Laura McGrath

Loneliness is a pressing public health issue. Although quintessentially individual, it is shaped by wider environmental, cultural, socio-economic, and political circumstances. Using a systematic review methodology, this paper draws on interdisciplinary research to conceptualise the relationship between the built environment and loneliness. We present a narrative synthesis of 57 relevant studies to characterise the body of evidence and highlight specific built-environment elements. Our findings demonstrate the need for further conceptual and empirical explorations of the multifaceted ways in which built environments can prevent loneliness, supporting calls for investment into this public-health approach

Forensic psychiatric institutions are tasked with both containment and transformation; with securely policing the border between institution and society and readying patients for return to the community. Forensic institutions can thus be theorised as a form of ‘rite of passage’, engaged in a process of transformation which both navigates and demarcates social limits. This article contributes to literature on risk and control in clinical institutions by offering a novel theoretical synthesis of features of rites of passage and liminality, as facilitated by an art project in a forensic setting.  Through the prism of the Graffiti and Wellbeing Project (GWP), an arts initiative, we explore the ways in which forensic institutions thus offer or impede opportunities for transformation. The project engendered a space for the transformation of difficult emotions and histories through the medium of art creating a liminal space of transformation within the confines of a secure institution.  Drawing on Douglas, Kristeva and Bahktin, we argue that forensic institutions largely attempt to manage their own transgressive, marginal status, and the abject experiences of patients, through a recourse to order, suppression and sublimation. We argue for a wider range of responses to the transgressive and marginal experiences and behaviours prevalent in forensic settings, drawing on examples from the GWP.

Background
Creative arts interventions have clear benefits for recovery within forensic settings, supporting the development of personal meaning, introspection, emotional expression, self-esteem and social relationships (Clements, 2004; Gussak, 2007; 2017; Koch et al., 2015). The Graffiti Art and Wellbeing Project was an expressive arts intervention based in North London Forensic Service, and facilitated by the artist Ben Wakeling.  The project ran for twelve weeks, starting in a room on the ward and moving to an outdoor ‘therapy wall’ half way through the intervention. Here patients worked on a collaborative graffiti art work, which was documented with photographs, and then painted over each week. This evaluation aimed to understand the impacts of the Graffiti Art and Wellbeing Project on the individual patients, the staff and the unit as a whole.
Methods
A qualitative process evaluation was carried out, combining participant observation, documentation, interviews with staff (n=3) and a staff survey (n=14). The data were combined and analysed using Thematic Analysis (Braun & Clarke, 2006).
Findings
The response to the Graffiti Art and Wellbeing Project was overwhelmingly positive. It was seen by staff as an innovative intervention which offered multiple benefits to the patients taking part, and had a positive impact on the wider environment of the ward.
For patients who participated in the project, key benefits included being a way for participants to build a visual language within a trusting environment, to express emotions and facilitate self-reflection. The fact that the sessions built up slowly across several weeks meant that patients were supported to find ways to express and transform difficult emotions and experiences, in a way which felt familiar and culturally appropriate.
For staff, the project provided a chance to see beyond illness and offending, instead appreciating the creative side of patients. The project also offered an opportunity for positive risk taking, and changed the overall feel and look of the environment of the unit.
Recommendations
1. Graffiti Art and Wellbeing Project should be recommissioned
This evaluation overwhelmingly supports the effectiveness of the Graffiti Art and Wellbeing Project. We have found that the project was a successful intervention, There were multiple benefits for both patients and staff, and which stretched beyond those who directly took part in the project. We recommend that this project should be recommissioned, repeated and expanded.
2. Preserve the core elements of trust, imagination, and expression
Working from imagination, and using art as a modality to build and sustain trusting relationships emerged as key elements of the success of the project. The process of building up art engagement slowly was key to the success found in this evaluation - starting with ‘expressive roaming’ through visual expression, before graduating to working with graffiti. We recommend that any extension of the project keeps these values at the core of the project, recognising the key role of relationality in the work of the Graffiti Art and Wellbeing Project. The project needs to be facilitated from a place of respect, adapting to the needs of each individual, based on “deep and respectful observation” (Fals Borda, 2001: 33).
3. Longer time periods working with patients
The project was successful in building trust and developing self-reflection, enabling emotional expression for patients. Longer term work would enable patients to further explore and hone these skills and aspects of themselves, which are so crucial for enabling recovery and supporting desistance. We recommend repeated work in the same spaces on the wards, as well as longer term work with individual patients.
4. Permanent art studio space
A key element of the success of the project is the process of ‘expressive roaming’ through which patients are supported to develop their own visual language in the early part of the project. This is key to the early process of developing trusting relationships and emotional expression. A permanent or semi-permanent art space in the unit would provide a richer environment for this process and we would recommend finding a space to house a studio.
5. Training facilitators
We would recommend the expansion of the Graffiti Art and Wellbeing project to other services, as well as repeated work within North London Forensic Service. We recommend that Ben Wakeling be supported to train further facilitators in his approach. This training should focus on communicating the art-led ‘mode of engagement’ (Liebert et al, 2018) at the heart of the Graffiti Art and Wellbeing project – trust, imagination, and expression.
6. Opportunities for creativity and ownership
Key benefits from the project were found in the opportunities provided for patients to explore their creativity, and create a feeling of ownership over the space of the unit. These extended beyond the core sessions, for instance patients using their own sketchbooks, and photographs of the graffiti wall being exhibited on the ward. Staff could consider ways to embed some of these elements into the design and use of the space of the wards, enabling patients to see more of themselves in the environment in which they live. For example, staff could consider creating a dynamic wall in the ward where patients could choose art or images for the ward which change relatively regularly. We recommend that secure services prioritise providing more opportunities for patients to be supported in imaginative, creative activity in forms which are culturally relevant and close to their lives, such as found in this project.
 

