Introduction

For those who have yet to embark on research funding or are interested in this area, this article shares our team's experiences and disseminates some of our outcomes on the potential of art therapy to address self-harm.

Background to topic

Lifetime prevalence rates of self-harm have reached 20% in young people under 25 (Gillies et al., 2018). As self-harm is the greatest risk factor for later suicide, there is a need for innovation in supporting young people who self-harm. Research into the motives of self-harm is challenged by a lack of agreement regarding terminology and definitions of self-harm. In the current article, we refer to self-harm following the NICE definition: ‘self-poisoning or injury, irrespective of the apparent purpose of the act. Self-harm is an expression of personal distress, not an illness, and there are many varied reasons for a person to harm themselves.’ (NICE, 2021)

Self-harm is a complex problem to which many factors contribute. A published systematic review and meta-analysis revealed that emotional dysregulation most strongly associated with self-harm includes the following factors:

• limited access to regulation strategies
• non-acceptance of emotional responses
• impulse control difficulties
• lack of emotional awareness. (Wolff et al., 2019).

During our discussions, our young coordinators with lived experience of self-harm reported similar feelings and sentiments.

P3: ‘I would say that my … triggers … like a mood or emotion, which is more of an internal trigger but I found like the main thing that triggered me would be like the feeling of like … I would do when I got angry so whenever I would like get into a rage I would think like this is the best way to maintain control, and I think that, like loss of control, every situation will trigger me to get angry and so that is just kind of one of my biggest triggers.’

P1: ‘um yeah kind of like XX said, like anger kind of yeah don't have triggers that are like a specific thing if that makes sense I’m not triggered by I don't know a place or specific person. But yeah like emotions like overwhelming anger, upset normally triggered by like relationship and friendship situations like I really struggle with that probably the most ...’

Successful prevention programmes are needed to address self-harm. The recent Cochrane review (Witt et al., 2021) identified some evidence of the impact of dialectical behaviour therapy. However, the majority of interventions for self-harm (including dialectical and cognitive behavioural therapy) are costly and protracted. It is also important to mention that interventions that have shown some effectiveness struggle to keep young people involved and report high attrition rates (Santamarina-Perez et al., 2020). These factors significantly impact intervention costs, further replication and implementation.

To overcome the challenges discussed, it is important interventions are tailored to meet the needs of individuals and involve service users in their development. Moreover, no studies exploring interventions for self-harm based on creative therapy approaches were included in the 2021 Cochrane review (Witt et al., 2021).

In a variety of settings, creative therapies (CT) are shown to improve patient mental health and reduce costs for the NHS by decreasing the need for GP consultations and hospital admissions (Gordon-Nesbitt, 2017) including primary care. Evidence indicates that drawing and ‘creative activity enhances mood’ (Bell & Robbins, 2007; De Petrillo & Winner, 2005) and can regulate and reframe negative emotions (Ruppert & Eiroa-Orosa, 2018). Furthermore, arts-based approaches offer a flexible, non-prescriptive approach which is led by participants' interpretations and perceptions of life events and can also be self-administered. For those who are more difficult to engage, the creative process can aid reflection by externalising concerns in a visual form. For people with mental health needs, arts participation increases levels of empowerment and has the potential to impact mental health (Hacking et al., 2008).

For some people who experience persistent or relapsing common mental health problems, participation in an arts-based programme provides 'added value' by aiding recovery in ways not facilitated by talking therapies alone (Makin & Gask, 2012). Even in terms of more severe forms of mental illness, arts-based interventions can augment a sense of self by supporting individuals to shift perceptions of what they can achieve (Davidson & Strauss, 1992). The introduction of the arts into mental health care helps patients find new ways of self-expression and acts as a vehicle for establishing communication with others. (Killick & Allan, 1999a, 1999b; Allan & Killick, 2000). Camic (2008) argues, ‘considering that the arts have been around for millennia, it is rather surprising that applied psychology has, for the most part, ignored the arts as part of an intervention strategy. This is particularly noticeable when one considers that nearly all psychological interventions involve altering behaviour, changing thought processes and/or transforming emotions. Similarly, the arts challenge people to think differently, engage in different behavioural experiences and experience different emotions. For many people verbal discourse may work well; yet for others, with a variety of problems, it does not.’

