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Project eARTh: participatory arts and mental health recovery, a qualitative study
Copyright © Royal Society for Public Health 2019 Month 2019 Vol XX No X l Perspectives in Public Health 1
SAGE Publications
ISSN 1757-9139 DOI: 10.1177/1757913918817575
PEER REVIEW
INTRODUCTION
A growing body of evidence suggests that
participatory arts activities can aid the recovery of
people who experience mental health
problems.1–3 Studies report on the social benefits
of attending participatory arts activities, including
peer support, the development of supportive and
collaborative relationships with arts facilitators and
peers, as well as improved social skills.4–6 Arts
projects that are based in community settings
provide non-medical contexts for important
therapeutic activities. Evidence suggests that the
physical space in which arts activities take place
can be highly valued and studies identify the
importance of a ‘safe space’ for participants,
which is often associated with being in
community-based rather than statutory service
settings.6–8 The personal attitudes and qualities of
artists and facilitators are important in terms of
providing an accepting, non-judgemental
atmosphere.
Stickley et al.9 have demonstrated how
participatory arts for people experiencing mental
distress can aid recovery by applying the CHIME
theoretical framework.10 The CHIME acronym
stands for Connectedness, Hope and optimism,
Identity, Meaning to life and Empowerment.
Research on participatory arts for people
experiencing mental distress highlights the
importance of connectedness, friendships and a
sense of belonging associated with one’s identity
through participatory arts.3–6,11–14 People
experiencing mental distress are particularly prone
to feeling and being socially isolated, through
experiences of mental distress, lack of social
support and/or where they live. Social isolation
and loneliness are increasingly recognised as a
concern across the lifespan.15 Individuals
experiencing mental distress living in rural
locations are more vulnerable to experiencing
loneliness and isolation while artistic activities
might be one way to overcome this.
Abstract
Aims: To identify the potential mental health benefits of a rural-based participatory arts
programme in the United Kingdom.
Methods: Fourteen narrative interviews were conducted among participants of the Project
eARTh programme. The data were subjected to a thematic analysis process.
Results: Three overarching themes were identified: identity and self-expression;
connectedness through occupation; wellbeing and personal growth. The importance of
meaningful relationships was highlighted as preventing social isolation, particularly in rural
locations. Engagement in artistic group activities enable participants to connect with their
communities.
Conclusions: Artistic activities help people to develop friendships and to engage with local
communities in rural locations. Connectedness to people and places were valued by
participants as part of their personal growth. The groups empower people to experience
increased confidence and identities beyond illness narratives. Artistic group activities can
benefit the mental health of participants in rural locations.
Project eARTh: participatory arts
and mental health recovery, a
qualitative study
Corresponding author:
Theodore Stickley, as above
Keywords
arts; mental health;
participation; recovery
817575RSH Project eARTh: participatory arts and mental health recovery, a qualitative studyProject eARTh: participatory arts and mental health recovery, a qualitative study
Authors
Ada Hui
Assistant Professor,
University of Nottingham,
Nottingham, UK
Theodore Stickley
Associate Professor, Institute
of Mental Health Building,
University of Nottingham,
Triumph Road, Innovation
Park, Nottingham NG7 2TU,
UK
Email: theo.stickley@
nottingham.ac.uk
Michelle Stubley
Research Associate,
University of Nottingham,
Nottingham, UK
Francesca Baker
Independent Researcher,
University of Nottingham,
Nottingham, UK
2 Perspectives in Public Health l Month 2019 Vol XX No X
Project eARTh: participatory arts and mental health recovery, a qualitative study
PEER REVIEW
Concepts of both individual and social
Identity are significant in the literature. By
working together as artists, people may
perceive themselves more positively, and
develop a sense of belonging through
their artistic activities.5,14,15 Furthermore,
in a non-medical and non-stigmatising
environment, people can change their
identities in the context of positive
relationships with others.7 It has been
asserted that participants rediscover
their identities linked with gaining self-
confidence.4 Participatory arts activities,
have helped people to form new belief
systems about themselves, based upon
worth and value.17,18 For some
participants, they come to refer to
themselves as artists and this becomes
transformatory in terms of
identity.3,5,12,13,17–20 As artists, people may
present themselves to society as an artist
and not as a mental health service user.
