was a major form of SWB for many and was fostered by the bonding relationship. Community (

Stepping stone/journey
Several articles showed how participants see and use the intervention as a way of re-engaging with everyday life, moving forward, 'enabling them to do things for themselves' (Makin and Gask 2011: 70) or negotiating 'stepping stones' (Lawson et al. 2014: 766). This reaffirms the significance of a term previously acknowledged in the field. Such a metaphor, connoting cautious but steady progress, implies a renewed openness to the future. For instance, Arts on Prescription provided a catalyst for positive change for participants such as Ron: 'it's opened up an avenue that I wouldn't have normally looked at' (Stickley and Hui 2012: 577). Making art was seen by one participant as 'a definite positive step […] one more step in a big long journey' (Colbert et al. 2013: 254), a hope-filled further step in the overall recovery journey. The negative side of this might be the fear of the world 'out there' and pressure to fulfil a task; only a few participants, though, expressed such a fear.

Authors and location Date Participants Intervention
Grey literature

Achievement/appreciation
The theme of tackling a task and taking on a project, aspects of everyday life that come as a routine to many, are what several subjects in the studies had been lacking until their engagement with the visual arts. Attendance itself on a regular basis was a form of achievement for some (Lawson et al. 2014), and participants in several studies (Thomas et al. 2011;Makin and Gask 2011;Lawson et al. 2014) appreciated the regular visual arts routine, offering some a sense of continuity and stability, which may have previously been absent in their lives. The making element, the capacity to produce and sometimes display or exhibit artefacts or artworks, could generate respect in ways that made participants feel appreciated. Ten participants in one study stated that the project had contributed to their well-being, through 'achievement, the physical process of art-making and distraction' seen as 'enhancing recovery and wellbeing' (Colbert et al. 2013: 254). For those new to participation in the arts, the sense of achievement was high: '[I]'ve been there and conquered a little bit' (Colbert et al. 2013: 254).

Distraction/safe haven
The most effective programmes took place in stigma-free public spaces, including galleries, museums or community centres, where the participants could feel that they were not defined by the mental health world or system. Well supported by a facilitator or a team of specialists, participants could relax in such a safe haven, and by engaging with the art and any related task, find a distraction from their everyday anxieties. Programmes such as Arts on Prescription created a safe space where participants could be creative with others who share similar experiences (Stickley and Hui 2012). With engagement in a non-threatening environment, homeless members of a regular weekly art group could escape from the problems of everyday life, as Ted put it: 'everything that is buzzing around up here in my brain just disappears when I sit down there and pick up these brushes' (Thomas et al. 2011: 432). Immersion in an activity provided the possibility of 'a few hours where your mind is occupied and absorbed by what you're doing […] so it takes your mind off reality for a while' (Makin and Gask 2011: 71).

Doing/action, not talking
To take on a commitment and enter a programme is a giant stride for people who have been experiencing chronic social isolation, and 'doing not talking' (Makin and Gask 2011: 72) was a critical feature of the programmes for numerous individuals. Talking therapies may be an important source of self-understanding, but engagement with and immersion in an activity could establish the basis of a new sense of identity since others, tutors, facilitators and artists, expressed interest in what you were doing, not 'what your condition is', as one respondent put it. For the homeless, a weekly arts programme acted as a centrepiece of the individual's week, a form of engagement in a meaningful occupation that could foster improved well-being and 'contribute to the goal of community participation' (Thomas et al. 2011: 434). Drawing mandalas, seen as sources of healing in certain traditions, including Jungian theory and Buddhist spiritual thinking, across three consecutive days for only twenty minutes each session, can reduce symptoms of trauma for those suffering from post-traumatic stress disorder (Henderson et al. 2007). Expressing the trauma could be the route towards a healing process: the drawings were an excellent way of subconsciously getting down to the real feelings that so many of us have tried to build a wall around. Sometimes these walls need to come down, so real healing can begin […] thank you. (Henderson et al. 2007: 152)

