From Recovery-Oriented Care to Public Health: Case Studies of ...

J. Psychosoc. Rehabil. Ment. Health (2015) 2(1):9–18 DOI 10.1007/s40737-015-0024-7

ORIGINAL ARTICLE

From Recovery-Oriented Care to Public Health: Case Studies of Participatory Public Art as a Pathway to Wellness for Persons with Behavioral Health Challenges Nathaniel Vincent Mohatt1,2 • Bronwyn A. Hunter2 • Samantha L. Matlin2,3 Jane Golden4 • Arthur C. Evans3 • Jacob Kraemer Tebes2

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Received: 19 November 2014 / Accepted: 1 March 2015 / Published online: 2 July 2015 Springer India Pvt. Ltd. 2015

Abstract The objective of this study is to identify individual mechanisms of change that result from engaging in an innovative participatory public art project for persons with significant behavioral health challenges. We present two case studies that examine how participatory public art promotes recovery and wellness. This research is part of a larger, multilevel comparative outcome trial on the impact of participatory public art on the health and well-being of adults in recovery from mental illness and addiction and on the distressed city neighborhoods in which they live. The case studies describe the unique ways in which participatory public art contributed to key recovery domains of growth in friendship, self-discovery, giving back, and hope. The two cases indicate that the development of a strengthsbased sense of self through art was accompanied by a growth in personal social responsibility. The two cases also indicate that participatory public art may have a profound impact on the internalization of stigma. The findings support the value of participatory public art as a strategy for blending recovery and public health perspectives to promote both individual and community wellness.

& Nathaniel Vincent Mohatt [email protected] 1

The Western Interstate Commission on Higher Education Mental Health Program, 3035 Center Green Drive Suite 200, Boulder, CO 80301, USA

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The Division of Prevention & Community Research and The Consultation Center, Yale University School of Medicine, New Haven, CT, USA

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City of Philadelphia, Department of Behavioral Health and Intellectual disAbility Services, Philadelphia, PA, USA

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City of Philadelphia Mural Arts Program, Philadelphia, PA, USA

Keywords Public art Arts participation Recovery Wellness Case study

Introduction Over the past four decades, treatment for individuals with serious behavioral health conditions, such as addiction and mental health disorders, has progressed from institutional care to a range of community-based services that emphasize a recovery perspective [9, 17, 19, 35]. The hallmarks of this perspective include community integration, collaborative service planning, consumer choice, and strengths-based approaches for use with persons who have serious behavioral health challenges [5–7, 9, 18, 34, 35]. This concept of recovery was developed from patient accounts and coupled with a growing body of research demonstrating that people can and do recover from behavioral health struggles and are able to lead thriving and socially integrated lives [9]. This manuscript presents two case studies that tell two distinct stories of how participation in an innovative public arts program promoted recovery from addiction and mental illness. The purpose of these case studies is to identify the mechanisms that underlie how participation in a public art program can promote recovery and wellness among people with significant behavioral health challenges. The term ‘recovery’ refers to a process that is unique to each individual and encourages living a fulfilling and productive life regardless of one’s disability [3, 28]. Individual factors conducive to recovery include empowerment, hope, healing, and connection to others [16]. From a patient’s perspective, Patricia Deegan [5] identified the three cornerstones of recovery as ‘‘hope, willingness, and responsible action.’’ Additional research emphasized the important roles

