Impact of creative workshops for people with severe mental health problems: art as a means of recovery

Abstract Background: In line with recovery theories, psychosocial programmes for people diagnosed with severe mental illness (SMI) should focus more on well-being and social connectivity outcomes rather than clinical symptoms. This paper assesses the impact of creative workshops participation on the psychological well-being, social connectivity and subjective experience of people diagnosed with SMI. Method: After participating in a creative workshop in a museum, 19 people, including service users, keyworkers, the art facilitator and a psychologist were interviewed. Four observers participated in the workshop and provided information about the creative process by means of a discussion group. Data were analysed in accordance with thematic analysis methodology and triangulated in order to obtain reliability. Results: Five essential categories were identified: learning process, social connection, psychological well-being, institutional change and mutual recovery. Conclusions: Creative activities may cause a transformation of the image of dysfunction associated with mental illness as well as promoting health and recovery.


Introduction
For almost a century, different disciplines have been studying the impact that creative practices (Van Lith, 2016) such as writing, music, dance, painting have on people diagnosed with severe mental illness (SMI). Over recent years and due to the implementation of the recovery model in health systems (Cornes, Manthorpe, Joly, & O'Halloran, 2014), non-clinical interventions have been sought in different fields to enable people diagnosed with SMI to reconstruct their identity and increase their autonomy. Thus, there has been growing interest in the artistic activities of people diagnosed with SMI from a particularly psychosocial and subjective perspective, focusing on the well-being and social connectivity and away from clinical results such as symptoms (Sagan, 2015).
Well-being is more aligned with the definition of "health" according to the World Health Organisation (WHO, 1948). Firstly, health takes into consideration a psychosocial and political dimension and, therefore, well-being can be considered a question of public health. Secondly, well-being is not just the absence of illness, but the psychological and social factors that promote resilience in both individuals and communities. Finally, well-being can be interpreted according to the hedonic and eudemonic approaches to happiness. Hedonic well-being is based on the notion of subjective well-being. Eudemonic well-being is based on self-actualisation and life purpose, challenges and growth. Accordingly, well-being is related to fulfilment in areas of autonomy and competence (Tennant et al., 2007). Several models have been suggested in order to achieve a set of evidence-based actions to improve and promote personal well-being. These models suggest five ways to wellness: connect, give, keep learning, take notice and be active (Dodd & Jones, 2014). Secker, Hacking, Spandler, Kent, and Shenton (2007) in a qualitative case study found that all participants of creative workshops with a diagnosis of SMI reported improvements in three psychological processes: motivation, concentration and connection with others. Thus, these authors showed empirical evidence of improved psychological well-being, empowerment and social integration among the participants (Hacking, Secker, Spandler, Kent, & Shenton, 2008;Secker et al., 2007). More recently, Bungay, Munn-Giddings, Boyce, and Wilson (2014) conducted an extensive review of the literature from 2011 to 2014 on artistic interventions in clinical settings. They found that the vast majority of the studies showed an improvement of psychological well-being, a drop in levels of anxiety and greater satisfaction in life.
Recently, museums have been the focus of attention for promoting health and social inclusion. The National Alliance for Museums, Health and Well-being shows that in 2016 there were up to 107 activities designed for people with mental health issues in the UK (Lackoi, Patsou, Chatterjee, et al., 2016). The efficacy of these interventions is poorly documented, but there is evidence that shows the positive impact these types of activities can have on the psychological well-being of those participating (e.g. Morse, Thomson, Brown, & Chatterjee, 2015).
Despite previous contributions, however, several authors have reported a lack of designs that allow the assessment of effectiveness in these creative interventions (Reynolds, Nabors, & Quinlan, 2011). Moreover, the lack of the client's or users' voice in the studies of this field has been criticised (Van Lith, 2016).
Traditionally, recovery-based interventions have been focused exclusively on mental health services, without taking into account the institutional changes and the reconfiguration of the professional-user relationships that are necessary for the success of the model. In addition, the implementation of services based on the recovery and the consequent empowerment of users has generated tensions between different agents and erroneous interpretations of the concept of "recovery" that have made paradigm change difficult (Slade et al., 2014). Nor can we forget that these tensions have generated high levels of "burnout" and work-related stress among both informal carers and health practitioners (Arber & Venn, 2011).
Based on Crawford, Brown, Baker, Tischler, and Abrams (2015), our study was framed under the notion of creative practice as mutual recovery: the idea that shared creativity, collective experience and mutual benefit can promote resilience in mental health, new insights and well-being among patients as well as their carers, friends, family and other healthcare professionals. Mutual recovery challenges the traditional recovery model as an individualised and unidirectional process whereby recovery is only considered in relation to the person formally identified as having a mental health issue but not those working with or in support of them, such as informal carers, health, social care practitioners or institutions which frame relationships between users and professionals. This paper assesses the perceived impact of creative workshop participation on the psychological well-being, social connectivity and subjective experience of people diagnosed with SMI as well as the healthcare professionals that accompany them. These workshops have been held at the Contemporary Art Centre of Andalusia (CAAC) since 2006 through an agreement between the Museum, the Andalusian Health Service and Andalusian Public Foundation for Social Integration of the People diagnosed with Mental Disorders (FAISEM).

