A myth-busting mental health tour of the National Gallery in London: Facilitators and challenges to its development and evaluation

ABSTRACT This paper describes a mental health-awareness audio tour of the National Gallery, London, and evaluates the development and implementation of the tour. This smartphone-based audio tour was co-produced by Gallery staff, young people with lived experience of mental health issues, academics, and technologists. Interviews (N = 22) were conducted with developers and data-collectors (who had gathered feedback from Gallery visitors who undertook the tour) with responses analysed thematically. Participants highlighted the value of the arts to raise awareness about mental health, and the importance of teamwork, lived experience, and co-production, but also raised the challenges of integrating low-budget projects into large-scale venues.


Introduction
Mental health stigma is highly prevalent (Kaur et al., 2016) and negatively impacts the physical health and employment prospects of people with lived experience, increases violence and hatred towards them, and substantially delays them from seeking help which unnecessarily prolongs distress (Clement et al., 2011;Henderson et al., 2013;Thornicroft et al., 2016). Campaigns like Time to Change in the UK have aimed to improve negative attitudes and behaviours (Evans-Lacko et al., 2014) but public stigma towards mental health conditions remains (Henderson et al., 2020), indicating the need for further interventions. Such interventions could usefully involve the arts as they have been shown to be an effective medium to stimulate public discussion and develop understanding about mental health (Harris et al., 2018;McCormack & Henry, 2016;. However, less is known about facilitators and barriers to successfully implementing and evaluating art-based ventures. Therefore, this paper reports on the development of a mental health audio tour of the National Gallery in London and examines the experiences of the interdisciplinary team involved in the project to inform future arts-based stigma-reduction interventions in large venues.

Programme rationale and goals
The goal of the project was to improve mental health awareness among visitors to the National Gallery by developing a free mental health-themed audio tour, similar to the Gallery's other themed audio tours (www.nationalgallery.org.uk/visiting/audio-tours). The National Gallery is a large art gallery in Trafalgar Square in central London, UK. It contains over 2,300 artworks from the thirteenth to the early twentieth century, including important works by Botticelli, Constable, Cézanne, van Gogh, Michelangelo, Monet, Raphael, Rembrandt, Rubens, Turner, Velázquez, da Vinci, and Vermeer. Millions of people visit annually making it one of the most visited art museums in the world (www.nationalgal lery.org.uk) and it is based in London which has a higher rate of mental health stigma than other UK regions (Henderson et al., 2020). Therefore, this seemed like the ideal arts-based venue to raise greater public awareness around mental health issues. The aim was that the tour should direct visitors to view artworks with relevance to mental health, either through representations of mental health in the artwork, through artists with lived experience of mental health issues, or by stimulating discussion about how artworks can make people feel. Developers wished to capture how the physical space and presence of other visitors in the Gallery could impact on a person's mood and agreed that the tour should be narrated in a way that made visitors feel they were "walking in the shoes" of a person with mental health issues to improve empathy. We also felt it was crucial to co-produce the tour with young people with lived experience of mental health issues as we have previously found this to improve the authenticity of public awareness-raising arts-based projects (Riches et al., 2019) and it is advocated as best practice for stigma-reduction campaigns (Hermaszewska et al., 2022). Moreover, we sought to include their voices in the audio recordings because contact with someone experiencing mental health issues appears more effective at reducing stigma than conventional educational campaigns (Thornicroft et al., 2016).

Development of the audio tour
The tour was developed by one staff member from the National Gallery; two members of the Gallery's Young Producers programme; two staff members and nine young people with lived experience of mental health issues from the McPin Foundation charity; two technologists from Antenna International, who produce audio guides for the Gallery; and two academics from King's College London with experience of using the arts to raise awareness about mental health .
Five structured workshops were held in the Gallery with young people, who had lived experience of mental health issues, facilitated by McPin and Gallery staff to develop the content and format of the tour. Table 1 presents a summary of the workshops. Workshops consisted of the young people exploring the Gallery and discussing artworks and topics that should be included in the tour. Tour content developed significantly in the workshops and, following the young peoples' suggestions, focused on "myths about mental health" that were linked to ten locations or Gallery "stops". Workshop discussions led to the writing of the audio tour script which was refined through several iterations by developers. As Gallery artworks moved frequently, a pragmatic decision was taken to focus stops on Gallery rooms, architecture, or immovable features, such as floor mosaics, in addition to key artworks.
Antenna technologists created a progressive web app, which allowed visitors to access the tour for free using their personal smartphones by clicking on a link through the internet browser on their phone (https://tour.aiwebservices.com/c/ngmentalhealth). The tour was narrated by the two National Gallery Young Producers involved in its development and comprised ten main stops. After listening to a brief introduction to explain the tour, visitors were encouraged to listen to the stops in order of preference. Each stop described a myth about mental health that was linked to an artwork or aspect of the Gallery and aimed to "bust" that myth. For example, the myth that "those with mental health issues are lazy, attention-seeking or manipulative", was challenged by directing visitors to the floor mosaics in the main entrance, which depict figures such as Virginia Woolf and Sir Winston Churchill, who achieved much during episodes of mental illness. Another myth, "mental health issues are a sign of weaknesses", was challenged by highlighting the resilience embodied by the Gallery's Barry Rooms, where recitals continued despite nine bombs falling around the Gallery during World War II. Most of the stops included audio excerpts of the young people involved in the tour's development talking about their own mental health issues in relation to the myth and artwork. Two of the stops involved activities to encourage visitors to engage with relevant artworks. Table 2 describes all stops, including myths, artworks, and content. The app also included information about the artworks featured in the tour and links to organisations that provide mental health information and support.