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of having friends as well as giving back to others and the community [3]. From a policy and treatment perspective, recovery-oriented care includes the protection of people’s human rights [9] and promotion of citizenship [2, 25]. An emerging trend in behavioral health is to integrate the recovery and public health frameworks [20, 21]. The resulting blended framework expands upon the recovery perspective to include an emphasis on population health, larger-scale social and environmental change strategies, and wellness [20, 30]. The population focus redirects interventions toward changing social systems and related environments that can impact many people at once [20, 21, 24, 31]. Such larger-scale changes are then examined for their impact on community integration, service planning, choice and the use of strengths-based approaches at a community or systems level [30]. In addition, a public health perspective emphasizes wellness as a by-product of recovery-oriented care and the community integration for persons with addiction and mental health challenges [20, 30]. Thus, change efforts seek not only to reduce or prevent illness, but to promote health, thriving, and wellness [20, 21, 24]. Participatory public art provides a unique opportunity to blend recovery-oriented behavioral health with a public health perspective by emphasizing both individual- and systems-level change to promote wellness [22, 29]. We define participatory public art as acts of voluntary and collaborative creative expression by a group of individuals to produce something of aesthetic value for permanent public display. The participatory public art program described in the case studies involves collaboration among professional artists, persons in recovery from addiction or mental health conditions, behavioral health professionals, and community members to design, paint, and install a large public mural in a distressed urban neighborhood. Existing research suggests that participatory public art can benefit people in recovery from behavioral health challenges in at least four critical ways. First, it provides peer- and professionally-supported opportunities for community integration for individuals with behavioral health challenges. In fact, research has demonstrated that arts participation can promote social inclusion among individuals who have mental health diagnoses [14, 15, 23, 27]. Second, it affords an opportunity to develop friendships based on mutual interests and enjoyment, thus expanding one’s social network [27]. Thus, participatory public art can foster shared connections, reciprocity, and mutuality in relationships with program participants, artists, behavioral health professionals, and community members [33]. Third, it creates a social setting in which individuals who are often stigmatized and marginalized can constructively interact with others to affect positive community change [8]. By working to beautify and improve the community,

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J. Psychosoc. Rehabil. Ment. Health (2015) 2(1):9–18

participants can change how community members view them and also how they view themselves as contributing members of the community. Fourth, the production of public art is a ‘‘nuts and bolts’’ activity in which a project is carried out from start to finish. Thus, participants engage in the process of envisioning and completing a large-scale public transformation project, which encourages the development of practical skills, such as planning, constructive social interaction, and implementation. These skills may be useful for other parts of participants’ lives, including readiness for employment [27]. Furthermore, the permanent quality of participatory public art, particularly the creation of a mural in a public space, creates a lasting testament to the creative process of envisioning a future that is better than the present. In this sense, participatory public art serves as a vehicle of cultural transformation, through envisioning and creating lasting change in how a particular neighborhood setting is understood and experienced [22]. Art products and processes interact with the social environment in which they are created, providing both artist and audience the opportunity to envision the future as something new [33]. Scarry [26] argued that experiencing the beauty of art inspires people to care for and create more beauty in the world; in essence, public art establishes a future-orientation to sustain and promote wellness [20]. The present case studies portray the individualized recovery processes that result from engaging in a participatory public art project for persons with significant behavioral health challenges. At the individual level, the project seeks to promote recovery, community integration, and wellness; at the community level it is an attempt to foster neighborhood revitalization among community members who are often socially and economically marginalized [8, 22]. Consistent with our literature review, we expect that individuals will report: (1) enhanced community integration; (2) increased friendships; (3) a view of one’s self as a contributing community member that is stimulated by reports of individual transformation, (4) the acquisition of practical skills; and (5) an increased sense of hope. These case studies portray the individual richness of experience—the two stories provide powerful illustrations of how common recovery themes uniquely emerge. Our goal in presenting and analyzing these stories is to find these potential unique mechanisms of change resulting from participatory public art.

Method This study is part of a longitudinal, community-based participatory research (CBPR) project that examines the impact of participatory public art on adults and youth


enrolled in behavioral health services and on the distressed city neighborhoods in which they live and participate in services. The project involves collaboration among various departments in a large city in the eastern US: a public arts agency that contracts with independent artists, a half dozen community agencies that provide behavioral health and related services, an academic partner, and local and national funders. The project spanned 4 years. We use a qualitative longitudinal case study method [1] to examine how participation in participatory public art contributes to wellness. Case studies are uniquely useful for capturing the individualistic processes of recovery [7, 32]. Intervention and Recruitment The intervention consisted of teams of artists who worked at identified partner agencies for approximately 9 months to paint and install a large mural in a public space. Participants engaged in program workshops that included conceptualizing and designing the mural; didactic art lessons; exposure to other art forms, including poetry and tapestry; and mural painting. The process of painting the mural allowed any level artist to participate by using a system similar to paint-by-numbers. Participants painted the murals indoors, section by section, on large sheets of parachute cloth, which arts program staff then professionally installed in a public space in proximity to the partner agencies. A professional artist or team of artists hired by the public arts agency led programming at each site. The programming was deliberately non-clinical with a focus on the production of public art for the betterment of the local community. Local community members and businesses provided input on the mural design and participated in mural painting on designated community event days. Program participants were clients of the behavioral health partner agencies who voluntarily signed up for and attended workshops. The behavioral health partner agencies offered the program to their clients as an optional activity; and for some clients participation was incorporated into the treatment plan they discussed with their primary counselor. 264 adults participated in the intervention and evaluation, with 71 % of the total sample identifying as African American and 94 % as a person of color. Informed consent was obtained from all individuals, and included a detailed description of both the quantitative and qualitative interviewing and data collection plans. Most program participants lived in proximity to the partner agency and the low-income neighborhoods where the murals were installed. At all intervention sites, the work culminated in the creation of a public mural available for permanent display. Through participant observation and discussion with study-site lead artists, the first author created an initial

