In-between-ness video performance Karen Heald & Susan Liggett
In-between-ness image Karen Heald

Date: April 2010 to April 2013
Location: Gwynedd Hospital, Bangor, Gwynedd, UK
Client: Betsi Cadwaladr University Health Board (BCU HB)
Partners: Bangor University, Glyndwr University & Leeds Metropolitan University
Research Team:  Artists – Dr Karen Heald and Dr Susan Liggett,  Scientists – Dr Richard Tranter, Professor Rob Poole and Professor Catherine A Robinson.
Funders & Supporters:  Arts Council of Wales, North Wales Clinical School Research Department and Bangor University.

The In-between-ness pilot study was a novel collaboration between professional artists, clinical researchers and people suffering from depression; to extend the exploration of experiential effects of antidepressant treatment. The research team worked closely with the participants at the Hergest Psychiatrist Unit, Bangor to explore the effects of treatment for depression.
Through this research the collaborators Dr Richard Tranter, (Consultant Psychiatrist), Professor Rob Poole, (Professor of Social Psychiatry and Co-Director of the Centre for Mental Health and Society, UK), GP surgeries, and artists Karen Heald and Susan Liggett explored if patient changes were reflected in the way people express themselves and respond to their environment prior, during and post antidepressant medication. In addition to the aims of the psychiatrists, the artists were keen to explore the role of preverbal language and creativity for patients navigating the ‘in-between-ness’ from depression to recovery through the creative use of video cameras. The artworks, with consent, have been displayed in exhibitions, discussed at conferences and included in a designated website

Research Questions & Aims

  • How do we construct our reality? Can this process be manipulated through medications? If so, what are the implications for the authenticity of self for someone who has had such treatment?
  • How does creativity relate to mental health and how does a search for the poetic help mental health patients?
  • What are the benefits of art/science research projects and how can artists make a difference to social science qualitative research projects?
  • Can creative art methods capture aspects of patient experience relevant to psychiatric research that are beyond the reach of reductionist psychometric measurement?

The aim of the study was to help us understand some of the effects of antidepressants and how people recover from depression. This work was set in the context of a rapidly expanding knowledge of how the brain processes emotional stimuli, how these processes are affected by depression, and how these processes change in response to treatment. People with depression show characteristic changes in the way they perceive the world around them, particularly the way they interpret emotional stimuli, for example interpreting facial expressions in others. To inform future directions of research in this area this innovative art/science collaboration explored experiential changes during treatment with antidepressants. In addition to the aims of the psychiatrists, the artists were keen to explore the role of preverbal language and creativity for patients navigating the “in-between-ness” from depression to recovery. This was informed by concepts of preverbal language and ‘in-between-ness’ (Heald, K. 2014), and ‘psychological resonance’ (Liggett, S. 2008).

Description of the arts activity

Karen Heald and Susan Liggett’s art practice acts as a personal rationale in their approach to the research. Initial research questions stemmed from the issues arising from their artwork, but now these questions have been recognised by the medical profession and are validated by the psychiatrists and social scientists they are collaborating with. This external rationale now drives their art practice as they make new artworks in response to the situations and experiences they encounter on their research journey. Their personal artwork cannot be disentangled from the research projects in the same way as the artwork produced by participants is seen as an integral part of the research methods.

Heald and Liggett worked one-to-one with the participants to explore how their view of themselves changed as they recovered from depression. This involved seeing patients before, during and after their treatment. The participants were asked to respond to visual prompts seen in the photographs here which were introduced as a stimulus for the patients to make artworks using a video camera. Participants met with the artists on a weekly basis after having been administered medication by the trial psychiatrist.

Participants began filming for 24 hours before commencing antidepressant medication, and continued throughout the first six weeks of treatment. Each week the participants met with the artists to review and discuss their films. From this visual analysis participants were encouraged to reflect on: how their emotional perception of their environment was changing; their sense of self and personal authenticity; and their sense of agency and affirmation in relation to their recovery.

Finally the participants were given the option of editing the works they had produced. It was entirely the participants’ decision whether they wanted to take part or not. However, all of the participants decided that they would like to take part in this aspect of the project.