Recent years have seen a renewed interest in integrating creative activities into statutory mental health practice in high income countries. In this article we offer an exploratory analysis of an arts project delivered within UK mental health services, Creativity for Enablement and Wellbeing (CREW). Drawing on data collected for a process evaluation of the project, we suggest that conceptualising CREW as liminal and liminoid provides a helpful way to articulate the processes, atmospheres, relationships and practices of the project. Through this theoretical lens we identify CREW as a mode of engagement comprising looseness, possibility and, collectivity, all brought together through a unique community event, the showcase. We explore CREW's mode of engagement through three themes: "carving out a liminal space"; "looseness and experimentation" and "from liminal to liminoid". Implications for service delivery are discussed, focussing on how CREW managed to create a transformative space of liminoid possibility rather than a recovery journey delineated by service-defined imperatives.

The climate or atmosphere of a ward in secure psychiatric care is typically studied by examining the relationship between social and environmental factors. However the experiences of patients are irreducible to a set of discrete dimensions or factors. Drawing on recent work in affect theory and architectural studies, we argue for an approach to atmosphere that places it ‘in-between’ persons and space, as a ‘spatially extended quality of feeling’ of which patients are intimately aware. The article discusses empirical material drawn from a broader study of inpatient medium-secure forensic care in a large hospital in the South of England. We show how the process of becoming attuned to the fluctuations and shifts in the atmosphere of the ward is a critical aspect of everyday life for patients. Attunement cuts across existing notions of power and resistance in these settings. We also demonstrate how attachments to a range of objects, some created by patients, can either expand or punctua...

This paper presents analysis from a study of staff and patient experiences of the restrictive environments of a forensic psychiatric unit. The paper conceptualises the forensic unit as an impermanent assemblage, enacted in and through practices that hold a future life outside the unit simultaneously near, yet far. We show how the near-far relations between life inside and outside the unit operate in three ways; 1) in relation to the ‘care pathway’, 2) practices of dwelling, and 3) creating and maintaining connections to life ‘beyond’ the unit. The paper concludes with a discussion about possible ways to overcome the limitations to recovery that can arise through practices of impermanence.

Medium secure forensic psychiatric units are unique environments within the
broader ‘post asylum’ landscape of mental health services. Length of stay is
much greater, a recovery-focused care system is much more difficult to
implement, and there is a paucity of suitable “step-down” services. The aim of
this study was to examine how forensic psychiatric environments contribute to
the shaping of recovery, by examining key features such as social interactions
and agency. Here, we report on the findings from patients participating in a
qualitative-visual study. This analysis forms part of larger study on staff and
patient experiences of secure hospital space. In this paper, the analytical
focus is directed towards two key elements of recovery - agency and
relationality, using the concept of ‘topology’ and ‘life-space’, developed by the
social psychologist Kurt Lewin. First, we explore how patients have relative
freedom to move within institutional spaces, yet lack relational space.
Secondly, we explore how life-space is expanded or compressed by the
manner in which the patient’s present life in hospital is connected or
disconnected from their past or pending future. Finally, we discuss the
implications of these findings for a recovery model within secure forensic
settings, focussed on personalisation and expanded life-space.