Context
Bar slight modifications, the structure of the creative workshops, has been the same since 2006. The workshops are structured in six consecutive weekly sessions each of them three hours long (total 18 h). Within the same week, four different groups of around 15-30 service users participate in these workshops as well as their carers (i.e. keyworkers). Each group always attends the workshop on the same weekday. Carers usually have a social care or health-related background rather than a clinical background and also participate in the workshops which run three times a year.
Every year the CAAC holds three temporary exhibitions by contemporary artists. These temporary exhibitions drive the topics and themes that are developed within the creative workshops. The data obtained in this research belongs to the workshop which took place during the months of March, April and May 2015. This workshop was based on the temporary exhibition of the artist Maria Thereza Alves: Long Way to Xico (1991Xico ( -2014. Maria Thereza Alves proposes a debate on issues that are crucial to contemporary culture and to Spain in particular: colonialism, empowerment and ecology.
The workshops were structured in two parts of 90 min each. During the first part, participants visited a specific, selected section of the exhibition. An art facilitator provided context and background information about the artwork, artist and other relevant facts. For example, for María Theresa Alves' exhibition, topics such as ecology, migration and social injustice were discussed. Participants were encouraged to join in the discussion, ask questions and share their opinions and impressions. This discussion was facilitated by the art facilitator who in some instances asked questions to facilitate reflections and critical thinking.
The second part also took placed at the CAAC and consisted of a hands-on workshop. Participants were invited to gather around a large table and use provided materials for painting, drawing and sculpture. Participants were encouraged to create their own artwork. On occasion the art facilitator suggested a specific topic such as "journey" or "seed" to inspire their artwork. During the first 75 min, the participants freely worked on their individual artwork using all the materials available. The artistic techniques employed varied but were largely drawings and acrylic paintings on cardboard or canvases. To close the session, each participant shared with the group their artwork and explained the process and intention. Participants were encouraged to comment on others participants' artwork, ask questions, make suggestions or new interpretations.