Audio tour launch and uptake
The tour was launched on World Mental Health Day, 10 October 2019. There was a press briefing and articles were published on the websites of King's College London, National Galley, Medical Research Council, McPin, and Antenna International. Members of the Introductions Developers got to know one another and the gallery space through a series of activities. These included observing how visitors move through the Gallery and creating their own maps of the Gallery to highlight potential routes for the tour. These maps included representations of how they felt in different rooms and sketches/collages of aspects of the Gallery building that were referred to in subsequent workshops. 2 Engaging with the gallery Developers each chose a painting that "spoke to them" and considered the feelings and backstory of the character in the painting to engage in dialogues with the characters in other paintings. 3 Script development Developers discussed which myths about mental health to focus on challenging in the tour and which piece of artwork/room in the Gallery the myth might relate to. The young people then voted on the most important ten myths. 4 Script refinement The script was reviewed, and feedback was provided. Developers recorded themselves talking about the myths and artwork in relation to their lived experience. 5 Audio tour pilot Developers listened to the first version of the tour and provided feedback that was incorporated into the final version. Table 2. National Gallery mental health-awareness audio tour stops.

Audio stop and myth
Artworks/gallery space Link between myth and artworks/gallery space (1) Mental health issues are a modern phenomenon -young people are too sensitive nowadays. The Sainsbury Wing of the Gallery, room 51. This is the newest wing of the Gallery but houses the oldest paintings thus mirroring how mental health issues have been around for centuries even though they may appear to be a modern phenomenon because people are more comfortable talking about them now.
(2) Everyone experiences mental health issues in the same way.
Two paintings of "The Virgin & Child" by Giovanni Battista Cima da Conegliano, room 57. The two paintings depict the same subject but from different perspectives. In the same way, experiences of the same mental health issues are often different and vary between people.
(3) Hearing voices and seeing things are rare and a sign of mental illness. "The Vision of the Blessed Gabriele" by Carlo Crivelli, room 57. Historically, having visions and hearing voices, such as depicted in this painting, were experiences that were celebrated and indicated that someone was special rather than unwell. Many people in the general population without mental illnesses have these experiences.
(4) People are destined to develop mental health issues from birth.
Landscape paintings, room 19. Listeners heard two contrasting pieces of music to see how it changed their emotional reaction to the paintings. Similarly, our experiences impact our emotional wellbeing and although our genes may increase the likelihood of mental health conditions, they are not deterministic.
(5) Ethnic minorities or those from developing countries are not affected by mental health issues. "The Adoration of the Kings" by Jan Gossaert, room 14. This is one of the very few paintings depicting people of colour in the Gallery. In the same way that ethnic minorities initially seem "missing" from classical art, mental health issues can also seem less visible among those from ethnic minorities or low-income countries because of a reluctance to speak out due to fear of stigmatisation or institutional barriers to accessing care.
(6) People with mental health issues are lazy, attention seeking, and manipulative. Boris Anrep Mosaics, in the Portico, main entrance of the Gallery. The Mosaics include depictions of Virginia Woolf and Sir Winston Churchill, who both achieved much while battling their mental health issues.
(7) An artist needs to have mental health issues in order to be creative.
Paintings by Van Gogh, Henri de Toulouse-Lautrec, and Claude Monet, Impressionists Gallery, room 43. Although some artists, such as those of these paintings, have experienced mental health issues, they had periods when they were too unwell to paint. The "tortured artist" stereotype can be damaging as it may prevent or delay people in creative jobs from seeking the help that they need, which may make their mental health issues much worse.
(8) Once you have a mental health issue, it will affect you for the rest of your life. "An Experiment on a Bird in the Air Pump" by Joseph Wright "of Derby", room 34. Like the uncertainty of the outcome of the bird in the painting, the outcome of mental illness is uncertain. Many affected individuals make a full recovery; others have periods where they feel well.
(9) Mental health issues are a sign of weakness.
The Barry Rooms, room 36. During the Second World War the pianist Myra Hess performed concerts in this room even during the Blitz to demonstrate London's resilience. People with mental health issues show similar strength and determination when dealing with these often very difficult experiences every day.
10. People with mental health issues are unpredictable, dangerous, and violent. "An English Vessel and a Man-of-war in a Rough Sea" by Ludolf Bakhuizen, Gallery A. This painting depicts a ship attempting to cross a turbulent sea with the sky overhead threatening to unleash a storm at any minute reflecting the common myth that people with mental health issues are unpredictable and may be dangerous or violent. Whereas they are more likely to experience violence from others and hurt themselves.
development team wrote blogs (e.g. https://mrc.ukri.org/news/blog/mental-health-audiotour/; https://mcpin.org/myth-busting-through-art-designing-a-mental-health-audio-tourfor-the-national-gallery/) and participated in a UK Research and Innovation video (http:// socsi.in/tmBy4) and an episode of BBC Radio 4ʹs All in the Mind (https://www.bbc.co.uk/ sounds/play/m000bfj1). Hashtag "#NGmentalhealth" was created for social media promotion. Over 2,500 people took the tour during the first six months. While most (80%) did so in the UK, with the majority visiting the Gallery in person, the app was also accessed remotely in the USA, Canada, Denmark, France, Portugal, Ireland, Italy, and the Netherlands.