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selection of potential case study participants from the larger pool of study participants. This selection process involved identifying participants who met three qualitative criteria: (1) the ability to share their personal experiences in the program; (2) the ability to communicate effectively about complex topics; and (3) a willingness to be candid in their appraisal of their experiences. All candidates were contacted and solicited for involvement. Following the first round of interviews the first author revisited the selection criteria and narrowed the participant pool to three per site per year to follow longitudinally. 10 participants from intervention sites completed case study interviews and five were followed longitudinally, with a total of 19 completed case study interviews. The decision to narrow the pool for longitudinal interviewing was made based on apparent data saturation at the time of the initial interview, and participants were selected to maintain diversity of background and neighborhood location. For the current study, we chose to focus on the two cases presented in order to provide an in-depth view of participant experiences from different perspectives. The two participants lived in different neighborhoods and attended programming at separate sites, with different lead artists and foci—one site was lead by a muralist focused primarily on painting, while the second site was led by a team of artists and included a substantial focus on poetry. Their unique stories are representative of accounts provided by the 10 participants interviewed. Data Collection The first author collected the case study data through several in-depth qualitative interviews that occurred during three periods over the course of 1 year—at the beginning of the workshops, immediately following the completion of workshops, and 6-months after the installation and dedication of the murals. The first author also conducted participant observation by visiting and taking part in program activities approximately once per month. Field notes from participant observation augmented the primary case study interviews. Case study participants received $10 gift cards each for completing the first and second qualitative interviews, and a $20 gift card for completing the third interview. Ethics approval for the study methods, including the case study interview protocol and participant observation method, was obtained from a city and a university IRB, providing active consent and ethical review of the study methods. The case study interviews followed a semi-structured format with a set of guiding questions. Questions focused on (1) how the project changed their view of themselves, others, their neighborhood, and perspective on life; (2) what it was like to work alongside other with addiction and

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mental illness, and whether the project impacted their sense of being stigmatized or the stigma they may have observed others experiencing; (3) how participation impacted their feelings toward the agency where they were receiving services; and (4) very generally, what was it like to participate in the weekly art workshops. The interviews focused on documenting the client’s perspective on these issues at the time of the interview, so that change could be assessed through analysis of interview notes. Interviewers used active note taking, reflective listening, and review of interview notes with the participants to create field notes of the interviews, followed by a detailed write up of each interview based on the notes and interviewer recall. Each interview lasted between thirty minutes and one hour. Data Analysis An existential-phenomenological orientation guided the analyses and construction of the background and participation storylines [4, 10]. This orientation leads to establishing a coherent story for each case based on case study participants’ experience and observations from the first author [12]. Following Giorgi’s [11, 13] phenomenological method, we interpreted the key meaning units and turning points in the raw data from a psychological perspective, leading to the identification of four emergent themes grounded in the literature on community integration, recovery, and wellness. The first and second author initially coded the interviews independently, and then engaged in an iterative process with the rest of the study team to organize the themes and arrive at consensus. Subsequently, the case studies presented below were organized under the four themes of: (1) friendship, (2) sense of self, (3) giving back, and (4) hope. The friendship theme encompassed descriptions of peer interactions and reflections on the meaning and nature of friendships. Sense of self includes reflections on self-awareness and changes in selfconcept. Giving back refers to contributing to one’s community and awareness of how one can help others, or what one has to offer the people around them. Hope refers to descriptions that either exemplified or directly expressed an empowered and future-oriented sense of capability and positive expressions about the future of one’s physical and social life world.

