“Recovery is a process, a way of life, an attitude, and a way of approaching the day’s challenges. It is not a perfectly linear process” (Deegan, 1988, p. 15). More precisely, personal recovery refers to an individual process that can primarily be assessed subjectively by the individual, and is not necessarily related to symptom reduction (Slade, 2010; Chan et al., 2018). In this sense, the process of personal recovery focuses on the individual’s journey rather than on reaching a goal or an outcome. Personal recovery is subjective and unique to each person, and can be an experience of self-discovery, change and personal growth. It requires commitment and optimism from those who have MHCs and their families, as well as a support system from professionals, health services and the community (Jacob, 2015). “CHIME” is a widely accepted conceptual framework to identify personal recovery processes, which consists of five essential components: connectedness (relationships, peer support, and part of society), hope and optimism (positive thinking, motivation, and aspirations), identity (positive self-esteem), meaning in life (meaningful life, goals, and spirituality), and empowerment (responsibility and strength) (Leamy et al., 2011; van Weeghel et al., 2019).

In Israel, as is the case in other countries (Slade et al., 2012; Solli et al., 2013; Fernando, 2014), the recovery-oriented approach has influenced psychiatric rehabilitation policy by shifting care from hospital to community services, as manifested in the 2000 “Rehabilitation in the Community of Persons with Mental Disabilities Law.” This law is aimed at the community rehabilitation and integration of adults with at least a 40% “mental health disability” (as determined by the National Insurance Institute) and enables them to achieve more functional independence and a better quality of life, while maintaining their dignity, in the spirit of the Israeli “Basic Law on Human Dignity and Liberty.” Indeed, this transition has contributed to the quality of life and community integration of people with MHCs (Dudai and Hadas-Lidor, 2008; Roe et al., 2012) and to the establishment of community rehabilitation programs designed not only to reduce self-stigma among people with MHCs, but also non-clinical community members’ public stigma (Roe et al., 2016).

Studies have shown that leisure activities make a positive contribution to the personal recovery process by endowing individuals with a sense of community membership, autonomy, capability, meaning and hope, while reducing depression, stress and boredom (Chan and Mak, 2014; Iwasaki et al., 2015; Fenton et al., 2017; Chan et al., 2018). A recent systematic review indicated that participation in social activities is one of the most common enhancers of social inclusion (Filia et al., 2018).

There is growing evidence that a personal recovery process can be fostered by pursuing activities in various fields of the arts, and that these activities can improve social abilities, connect communities, and promote well-being (Crawford et al., 2013). Lomas (2016) discussed the significant potential of the arts as a means of experiencing growth and fulfillment, and proposed the term of “positive art” to designate the field that encompasses theory and research on the positive effects of arts activities on well-being. His literature review shows that artistic expression in or appreciation of visual arts, music, literature, and drama contributed to five positive outcomes: awareness, enrichment, aesthetic appreciation, entertainment, and connection with others (Lomas, 2016). Leisure activities such as theater or music, when moderated by a professional with an artistic background, enable the participants to perceive themselves as musicians or actors and not as patients (Ørjasæter and Ness, 2016).

Another literature review identified the core components of theater that may contribute to positive change in people with MHCs. These include “processes of group cohesion and affiliation, common goals, common experiences, setting characteristics of openness and inclusion, opportunities for community connections and integration, flexibility, and ownership” (Faigin and Stein, 2010, p. 307). Theater also enables people with MHCs to take on valued social roles and publicly challenge mental health stereotypes (Faigin and Stein, 2010). A qualitative study explored the experiences of people with MHCs, their relatives, and health professionals in a local community theater project where all the participants presented as equal members without explicitly revealing their background (Bosco et al., 2014). The participants with MHCs reported improvement in social relationships and quality of life. The relatives of those with MHCs reported noticing personal growth, empowerment, and reduction in their family members’ self-labeling (Bosco et al., 2014). A different qualitative study of a theater ensemble involving people with MHCs identified several ways in which this community-based theater impacted people with MHCs, including “personal growth through acting, performing as escape from the self, sharing personal stories on stage and the power of personal stories to connect to audiences” (Faigin and Stein, 2015, p. 153).