Evaluation of the development and implementation of the tour
Ten data-collectors (eight research assistants who were not involved in developing the tour and the two academic developers) were present in the Gallery for four days from the launch to invite Gallery visitors to experience the tour and to administer via tablets measures of mood and attitudes about mental health pre-and post-tour, and obtain narrative feedback. Note, the data collected from Gallery visitors has been published separately and found visitors' attitudes towards individuals with mental health issues were more positive after taking the tour (Riches et al., 2022). Here we focus on evaluating the developers' and data-collectors' experiences of the development and implementation of the tour to understand the key facilitators and challenges they faced during this process. It is hoped this will inform future art-health collaborations to raise mental health awareness more effectively in large-scale venues. These experiences were captured via interview or written responses six months after the launch by a researcher with no involvement in the development or visitor-evaluation of the tour (RV). Before participating in this evaluation, developers and data-collectors were provided with a detailed information sheet and the opportunity to ask questions. They were then asked to sign a consent form confirming they understood what involvement entailed, that participation was voluntary, that they could withdraw at any time, that their responses would be anonymised (identified by a number and removal of names, places, etc.), and that they consented to being recorded (for the interviews).

Developer interviews
Twelve developers (seven people with lived experience, two Young Producers, one McPin staff member, one Gallery staff member, and one academic) either took part in audio-recorded semi-structured interviews or provided written responses to questions. Participants were asked about their experiences of developing the tour (e.g. "How did you find the workshops? What was it like to work with the young people, academics, National Gallery team, and the company that produced the app? Which activities were most/least enjoyable? Were there any challenges or anything you particularly enjoyed? In what ways did being involved in the development of the audio tour have an impact on you?"), their thoughts about the tour (e.g. "Which parts of the audio tour did you like most/least and why? Is there anything that you would like to change about the tour?"), and potential future directions (e.g. "Where could we take the tour in the future? What are your thoughts about using art to raise awareness about mental health? Are other approaches more useful?").

Data-collector interviews
Audio-recorded, semi-structured interviews were conducted in-person or by videocall with ten data-collectors (eight research assistants, two academics) who had collected visitors' feedback during the four-day launch. These participants were asked about their experience of data collection (e.g. "What was your experience of collecting data within the Gallery? How does it compare with your experience of collecting data in other settings? Did the physical environment of the Gallery impact on data collection? What was it like to be part of a research team in the Gallery? What was your experience of using the electronic devices involved in data collection? What could be done differently if we were to collect data in that setting again?"), and the same questions as developers about the tour and potential future directions.

Analysis
Interviews were anonymised and audio-files transcribed. Audio and written data were pooled. Data were thematically analysed using the software package NVivo12 by the researcher (RV) and codes were agreed with the academic supervisors (SJ and HLF). Thematic analysis was used as it is recommended for analysing narrative data in applied health-related research and recognised guidelines were followed (Braun & Clarke, 2006). Data were organised into categories of facilitators and challenges of development (for developers) or of data collection (for data-collectors), tour strengths and weaknesses, and potential future directions.

Findings -developers
Sixteen themes were identified. Participants reported that development facilitators were teamwork, ongoing learning, the safe space of the workshops, feeling pride in the project, involving lived experience, and personal interest in the topic. Barriers were variable attendance at workshops and limited time for the project. Tour strengths were the value of art to raise awareness and involving young people's experiences. Weaknesses were insufficient advertising and difficulty locating artworks. Potential future directions were alternative media and venues, online versions, incorporating lived experience in app development, and increased interactivity for users. Table 3 presents the themes, explanations, and illustrative quotes.