Results Ben’s Story Ben is an African American male, now in his 50’s, who grew up poor in the city in which he currently lives. His mother was an alcoholic and was not able to care for him

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and his younger brother. He began working at a young age, dropped out of high school, and turned to the streets for a sense of family: You see, as a child I lived in a dysfunctional family, with lots of drinking. My mom was an alcoholic, and it deviated me from sticking with my education and school. When I was 14 I started working… And so, because of the arguing in the house, I turned to the streets. The streets became my family. Through the self-reliance he learned at a young age, he was able to maintain employment throughout much of his life despite being in and out of substance abuse treatment ‘‘for a long time.’’ Following a divorce after 25 years of marriage, he started dating a woman with whom he would have heated arguments. One evening, while they were arguing loudly and violently outside their house, he was arrested for domestic violence. After pleading guilty, Ben was released on 5 years of probation, but says, ‘‘I got out, but the guards in there really messed with my head. So I went and got all sorts of drugs, and started taking them all. I tried more than I ever had, drugs and alcohol, everything. I tried to kill myself.’’ His probation officer confronted him and sent Ben to a residential drug and alcohol treatment center. Ben’s involvement in the program started approximately eight months after his return to outpatient care. Friendship During the first interview, Ben said that art opens one up to ‘‘the beauty of life and how you can reach others.’’ He described how he learned to help others by emulating the lead muralist: Like how [the muralist] always works with new people to help them feel comfortable. He gave that to me, made me feel comfortable, and helped me figure out how to do the project. So when new people come, I try to give them what [the muralist] gave me. When prompted to explain this more, Ben offered the following example: There’s this one young lady who comes here, a friend of mine. She’s like a sister to me. We laugh and joke about things and are always calling each other… I was always calling her and giving her support, but she wasn’t calling me. I got on her about needing to call me and help me out as well. And she did. This example illustrates how Ben began to develop reciprocal relationships with project staff and participants through the project. He attributes the role modeling from the lead muralist to teaching him how to be a friend to


others. The friendships that Ben developed embodied mutual helping relationships, in which he helped others while also expecting and asking for support in return: ‘‘[Here] we have everyone coming together to help each other. Other people help me, and I try to help others.’’ Sense of Self Initially, when asked how the project was helping him with his recovery, Ben identified the importance of having art as an activity: I am comfortable here. I was thinking, can I still paint? And I thought yes. It’s blessings. I want to continue now long-term, continue to travel this journey, and meet new people. I might do art at home now. There is more to learn. I am looking for an outlet to take my mind away from the streets, to give myself something different. I found that here at [here], creativity is that outlet. At this stage of his involvement, the project had shown him that making art could be a long-term activity that would keep him both physically and mentally ‘‘off the streets.’’ Later in the process, Ben asserted that the project helped him discover a sense of self and purpose. He described how the project ‘‘took [him] back to how [he] used to love art’’ and ‘‘opens [him] up to what [he] wants in the future.’’ He stated, ‘‘It makes me remember what I want, and I want to apply this to my life, too;’’ and, ‘‘I found myself in [the program].’’ This strengthened sense of self further manifested by increasing specificity regarding his life goals. At the first interview, Ben’s goals were aspirational, but broad and scattered, including completing school, becoming a truck driver, and traveling the country. At the second interview, he honed in on getting his GED and starting a janitorial business, a goal drawing on his past work experience. During the final interview, he had very concrete plans as to how he was going to achieve each of his goals and which came first. Giving Back Through learning who he is and what he wants, Ben also reported feeling more equipped to help others and give back to the community: I had to find something about myself before I was using. I had to learn who I am, about who I was before. [The program] has helped me learn new things that I can take out of here. You see, once you find yourself people appreciate you for who you are… Now I can give back.