A narrative study examined the associations between recovery and participation in a theater group that was part of a community rehabilitation program for people with MHCs (Torrissen and Stickley, 2017). Participants in this study reported an improvement in sense of meaning, sense of belonging, social interaction, peer support, and self-esteem. The authors suggested that participation in community-based theater may have a positive impact on the participants as regards all five recovery processes in the aforementioned CHIME model (Leamy et al., 2011). The qualitative findings of a mixed method study reported trends where people with MHCs who participated in playback theater reported improved self-esteem, creativity and self-expression, self-knowledge, as well as experiences of fun and relaxation (Moran and Alon, 2011). The authors argued that consistent with the recovery approach, playback theater encourages people with MHCs to meet as equals with others, promotes contact, facilitates a sense of community, and helps reduce feelings of isolation and stigma. They claimed that “re-authoring one’s own story is the way to shed the identity of “patient” and adopt a new identity with multiple roles” (Moran and Alon, 2011, p. 321). A different playback theater group specially trained to raise awareness of mental health issues gave the audience an opportunity to share experiences of prejudice and discrimination, to protest negative attitudes, and look beyond mental health labels (Yotis et al., 2017). Overall, these studies underscore the contribution of theater to the recovery process. Theater’s rehabilitative power lies in its inherent reliance, as an art form, on the presence of an observing other; theater is often defined as A performs B for C, and “theater” in Greek (théâtron) means a “place to behold” “to view” (Theater, 2019).

Music has also been found to impact the recovery process among people with MHCs. According to Ansdell (2010), musical performance not only creates social bonds between people and communities, but also helps to “perform the self” which validates one’s existence; namely, “I perform, therefore I am” (Aldridge, 1996 as cited in Ansdell, 2010, p. 171). A qualitative study examined the effect of a drumming group on people with MHCs, compared to a non-music control group. The findings indicated a decrease in depression, a significant improvement in social resilience, and a significant reduction in anxiety compared to the control group (Fancourt et al., 2016). Another qualitative study examined the contribution of a community-based singing activity to the recovery process of people with MHCs (Lagacé et al., 2016). Participants noted a re-discovery of their identity, increased self-confidence, resuming and engaging in meaningful occupations and projects, improvement in social and cognitive skills as well as in their physical condition. These benefits were attributed to a normalizing environment, lack of stigma, high expectations and support for participants, stress relief activities, emotional expression and arousal of cognitive functions (Lagacé et al., 2016). A qualitative study that included 20 interviews and 2 focus groups indicated that engagement in the community-based singing workshops in “Sing Your Heart Out” (SYHO) project improved or maintained the mental health and well-being of the participants, people with MHCs, as well as the general public (Shakespeare and Whieldon, 2018). A thematic analysis of semi-structured interviews of 25 choir members and 23 creative writing group members with mental health conditions indicated that participating in arts-based groups can be empowering, because it increases the participants’ awareness of their psychological needs such as belonging, support, self-efficacy, purpose and positive emotions (Williams et al., 2020).

With regards to creative writing, it was suggested that “creative writing might play an important role in recovery from mental illness” (King et al., 2013, p. 450). These authors argued that creative writing in the psychosocial rehabilitation for people with MHCs can contribute to personal identity development, the repair of symbolic functions, and the remediation of cognitive functions. They emphasized the importance of the facilitator’s identity as a professional writer rather than a mental health professional in enabling participants to identify themselves as writers rather than as patients (King et al., 2013). The benefits of creative writing in the recovery of people with MHCs were also examined in Writing for Recovery (Taylor et al., 2014), a narrative practice development project which provided the participants with a protected space to explore their identities through the writing processes, express their individual unique voices, share social experiences and find personal and social meaning in recovery. In the process of re-storying identities, new relationships were created and the participants’ social and self-confidence increased (Taylor et al., 2014). This is consistent with the view that the process of re-authoring one’s life story is an integral ingredient of the recovery process because it gives the individual an opportunity to regain ownership of his or her personal story (Roe and Davidson, 2005). A phenomenological qualitative study indicated that personal writing (i.e., poetry, creative writing, story-making, or journal writing) may improve the development of self-identity, expand points of view, enhance self-awareness, assist in the understanding of others, enable spiritual transcendence, and promote personal growth and recovery (Haertl and Ero-Phillips, 2019). In sum, the reviewed studies above focused on the potential impact of theater, playback theater, music, singing, and creative writing on people with MHCs- art forms that are offered in the Amitim program.

