The evaluation was a mixed methods service evaluation using stakeholder group discussions before the workshop, participant-observation of the workshop, questionnaires completed with participants before, immediately and two weeks after the workshop, and a focus group held on the day after the workshop. This range of methods allowed us to capture different voices, both of the facilitators and participants, and for the participants, allowed for flexibility in how they took part. Two of the study team researchers (MC, JC) acted as participant observers, recruiting, assisting with data collection, and running the focus group alongside full participation in the workshop itself. We took this decision to support building trusting relationships, which we felt was especially important given the potentially exposing nature of vocal improvisation and potential vulnerabilities of the group. We took a critical realist perspective, acknowledging the influence of language and culture upon each person’s experiences and understanding of the group (27, 28). Accordingly, our epistemology was contextualist, acknowledging the individual contexts of researchers and participants in shaping knowledge (27). We took an experiential approach to the data, focusing on participants’ and researchers’ individual perspectives and contexts. The service evaluation was reviewed and approved by the Audit team at South West London & St. George’s Mental Health NHS Trust.

As this was a small, descriptive and evaluative study, we used a convenience sample of Recovery College members who had signed up to participate in the workshop as part of the Recovery College summer school within an NHS mental health trust located in London. Recovery College members were adults living with mental health problems in the community. The course was advertised in a summer school course selection pamphlet. This advertisement can be found in the Supplementary Material (see Supplementary Material 2.1). The course consisted of two full day workshops, followed by a third day that consisted of a focus group and group picnic run in August 2024. Those who signed up for the workshop were approached by researchers prior to the start of the group to be given an information sheet about the service evaluation. Researchers welcomed questions about the evaluation and ensured that participation in the evaluation was voluntary and did not affect their participation in the group.

On the first day of the workshop, group members who wanted to participate in the service evaluation completed a consent form and the initial pre-group assessments. Questionnaires were completed again after the completion of the second day of the course, as well as two weeks after the completion of the workshop.

Pre-group questionnaire: The pre-group questionnaire consisted of general demographic information, including age, gender identity, and ethnicity. Participants were asked to describe their main mental health challenges, circle feelings on feeling chart based on how they were currently feeling, and report if they had previously taken part in this workshop.

Short Warwick Edinburgh Mental Wellbeing Scale (SWEMWBS): The SWEMWBS was used in both the pre-group and two-week follow-up questionnaires. It is a seven-item questionnaire consisting of statements about feelings and thoughts regarding the last two weeks. Answers range from one to five, with one being “none of the time” and five being “all of the time.” It has been validated for use within a mental health population (29–31).

Post-group questionnaire: Participants completed the same feelings chart from the pre-group questionnaire. They were also asked why they chose to participate in the group, if they found the group helpful and/or enjoyable, and how they felt after the group. They were asked to describe the most helpful and unhelpful parts of the course, as well as the most important event from within the course and why. They were also asked to write up to three goals they had going into the course and rate the extent to which they felt they achieved these.

Two-week follow-up questionnaire: Participants completed the SWEMWBS and had the opportunity to provide any final feedback they had for the group.

Researcher observations: Researchers (JC and MC) completed a structured reflection form at the end of each workshop day, detailing the activities and timings of events that had taken place, observations on group process, leadership and reflections on their own feelings and experiences of participating.

Focus group: The focus group was completed on the third day of the workshop and lasted for 90 minutes. This was facilitated by the two participant-observer researchers. The group involved both workshop attendees and facilitators and took place in the same venue as the workshop. The group sat in a circle and consented to the group being audio recorded. A topic guide, modelled on the feedback questionnaires, was developed with input from workshop leaders and the Recovery College lead (see Supplementary Material 1). The focus group began with each participant stating a word that they would use to describe the workshop. Discussion continued onto topics including helpful and unhelpful aspects of the workshop, as well as suggested changes or improvements for future workshops.

Considering our subjectivity and the context of the review, our own experience in taking part in the course helped guide us on how to facilitate the focus group and respond with participants. This led to a more empathetic and curious approach in hearing what the participants had to say. We considered our subjectivity as a resource when gathering and analysing the data (32).

To ensure the safety and consideration of needs of those attending the workshop, researchers worked closely with the Recovery College lead and workshop facilitators in both the study and questionnaire design. Some members of the research team had lived experience of mental illness, which we also drew upon when designing our evaluation. In acknowledgement of the Recovery College ethos, we chose not to collect formal mental health diagnoses and instead, developed a range of experiences that were common in mental illness. To aid sharing of feeling states, we used freely available “emoji” pictures. Attention was paid to how to introduce the evaluation so as not to deter members from joining or participating fully in the workshop and included steps to introduce the researchers. We ensured that the researchers were present for the full workshop and follow-up calls to build trust and offering the Recovery College lead as an independent point of contact, should participants encounter issues or concerns.

The two participant observer researchers (MC, JC) completed data collection and analysis with the study lead (CC) to support and oversee the analytic process. All had experience of inviting participation and collecting data with mental health populations. This was the first experience for the participant observers of participating in a music-based group, which we felt was important as this was likely to mirror the experiences of wider participants. The study lead held experience as a music therapist and researcher working with mental health populations and experience of participating in group vocal improvisation.