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According to Deegan [6], finding a sense of self independent from one’s diagnoses, a sense of value, is critical to the recovery process. For Ben, the program connected him to a sense of value and helped him discover who he is, and he considers this sense of self to be a prerequisite to his ability to give back. Six-months after mural installation, he had developed a strong sense of wanting to give back that was directly connected to his strengthened sense of self and purpose. Now that he had found himself and art, he wanted to get his younger brother involved in the project and to spread art to other people: ‘‘I want to spread the art, you know, each one teach one. So I want to spread it to others.’’ He feels like he has acquired a skill—art—and learned the process involved in making change, and now he wants to pass that on to others. Hope From his first interview, Ben experienced the project as an attempt to make his home a better city. Initially he stated, …we can get everyone together and make this a better city. At least we can try. We might not be able to, it is hard to do. I used to give up…, but we can try to make it a better place. At this time he was not sure what kind of impact the project could have, but felt positive about working with others to try to give back to the city—his hope for the project was tentative, but emerging. After completion of the workshops, his opinion regarding the potential for the project to create community change was more positive. He said, ‘‘I think the project will change the community outlook. It shows a sign that everyone can come together to change things.’’ Ben not only believes in the power of the program to improve his home, but his experience in the program was appeared be enhancing his capacity for hope by teaching him the processes involved in creating change: You can transform anything with art if you try. Every negative is a positive if you look at it, or put it in the right way. Like, I was working on this collage at home and I saw all these negative words in a magazine. At first I just saw how negative they were, then I thought, I can make them positive. So I took those words and turned them into something positive with the collage. For Ben, art has shown him how to change the negative into a positive in his life. Instead of feeling defeated by the negativity of the words he saw, he was empowered to transform them into a positive message. Ben’s affirmative and empowered stance towards changing the world

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exemplifies the capacity for hope described in the literature [3, 7]. During his final interview, Ben articulated the idea of applying a methodical process to achieve his goals, which linked the development of his capacity to participation in the mural project: ‘‘I’ve always believed that anything can come true, but now I see the step process involved in getting there.’’ The project not only taught him the step process involved in creating change in the community and his personal life, but he had begun to apply these skills as well—for example, he offered: I had been meaning to find out about taking GED courses, but kept not doing it… So one day… I got the courage and walked in there and got the information on the GED courses. The people there were really encouraging, and excited to see me. They said how great it is to see someone like me, in their 50’s, coming in and wanting to take classes. So I have the information, and next week I see my case manager. I’m taking her the information… The enhanced sense of self combined with knowledge of how to accomplish goals through a step-wise process has been critical for Ben’s development of a sense of hope: I wanted to volunteer to be part of the art. It is soothing. Keeps my mind focused, keeps my mind clear and open. And I wanted to achieve my goals. Now it seems like I am going to get there.

Rose’s Story Rose is an African American woman in her 40’s who has lived in the city in which the arts program takes place all her life. Rose started using drugs when she was 18, mainly using marijuana and crack. She was homeless off and on much of her adult life. Rose has not used drugs in about 11 years. Ten years prior to the start of the program, Rose moved out of a shelter and into permanent housing for homeless mothers and started participating in mental health and substance abuse treatment. She described the motivation for her sobriety and recovery as stemming from a fear of death: If you want to know what really got me clean, I’ll tell ya, I saw death. I didn’t want to die. I robbed some guy… I’m glad I didn’t know about credit cards then. So I took his ID, and credit cards, and keys, and put them back in his mail box. A couple of days later I got high and ran into that same guy. I didn’t know it was him, but he knew me. He took me, grabbed me, and put a gun to my head. He made me take off all

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my clothes and give him everything I had. He told me, the only reason you ain’t dead already is ‘cause you gave me my cards, ID, and keys back. Then he hit me over the head with the gun twice, and I ran away. I was running down the street naked, and there was this guy and gal in this van, and they saw me… took me to the hospital and got me into a program… I didn’t want to die, I wanted my kids back, I wanted respect. I stunk. I was dirty and smelled. I wanted my respect back. I wanted to live. Coming face to face with the prospect of dying had a profound impact on Rose and showed her that she did not want to die. She realized that she wanted to be there for her kids and regain her respect for herself. Friendship Rose initially went to the program for free food, and the first week she ate and left. The next week, she went back for the food again, and, as she was eating, the lead artist started reading a poem: ‘‘I just got stuck in my seat by the poetry and all. Real inspirational. And I been going since. I even go to help with the children.’’ From then on, whereas Rose had previously kept much to herself, the program connected her to a community: ‘‘I get to meet people, socialize. I don’t like a lot of people around me, but now [the other participants] are like a family. I’m all giving out my number and stuff.’’ Furthermore, she observed that the program was bringing the community together: Now lots of adults are coming, and they helping the new people who come. And they are starting to send their kids when before they wouldn’t do that… It’s like bringing the community together. Gathering the kids up and sending them to mural arts every week. The parents know where the kids are and the kids know where the parents are, at mural arts. It’s the community trying to get together as a whole now. The program provided Rose regular access to a new and expanded community of friends, and she observed the development of a positive community in a place that she had initially characterized to the first author as very negative, dangerous, and drug-ridden. Sense of Self Rose also expressed that the project helped her learn more about her own talents and abilities. In particular, the program boosted her sense of agency: I thought, oh my god, this is me putting up a mural. Never would have thought that about me before. And here I am. Who would have thought I could make