Participants
A meeting which included the first author, the representatives of public mental health services and CAAC took place. This committee approved the research protocol and the content of the interviews in accordance with the Helsinki Declaration's ethical requirements. All participants were informed about the study, potential risks and benefits, the voluntary nature of their participation, and the possibility of withdrawing at any point. Then, verbal and written informed consent was obtained from each participant. Participants' rights to privacy and confidentiality were protected at all times.
Although we have used some clinical terms to describe participants in workshops, it is clear that psychopathological labelling involves stigma. In order to reduce the stigma associated to psychiatric labelling, we use always the expression "people diagnosed with …". In this way, we want to prevent the identification of people with the illness's categories.
All users were diagnosed by health services with an SMI, compatible with international standards for SMI (Ruggeri, Leese, Thornicroft, Bisoffi, & Tansella, 2000). Their diagnoses was mainly schizophrenia but with some cases of bipolar disorder or borderline personality, with the criteria of a long duration and a high degree of dysfunctionality. While the severity of the symptoms was not a reason for exclusion in the workshops, disruptive behaviour was.
The theoretical sampling for our research consisted of four phases. First, one user and one professional from each of the four groups were interviewed to explore the validity of the interview questions. We interviewed people who first answered our call. Because all these participants were women and most keyworkers were male, in the second phase it was decided to interview male users and professional women. In the second phase, three male participants and two female professionals were interviewed. In the third phase, because the experience in the workshops seemed to be an important factor, it was decided to actively seek for more experienced participants. Thus, four men who had taken part in previous creative workshops were interviewed. In the last phase, due to the references found in previous interviews, the art facilitator who ran the workshops as well as the representative of the public health services project were also interviewed.
In total 19 people (Table 1) were interviewed, including users (n = 11) with different levels of previous workshop participation, keyworkers (n = 6), the art facilitator responsible for the design and management of the workshops and the clinical psychologist that oversaw and managed the project. No user or keyworker refused the invitation to participate in the research. See Table 1 for participants' demographic information.
In addition, four psychology students participated as observer-participants in each workshop as well as in the group discussions (GD) that were held at the end of workshops.

Analysis and procedure
According to the recommendations for high reliability in qualitative designs, results were triangulated using different techniques of data collection and information sources (Cohen & Crabtree, 2008). Thus, the results shown are those with a high consistency between sources and techniques. Also, with this method we could point out singular and noteworthy results and the discrepancies between different participants. Our data collection techniques were three: Brief structured interviews: these were designed to explore the psychosocial impact and the meaning given to the activity by users, keyworkers and other key protagonists of the activity (i.e. art facilitator and clinical psychologist). Interviews for users and keyworkers took an average of 12 and 20 min, respectively, to be completed. The interviews for the art facilitator and clinical psychologist took 27 and 72 min, respectively. The interviews were brief and highly structured and included questions such as: What would you highlight from the workshops? Why? Do you think participating in the workshops has had any effects on you?
If yes, what exactly? Do you think your family or friends had noticed anything different after your participation in the workshops? If yes, what exactly? The interview protocol is available upon request from the first author.
Participant observation (n = 4): three undergraduate and a doctoral student in psychology (one in each group) were integrated and participated in the workshops. They were instructed to keep a diary about their experiences. At the end of each workshop, observers interviewed all users and keyworkers. The art facilitator and the clinical psychologist were interviewed by the first author.
Group discussion (GD): once workshops were completed and interviews transcribed, a GD that included the four observers and the first author (n = 5) took place. The GD was designed to: (a) discuss the impact of the workshops on the observers who had not had previous direct experience with people diagnosed with SMI and (b) perform a group analysis of the interview and observational data. The GD had a total duration of 105 min. A thematic analysis was chosen for the qualitative research because it is a well-established and parsimonious method of enquiry data (Braun & Clarke, 2006;Vaismoradi, Turunen, & Bondas, 2013). Thematic analysis is a method for identifying, analysing and informing patterns from data. A theme or category can be defined as utterance important about the data in relation to the research questions, and involves a convenient and fruitful articulation of the participants' responses.
The idea behind data sampling in thematic analysis is to select participants and topics that will best contribute to the understanding of the problem and the research question (Boyatzis, 1998). Accordingly, the interviews were designed to address our theoretical interests (i.e. creative practices and recovery). However, from an inductive perspective during the coding process the analysis was data-driven and new themes or descriptions were captured. In this way, we have used some original words to denominate categories from some participants like "learning", and we have utilised concepts from the literature which can be applied to the participants' experiences like "mutual recovery" or "psychological wellbeing".
The research procedure encompasses both a description of the themes emerged from the thematic analysis and also an interpretation of the themes as an attempt to explore the significance of the linguistic patterns and implications in relation to previous literature (Braun & Clarke, 2006).
The main author carried out the first analysis of interviews and conducted the group discussion. Finally, the other three authors, who were independent to the running and execution of the workshops, reanalysed and audited all the interviews using the categories that emerged in the GD as an expert checking team. This process of analysis can be observed in Figure 1.
Interviews and GD were transcribed and analysed using Atlas-Ti 15 version software.

