Recovery and creative practices in people with severe mental illness: evaluating well-being and social inclusion

This is an Accepted Manuscript of an article published online by Taylor & Francis Group in Disability and Rehabilitation on 06/02/2017, available online: https://doi.org/10.1080/09638288.2017.1278797 For Peer Review Recovery and Creative Practices in people with Severe Mental Illness: Evaluating Well-Being and Social Inclusion Journal: Disability and Rehabilitation Manuscript ID TIDS-04-2016-037.R1 Manuscript Type: Research Paper Keywords: Recovery, Creative Practices, Severe Mental Illness, Well-being, Social Inclusion URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation For Peer Review Implications for rehabilitation: • Creative practices can significantly improve social inclusions and well-being in people with severe mental illness. • Participating in creative workshops help to elaborate personal meanings and promote recovery. • Creative practices in mental health services can challenge professional roles and institutional practices. • Participation of people with and without severe mental illness engaged together in artistic activities can decrease public stigma. Page 1 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 1 Recovery and Creative Practices in people with Severe Mental Illness: Evaluating Well-Being and Social Inclusion Purpose: This mixed (quantitative-qualitative) study evaluates the impact of an artistic workshop on a group of people with severe mental illness. This study focuses on the impact of creative practices on well-being and social inclusion outcomes. Method: After participating in a creative workshop, 31 people diagnosed with a severe mental illness completed pre/post-intervention measures, namely, the Warwick-Edinburgh Mental Well-Being Scale and the Social Inclusion questionnaire. It was applied in two-way repeated measures analysis of variance. The statistic Wilcoxon and Kruskal-Wallies were applied for non-parametric data to measure pre/post-test effects and workshop experience effects respectively. In addition to quantitative measures, one observer participated in each workshop that ran in parallel in order to deepen and triangulate quantitative outcomes. Results: The qualitative and quantitative results show that social inclusion improved in a significant way with an important size effect. Psychological wellbeing increased significantly with a low size effect. Conclusions: In accordance with these results, creative practices with people diagnosed with severe mental illness are recommended. In order to increase the impact of these interventions, it is recommended to utilize public space away from clinical environments and to include people without severe mental illness in creative activities together with severe mental illness patients. Keywords: Recovery; Creative Practices; Severe Mental Illness; Well-Being; Social Inclusion Page 2 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 2 The appearance of the recovery model within the area of mental health has promoted the search of alternative interventions for people with severe mental illness and an abandonment of conventional clinical contexts and orthodox treatments in line with pharmacological symptom reduction, cognitive-behavioural or psychoanalytical interventions. The boundaries between non-clinical and clinical interventions are diffused, however, in our opinion the first one could be defined by three main characteristics. First, these interventions should not be necessarily directed by clinical staff (i.e., psychologist, psychiatrist, etc.). Second, interventions take place in normalized and non-clinical contexts (e.g., communitarian centres, schools, museums, public spaces, associations, etc.). Finally, people from the community without mental health problems, when appropriates, could participate in these activities. The rationale for new and alternative interventions is based on three specific aspects of recovery that have been systematically ignored [1]. Firstly, people with severe mental illness (SMI) need to rebuild their identity, build a narrative about themselves that is acceptable and makes sense beyond the appearance of lack of symptoms. Second, they need to feel a sense of control of their own lives not only regarding symptoms and condition management, but also about other aspects of their life such as employment, housing and interpersonal relations. And third, there is an urge to normalise the day-to-day of people with SMI and avoid the constant referral to clinical contexts. In summary, the recovery journey is personal, non-transferable and involves transcending the pathological and promoting other variables such as psychological wellbeing, the construction of new meanings, social inclusion and civil rights. Among other interventions, creative practices have been often put forward as therapeutic interventions for people with SMI [2]. Although creative practices involve a wide range of activities (e.g., writing, music, dance, painting, etc.), investigations