Identity formation is central to these
activities, however this may be complicated
by conflicts that emerge, for example,
times when creative expression does not
help with mental health difficulties.21
Several studies specifically claim that
participants become ‘empowered’.3,4,14,16,20
Empowerment within the context of these
studies have been defined as having
choice, being involved in decisions and
dialogue and being engaged in activities
with beneficial effects.3,4,14,16,20 Participants
become empowered by adopting an artist
identity, as well as exhibiting one’s
work.7,14,21 Hope and meaning to life are
claims that have been made in the literature
and are viewed as an internal resource that
can motivate individuals to be and do
more.4,6,14,16,20,22 Becoming an artist
enables people to have a positive outlook
towards the future and aspire towards
creative expression.5,8,17,18 Few studies
specifically report findings from rural
programmes such as Project eARTh set in
the Peak District area in the United
Kingdom. As one in four of the population
are expected to experience mental health
problems, there is potential for community-
based arts programmes to promote public
mental health.
About project eARTh
Project eARTh has been established in
the Peak District since 2010. It provides
weekly group arts activities for people
who use mental health services. The
groups are led by professional artists
with the support of volunteers. The lead
artists’ role is rotated approximately
every 6–12 weeks to allow for different
approaches and a variety of media. The
project has a focus upon the local
environment and seeks to integrate arts
activities within local communities. For
example, art works created by the
groups have included mosaics,
sculptures, bird boxes, wood-carving
for parks, installations for public
buildings, railway stations, general
practitioner surgeries and so on.
Around 15–20 people attend each
session which are deliberately informal.
Hot drinks and biscuits are provided
and the social aspect of the project is
encouraged.
METHOD
Qualitative interviews
This study adopted a qualitative,
narrative approach to the research.23
While narrative research method has
been historically associated with the arts
and humanities,23 there is increasing
evidence of narrative methods being
used in healthcare research.24 Narrative
has been regarded as fundamental to the
development of the human species and
culture.25 Furthermore, it is claimed that
narrative enables people to make sense
of their lives in terms of personal and
social identity.26,27 In narrative research,
interviewees become narrators and
constructors of their stories28,29, which
then becomes qualitative data for
narrative analysis.
Participants were notified in advance
of the request for people to be
interviewed; information was given and
participants were self-selecting. Two
researchers visited both projects and
separate rooms were provided for
interviews to take place. Each participant
gave informed consent and agreed for
the interview to be digitally recorded and
later transcribed. Participants were also
informed that they could withdraw from
the study at any time. Following a
narrative approach, there was no fixed
interview process and people were
asked to talk about their experiences of
the project and were encouraged to tell
their personal stories. Once the
interviews were transcribed, they were
checked for accuracy by the
interviewers. Identifying factors were
removed and pseudonyms were used
throughout to ensure anonymity in the
research.
Qualitative data analysis
One approach to narrative analysis is to
identify themes in the data.23 A thematic
analysis approach was therefore
undertaken following Braun and
Clarke.30 The transcripts were read and
notes taken, sentences highlighted and
observations made, questioning: ‘how
do participants experience the group?’.
An adapted framework approach30 was
used to organise the themes, and
codes were used to group the themes
and make sense of how the themes
related to each other and the patterns
that were beginning to form. The study
used a five-stage approach to data
analysis:
1. Familiarisation with the data;
2. Producing initial start codes;
3. Developing these initial start codes
into broader or overarching themes;
4. Refining and reviewing the themes;
5. Looking at all the themes together,
what story do they tell about how
participants experience the art groups
and why is this important?
FINDINGS
Fourteen interviews were conducted
with participants who attended a weekly
community arts group in one of two
locations within Derbyshire. Ten people
attended one group (A Group) and four
attended another (B group). The
interviews suggest that the participants
from B group had been attending for a
shorter period, it may be a less
firmly-established group and perhaps
reflecting this, the interviewees
appeared less confident and
less vocal.