Psychological treatments of mental health issues have acquired a justifiable notoriety for their tendency to engage in generalisation and reductionism. By contrast, the emergent geographies of exclusion make visible the fine-grain material and spatial contours of the lives of individuals who experience mental health difficulties and distress. However, this can come at the cost of a relative neglect of the psychological. In this paper we propose a set of concepts for facilitating the study of intersecting planes of experience, which demonstrates the interdependency of the spatial, the psychological and the technological. Drawing on empirical work with participants who live with persistent anxiety, we demonstrate how online support networks mediate – that is transduct, intersect and transform – how experiences of anxiety are lived out. Attention to endogenous ‘tactics’ or ‘modes of normativity’ provides an interesting agenda for the emergent engagement of social psychology with social/cultural geography.

One challenge facing psychological studies of affect and emotion is how we can capture the situated, located assemblage of practice involved in affective experiences: the where, how, when, who, and what of affective meaning making. Here we argue for a place for map making in the methodological toolbox of qualitative psychology. Participatory mapping is a well-established technique used in geography, planning, and community development, with a growing tradition in psychology and sociology. The examples drawn upon here are from two studies, exploring experiences of space in mental health service use and in an intentional community for people with learning disabilities. Mapping is argued to be useful both as a process and product within the construction of sense making in qualitative research. Particular strengths are argued to be locating specific affective experiences, exploring layers of ambiguous or contradictory experiences, and making materiality visible in participants’ narratives. The potential of mapping as a tool for qualitative research in affect and emotion is discussed.

This chapter explores how newly homeless people negotiate the hostile climate of public space, to seek out protective immunological bubbles in which they can exist in relative safety. Sloterdijk argues that all bubbles that they create as spaces of intimacy and interiority 'work towards bursting'. The bubbles of safety are created through drawing on past relationships and institutions, but can be seen as performing the same function, of creating interiority within the skinless world of homeless living; they here immunise their personal microclimates against the hostility of public space. The chapter focuses on some of the participants, who described a crisis of containment, a need to escape or overflow. The participant, who lay down outside their mental health service, spent only one night sleeping rough. Homelessness is an increasing problem in the UK, which intersects in multiple ways with experiences of mental distress.

Improving Access to Psychological Therapy (IAPT) has lead to a huge increase in the delivery of psychological therapy within the UK over the past ten years. Central to the culture of IAPT is outcome monitoring, brought into every therapeutic encounter through the compulsory collection of the minimum data set in each session (MDS). This paper explores the role of compulsory outcome monitoring in service users’ experiences of using IAPT, with a focus on how these forms are folded into distress, therapy and recovery. Data from a small scale qualitative study are drawn upon. A process orientated thematic decomposition analysis was conducted on multimodal interviews with current service users. The paper explores the ways in which the MDS acted as a ‘quasi object’, exploring three main roles of the MDS: as an authorising mediator; an alienating adversary; and a deferring gatekeeper. Pictures of therapeutic progress, as presented via outcome measures, often ran counter to users' reported experience of distress. We conclude that far from being a neutral and objective assessment tool, the MDS functions as a living actant in the therapeutic encounter.

This article explores the ways in which creative, multimodal methods are well-suited to research with groups holding multifaceted roles within complex systems. The potential benefits of using imaginative methods in qualitative inquiry will be discussed in relation to the participants, organisation and researcher. The first author's ongoing doctoral project is discussed, which employs a creative, multimodal method combining vlogs and interviews for data collection to explore prison officers' (POs) emotional experiences of their complex work roles. The PO role is multifaceted and requires the balancing of competing demands, such as discipline and rehabilitation, within the complex prison environment. Given the intricacies of the PO role and prison system, the question of why multimodal methods are particularly well-suited to research with this group shall be explored. The article will begin with an overview of the complexities of the PO experience, and then consider how multimodal methods might address these multiplicities.