have paid attention mainly to plastic arts like painting. For more than a century, and across many Page 3 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 3 disciplines, there has been an interest in a assessing the impact of these creative practices as treatments for people with SMI, however, this approach has been dominated by a strong clinical perspective which has emphasised the psychopathological interpretation of the artistic production including the resolution and expressions of psychological distress of the patient. The predominance of art therapy as an intervention in the area of mental health is a sign of this bias. From a different perspective, many professionals have pointed out the psychosocial benefits of creative practices. For example, Parkinson [3] showed a reduction of depression and anxiety symptoms when patients engaged in artistic activities. In relation to SMI, a study with patients from the National Health Services in the United Kingdom that had participated in creative workshops, reported that all participants experienced improvements on their concentration levels, motivation and connection to others [4]. These authors presented empirical evidence regarding the benefits experienced on psychological wellbeing, empowerment and social connection among the study participants. Recently, it has been conducted a systematic review of the literature, from 2011 till 2014, to assess the effects of creative practices within clinical contexts [5]. The authors concluded that most of the studies reviewed showed a significant improvement on wellbeing and satisfaction, and a reduction on anxiety levels. There is also evidence showing that engaging and participating in creative and artistic practices can reduce the stigma associated with mental illness. Visitors of an art exhibition that displayed artwork created by people experiencing mental distress demonstrated better understanding of mental illness, empathy towards people suffering from mental illness and acknowledged and valued the artistic skills and talent among the artists [6]. Their observation reflects the positive effects that creative practices have, not only on the patients, but also on the healthcare professionals and general population. In this line, it has been proposed the Page 4 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 4 concept of ‘mutual recovery’ as potentially valuable [7]. In contrast with traditionally recovery-based interventions, which tend to focus almost exclusively on treating service users, mutual recovery involves a reciprocal relationship amongst several agents: Service users, residents, professionals, clinicians, and everyone else involved in creative practices. Therefore, mutual recovery makes emphasis on cross-community recovery rather than individuated interventions. Other vulnerable groups, besides people with SMI, have also shown significant benefits when engaging with creative practices. In Australia, the effects of three different community interventions that included drama, music, circus skills among other techniques with vulnerable population such as women in prisons was assessed [8]. This mixed methods study showed that even though the interventions were not designed to improve mental health outcomes, participants experienced an improvement in their confidence, self-efficacy, autonomy and connection with their community after treatment intervention. Even though there is cumulative evidence regarding the psychological benefits of creative practices experienced by vulnerable groups, the quality of the studies and the measures employed to assess such benefits is poor and lack scientific rigor [8 - 10]. Other criticisms have pointed out the excessive reliance on anecdotic evidence, the lack of longitudinal studies and lack of attention to the processes involved. This repeated measures study intends to overcome these methodological shortfalls by assessing social inclusion and wellbeing outcomes among a group of people with a SMI that enrolled on series of activities and workshops that took place within a museum of contemporary art. This study focuses on further understanding the underlying creative processes, as well as participatory effects, that took place among study participants. Special emphasis was also given to the changes experienced by the keyworkers and other naïve Page 5 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 5 observers that were accompanying the study participants to contrast their predefined ideas and believes associated to people with SMI before and after the creative practice intervention. Methods Study Participants and Context This study shows the assessment of one of the workshops that have been taking place at the Contemporary Art Center of Andalusia, Seville (Spain) for people with SMI since 2006. After two years of running this initiative a formal agreement between the Andalusian Public Health Service (SAS), the Andalusian Foundation for the Social Integration of People with Mental Health Disorders