The Amitim program, founded in 2001 by the Israel Ministry of Health and the Israel Association of Community Centers, operates nationwide in about 80 community centers and serves approximately 3,500 adults (aged 18+) with at least a 40% mental disability, who are eligible for rehabilitation services by law. The professional coordinators of the Amitim program accompany the adults with MHCs, facilitate their integration in community center activities and support their personal recovery process and psychosocial rehabilitation (Halperin and Boz-Mizrahi, 2009).

Amitim’s flagship activities are its integrated arts-based groups which are designed to enable interpersonal contact and meaningful dialogue between people with MHCs and non-clinical community members. The process is focused on a joint creative activity and is accompanied by a structured discussion on mental health issues and the shared experience. Thus, the integrated arts-based groups aim to impart knowledge and skills in theater, music, writing, or other arts, and to facilitate direct interaction between participants. Intergroup contact (i.e., contact between members of different social groups) have been found to be an effective way to reduce prejudice and intergroup tensions as well as to improve intergroup relations (Christ and Kauff, 2019). This format is consistent with Allport’s intergroup contact hypothesis (Allport, 1954), which stipulates that four key conditions are required to create the positive effects of intergroup contact: equal group status within the situation, common goals, cooperation between groups, and support by social and institutional authorities.

Amitims’ integrated arts-based groups aim to change attitudes toward mental health in non-clinical community members and to promote personal recovery among people with MHCs. This goal is consistent with the aforementioned cumulative evidence that participating in arts-based groups can have positive psychosocial outcomes. Approximately 15 integrated arts-based groups operate annually in community centers and in several academic settings throughout the country. Each group consists of about 10–25 participants (of whom about 50% are with MHCs), and is led by a group facilitator who is an artist, arts therapist, or other human service professional. Each group is also accompanied by an Amitim coordinator. The groups meet weekly for about 2 h and overall group duration ranges between 13 and 36 weeks. A detailed description of the characteristics of participants enrolled in Amitim’s arts-based groups is reported elsewhere (Nitzan and Orkibi, 2020).

This qualitative study is a part of a larger mixed methods research program which includes quantitative data collected at beginning and end of the Amitim program’s annual activities. The present report focuses on the qualitative data collected between August and September 2019 from five focus groups to better understand the participants’ experiences in the integrated arts-based groups, as well as the contribution of the groups to the integration of people with MHCs in the community and the reduction of public stigma and self-stigma.

Thirty-eight individuals were recruited from 15 integrated arts-based groups to take part in five focus groups (singing, music, writing, theater, and playback theater). Of the participants, 26 were females (M = 42.3, SD = 16.48) and 12 were males (M = 34, SD = 12.83). There were 17 participants with MHCs (females = 12) and 21 non-clinical community members (female = 14). See Supplementary Table 1 for a summary of participants’ demographics.

In May 2019, Amitim program research supervisors together with University of Haifa researchers sent a joint letter to the Amitim integrated groups coordinators reiterating the importance of focus groups to understand the participants’ experiences and get feedback on the groups. The coordinators were asked to help recruit participants for the focus groups. Amitim coordinators of five integrated groups were able to recruit participants for the focus groups and mediated between the researchers and the participants to schedule the time for the sessions. The study was approved by Mental Health Division of the Ministry of Health and by the Ethics Committee at the University of Haifa (approval # 287/17). Participation in this study was voluntary and all the participants signed an informed consent form indicating their willingness to take part in the focus group.