something… Deep inside there is something amazing that we can all do, something we can make. And [the artists] show you this, bring it out of you. Of special significance for Rose was the link between writing poetry and reading. Prior to the project Rose could not read or write. Yet the artists running the project at her site were focused on poetry. Rose explained that they not only did not judge her, but they inspired her to start learning to read: Even despite my reading problems, they help me out. [The lead poet] said you can just tell me what you want to say and I will write it down and those will be your words. Real deep. My words. Rose explained that once she was open with the artists, they enabled her to discover her own voice. In this way, art, and the public display of her art, reinforced the courage that she relied on to admit her struggles with reading, and ultimately, motivated her to learn to read. Giving Back In further discussions regarding the role of the program in her recovery, Rose described her enhanced sense of agency in terms of contributing to society: Well, I look at it as a savior. Before I was clean I couldn’t love me. I robbed, stole, shot at people. I did all that. I didn’t care. I didn’t love me. I just wanted to get my drugs, marijuana, crack… Art doesn’t make the monkey go to sleep. It’s still there… Art makes me happy though. I can be one of those people who do something, a poet, a musician, talk to kids, have talent. I can do that. It let’s you know… you can do something. Rose recognized the program playing an essential role in her recovery by teaching her that she has something valuable to give. She talked about wanting to continue to be involved in any way, even cleaning up after workshops. Whether by helping others or creating art, the program became a venue for Rose to be happy by giving back. Hope Rose’s experience with the program is especially characterized by a growing sense of hope. In each of the above examples, Rose expresses how both the individual teaching by the artists and the opportunity to create art were ‘‘real inspirational.’’ The way that Rose discussed learning that she could make ‘‘something’’ is a quintessential expression of hope, which developed from a prior sense that she did not have anything to contribute. Throughout the interviews,

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Rose expressed how both the individual artists and the opportunity to create art were inspirational: Seeing the artists is inspiring. They came from nothing, now they doing this. They are striving, and making something of their lives. And helping people. Being role models. This is something you can do with your life that is positive. Instead of shooting, doing drugs, whatever, doing something positive and productive. [The program] is the place to do it. Rose saw that like the artists, she, too, could be a productive role model. Rose saw her past not as a mark of shame, but as the back story to inspiration. Furthermore, she now identifies the mural-making process of creating and displaying art as the central transformational experience and opportunity. Parallel to her appraisals about herself, in the first two interviews, Rose expressed that she had little hope for her community, going so far as to compare her neighborhood to the ‘‘Carter’’ from the movie New Jack City, an expansive and militaristically fortified crack production factory and place to use drugs. She also expressed doubt that the program could change anything of substance about her community. At later interviews, however, she took a different stance, one filled with both personal and collective hope: Yeah, I did think the community was too far gone, until I saw all these people coming. Why sit around and gossip when you can go to mural arts? I believe it, the mural, will do a lot of good. There are lot’s of people doing it now. And it will inspire kids to get into something. And it’s fixing up the community. It ain’t just spray paint. It’s real art, beautiful art. When I see it I think, wow, I did that.

Discussion The purpose of these case studies was to describe how a participatory public art program can promote recovery and wellness among individuals with significant behavioral health challenges. We also wanted to identify how well the underlying change mechanisms fit into a blended recoveryoriented, public health framework. Specifically, we sought to elucidate how change occurred through intensive longitudinal case studies of program participants to provide the basis for subsequent larger-scale empirical research on the impact of participatory public art on individual recovery and wellness. We hypothesized that participatory public art would foster recovery by promoting facets identified in prior research and from patient accounts, namely, enhanced friendships, a sense of one’s self as