The participants talked openly about
their lives. Some explained that they
had disabilities or were living with
illness such as cancer. Some were
carers for their partners or relatives. For
Month 2019 Vol XX No X l Perspectives in Public Health 3
Project eARTh: participatory arts and mental health recovery, a qualitative study
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example, one gentleman described
himself as having ‘lost everything’,
having become a widower and had a
brain tumour within a short space of
time. Another respondent had lost her
daughter through illness and had
herself become unwell and isolated as
a consequence of caring for her
daughter prior to this. There were
members of the group whose physical
health meant they were, for example, in
wheelchairs or on crutches and some
people referred to the need to take
medication for physical and mental
health conditions. Being able to attend
the group with a carer helped some
people because they were there to
support them with medication and
mobility. For those carers who did
attend, it appears the group was
important for them too. As well as
physical health issues, some of the
interviewees referred to having mental
health diagnoses which included post-
traumatic stress disorder, obsessive
compulsive disorder, schizophrenia,
depression, anxiety and social phobias.
The interviewees had attended the
weekly art groups for various lengths of
time. Some had only attended a few
sessions and some had been going for
years; one person had attended since
the project began. The groups are
located in rural Derbyshire and being
able to get to the groups by taxi or being
met to go on buses together was a very
practical but extremely important way in
which the interviewees felt supported to
attend.
Themes
Findings from the 14 narrative interviews
emphasised the therapeutic benefits
associated with participatory arts. Three
overarching themes were identified
through the analytic process. Each of
these themes are presented together
with direct quotations from the data to
illustrate each theme. The data were
analysed by individual members of the
research team, discussed and combined:
•Identity and self-expression;
•Connectedness through occupation;
•Wellbeing and personal growth.
Box A contains the coding table.
1. Identity and Self-Expression
Of the 14 participants taking part in the
interviews, the majority identified
themselves as experiencing either
physical or mental health problems, or a
combination of the two. Each of the
individuals spoke of their participation in
artistic activities as being important
towards their personal sense of identity
and self-expression:
The thing is we’re coming to something
like this, you can very often experience
something very different than what you
think of yourself really, you know,
because you don’t know what they’re
going to ask you to do. So you know,
try something new. (Derek)
Participants highlighted the importance
of feeling able to talk openly about their
experiences, of being able to be
Box A
Coding table
Overarching
themes
Sub-themes Codes
Identity and self-
expression
Co-morbid health
conditions
Difficult life events
Pride, achievement
Confidence
Mental health
Physical health
Bereavement
Being a carer
Social anxiety
Choosing the artists
Choosing the settings
Exhibiting
Connectedness
through occupation
Collaboration and
community
Getting out of the house
Social isolation
Group support
Skills
Working together
Visiting sites
Atmosphere
The local environment
The local community
Nature
Isolation
Making new friends
Understanding and empathy
Supporting each other
Wellbeing and
personal growth
Variety
Inspiring
Escaping
Remembering and
reminiscing
Group support
Humour
Trying new things
Getting out of your comfort zone
Sharing ideas
Remembering people and places
through materials used and through
visits
Escaping your thoughts, getting lost in
the art
Gaining new skills
Remembering and improving on old
skills
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themselves when they were experiencing
a ‘bad day’ and of being accepted,
understood and mutually supported.
Participants also spoke of developing
their sense of identity beyond that of
‘patient’ or ‘carer’, and of strengthening
their relationships outside of the ‘patient/
carer’ roles though attending the groups:
I’m not an especially social person,
but I’ve become a bit more social I
think probably through this group.
What I get from it in particular is
learning new things and being creative
... So it’s not just any art group. It’s
not just going doing some art. It’s that
we’ve all got a story. (Hattie)
Some participants took on
responsibilities in the organisation of the
groups. Some were involved in choosing
the artists and sat on a panel of
interviewees to help to decide who would
come and work with them. The qualities
that they liked in the artists included
skilled, well-organised, calm,
professional, good sense of humour,
‘does not flap’, ‘does not get irate’ and
‘does not treat you differently because of
your mental health issues, joyful, bubbly,
friendly and exciting’. Participants spoke
of the importance of being part of the
interview selection process, of ensuring a
connection with the artists and
relationship based on mutual
understanding:
All the artists that come in have been
great with us all, they’re friendly, they
understand if you want a break, they’ll
just let you wander off. They’ve all
been great really, all the artists we’ve
had in. (Maggie)
In terms of evaluating the groups, as
well as the artists’ personal qualities,
participants identified that the groups
were well-organised. They appreciated
how welcome they felt and they also
appeared to relish the opportunities to
get involved in decision-making.