Focus groups were chosen as data collection method because they constitute a collaborative space which enables an open dialogue between participants following a shared experience. All participants can express their opinions, share personal and collective experiences, exchange diverse perspectives, and offer different interpretations. In addition, focus groups may encourage participants who refrain from one-on-one interview to take part in group interview (Bloor, 2001). Five focus groups were held at the end of the integrated arts-based groups annual activities. The focus groups were documented on sight by a professional typist who was committed to confidentiality. The focus groups adhered to a semi-structured interview protocol with open-ended questions and lasted 90–120 min each. At the end of the focus group, each participant received a gift card as an expression of thanks. See Supplementary Table 2 for the focus group interview protocol.

Data were coded using reflexive thematic analysis, which is characterized by theoretical flexibility and is suitable for questions related to participants’ experiences, attitudes, and perceptions (Braun and Clarke, 2020). The process included six phases: familiarization with the data by reading the data repeatedly to be intimately involved in the corpus; coding by identifying key characteristics in the dataset and generating codes; generating initial themes by identifying broader meaning patterns (potential themes) across codes in the collected data; reviewing themes by examining candidate themes checked against the dataset and refining them if needed; defining and naming themes by analyzing each theme in detail and giving an informative name to each theme; writing up the report by weaving the data extracts together with the narrative. The checklist for conducting a good thematic analysis was used as a guide to ensure an analysis that was rigorous and robust (Terry et al., 2017; Braun and Clarke, 2020).

The group was compared to a boat sailing on the water with everyone on board. The weather is constantly changing, the sea is sometimes calm and at other times stormy, strong winds are blowing and currents of water from different directions threaten to capsize the boat. The boat reaches the shore, thus culminating the journey in performance. During this emotionally challenging journey, the group members learn to listen to themselves and to others, to take space as well as to give, and utilize the artistic medium to look within and outside into the world, look straight in the eyes of their community.

Most participants indicated that the facilitators provided equal opportunities for all of them, regardless of their mental health status. The facilitators made equivalent demands of high artistic quality and commitment to the artistic process, which contributed to the sense of equality experienced by the participants with MHCs.

The facilitator’s identity was perceived as a significant factor for the participants. The music group was facilitated by a well-known musician, the singing group, by a singer, the writing group by a writer, the theater group by both a theater director and psychodrama therapist, and the playback group was facilitated by a drama therapist. On one hand there are many advantages to having facilitators who are well-known professional artists in that they have the skills to support the creative process and set the same standards for everyone. Studies have shown that the facilitator’s identity as a professional with an artistic identity, rather than a mental health professional, allows participants to identify as writers, actors, or musicians rather than as patients (King et al., 2013; Ørjasæter and Ness, 2016). On the other hand, an artist is probably less well equipped with the knowledge and skills to deal with situations that may arise when group members experience personal or interpersonal difficulties. The consistent presence of a mental health professional in the group, such as the Amitim coordinator, may provide an adequate response. The need for the presence of a mental health professional can be resolved by assigning an arts therapist who has been trained in arts and therapy as a facilitator, as was done in a playback theater group in which some of the actors were also therapists (Yotis et al., 2017). Interestingly, the need for the involvement of a mental health professional was voiced to a greater extent by the non-clinical community members than participants with MHCs; possibly because the latter are more familiar with mental health issues and are undergoing treatment. In fact, the non-clinical community members’ need for emotional support also contributed to the sense of equality in participants with MHCs.

Most participants felt that creation and expression through the arts promote well-being, consistent with findings that engagement in community-based arts groups promote well-being (Shakespeare and Whieldon, 2018), social connectedness and the process of personal recovery (Crawford et al., 2013). Opportunities for community connections and inclusion are recognized as among the core components of theater that may contribute to positive change in people with MHCs (Faigin and Stein, 2010). The participants referred to the creation and expression through the arts as a unique channel of communication which mediates the inner and outer world, allows for self-expression, and focuses on strengths rather than the illness. They emphasized the arts’ unique qualities that enable introspection, self-discovery and insights as the creative process unfolds. Disclosing personal contents in the groups encouraged mutual empathy and promoted a sense of belonging. The participants had the opportunity to share their emotional experiences in a safe space, while experiencing acceptance, containment, and support. This is consistent with the idea that “re-authoring one’s own story is the way to shed the identity of ‘patient’ and adopt a new identity with multiple roles” (Moran and Alon, 2011, p. 321). Similarly, research on community-based singing activity suggests that people with MHCs experience re-discovery of their identity (Lagacé et al., 2016). This is consistent with the recovery-oriented approach which perceives people with MHCs holistically, places the person in the center rather than the illness (Slade et al., 2012; Davidson, 2016), and views the recovery process as a subjective journey of self-discovery, change and personal growth (Jacob, 2015).