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having capabilities, enhanced desire to give back to the community, increased acquisition of practical skills, and increased hope. Broadly speaking, we identified evidence for each of these processes but did not find consistent evidence for the acquisition of practical skills. Both participants indicated that participation in the program helped them develop friendships with other participants that were nurtured by the artist, which, in turn, fostered a sense of community with the group and a desire to give back to one’s community. The desire to ‘‘give back’’ is often a by-product of enhanced community integration among persons with behavioral health challenges [36]. For Ben, the program provided a social space to connect with peers and develop new friendships. In particular, Ben’s experience demonstrated learning how to ask for reciprocity in his friendships, indicating that the processes involved in working together to create a large scale project helped him to develop healthy interpersonal skills. Similarly, the program created a social and fun place for Rose to develop new friendships. In contrast to Ben, who had always identified as a ‘‘people person,’’ Rose had previously preferred to stick to herself. Ben reported learning to help and be helped, while Rose learned that there could be a strong sense of fellowship in a community about which she previously had little hope. In this way, the program contributed more directly to a sense of community integration for Rose that arose from the community building elements of participatory public art. Ben’s story points to mechanisms of connectedness and reciprocal helping, while Rose’s story points to community building as the salient elements of participatory public art that promote friendship in support of recovery. At the heart of Ben and Rose’s stories of friendship was also belief in being able to give as well as receive. Ben spoke of teaching new participants the ropes, as well as the desire to pass along his new knowledge of art and mural making to his family. Rose spoke of learning that she had the capacity to create something meaningful in her life, which inspired her to want to continue being part of the project, whether she was driving children to and from workshops or writing new poems. For both Ben and Rose, this sense of being able to give back was driven by self-discovery. Ben’s story speaks directly to art as a facilitator of the development of a new identity [23] that defined him beyond his disability [3, 6]. He describes how he had to learn who he was prior to his struggles with mental illness and addiction and that the mural arts project helped him learn about himself and develop an identity as an artist. Although Rose never expressed a new identity as an artist, she did discuss how the project taught her that she could create meaningful things in this world. For Rose, arts participation fostered a newfound sense of agency as she pursued learning to read,

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which promoted the development of new life goals. Based on Ben and Rose’s experiences, participation in public arts appears to promote self-confidence by teaching people that they can produce meaningful and beautiful works of art worthy of permanent display, that is, worthy of inspiring others. This, in turn, reinforces the formation of a new identity for Ben, whereas for Rose, it reinforces confidence to succeed at other life goals. We also observed in both Ben and Rose that participatory public art nurtured a desire for each to give back to others and their community. Ben’s transformed sense of self ignited a desire for continued involvement in mural making, captured in his phrase ‘‘each one, teach one.’’ Ben’s desire to teach art to others translated into his plan to continue with the project in subsequent year as an assistant artist. Rose also expressed a wish to stay involved in some capacity, in part, because she saw the power of participation. This theme reinforces and informs the study’s interest in using participatory public art within a blended recovery and public health framework—through participation in a public wellness oriented project, both participants not only gained self-confidence, but they specifically developed new self-concepts as contributing members of society with a desire to continue contributing to their communities in a positive fashion. Participatory public art reinforces citizenship in this way, a key domain identified in recovery theory [3]. Rose and Ben also described ways in which their participation contributed to their sense of hope. Rose talked about how the project taught participants that they could do something worthwhile in their lives, and she discussed discovering that she could create change and beauty in the world. Her expression of new-found agency is indicative of a positive, future-oriented perspective on life. For Ben, hope arose from two foundations. On one hand, he learned how to transform the world around him through art. Arts engagement is a transformative process whereby a person participates in their social world through envisioning and enacting symbolic transformation [15, 23, 33]. By engaging individuals in transformative and symbolic processes of creative expression, participatory public art may enable participants to conceptualize and enact transformation in their own lives; a transformation that may take place individually and collectively [22]. For Ben, art has become a means to transform the negativity that he encounters into positive forces. On the other hand, Ben also learned that the process in creating such transformations, that is, the process to envision, plan, and execute change, provided him with a newfound skill to help him with his life goals. The agency Ben speaks about with regards to transforming negativity through art, and the enhanced sense of empowerment evident in both Ben and Rose’s newfound identities as capable and contributing community members,