Results
The five essential categories identified are presented along with their definition and analysis: learning process, social connection, psychosocial well-being, institutional change and mutual recovery. Excerpts from some of the interviews are shown to exemplify the definition of the categories.

Complex learning process
All participants, users, keyworkers and observers describe a complex learning process that involves various cognitive functions and different skills and knowledge. The most consistent result is that each user points to or emphasises a particular aspect of this process ( Figure 2). Users with more experience participating in the workshops express an increase in their general cultural level and a better knowledge of artists and styles. For some users this knowledge is so internalised that it influences their lives. According to observers and keyworkers, the dynamic of the workshops allows some users to give new meaning to their life events through the discussions of the artists' work.
Learning is evident in the discourse of more experienced users and an appropriation of the artistic discourse is observed through the use of the artists' names or the reference to artistic styles. In other words, what is observed here is an interpretive and critical style characteristic of what might be called "artistic discourse genre". Observers in the discussion group stressed their surprise and, at the beginning, their lack of confidence to participate because of the quality of the interpretations given by the users.
Some keyworkers in the interviews detail various cognitive tasks that are promoted in the workshops: memory, creativity, imagination and work with personal conflicts. Users, independently of workshop experience confirm these cognitive challenges. The vast majority of users express with different words that the dynamics of the workshops let them free their minds of negative thoughts and ruminations. Some users talk about "unlocking" while others describe stopping the "mulling over". We could call this effect of stopping obsessive thoughts a "time out". One user said that after the workshops he enjoys a "more alert mind", while others note them as "entertaining". In short, these comments tend to refer to a time of focused work, focusing, with moments of flow, especially in plastic art (painting, modelling, collage, ceramics, etc.) that frees the mind from thoughts. The art instructor who leads workshops even speaks of moments of  Mainly, the most important steps to train these skills are twofold. First, to analyse and discuss the interpretation of the visited work and, second, to expose the plastic art personally developed and the shared meanings and motives that have inspired them. But beyond the communication and self-expression skills training, what all users most value is that workshops are areas of horizontal and free expression on any topic. Both users and keyworkers consider that these are exceptional scenarios which rarely can be enjoyed outside the workshops. So much so that some users said they had to push themselves to give their personal opinion.
All respondents highlighted the structure of the creative workshops as key to their success. The dynamic of the workshops is circular, so that it starts with a space for observation-expression and interpretation (active guided visit to the temporary exhibition), secondly a phase of artistic creation (free work with different materials and techniques on the theme of the exhibition) to return at the end to the stage of group expression and interpretation in which participants explain and analyse their artistic creations.

Social connection
The second category of analysis that has been unanimously described by all interviewees has been the significance of the social contact, which has increased through the participation in the creative workshops ( Figure 3). The creative workshops are considered to offer a social space for personal knowledge between users and keyworkers outside the clinical contexts where they spend most of their time. Participants explain how, sometimes, the creative workshops in the CAAC have helped them to meet new people and make new friends that they continue to meet and join in activities with outside the museum.

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User: … I am, I'm a little better, more … I accept other people more, that did not, I did not have that, that appreciation […] I am more tolerant now. And being in a group and all that… you end up making friendships with people.
The emergence of the art as a new topic of conversation can change the relationships with family, friends or acquaintances. This topic is valued by others and is a secure base from which to deepen relations, beyond the typical issues of disease or common conflicts.