and the Contemporary Art Center was put in place to ensure commitment and sustainability. The structure of these workshops, except minor changes, has remained the same since 2006. The workshops run three times a year and have a duration of 18hrs spread across six days (3hrs/day). Four workshops run in parallel and each one is attended by approximately 15 service users. The workshops are also attended by an art facilitator and one or two keyworkers per institution involved in this project, including therapeutic communities, hospitals, mental health rehabilitation units, semi-independent housing and relevant associations. Each workshop has two phases, the first one consists on a group visit to the contemporary art exhibition currently taking place at the art center. During these visits participants are encouraged to reflect and discuss the artwork, its meaning and possible interpretations. The second phase focuses on developing pieces of art, individually or as part of group, following the themes that have emerged during the previous discussions with assistance from the art facilitator. Although the types of creative technics employed in workshops was diverse, most of creative practices used were related to visual arts such as drawing, painting, sculpture, printmaking, collage , etc. The data presented in this study Page 6 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 6 belongs to the workshop which ran from March, to May of 2015 and was based on the artwork by contemporary artist “Maria Thereza Alves: El largo camino a Xico (1991-2014)”. In total we gathered data from four workshops run in parallel that included 31 service users that had a diagnosis of SMI compatible with the international criteria for severe and persistent mental illness [11]. The most common diagnosis included schizophrenia followed by bipolar and personality disorder. All participants were classified as having a long-term and high degree of dysfunctionality. This sample included ten female and 21 male with and mean age of 44.78 (sd. 11.42). Their educational background included 35.5% of participants not achieve any education degree or only completing primary school, 16.1% surpassed the compulsory stage of secondary education, 38,7% achieved high school diploma and 9.7% obtained a university degree. Ethical Approval A meeting including the first author, professionals and representatives of public mental health services and Museum’s management was held. This committee was informed about the research project and approved the research protocol and the content of the interviews in accordance with ethical requirements. All participants were informed about the study, 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. Unique identification numbers were used to link pre and post measures. Design and Procedure This is a mixed method design that included quantitative measures such as the Spanish translation of the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS) [12] Page 7 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 13 O1 (Observer 1): […] finding people paying attention (to users) is an improvement. They feel free and their social interactions improve as well as their wellbeing and self-esteem. Especially their self-esteem, because inevitably, if you draw a picture and people value and praise you and say how beautiful it looks, consequently that challenges you next week to do it better. That is the benefit that I have noticed. The participant-observers also coincide when describing a complex context and a horizontal structure in which participants are allowed to express and developed emotions both verbally and by creating artwork in a non-judgemental environment. This context influences positively work dynamics, facilitates social interactions and can provide new communicative skills to users. As the reader may appreciate in the selected extract below, the participantobserver reflects on the personal experience while constructing new meanings around recovery [18]. Extract 2 O2: … I think it is especially relevant that [service users] were able to synthesise all their worries, all their fears, everything in something positive. Because usually they speak about what concerns them, about their problems… For example, a service user that had children was worried about them but instead she wrote a wonderful poem. She was describing her worries as a mom and as soon as these thoughts were expressed in a poem or a drawing or whatever, her worries turned into something positive, something productive. And this also makes them feel more accepted, this also influenced by that sense of horizontality. This [the artwork] is not better that this one, it is worth it by itself full stop. And that is also something I really enjoyed, a way to give sense to their experiences. Another participant-observer (see below) pointed out the richness of the learning process that the participants enjoyed while taking part in the creative workshops. Some service users pointed out the influence that some of the temporal