are in stark contrast to a diminished sense of ability characterized by internalized stigma. Although neither Ben nor Rose emphasized their own experiences of stigma in coping with a behavioral health challenge, the undercurrent of devaluation and discrimination was evident in their selfperceptions and accounts of how others viewed them. Rose expressed clear surprise that she could create something worthwhile, and both expressed a sense of shame with regards to their education levels that they now feel they are overcoming. Engagement with others—some with obvious behavioral health challenges and others without—in the creation of permanent public art was transformative in revising these negative self-perceptions toward helping Ben and Rose see themselves as contributing members of society. Participatory public art enabled them to shed their stigma, at least temporarily, as they gave back to their community with a purposeful activity to make it a better place [22, 30]. In this way, participatory public art provides an opportunity for turning the stigma script on its head by having individuals identified with the stigmatized group becoming the catalyst for community revitalization, beautification, and positive change [8, 20]. Although the results documented in Ben and Rose’s stories provide valuable insights, there remain a number of limitations to the current study. The two accounts presented here are limited in their ability to capture the experience of all participants, as the specific details of the program’s impact will likely vary from one person to the next. Despite this, we selected these two stories as they are representative of the experiences described by all 10 case study participants. Furthermore, by tracking the participants over a year’s time, seeking data saturation, and pairing the interviews with participant observation, these experiences may describe the perspective that many in recovery would experience when engaging in participatory public art. Secondly, case studies constructed primarily through interviews with the participants are limited to representing primarily a single subjective point of view, which may not be reflective of objective accounts of behavior. Our ethnographic design, however, seeks to address this limitation by allowing us to observe and describe the context within which the subjective experience are reported, thus tempering what would otherwise have been an exclusively subjective account. Finally, there is an important distinction between description of experience and explanation of causality. Whereas case studies may strive to explain causal relationships, they rarely are able to and our study is no exception. However, case studies are extremely useful in their ability to provide rich description of experience. Ben and Rose’s stories provide compelling descriptions of two participants whose experiences are representative of the 10 who participated in the case study design. This descriptive data is particularly useful in

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providing guidance for future rigorous trials of the intervention.

Conclusion Although the focus of each of these case studies is on individual change processes, they represent stories that are part of a broader initiative to effect positive community change by integrating recovery and public health perspectives. Ben and Rose’s development of a strengths-based sense of self through art blended seamlessly with a growth in personal social responsibility and the ability to see how they could contribute to change in the larger physical and social environment. Their improved understanding of who they are fed a growing desire to give back, and their enhanced hope grew not only for themselves, but for their communities as well. Ben and Rose’s stories offer rich insight into potential mechanisms for future qualitative and quantitative study with larger samples. One such path is for future research to examine the reciprocating influences of individual and community-level recovery factors—for example, how do personal agency, hope for one’s community, and hope within the broader community relate to and promote each other? Based on Ben and Rose’s stories, there appears to be strong reciprocal relationships between an individual sense of agency, a desire to give back, greater community integration, and broader community building and expansion of social networks. Quantitative research can also apply the processes identified in Ben and Rose’s stories to guide analyses that seek to explain mechanisms of recovery; for example, their stories point to the need to examine further how participatory public art enhances friendship and connectedness leading to changes in sense of community integration and a desire to help other. Finally, both Ben and Rose spoke to their belief that the murals would be inspirational to the community. It will be critical to evaluate the impact of long-term display of the art on communities and whether any community change as a result of the art reinforces the individual recovery from addiction and mental illness. Acknowledgments This work was supported by Grants from the National Institute on Drug Abuse (T32 DA 019426), the Philadelphia Department of Behavioral Health and Intellectual disAbility Services, Philadelphia Mural Arts Associates, the Thomas B. Scattergood Foundation, and the Robert Wood Johnson Foundation. The authors are grateful to: the many program participants who shared their experiences; Sara Ansell, Will Pace, and Joan Reilly from Philadelphia Mural Arts Program; Kyra Turner and Anthony McLaughlin from Philadelphia DBHIDS; collaborators from partner agencies, especially Gustalvo Castro and Adolfo Gonzalez from APM, Vera Owens from Project HOME, Natalie Charney and Vincent Faust from S.T.O.P, and Patty Gerrity and Lindsay Meeks from 11th Street

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18 Family Health Services; artists James Burns, Betsy Casanas, Keir Johnston, Nina Lyrispect Ball, Perry ‘‘Vision’’ DiVirgilio, Ernel Martinez, Kathryn Pannepacker, and Ben Volta; Joe Pyle and Alyson Ferguson from the Thomas B. Scattergood Foundation; and Susan Florio, Erin Hoffman, Tanisha Mair, Roy Money, Lauren Moss-Racusin, Frank Snyder, Nghi Thai, and Azure Thompson from the Division of Prevention & Community Research and The Consultation Center, Yale University.

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