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User: We always have more topics of conversation; we can tell others that we were here or there, what the place looked like; we can encourage others to come and visit the place; we can connect other people and introduce those people to the network developed during the workshops and encourage them to visit the museum and have a guided visit, because they [the museum staff ] can do a really good job guiding visitors around, you know what I mean?
The user becomes an active subject when becoming a "guide" or "counselor" thanks to their knowledge and contacts in the museum. Some users revisit the museum with their families, becoming guides and mediators between the artistic work, the institution of the museum and their families and friends. Something as simple as a new conversational topic can increase the users' confidence and self-esteem.
A social practice in which people diagnosed with SMI hardly get involved because of their reduced economic resources is the practice of "giving" rather than "receiving gifts". The artwork can become very personal and meaningful gifts. The explicit and public appreciation of the artwork produced by the users has an important effect on them. In addition to an increase in self-esteem, this appreciation may help the development of a process of identity reconstruction (Saavedra & Rodríguez, 2008).
Some observers and keyworkers consider that within the workshops, some interactions could be identified as mutual aid. As one user stated: "Because I see others giving the same effort I do … in attending, to come over here and there … to strive to draw … of … all the things … I do too …". Some users find that the group is an encouraging environment: "I see myself again with the inspiration for painting".
These new social contacts, social practices, the transformations of old relationships and the self-esteem's increment encourage users to accept new challenges: for example, using public transport alone to go to the museum. In this way, some workshops participants improve their autonomy.

Psychological well-being
Most users recognise an improvement in their psychological well-being due to their participation in creative workshops. This improvement is described in connection with a decrease of stress, a greater ability to relax or escape from their problems. Most significantly, a 46 yearold user participating for the first time in the workshops refers to the good mood within the workshop: "We laugh there, because that's the best a person has, laugher, to laugh at everything". It is known that laughter is an essential health factor.
Undoubtedly, these effects are connected with increasing self-esteem and the "time-out" phenomenon mentioned in the previous section. In the following extract a user who has participated in over 10 workshops expresses both affective development, "I feel more lively", and cognitive development, "the mind is more awake", when asked about the impact of the workshops on his health.

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User: I feel more relaxed, I can develop my mind, I work more in groups, and … I like it … it's a new thing I've learned, it's a physical and mental development as well.
It is easy for keyworkers to find examples of improvement in the welfare of users when they are asked. However, these results are not as unanimous and homogeneous as the first two categories. The user's statement about the change in his health, though positive, is not described with the same intensity. In the GD, observers pointed out that it is difficult to detect improvements in psychological well-being both in groups of users with more chronic SMI as in those whose health conditions were more positive in short-or medium-term. In their opinion, in the groups of users with an intermediate degree of autonomy, there is a more evident improvement in overall health and psychological well-being.
On the other hand, as you can see in the excerpt 6, two users describe an increase in stress due to creative activities. In both cases, this negative experience is confronted and overcome in a positive way, as a logical part of the process. In this sense, stress should be understood by professionals as not always a threat to avoid. Users and professionals should cope with stress as part of life (Saavedra, Cubero, & Crawford, 2012).

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Interviewer: And … Which are the main changes you have noticed about yourself since you started participating in the workshops?
User: I used to have anxiety attacks before going to work, but the more I participate, the less frequently I experience these. I love art, I love art … The anticipation of coming to a new exhibition can make me feel nervous, but I like participating in the workshops and it is definitely worth it.
According to all research participants, one of the causes of the beneficial effect of creative workshops on users is the scenery in which they were developed: The Centre for Contemporary Art of Seville. This centre is located in the historical quarter in a very significant monastery in the city of Seville with open spaces and beautiful gardens.

Institutional change
A very important category of analysis was the change at the organisational, professional and institutional levels in the users' various living accommodations, apparently caused by the activity of the creative workshops. Observers in the GD and most keyworkers show an increase of the activities of cultural and artistic type independently promoted by users and keyworkers of therapeutic communities, foster homes, rehabilitation units, etc. from which the users came.
This transformation of the roles, activities and professional practices is a challenge for institutions that may see it as a threat, due to a sort of "loss of control".

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Keyworker: (…) Maybe they do not want to know … Because they may feel questioned. I don't know … sometimes we don't engage enough, we feel burned out as many service users also think. Stuck … then they [the professionals] do not make any effort, do not develop new research and then nothing changes and where they feel safe is behind their desks in the offices. Then they do not want to know about new ways and alternative perspectives, these things are for a handful of crazy people like me. Others … I actually do not know what other professionals do with their patients because they do not show any interest [towards the service users] … In fact, according to the representative of the public health services interviewed, creative workshops at the Museum "are a wedge" in the current management model and mental health care: "You are challenging the system". Undoubtedly, activity in the creative workshops at the museum not only empowers users, but at the same time gives prominence and visibility to keyworkers and other health professionals without a clinical profile.