Details of the project participants

The participants were a carefully selected purposive sample rather than a representative one. GPs identified patients who were suitable for, and wished to commence, antidepressant treatment. The trial psychiatrist assessed potential participants within one working day of referral. Those fitting the suitability of the project – by engaging in the creative process – were selected by the psychiatrist.

The participant’s diagnosis was confirmed by the psychiatrist using the Mini-International Neuropsychiatric Interview and baseline symptom severity measured using the Beck Depression Inventory II. The psychiatrists assessed capacity to consent using routine clinical methodology.

Project management

This project was a qualitative study using a variety of media and guidance from professional artists to capture changes in emotional perceptions, personal authenticity, multiple intelligences and the process of recovery during treatment with antidepressant medication. Alongside qualitative methods the trial psychiatrist performed psychometric tests. The artists, working in partnership with psychiatric patients, produced collaborative artworks whilst also creating their own artworks in response to the process.

The research project offered a multidisciplinary approach to creatively investigating the self, the unconscious, different realities and time alongside the observational methodologies operating in science, thereby creating a fusion between the two disciplines. It provided access to the thinking process, and possibly unconscious process underlying how people interpret their emotional environment, whilst also stimulating new trains of thoughts.

Elizabeth Aylett, Head of Arts Therapies and BCUHB Arts in Health manager states:
‘This research is an integral part of the Betsi Cadwaladr University Health Board’s Arts in Health & Wellbeing Programme. The research activity supports health outcomes resulting from arts interventions and provides evidence toward further development and funding of this work to the benefit of patients and families.’

While this work may contribute towards how we manage this illness in the future, we could not guarantee that taking part in the study would have any direct benefits for the participants. However, patients who have been involved in arts in health projects in the past had found the experience rewarding. For some people engaging in a creative process like this can help them make sense of their condition.

The participants in the project received travel expenses.

The project was approved by the NHS ethical committee. The research included a two stage consent process, the first phase to take part in the research and the second phase to include their artwork in specified exhibitions, relevant art and science conferences and on the designated website:

Evaluation methods and findings

The project utilised a creative process to generate rich qualitative data alongside a conventional reductionist method (use of a validated psychometric instrument to measure depression). The changes that were seen in the former contradict more static findings in the latter. The project threw up many methodological questions, such as the extent to which change was dependent upon the individual characteristics of the artists. It presented a profound challenge to our understanding of the relationship between depressive symptoms and recovery. The role of antidepressant medication was also of interest; it would appear that these medications do not necessarily suppress individual creativity. The project raised many more questions than it answers, which is why it was so exciting to be involved.

The unique aspect to this methological approach of recording response to treatment was that a continuous daily narrative (through the use of the video camera) was obtained from before treatment began right through to participants potentially achieving remission. The participants themselves were in control to record impressions and thoughts as they occured in different situations. This contrasts to the use of psychological paradigms that measure specific domains of functioning and have to be administered at predetermined time points and in specific settings. The video narrative captured changes in the types of situations that participants entered into, changes in the focus of their attention and changes in levels of social interaction over the course of treatment. Along with the interview transcripts this material provided an immensely rich data source that was analysed and explored in numerous ways.

This project offered the participants an opportunity to tell their visual stories through video and was about starting dialogues as people process their internal worlds very differently. In the touring exhibitions the participants experimental films and video stills were presented alongside those of the artists and explored a preverbal language of ‘in-between-ness’. These artworks created a language of ‘painterly video’ that communicated difficult social issues with subtle, oblique visual stanzas.

Although the project was conceived as a method of exploring the experiential effects of antidepressant medication, preliminary findings raised the possibility that engagement in the creative process itself may aid recovery from depression. This may be through diverting attention from internal ruminations towards external sensations, enhancing self-worth through the creation of aesthetic work and promoting the reconstruction of a meaningful personal narrative. In measuring success the collaborators were searching for changes to the self from a biomedical perspective and in the creative outputs.

The material generated by the participants and the response of the professional artists to this material formed part of a touring exhibition and website (2013). Building upon this experience several of the prompts from the In-between-ness project were also exhibited in Venice, Italy during the Biennial (2011).

Supported using public funding by the Arts Council England