Examples they gave were interviewing
artists, fundraising, choosing locations for
finished pieces and finding trustees to
take part in the management of the
groups. Such responsibilities enabled
people to feel responsible and
contributed to this sense of a positive
identity.
2. Connectedness through occupation
Participants spoke warmly about the
sense of connectedness they had
developed from being involved in the
arts projects. They also spoke of the
significance of the support of the artists
and organisers. This supportive
environment enabled sharing within the
group, which was also facilitated by
members of the group having had
similar experiences. These shared
experiences enabled the development
of supportive relationships, group
cohesion, and the building of
confidence, all within an accepting and
supportive environment:
It is a wonderful group because we’re
all in the same situation. We have
days when we’re not very good. We
have times that we are more able ...
You know, we help one another and
reach out to one another ... It’s the
encouragement and the help that you
get from one another. (Claire)
A sense of connectedness was
highlighted by the participants not only
as being part of a group, but also as
being part of their wider communities.
Participants spoke of their sense of pride
at having their work displayed to the
public, of visiting new places and of
getting to know the communities they
inhabit:
Sometimes we do things individually
but then they come together to
produce a whole thing that is then
publicly celebrated. (Hattie)
As well as the making of artworks and
the support of the artists and the
organisers being important to the
participants, it was also the fact that they
were sharing these experiences with a
group of individuals, many of whom had
similar life experiences to themselves.
This shared experience allowed
participants to offer mutual support,
make new friends, celebrate birthdays
together, enjoy laughing together,
encourage and help one another, accept
and support each other and boost each
other’s confidence:
You get a lot of support from the
people who actually work here. But
meeting people who suffer with similar
problems is very useful. ... it’s easy to
open up to people and it feels like
everybody is very understanding of
each other ... and that’s why obviously
people attend the group ... (Debbie)
The meeting of new people and
making friends was described as a ‘life
saver’ by some and for people attending
the group who had been isolated prior to
joining the group, it does not seem like
an exaggeration:
... I think it’s worth its weight in gold,
you know. I really do feel that for some
people, myself included, it’s a
lifesaver, you know. (Claire)
The isolation people faced was due to
a combination of factors such as physical
and mental illness, caring responsibilities
and social anxiety or fear. Therefore, the
way they were brought into the groups,
the ongoing support available and the
fact that people could come in pairs or
with support workers was very valuable.
Despite participants identifying initial
challenges of attending group activities in
rural locations, many participants spoke
of having attended the group for years.
The positive changes through
engagement with artistic activities had
been noticed by individuals as well as
their friends and families:
Yeah it’s just being able to talk ...
Actually get up and go somewhere,
and then integrate and mingle with the
people and talk to them whilst I’m
here. My wife said I’m getting back to
my old self. (Dan)
Findings from this study indicate the
importance of this group in tackling
serious social isolation. Interviewees
spoke almost unanimously about this
issue, about how attendance was the
only thing that got them out of the house
every week. Getting out of the house
was a profoundly important factor for the
interviewees, several of whom would
Month 2019 Vol XX No X l Perspectives in Public Health 5
Project eARTh: participatory arts and mental health recovery, a qualitative study
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have been socially withdrawn without
their weekly visits to the group. For many,
it was the only time they went out all
week:
I’ve really enjoyed it, yeah. It’s
basically saved my life in one way
because I was really poorly at one
stage where I lost all my confidence, I
couldn’t talk to anybody, I was a
wreck living in a bubble. (Daisy)
Connecting with others, forming new
friendships and creating safety-nets to
care for each other were regarded as
valuable to participants who were
experiencing social isolation and
loneliness prior to joining the class:
... I used to find it very difficult in college
or at school to work in groups and this
has helped me to communicate with
people more and learn how to work in
a group ... But some of the projects, it’s
necessary to work in a group, you
know, and in order to finish it you have
to work with other people. (Debbie)
An important aspect of the art groups
for the interviewees was the chance it
gave them to be involved within their local
communities. Interviewees were involved
with various activities including
volunteering roles within their
communities as a result of their
involvement in the art group:
And we sort of find out what’s going
on a bit as well because we’ve lived in
(the area) for probably about 5 years
but we don’t know anyone. But now
we do know people. (Sophie)
One person talked about how their art
was used for posters and signage at the
local railway stations. Their work was
also displayed in an old people’s home