Prison is a complex, hierarchical environment, which has been shown to both
prompt existential reflection and act as a barrier to authentic emotional expression. The
risks associated with emotional expression within prison are further suggested to inhibit
forms of self-reflection crucial to successful desistance. This paper explores the use of
poetry as a practice and a research method within such an environment. Using Narrative
Thematic Analysis, 27 poems published in Inside Times magazine were examined, selected
because of a focus on inmate subjectivity. Findings focus on the emotional, reflective and
transportational qualities of poetry. We explore the capacity of poetry to both mediate
reflexive, emotional experiences, and mitigate counter-therapeutic aspects of secure
environments. We suggest shifting professional’s focus from changing inmate behaviours to
the creation of ‘safe spaces’ or atmospheres within prison which will allow inmates the
opportunity for emotional authenticity and the exploration of non-criminal selves.

There is ample evidence that loneliness and social isolation are important in the development of distress, and harmful to recovery. UK mental health services, however, have been moving away from interventions which prioritise relationality, and towards professionally-led, individualised treatments. In addition, those experiencing distress experience multiple spatial exclusions which can compound isolation and loneliness. This paper examines the role of an urban Walk and Talk group in the lives of long term mental health service users. Using an ecological frame, Ingold's concept of 'meshwork' is used to explore the complex of social, personal and spatial relationships which contribute to participants' experiences of everyday living. Four themes are explored: Fading lines: Fossilised meshworks of loneliness and loss; Therapeutic nodes: Atomised sanctuary and respite in everyday space; Reciprocity and authenticity: Strengthening relational meshworks; and Remaking everyday spaces: Revitalising meshworks through collectivity. The findings are discussed in light of the literature on loneliness, relationships and mental health interventions.

Background
The practice of reading and discussing literature in groups is long established, stretching back into classical antiquity (Fischer, 2004). While benefits of therapeutic reading groups have been highlighted, research into participants’ perceptions of these groups has been limited (Walwyn & Rowley, 2011).
Aims
To explore the experiences of those attending therapeutic reading groups, considering the role of both the group, and the literature itself, in participants’ ongoing experiences of distress. 
Method
Eleven participants were recruited from two reading groups in the South East of England. One focus group was run, and eight individuals self selected for individual interviews. The data were analysed together using a thematic analysis drawing on dialogical theories. 
Results
Participants described the group as an anchor, which enabled them to use fiction to facilitate the discussion of difficult emotional topics, without referring directly to personal experience. Two aspects of this process are explored in detail: the use of narratives as transportation, helping to mitigate the intensity of distress; and using fiction to explore possibilities, alternative selves and lives.
Conclusions
For those who are interested and able, reading groups offer a relatively de-stigmatised route to exploring and mediating experiences of distress. Implications in the present UK funding environment are discussed.

Executive Summary: This report directly links cuts to public services with mental health problems. Well-established psychological research that explains these links already exists. However, this knowledge has been missing from the debate on austerity so far. Psychologists are often in a position to see the effects that social and economic changes have on people. We also occupy a relatively powerful position as professionals and therefore have an ethical responsibility to speak out about these effects. Austerity policies have damaging psychological costs. Mental health problems are being created in the present, and further problems are being stored for the future. We have identified five 'Austerity Ailments'. These are specific ways in which austerity policies impact on mental health:

The change from an institutional to community care model of mental health services can be seen as a fundamental spatial change in the lives of service users (Payne, 1999; Symonds & Kelly, 1998; Wolch & Philo, 2000). It has been argued that little attention has been paid to the experience of the specific sites of mental health care, due to a utopic (idealised and placeless) idea of ‘community’ present in ‘community care’ (Symonds, 1998). This project hence explored the role of space in service users’ experiences, both of mental health care, and community living. Seventeen ‘spatial interviews’ with service users, utilising participatory mapping techniques (Gould & White, 1974; Herlihy & Knapp, 2003; Pain & Francis, 2003), plus seven, already published first person narratives of distress (Hornstein, 2009), were analysed using thematic analysis (Braun & Clarke, 2006). Mental health service sites are argued to have been described as heterotopias (Foucault, 1986a) of a ‘control society’ (...