exhibitions, in which the Page 14 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 14 workshops were based on, had in their lives. This learning process is usually not explicitly described or explored in researchs. However, without undermining the importance of other outcomes, the most obvious positive outcomes derived from participating in this type of creative workshops is an increase on artistic knowledge/skills and also personal development. Extract 3 O2: […] one of the service users told me that she was attending the workshops since it started because the activity was very fulfilling and that many artists had helped [the service user]to make decisions in life because all she had learnt. Access to information was also important, one service user mentioned that he loved the workshops because it was a way for him to find out information that otherwise he couldn’t not access, which is a sensation many of us have had. To be with others, to meet new people, and mostly the heterogeneity of the groups, with so many pathologies, and also the respect between participants is important, you know? They are very different, but this is not a problem… The participation in this enriched scenery which provided new meanings to users can help to increase their social network, “new friends”, but also, what is most important, to redefine old relationships. This is being supported by the large impact size of variable ‘Social Acceptation’. The effect of the creative practices on health measures is well reported [19]. For example, Pennebaker [20] demonstrated the effects of expressive writings on blood pressure and stress hormones among students. Within the current study, we go beyond the biological variables, as measured according to the Warwick-Edinburgh Mental Well-Being Scale, by also focusing on the capacity to deal with stressful situations and to build positive relationships with others. The current study shows a significant increment, though effect size is small, on the mental wellbeing experienced after participating in an artistic workshop held Page 15 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 15 at the art center. It is worth to mention that this significant effect takes place only after 18hrs of intervention. Some of the participant-observers pointed out, after conversing with other workshop participants, the benefits perceived on the service users as well as on themselves (see extract 4). While engaging in creative practices, the service users were able to free their minds from recurrent thoughts (i.e., rumination) and also mindfully focus on creative tasks, being able to achieve a ‘state of flow’ with its associated benefits [21]. Extract 4. O4: While they (the service users) were painting, they would not think about anything else, because they did not have anything distracting their minds. They were able to relax. They (the service users) were looking forward Fridays to come back because they felt relaxed, listening to the music while painting, and they say: ‘I, while I am painting, I am not thinking in anything else, then that is good. I am feeling good because I am not going on and on in my head all they long’. With regard to psychological well-being, observers highlighted the benefits on the service users’ communication skills including a decrease in delusive speech while engaging in the workshops due to the social interactions within the group of participants. In this sense, some researchers have found that certain social interactions may promote a more coherent discourse and a decrease of the delusional speech in patients with SMI [18; 22; 23]. Anecdotic evidence from the keyworkers indicated a reduction of hospital admissions as a result of workshop participation, however, when observers were asked about any healthrelated changes among service users, responses were mixed. Our quantitative data shows that differences in the amount of previous workshop experience at baseline could explain the observed differences. For example, while participants with more experience scored higher at pre/post-test measures when assessing Social Relationships, the most notable change was observed in the medium level experienced group. It may be suggested that highly workshop- Page 16 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 16 experienced participants have reached a ceiling effect and, therefore, it is difficult to see significant improvement in this group. Benefit on their social relationships was perceived by the group with less or no experience, but it was not as remarkable as in the group with medium level of experience. In this case, it is possible to hypothesize that the less workshopexperienced group needs to accumulate more hours of workshops to increase the efficacy of the interventions. Because the workshops include different activities, the question about which activity is influencing the results the most, cannot be elucidated by the present design. This is one of the most complex issues when conducting field research. However, thanks to the