Findings -data-collectors
Nineteen themes were identified. Participants reported that data collection facilitators were teamwork, use of portable electronic devices, online communication, and the uniqueness of the experience. Barriers were the Gallery size, on-the-spot recruitment, participant retention, limited integration with the Gallery, insufficient promotion, insufficient equipment, insufficient branding, a lengthy survey, and public discomfort with mental health as a topic.
Tour strengths were the value of using art to raise awareness, the inclusion of young people's experiences, and the positive response from the public. Weaknesses were tangential links between artworks and audio content and limited information about artists. Potential future directions were alternative media and venues, such as online versions. Table 4 reports the themes, explanations, and illustrative quotes.  Increased interactivity Participants felt it would be interesting to include more interactive activities within the tour.

(25)
"I'd be lovely to do some more immersive stuff and interactive things, think about things for different ages because this is a tour really for kind of 14ish and above, so thinking a bit more about school children and interactive activities or kind offshoot bits that you could do yourself would be interesting." (#10) Table 4. Thematic analysis of data-collectors' experiences of data collection and the audio tour (N = 10).

Illustrative quotes
Data collection facilitators Teamwork Participants reported that the team was supportive, and they learned from each other.
10 (100) "Being part of the team was really great." (#4) "We all got to learn together . . .each day we understood a little bit better the dynamics of the gallery." (#2) Portable electronic devices Participants reported that tablets enabled them to move freely and looked professional.
9 (90) "The iPads, they were really easy . . . you could take them around everywhere." (#9) "It looked much more professional than having pencil and paper and was much easier."  'mental health no, no, no, no, I don't want, I don't

Lessons learnt and looking forwards
Key facilitators of this large-scale arts and health collaboration included teamwork, communication, ongoing learning, passion for the topic, and the inclusion of lived experience. Key challenges included insufficient time and resources associated with a relatively low budget, and limited integration with all functions of such a large gallery, especially where externally contracted staff are used. Challenges for data collection were consistent with previous art gallery-based mental health research , indicating the need for researchers to have a comprehensive understanding of the physical space and access to greater resources. Common themes between developers and data-collectors, such as teamwork, practical constraints, and alternative media serve both to validate the analysis and to highlight issues that pervade all stages of such projects. Both groups also highlighted that using art to raise awareness about mental health issues was beneficial and provided opportunities to reach a different audience than media campaigns. The data-collectors reported though that the links to the art works in this tour were sometimes too tangential and suggested creating clearer links in future versions as well as including more information about the artists. This is consistent with gallery visitors' suggestions regarding the tour (Riches et al., 2022). However, it should be noted that the interviews conducted were fairly brief and undertaken with a reasonably small number of people several months after the tour had been developed. The young people with lived experience of mental health issues reported that involvement in the development of the tour had a positive impact on themselves, which was a welcome outcome. Providing safe, collaborative development processes have previously been shown to enable people with lived experience to engage with the arts, feel pride, and increased self-esteem (McKeown et al., 2016), highlighting how museums and art galleries can play an important role in public health initiatives (Camic & Chatterjee, 2013;Roberts et al., 2011). Co-production was key throughout this project, which is consistent with previous research on the arts and mental health literacy (Koh & Shrimpton, 2014). This indicates the merits of involving those with lived experience to facilitate public understanding of mental health (Riches et al., 2019) and appears more effective at reducing mental health stigma than conventional educational campaigns (Thornicroft et al., 2016).
This app-based tour embraced technological advancements in art galleries. Given recent movements towards digital art and virtual tourism, similar tours may reach wider audiences in an online format. Themes indicate that the tour could be expanded and adapted to reach broader contexts within popular culture, e.g. social media, festivals, theatre, educational institutions, online platforms, and large-scale community projects, particularly to tackle stigma within groups that are less likely to attend art galleries. Social media is a particularly powerful source of social influence, reaching large audiences and has been shown to reduce mental health stigma in the general population (Schomerus et al., 2016). Future art-health collaborations might explore alternative cultural spaces to raise awareness and investigate online arts projects, particularly given the COVID-19 pandemic, as consumers seek remote access to arts and entertainment.
In conclusion, despite development and evaluation challenges, the National Gallery mental health awareness audio tour was successfully implemented on schedule, was accessed by many Gallery visitors, and had a positive impact on those involved. Coproducing such large-scale mental health awareness arts-based projects with people with lived experience, ensuring full integration with all partners, greater resources, time and understanding of the venue, along with wider advertising will ensure future ventures are even more successful.