Mutual recovery
The most obvious perceived effect both on observers and keyworkers has been the change of perspective about people diagnosed with SMI. The idea that keyworkers had about the functionality, ability to think and traits stereotypically attributed to people diagnosed with SMI seems to changes radically when interacting with them and participating in creative activities. This view is described by observers as surprising. The representative of the Health Services in the workshops that we interviewed alluded to a "wow factor" in all people who begin to participate in the workshops.
This place becomes a setting where the relationship with users completely changes due to the possibility to develop more horizontal relationships that allow a deeper understanding of one another.

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K: For me it is so healthy to come out of the clinical context and to establish a more gratifying and satisfying relationship with the service users … I prefer to be here than to … I always try to spend time with them, and if it is possible, to spend time outdoors, because this is when you connect with them as equals and find out more about them as people [rather than service users]; inside the office we are not ourselves, neither us nor them. However, here the atmosphere is relaxed and flexible, they express themselves as they really are providing insights about their lives, their current situation, their handicaps and most of all, in this environment we are all equal.
After creative workshops, users enjoy new and significant interactions with professionals who accompany them. For example, a keyworker found the workshops "very healthy", describing in detail the relationship changes that occur within the workshops and recognising the growth of their knowledge regarding the contemporary art. Most observers and keyworkers narrated processes of personal growth and self-knowledge through the participation in these workshops.
Observer: It has really helped me, emotionally and in all aspects. I went there and it was important to find out how I was, because we often do not stop to see how we are, how we feel, and we ignore it and keep going as donkeys.