Many participants referred to creation and expression through the arts as a mystical process of consciousness, spiritual elevation, and a sublime experience of connection to the powerful divine spring of creativity. Similarly, research indicates that people with MHCs experienced personal writing as enabling spiritual transcendence (Haertl and Ero-Phillips, 2019). Transcendental or “divine” awareness can be expressed in poetry, music, or other arts (Mitchell, 2011), and is associated with hope, empowerment, and a sense of well-being (Tanyi, 2002). Spirituality was noted to be inherent to the rehabilitation process of people with schizophrenia and their well-being (Ho et al., 2016), and is one of the significant factors supporting the recovery journey (Wood and Alsawy, 2018). This is consistent with the CHIME framework for personal recovery processes, where spirituality is part of having a sense of meaning in life (Leamy et al., 2011). Hence, the spiritual experience described by the participants and expressed in creation and expression through the arts may play a central role in the process of personal recovery.

Some participants experienced the creation and expression through the arts to be “just like therapy,” consistent with the findings that participating in arts-based groups can be empowering, because of the participants’ increasing awareness of their psychological needs (Williams et al., 2020). However, a participant with MHC objected that the group could become therapeutic because “there are already enough therapies.” This view emphasizes the need to preserve the group as a place for artistic development accompanied by an in-depth process of growth and personal empowerment. Nevertheless, different participants have different needs and groups differ in terms of their level of disclosure, need for support, and the ability to contain the intensity and pressure associated with the final performance. Still, it would be useful to compare the impact of integrated arts-based groups to that of creative arts therapies (Orkibi et al., 2014; Orkibi and Feniger-Schaal, 2019; Feniger-Schaal and Orkibi, 2020; Shafir et al., 2020).

Some of the participants described the final performance as “a moving from the darkness into the light” and referred to the empowering experience of “being seen” or the “performance of the self” which validates one’s existence (Ansdell, 2010). The sense of being transparent causes people with MHCs to hide from society (Corrigan et al., 2016; Jahn et al., 2020), thus the experience of “being seen and being heard” was a particularly empowering experience for the participants with MHCs. The final performance was an opportunity to reveal themselves to their family, friends, and community, to share the healthy parts, their abilities, vitality, and creativity. They are equal human beings just like the non-clinical community members who perform with them. The audience may change their perception focused on illness and inability, and see them in a more positive light, which may help reduce public stigma. According to the participants, experiencing competence and success is a corrective experience that helps to increase self-confidence, self-esteem, and a sense of self-efficacy, and may reduce self-stigma. The path to further successful experiences, even in everyday life, has been charted.

While the study consisted a sizable number of participants, it only included five focus groups, out of 30 integrated arts-based groups, and only included individuals who volunteered to participate in the focus groups, rather than all members. Future studies would benefit from interviewing people with MHCs in Amitim who chose not to participate in the integrated groups to learn about potential barriers and hindering factors. Furthermore, the only clinical information available from Amitim was that the participants had a mental health disability of 40% or more. While this approach is consistent with the non-labeling stance of the recovery model of Amitim, as well as the ethics approval obtained for this study, it would be useful to assess how individuals with different MHCs (i.e., diagnoses) experience the program. Future studies should also examine the unique meaning of each artistic medium per se and arts forms not included in this study, such as visual art and dance. Future work could examine the associations between spirituality, creation and expression through arts, mental health, and recovery. Finally, our quantitative findings of pre- and post-participation in the integrated arts-based groups would shed light on the influence of the program on stigma reduction, sense of community, and personal recovery.