Confidence building
Acquiring new skills can boost confidence and self-esteem when making art and exhibiting, in a private view for families or friends (Jones 2016;Calvert 2016). Meeting new people can reduce everyday fears, as a participant in the Colour Your Life prescribing scheme in County Durham commented: 'it's made me a happier person. My depression isn't as bad. I'm not as scared of doing new things and meeting new people. It has changed my life' (Allan 2015: n.pag.). The art practice in a supportive context was a source of increased confidence, restoring 'self-worth': 'it's lovely to be able to do something that reminds you that actually you have some worth', as Caroline said, thus bringing the person back 'into the world' (Lawson et al. 2013: 770). A participant at 'Designs in Mind' observed that: Before I came here, I very rarely left the house. I couldn't talk. When I look back to how I was then to how I am now, it is an enormous change. This place has taught me new skills. Slowly my confidence has come back […] I now realize that there is a future. I do a lot more out and about now. I can go to the shops; I take my son to school now on my own, which I could never do before. My life has expanded; it has opened up. Before, it was isolated and closed off to everything. (Wilks 2017: 2)

Identity gain
Engaging with and in the visual arts can provide a foundation for a renewal of identity: in participant Sinead's words, 'you're not treated like a weirdo; you're allowed to be you. That's the main thing; you're allowed to be you' (Stickley and Hui 2012: 576). In one study, seven out of eight subjects agreed that engagement in art was enabling them to forge an identity beyond the overdetermining influence of their mental illness. This was greatly helped by the ways in which they felt treated as normal members of the public in a museum/ gallery: 'stepping into their world and being welcomed in', as observed by Tina, and the quote from the article's title, in participant Paul's words, 'it's like having a day of freedom' (Lawson et al. 2014: 771-72). These participants showed convincingly that identity gain through an increased sense of belonging in engaging in the visual arts with others has reduced mental health labelling and stigma, as felt by the participants. The process of recovery through re-narrativization can also contribute to a renewal of identity (Colbert et al. 2013). Participants who become members or volunteers can experience beneficial changes in their sense of identity (Wilks 2017).
The use of the Warwick-Edinburgh Mental Wellbeing Scale (WEMWBS) has shown in a number of settings described in the grey literature (Wilks 2017;Allan 2015;Willis Newson 2015;Coan et al. 2017;Calvert 2016) how committed engagement in visual arts and art/design practices can achieve considerable improvement in well-being for people suffering from long-term addiction or depression.