contributions of observers and to our analysis, it is possible to make some considerations about this issue. For example, during the initial phase in which participants visit and discuss the current artwork exhibited at the art center, verbal exchanges, emotional expression and communication skills’ training are very important in this initial phase. However, in the second phase of artistic creation participants also discuss together, in most cases, individual artwork. According to observers, training of communication skills is essential for improving social interactions and the search for new meanings (extract 1 and 2). At the same time, with regard to the second phase, creative activities make the flow state and the mind releasing experienced by users possible (excerpt 4). In our opinion, one of the most relevant workshop design’s aspects is the integration of activities which involves plastics and linguistics dimensions. Study limitations include the absence of a control group (i.e., delayed treatment) or an active control to account for the location (e.g., same workshop run in a clinical setting) or the type of activity (e.g., non-creative activity run at the museum). Secondly, even though all participants had a formal SMI diagnosis, the degree and severity of the symptoms as moderator factors was not assessed when analysing the questionnaire data. Thirdly, it would Page 17 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 17 be convenient to track the users’ progress over a longer period of time in order to clarify the persistence over time of positive outcomes and the influence of the amount of experience in previous workshops. Fourth, the changes observed in a self-rated questionnaire survey may not reflect the change in behavioral attitude among the participants. However, observers offer us a workshop process’ landscape and provide useful information about the workshops’ impact on users and themselves. We remind that naïve observers do not have previous information about recovery theories or models which can mediatize observations. We considered especially relevant the efforts for triangulating qualitative and quantitative results. Obviously, the observers’ contributions cannot be generalized and should be considered with precaution. With regard to the instruments employed, even though the internal consistency for the Social Inclusion questionnaire is acceptable, some authors [24] consider that its internal consistency is within the lower acceptable interval and therefore it should be applied with caution. Moreover, to our knowledge, this is the first time that the Social Inclusion questionnaire [4] is applied to a Spanish sample without a priory psychometric validation. In contrast, the Warwick-Edinburgh Mental Well-Being Scale shows a higher internal consistency and reliability. The evidence presented in this study, the low cost associated in running these workshops and the lack of side or negative effects, supports the concept that creative practices run in museums are beneficial to promote the wellbeing and social inclusion of people with SMI, as well as their keyworkers and other healthcare professionals, and therefore, facilitates opportunities for mutual recovery. According to our experience and the data gathered using a mixed methods approach, we can recommend three suggestions regarding the location to develop and deliver creative practices for wellbeing and social relationships. Firstly, we highly recommend utilizing public spaces, such as museums far Page 18 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 18 from the clinical environments, to deliver the creative practices (e.g., artistic workshops and seminars) as it promotes positive social interactions. Second, undoubtedly, activity in the creative workshops at the museum not only empowers users, but at the same time it challenges institutions and organizations in order to improve interdisciplinary collaboration that according to some authors [25] need to be developed. And, finally, we suggest the participation of people with and without SMI engage together in these activities [6]. Our observers noted a radical change on negative associations and prejudice associated to people with SMI. This positive impact and greater awareness illustrate the benefits of creative practices as a mechanism for mutual recovery [7]. Acknowledges This study is part of the project: 'Creative Practice as Mutual Recovery: Connecting Communities for Mental Health and Well-being' (AHRC grant ref. AH/K003364/1). We would like to thank to Contemporary Art Center of Andalusia, Andalusian Foundation for the Social Integration of People with Mental Health Disorders, Andalusian Public Health Service and all professionals that collaborate with us. Declaration of Interest The authors report no declarations of interest Page 19 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 19 References 1. Sheperd J, Boardman J, Slade M. Making Recovery a Reality. London: Sainsbury Centre for Mental Health; 2008. 