and parks:
... You know ... it was in Buxton
recently that willow sculpture and its
gone into an old people’s home’s
garden and that will bring them some
happiness. (Dan)
Another important aspect of the sense
of connectedness is shared humour,
which seemed to play an important role
in enabling people to get on well and
support each other:
Humour is very important, yes ... while
we kind of all know each other and
know what to expect from someone
new coming into that, yes they’ve got to
have sense of humour, being
encouraging and supportive ... pride and
joy, you know ... encouraging. (Hattie)
3. Wellbeing and personal growth
Each of the participants spoke of the
importance of the arts group in maintaining
their sense of wellbeing. Participants
frequently associated their involvement in
the arts with having meaning and purpose,
while enabling them to develop, grow and
transform as part of their personal
journeys towards recovery:
I think that these classes are
absolutely wonderful, well they’ve
been for me because they’ve enabled
me to stay well, given me a purpose
and a reason. (Jenny)
My wife said I’m getting back to my
old self. (Dan)
Recovery or coming to terms with
illness was an important aspect of the
art group. By being enabled to create
something and learn new skills, people
experienced a renewed sense of their
own abilities and this was perhaps,
especially poignant in the examples
given of people who had lost their
ability to carry out their usual work
because of illness or disability:
... I was once with a gentleman in my
class and he was a very clever
person, a university lecturer ... but he
had a major stroke ... ... I saw him go
from really being a very sick man, very
frustrated with the world because he
couldn’t do his work or anything ... It’s
just wonderful (seeing him now).
(Jenny)
Fundamental to the success of the arts
groups was the atmosphere that was
created between the participants, arts
facilitators and organisers. Participants
spoke of the social isolation they had
experienced prior to being part of the
arts groups and, by way of contrast, the
mutual support they subsequently
experienced in the groups.
You get a lot of support from the
people who actually work here. But
meeting people who suffer with similar
problems is very useful ... it’s easy to
open up to people and it feels like
everybody is very understanding of
each other because everybody
appreciates that somebody is suffering
from something and that’s why
obviously people attend the group ...
So I don’t seem to get as paranoid like
that when I’m here. (Debbie)
Participants spoke of the environment
as feeling calm, relaxing and safe. The
participants spoke of the therapeutic
nature generated by the arts groups as
being through a combination of the
environment, artistic activities and
opportunities for reminiscing, hope and
escapism:
I think just mixing with people and its
quite a calm environment and you
know you can just get absorbed in
what you’re doing really and just
switch off a bit, you know, depending
on what you’re doing. (Sophie)
Along with gaining new skills, the
enjoyment of producing art and
seeing the finished pieces, people
also spoke about how being creative
enabled them to become ‘lost in the
moment’, engrossed and they may
momentarily forget themselves and
their worries. One man described how
he had learnt to restore old photos
and this was very special to him as his
wife had died but he had been able to
restore an old photograph of her,
which he kept with him and treasured.
Another woman talked about she had
been able to incorporate some
ribbons into a weaving that the group
did. The ribbons had been collected
over the years by her and her
daughter who had sadly died, so
being able to use them to create
something like this was very
meaningful to her.
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The art groups were also therapeutic in
the sense that people were able to lose
themselves in the work, feel calm, have
their mind occupied and relax.
It helps me relax really because
sometimes I can’t concentrate for so
many length but when I get into it I
start relaxing and I just sit there and
doodle away with it. (Maggie)
DISCUSSION
The findings of this study are in support
of the recovery outcomes identified by
Leamy et al.10 in their CHIME framework
and a further study which applied the
framework to participatory arts.9 This
project builds upon this evidence
especially in terms of the co-production
of arts works between the arts groups
and the local community. Indeed, the
strengths of the project have included
contributions made to the local
community and cultural environment, as
well as the concomitant personal
benefits engagement in group artistic
activities has for participants. Social
connectedness, group identity and
sense of purpose and belonging were all
highlighted as personal benefits gained
through engagement with the
arts.3,4,5,7,14 Acceptance, shared
experiences, peer support and
developing friendships were benefits of
being part of a group. This is of great
significance, as the arts groups are set in
rural areas identified as high risk for
loneliness.31 In the studies identified in
the earlier section, it appears that most
projects were based in cities where there
may be greater opportunities for people
to ‘move on’ and establish new
identities. However, initiatives to promote
social inclusion for people with ongoing
mental health difficulties is a complicated
process and cannot be universally
defined or prescribed; what may work in
a city, may not work in a rural area.