CONCLUSION
The two research questions that guided this review were: 1. What are the SWB outcomes of engaging with (taking part in, performing and viewing) visual arts for adults (of 'working-age': 15-64 years) with diagnosed mental health conditions? 2. What are the processes by which the SWB outcomes are achieved?
On the basis of the experiences, feelings and perceptions of participants and respondents, the following positive outcomes can be identified: • Reduction in felt and reported levels of depression and anxiety • Increase in self-respect, self-worth and self-esteem • Re-engagement with the wider, everyday social world (enhanced social capital) • Potential renegotiation of identity through practice-based forms of making or doing.
The answer to the second question is threefold. Intervention programmes should: • Provide secure safe spaces and havens for programmes • Recognize the value of non-stigmatizing settings • Support and sustain collaborative facilitation of programmes and sessions.
It is clear that activity programmes undertaken in non-clinical settings can be experienced as liberating and potentially transformative, in 'normalizing' ways, for participants. Adults suffering from mental health conditions, many of whom have endured long-term experiences of anxiety and depression, reported that they experience existential problems connected with loneliness, isolation, a lack of focus for a projected activity and low levels of self-worth and self-esteem. Sustained engagement in or with the visual arts can create conditions in which self-esteem and confidence are restored. This can offer people a sense of future and re-engagement with others, that is 'bonding' within groups, as some studies reported.
The synthesis of the qualitative studies has produced clear findings. Common to several of these studies, all in the United Kingdom (London, Salford, Nottingham and Woking/Surrey) was a focus on: 'visual arts'based programmes in a local in-situ setting, a gallery or an up-and-running programme; and settings that were seen as safe and a form of haven, outside of the traditional 'mental health system', as some saw it. The voices of the subjects in these studies indicate the importance of social contact, intragroup bonding and support, improved confidence, achievement and accomplishment, the immersive distraction in art-making and the potential re-formation of identity for enhanced SWB. The views expressed in these qualitative studies reiterate Stickley and Eades' (2013) findings regarding improved confidence, self-esteem and increased motivation and aspiration. These 'soft' findings, as Stickley and Eades (2013) call them, help facilitate the 'hard' outcomes, such as educational attainment, paid work or volunteering. The study in Queensland, Australia, confirmed the capacity for art-making as a meaningful activity, contributing to community participation for chronically homeless individuals.
The evidence from the grey literature complements the key findings of the published studies. It expands the evidence base and demonstrates the importance of secure participation, what Wilks (2017), in the 'Designs in Mind' project in Oswestry, England, calls 'membership'. This breaks the language of client, participant or patient-dependency, and puts in place a longer-term trajectory of art and design activity albeit with the risk of the practice itself becoming a new form of dependency, rather than acting as a 'stepping stone' to a new phase of life.
The most effective 'working ways to well-being' are confirmed in the processes of implementation identified in response to the second research question. These processes can be seen as facilitating factors for practitioners planning effective programmes and targeting particular outcomes in professional collaborations (What Works Wellbeing 2018). Some, though very few, negative outcomes from engagement with the visual arts were identified, including the stress and pressure felt to complete activities or commit to art-making, and the valid fear that the end of an intervention would mean a return to heightened anxiety, decreased confidence and social isolation. A few included studies report positive cases of bonding, the forging of in-group connections, but it must be recognized that such bonding can sometimes have a negative dimension in reinforcing what in sociological and social psychological theorizing as early as 1904 was labelled a source of intergroup conflict: 'a differentiation arises between ourselves, the we-group, or in-group, and everybody else, or the others-groups, out-groups' (Sumner [1904(Sumner [ ] 1967. Such differentiation can contribute to the reproduction of social inequalities (Bourdieu 1984).
To conclude, the visual arts and related artistic, creative and craft practices have the potential to enhance the SWB of adults affected and afflicted by mental health conditions. The included studies have also shown the usefulness of qualitative and mixed methods approaches in the development of a theoretical understanding of the complexity and importance of SWB , relevant to both policy-makers and future researchers. A qualitative study has also confirmed that an open-studio approach to art-making has built effective relationships of mutuality -connectedness -between members of a mental health organization and studio managers (Lewis and Spandler 2019). Such studies echo our finding that the potential for a phased progress towards recovery, building community engagement and re-employment of people whose confidence has been rebuilt and restored, some of whom have thrived with the new identity of 'artist', is substantial. In several of the themes presented in our theoretical synthesis, the 'doing' element, comprising both critical appreciation of the art form and the process of art-making, shines through the voices of the subjects. In the study of the participants in the Dulwich Gallery, London, for instance, one male subject, Kevin, stated that '[I] felt like […] I was with the Dutch master at the top'; another, Roger, reflected that 'all arts and things like art, when you gain an insight into it, it's an achievement' (Colbert et al. 2013: 253).
The lack of extensive published evidence identified in this review should not blur the policy need. Alan Howarth, co-chair of the UK's All-Party Parliamentary Group on Arts, Health and Wellbeing, has noted that policymakers, along with funders and clinicians, can 'unlock change' though 'they may not believe that the arts can be an effective means to help them in their purpose' (Gordon-Nesbitt 2017: 6). The evidence in this review shows how and in what circumstances such effective means can be put in place for the enhanced well-being of people with mental health conditions. Bungay and Clift (2010: 280) argued persuasively that 'qualitative methodologies are most appropriate to capture the experiences of participants' in programmes and schemes, also noting the value of reports and evaluations in the 'grey' literature. Our findings echo and reaffirm Bungay and Clift's (2010) observations and demonstrate an accumulating evidence base on subjective well-being and its expressed dimensions. Also, in answering the second research question, we provide guidance on 'what works' for well-being for the populations concerned. Bungay and Clift stated with confidence that available evidence indicated 'that participation in creative activities with others promotes well-being and social inclusion', but that 'the mechanisms involved are as yet uncertain ' (2010: 280). In identifying the importance of safe spaces and havens for programmes, the value of non-stigmatizing settings and the importance of a collaborative facilitation of programmes and sessions, this review brings a greater degree of certainty to the question of the mechanics of implementation.