Journey to this research

To address the challenges and potential mentioned above and influenced by the value of Patient and Public Involvement (PPI) and co-production, we initiated an information-gathering project. The project aimed to involve young people and practitioners in preliminary work on intervention development. This research journey began with a £1500 seed funding grant received from Emerging Minds via the University of Oxford.

Emerging Minds is a research network that aims to reduce the prevalence of mental health problems experienced by children and young people (https://emergingminds.org.uk/special-interest-research-groups).

In partnership with Young Minds (https://www.youngminds.org.uk) and the Centre for Mental Health (https://www.centreformentalhealth.org.uk), Emerging Minds set four funding challenges as prioritised by young people, families, practitioners and policymakers.

Those relevant to our proposal included:

1. How do we implement effective promotion of good mental health, prevention and early treatment for mental health problems at scale amongst children and young people?
2. How can societal values, attitudes and behaviours be changed in ways that have a positive impact on children and young people's mental health and wellbeing?
3. How can young people be better enabled to help each other promote good mental health and prevent and overcome emerging mental health problems?

Emerging Minds’ hope was that their funded research groups would:

• Drive increased interest and engage new people with a diverse range of expertise and experience in important research areas.
• Develop new fundable collaborative project proposals.
• Progress research agendas in key areas, for example by publishing proposed priorities for further research in the grant recipients’ focus area.

Project design

Via Collective Arts, a London-based community arts organisation (https://collective-arts.org), our aim was to run a 12-month Special Interest Research Group (SIRG) exploring the potential of the creative therapies to address self-harm in young people. Dr Vlad Kolodin led and coordinated the project with support from Art Therapist Julia Ruppert.

As part of PPI, we recruited three young people with experiences of self-harm and CAMHS to take part in the SIRG. Over the next several months, we used Zoom to run one session each of positive visual reframing (one-to-one work) with art therapist Julia Ruppert, one session of phototherapy (group session) with Vlad Kolodin and one session of drama therapy (group session) with art therapist Kit Loring. The SIRG included an end-of-intervention focus group with our young researchers. We also recruited a student film-maker from the University of East London to help us produce a short film on the process and outcomes of the SIRG. Currently, our film-maker is finalising her film, and we are hoping to present our work at the Big Emerging Minds Summit (https://emergingminds.org.uk/summit).

SIRG Outcomes

In our focus group and with themes touching on group process, disclosure, choice and control, the young research team reported the following issues regarding involvement with different types of therapies:

• the importance of early education on mental health and wellbeing for young people (e.g. ages 10–11)
• the necessity of addressing diversity
• the importance of tailoring interventions to meet the needs of individuals
• the importance of reclaiming a sense of control regarding one's personal recovery and treatment
• the value of an intervention that enables participants to express their thoughts, feelings and ideas – on their terms
• highlighted feelings that creative therapies invited flexibility into the therapeutic process, versus a default to standardised intervention formats, such as CBT.

Next stages

The next stage of this exploration will be to apply our learnings to future grant applications exploring the impact of art and creative therapies on addressing self-harm.

Co-production methods are an effective approach for developing mental health interventions with and for young populations. By establishing relationships between professionals, service providers and service users, service users share the power to design, plan and deliver support together. Co-production methods enable a more complete understanding of young service users' needs, ensuring the intervention's acceptability and sensitivity to the needs of both service users and providers. These methods focus on establishing equally valuable input from all stakeholders and are used in the effective development of mental health interventions for young people.

Future intervention development

Young adults aged 18–25 who have engaged in self-harm, mental health professionals and creative therapists will be engaged in an intervention development study. The intervention structure, format, content and delivery will be developed through three phases of co-production research:
Phase 1 Formative research – 9 months.
Phase 2 Co-production workshops and materials development – 3 months.
Phase 3 Piloting and evaluation – 12 months.

The aims of this research are to:

• Co-develop and test the feasibility and acceptability of tailored creative-based group interventions to reduce mental health problems and prevent self-harm.
• To use co-production methods to understand what is needed in terms of structure, format, delivery and content, to ensure the needs of young people are met.
• To develop a creative-based intervention which is acceptable to the needs of service users and providers and is implementable within the healthcare system.
• To pilot and evaluate the intervention.

At this stage of the inquiry, we are extending an invitation for art therapists, researchers and people with lived experience interested in contributing to this research and intervention development to join our research team.

Please contact:
Dr Vlad Kolodin: vladimir.kolodin@kcl.ac.uk / v.kolodin@ucl.ac.uk; and
Julia Ruppert: julia@collective-arts.org.