2. Hacking S, Secker J, Kent L, Shenton J, Spandler H. Mental health and arts participation: the state of the art in England. Journal of the Royal Society of Health Promotion 2006;126(3):121-7. 3. Parkinson, C. Invest to save: arts in health-reflections on a 3-year period of research and development in the North West of England. Australasian Journal of Arts and Health 2009;1:40-60. 4. Secker J, Hacking S, Spandler H, Kent L, Shenton J. Mental Health, Social Inclusion and Arts: Developing the Evidence Base. Anglia Ruskin University and Department of Health; 2007. 5. Bungay H, Munn-Giddings C, Boyce M, Wilson C. The value of the Arts in Therapeutic and Clinical Interventions: A critical review of the literature. Anglia Ruskin University; 2014. 6. Koh E, Shrimpton B. Art promoting mental health literacy and a positive attitude towards people with experience of mental illness. International Journal of Social Psychiatry 2013;60(2):169-74. 7. Crawford P, Brown B, Baker C, Tischler V, Abrams B. Health Humanities. Palgrave McMilliam: New York; 2015. 8. Kelaher M, Dunt D, Berman N, Curry S, Joubert L, JohnsonV. Evaluating the health impacts of participation in Australian community arts groups. Health Promotion International 2013;29(3):392-402. Page 20 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 20 9. Reynolds MW, Nabors L, Quinlan A. The Effectiveness of Art Therapy: Does it Work? Art Therapy: Journal of the American Art Therapy Association 2000;17:207-13. 10. Slayton SC, D’Archer J, Kaplan F, Marylhurst, OR. Outcome Studies on the Efficacy of Art Therapy: A Review of Findings. Art Therapy: Journal of the American Art Therapy Association 2010;27(3):108-18. 11. Ruggieri M, Leese M, Thornicroft G, Bisoffi G, Tansella M. (2000). Definition and prevalence of severe and persistent mentally illness. The British Journal of Psychiatry 2000;177:149-55. 12. Tennant R, Hiller L, Fishwick R, Platt S, Joseph S, Weich S et al. The Warwick- Edinburgh Mental-being Scale (WEMWBS): development and UK validation. Health and Quality of life Outcomes 2007; 5(1). 13. Braun V, Clarke V. Using thematic analysis in psychology. Qualitative Research in Psychology. 2006; 3: 77–101. 14. Burnard, P. Writing a qualitative research report. Nurse Education Today 2004;24(3):174-179. 15. Nederhof AJ. Methods of coping with social desirability bias: A review. European Journal of Social Psychology 1985;15(3):263-80. 16. López MA, Gabilondo A, Codony M, García-Forero C, Vilagut G, Castellví P, Ferrer M, Alonso J. Adaptation into Spanish of the Warwick–Edinburgh Mental Well-being Scale (WEMWBS) and preliminary validation in a student sample. Qualitative Life Research 2013;22:1099-1104. 17. Watson D, Clark LA, Tellegen A. Development and validation of brief measures of positive and negative affect: The PANAS scales. Journal of personality and Social Psychology 1988;54:1063-70. Page 21 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 21 18. Saavedra, J. Schizophrenia, Narrative and Change: Andalusian Care Homes as Novel Sociocultural Context. Culture, Medicine and Psychiatry 2009;33:163-84. 19. Stuckey HL, Nobel J. The Connection between Art, Healing, and Public Health: A Review of Current Literature. American Journal of Public Health 2010;100(2):254- 63. 20. Pennebaker JW. Writing about emotional experiences as a therapeutic process. Psychological Science 1997;8(3):162-166. 21. Robinson K, Kennedy N, Harmon D. The Flow Experiences of People with Chronic Pain. Occupation, Participation and Health 2012;32:104-12. 22. Saavedra J, Cubero M, Crawford P. Incomprehensibility in the Narratives of Individuals with a Diagnosis of Schizophrenia. Qualitative Health Research 2009;19:1548-58. 23. Saavedra J. Quantitative Criteria of Narrative Coherence and Complexity in Persons with Paranoid Schizophrenia. Journal of Nervous and Mental Disease 2010;198(5):349-55. 24. Huh J, Delorme DE, Reid LN. Perceived Third-Person Effects and Consumer Attitudes on Prevetting and Banning DTC Advertising. Journal of Consumer Affairs 2006;40(1):90-116. 25. Holwerdaab A,Fokkensc AS, Engbersab C, Brouwerab S. Collaboration between mental health and employment services to support employment of individuals with mental disorders. Disability and Rehabilitation 2016;38(13):1250-56. Page 22 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 For Peer Review 22 Table 1. Differences pre-post test for the WEMWBS and The Social Inclusion questionnaires (ANOVA and Wilcoxon test). Effect within groups n Pre - test Mean (Sd) Pre - test Mean (Sd) df F and z p η 2 Mbox(p) Psychological Well-being 30 3.55(0.82) 3.73(0.69) 1 F =7 . 78 0 .038 0 .150 10.594 (p=0.153) Social Isolation 31 3.3(0.50) 3.27(0.55) 1 z = - 0.605 0.545 20.004 (p=0.007) Social Relation 31 3.09(0.79) 3.25(0.59) 1 F =5.054 0 .033 0 .153 12.200 (p=0.097) Social Aceptation 31 2.65(0.45) 3.33(0.54) 1 F =135.4 <.001 0 .829 9.457 (p=0.211) Page 23 of 29 URL: http:/mc.manuscriptcentral.com/dandr Email: [email protected] Disability and Rehabilitation 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60