Discussion
Users consistently describe this experience as a learning process by which they expand their knowledge and skills in relation to contemporary art. This knowledge personally impacts their lives and, in some cases, promotes a re-elaboration of their personal experience. Especially in the more experienced users, the artistic discourse has been so internalised that it has become explicit in some of their answers. Activities within the workshops serve as a forum for communication and self-expression skills training. As one user said, "here I am learning to listen". Previous research has found that certain social interactions and an appropriate accompanying narrative may promote a more coherent discourse and a decrease of the delusional speech in patients diagnosed with SMI (Saavedra, 2010;Saavedra, Cubero, & Crawford, 2009). This emphasis on discursive and pragmatic aspects, attention training and the effect of release from rumination suggests a value to cognitive rehabilitation through creative practice. Cognitive training interventions can result in significant improvements in specific cognitive functions (e.g. memory, attention, problem-solving) across a range of mental illnesses (Keshavan, Vinogradov, Rumsey, Sherrill, & Wagner, 2014) and creative practices have been applied as effective interventions in rehabilitation programmes with people with dementia (Viola et al., 2011).
According to the views of people diagnosed with psychosis, well-being requires a state of mind oriented to a significant action in the world that, even in some cases, could result in paths of spiritual growth and identity re-construction (Lal, Ungar, Malla, Frankish, & Suto, 2014). Although learning processes in artistic activities for people diagnosed with SMI have not been frequently highlighted, undoubtedly these processes can function as significant actions in the world.
The creative activity we have described enables people diagnosed with SMI to participate in various social practices away from clinical contexts, and helps them to increase the quantity and quality of their social activities. Giving art as a present or guiding others in a museum visit are activities that motivate, increase their self-esteem and can help re-elaborate their identity. Accordingly, all participants highlighted the importance of the context (i.e. museum) as a facilitator for these practices, suggesting that recover is only possible when participating in normalised social practices.
Sometimes, taking part in activities specially aimed at people diagnosed with SMI can be considered labelling as well. For this reason, it is especially important that joint participation in creative activities by people diagnosed with SMI and the general public causes in the latter a transformation of the image of dysfunction associated with mental illness (Hurley, Linsley, Rowe, & Fontanella, 2014). In this way, a very de-stigmatising effect is achieved (Corrigan, Kerr, & Knudsen, 2005). Therefore, it becomes necessary to promote creative activities out of the socio-sanitary spaces, where the contact with other people is possible.
According to users and keyworkers, even the relationships between them are transformed and become more horizontal and less stressful. This effect has also been found in leisure activities between professionals and people diagnosed with SMI living in care homes (Saavedra et al., 2012). These changes in people without SMI, together with the new knowledge and experience, suggest a phenomenon called "mutual recovery". We foresee that the benefits that these creative activities could bring to mental health institutions and organisations, not without challenges, are worth the effort.
With regard to the improvement of social networks, there is empirical evidence that having significant social relationships are associated with well-being (Webber, Reidy, Ansari, Stevens, & Morris, 2015). Moreover, in our case most keyworkers have observed a clear psychopathological improvement in users, for example, a reduction in hospital admissions; although specifically this data have not been verified. Users' self-reflections only indicate, however, an increase in their resources and tools for relaxation and liberation of the mind. Even though few users have claimed that creative activity increases anxiety, this anxiety can be categorised as positive.
The benefits to that the user reported in terms of their general well-being are evident, however, the specific effect of the creative activity on physiological and psychopathological variables must be explored more deeply considering possible mediating factors.
According to Wallcraft et al. (2011) the active participation of users, families and professionals in mental health services is a sine qua non condition for the recovery. Slade et al. (2014) have identified the contact spaces between different positions in the mental health field as "mental health trialogues". In this sense, we consider creative practices as a space for dialogue. Obviously, joint participation in creative practices of users, professionals and family members or people in the community do not dissolve the tensions between the different agents, but we have seen in our results, that they help reconfigure the different roles, generate new experiences and challenge established institutional practices. Thus, mutual recovery does not only imply an improvement in the psychological health of users and professionals, but rather a change in the paradigm that governs their relationships.
We designed a structured interview with the view to facilitate communication with participants that exhibited different levels of cognitive functionality. Open interviews could be very confusing and complex for people with attention and memory problems. Moreover, the interviews were carried out at the museum while the workshops were running, and therefore, we had to be very effective with the use of the time. Interviewers and participants were free to explore new meanings within our research question and we took in account these contributions in the theoretical sampling and in the discussion group. Nevertheless, we have to explicit these facts as possible limitations of our study. Clearly, the results of this exploratory study are not generalisable yet offer new insights into the possibilities of mutuality in mental health recovery that extends beyond the unitary focus on recovery of people explicitly diagnosed with SMI or other mental health conditions, irrespective of positive impacts on a wider population, such as health and social care practitioners. The principal author of the research previously knew about the existence and development of creative workshops and he is an advocate of using creative practices. This could have biased some analysis. Attempts have been made to lessen this possible bias by several methods. Users' interviews were conducted by people with no previous experience in this area and were not familiar with the objectives of this research. Furthermore, the results were audited by a group of three experts without the theoretical commitment than the first author had. In some results, previous analyses of the first author were updated by further analysis of the verification team. In addition, this team noted some limitations such as the absence of interviews with people who withdraw from the workshops (n = 9). It is unfortunate that due to organisational issues we were unable to those participants. Undoubtedly, it is necessary to deepen the analysis of the impact of these activities through quantitative-qualitative and longitudinal mixed designs.

Conclusions
In accordance with our results, it is possible to state that creative practices were reported to improve users' social connections and communication skills as well challenging the functioning of mental health institutions and professional practices. The joined-up approaches to participation from community groups, professionals and service users in creative practices in non-clinical contexts could reduce public stigma and improve their psychological well-being (mutual recovery).
In summary, the perceived positive impact of creative workshop activities on recovery, their low cost, together with the added potential for mutual benefit to health and social care practitioners, present tentative evidence to recommend the development of creative activities in non-clinical settings (e.g. a museum), and, where possible and feasible in partnership with a varied stakeholder group including people diagnosed with mental disorders.

Disclosure statement
No potential conflict of interest was reported by the authors.

Funding
This project was an additional enquiry to a larger study funded by the Arts and Humanities Research Council, UK, entitled "Creative practice as mutual recovery: Connecting communities for mental health and well-being" [grant number AH/K003364/1].