This study adds an insight to the
current research evidence into how
participatory arts activities might be
best provided in a rural setting and
with a less-transient client group. The
groups are not a form of ‘social
prescribing’ and more aligned to the
needs of people using secondary care
mental health services rather than
primary care. While previous studies
have focused upon short-term
projects, with an expectation for
people to ‘move on’, this study is
more concerned with ongoing
provision. The groups have become
well established (since 2010) and have
allowed friendships to form over time.
These longer-term groups may provide
rich benefits such as a deepening of
relationships and becoming more
established in local communities and
being able to contribute to them
through the displaying of public
artworks. These social benefits include
a sense of social connectedness and
belonging identified as core processes
in mental health recovery.10
In terms of personal benefits for
those attending the groups, they
valued developing their creativity and
people described how it enabled
them to learn new skills, encourage
and develop existing or forgotten
talents. They talked about how they
had new opportunities to expand into
more professional art worlds, for
example, displaying art in galleries
and public settings and doing more
arts and crafts at home. The work
produced was of a high standard and
technical skills (e.g.in ceramics) were
mastered. The participants were often
amazed at their own
accomplishments, such as writing
and producing a song or having their
work installed in public places such
as railway stations. Each of these
personal benefits may enable a more
positive identity consistent with
previous research findings.3–6,11–14
The groups included varied art forms
such as computing, writing, singing,
ceramics, dancing, glass work, poetry,
song-writing, willow-weaving, mosaics,
felt-making, metal sculpture and photo
restoration. Participants value the variety
on offer. Some preferred visual art
whereas others felt the singing classes
were wonderful ‘like a night out’, and
some found they were occasionally
outside of their comfort zone.
Overall, the participants appear to hold
the groups in high esteem and enjoyed
feeling challenged. They were clearly
enthusiastic and grateful for the
opportunities the groups afforded them.
The artworks produced also seemed to
have themes that tied in well with the
local natural environment and highlighted
the positive qualities of the local area
such as nature, railway heritage, wildlife
and so on.
In this study, the groups are regarded
by participants as invaluable and for
some, a lifeline. For many, it is the only
time during the week when they would
leave their homes. These groups are
therefore important in preventing social
isolation as well as in providing a
supportive and nurturing environment in
which people can be creative.
Involvement in the art groups has allowed
individuals to connect and re-connect
with their local communities, widening
their social circles and facilitating them to
expand and develop creatively. The
groups have helped the members to
become well and stay well. The work
produced is of a high standard and is
embraced by local communities, giving
the group members a sense of personal
pride and achievement and a sense of
purpose and role in their respective local
communities. Loneliness has been
identified as a serious factor for those
who experience mental and physical
health difficulties32 and groups such as
those presented in this study, may
provide a solution to this problem.
CONCLUSION
A growing body of evidence is
developing to support participatory arts
activities to promote mental health
recovery. This rural-based programme
enables people to develop friendships
and to engage in local communities over
a period of time. Spontaneous peer
support is highly valued by participants
as well as a professionally led arts
provision. The groups enable people to
experience increased confidence and
identities beyond an illness narrative.
The long-standing nature of the groups
contributes towards the formation of
richer relationships and the enabling of
personal and skills development. Such
groups have yet to be evaluated in terms
Month 2019 Vol XX No X l Perspectives in Public Health 7
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of their potential to prevent mental health
problems, but given the mental health
benefits participants experience, there is
a strong argument for such groups to
become mainstream activities to
promote the public’s mental health.
ACKNOWLEDGEMENTS
Project eARTh is a partnership between
High Peak Community Arts, High Peak
Mental Health Project and High Peak
Community Mental Health Team. It is
funded by the Reaching Communities
programme of the Big Lottery Fund, which
also funded this research. Ethical approval
for the study was granted by the University
of Nottingham Faculty of Medicine &
Health Science Ethics Committee. The
authors would like to thank the organisers
for their help and cooperation, and declare
no conflict of interest.
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