As this was an exploratory evaluation, no sample size calculations or statistical tests were performed. Quantitative data were analysed using SPSS 24. Descriptive statistics (mean/SD or frequencies) were generated for baseline data. For SWEMWBS, items were summed, and raw scores were converted to metric scores (31). Scores were classified into high (>27.5), medium (19.6–27.4) or low (<19.5) wellbeing (32) and meaningful (clinically-relevant) positive/negative change based on a change of 3 points (33).

Audio from the focus group recording was transcribed using an approved NHS transcription company. Qualitative data from the group, as well as researcher observations and questionnaires were anonymised and checked for accuracy before importing into NVivo. In keeping with our aim to primarily describe the group, we used interpretive content analysis to summarise the data. Thie approach enabled us to quickly examine content from the different data sources and facilitated replicability for future evaluations (33). After initial familiarisation with all data sources, we began to code individually. Researchers broke down the content into the pre-defined categories of goals, group practice, important events and why, helpful aspects, unhelpful aspects, reasons for attending, and suggested improvements. Within each of these categories, we initially stayed close to the content of the data, especially for questionnaire data, where wider contextual information was often missing. Workshop content was summarised following the TIDieR format (34) and guidance for reporting music-based interventions (35) from researcher observation forms. This data was supplemented with additional insights from participant questionnaires and focus group discussions. The complete TIDieR table can be found in the Supplementary Material (see Supplementary Material 2.2).

Initial coding was done independently within the group by three researchers (MC, JC, CC). After initial coding, we met as a group and shared our codes, using Post It notes grouped under the initial categories, referencing the participant and the data source. Together, we refined the codes within these categories, reducing duplicates and grouping similar codes together and renaming them. When there were differences in coding, we discussed it as a group to understand the different perspectives this brought and then agreed how to represent this more fully within the coding frame (33).Where categories implied a process (group practice, important events and why), we took a chronological approach to ordering the codes and began to interpret the main processes being described. We agreed to these main processes as a group and summarised them in text form, along with exemplary quotes. We then began to make inferences, drawing upon the deeper content contained in focus group discussions and researchers’ reflective observations to draw out the links described between specific activities and their impact for participants. Once we had finalised our analysis, we shared this with workshop facilitators for their review and feedback. A simplified summary was also shared with workshop participants with the opportunity to comment further.

Of the nine service users attending the group, seven consented to complete the questionnaires and the focus group, one consented only to participating in the focus group, and one chose not to participate in either. Participants were aged on average 43 years (SD = 9.4). Four participants identified as male and three identified as female. Regarding ethnicity, five identified as White British, one as White Other and one as Chinese (Table 1).

Table 2 displays the full list of mental health challenges reported by the participants. Participants reported living with an average of seven mental health challenges each (range 3–11). The most commonly reported challenges (by 6/7 participants) were feeling anxious, depressed, living with past traumatic events, and finding it hard to motivate oneself. Three participants self-reported holding or awaiting a diagnosis of Attention Deficit Hyperactivity Disorder (ADHD).

The course was held over the span of three days at the NOS. Day One and Two ran for five hours with a break for lunch. Day Three consisted of the focus group and a group picnic. The facilitators included a Feldenkrais method facilitator, an opera singer, a cellist, and the studio director of artist development, who has extensive experience in access to arts and education. Two members of the Recovery College staff and two researchers from SWLSTG also participated in the group alongside the nine participants.

Day One: The first day began with introductions within the group. Participants stated their names and were told the loose plans for the workshop. The session began with a Feldenkrais session where participants were guided through to recognise different body parts through slow movements and breathing. This transitioned into the vocal component of the course, which was led by the opera singer. Participants were instructed to stand up and walk around freely while making sounds (such as ooooo, ahhhh). The group was then guided into the next task, which involved small groups writing down words they associate with a particular fruit. These words were then presented to the group. The next activity involved completing an improvisation for a chosen fruit, this time being a lemon. The associated words were “energised”, “summery”, and “healing”. The group made sounds and vocalisations to contribute to the lemon song, where the cellist accompanied. Throughout this session, there was a lot of jokes and laughter. Connections and cohesiveness were both noted as being developed as the group became a safe space for individuals to contribute. After the lunch break, the group reconvened and went through another Feldenkrais session to recentre back into a calm headspace. The group transitioned back into the fruit work and created songs for both nectarines and pineapples. Participants began to introduce new sounds throughout, including non-vocal noises such as tapping or clapping. The last activity of the day involved combining the three fruits and creating a melody with them, where the group transitioned from one to the other. Feedback in final group discussions from Day One included that participants felt immediately welcomed and that the space was inclusive and judgement-free. Members said that it was nice to interact with the group and not have to discuss diagnoses. Group members had different levels of involvement, with some offering feedback frequently and others choosing not to share.

Day Two: Day Two began with a guided Feldenkrais session, then back into the vocal work, making sounds such as “sssss, aaaa, ooooo” and phrases such as “no way, wooowww”. It was discussed how these sounds could be felt in different parts of the body. The group then moved into the fruit work. The first fruit chosen was a grape. To build upon previous methods, group members were each given a grape to look at and feel as they made improvised sounds, accompanied by the cello. This continued with an apple and then a melon. This time, there were no set words to go by as a precursor to sound making, it was “just a matter of starting”. Afterwards, the group discussed this song, with people stating it was harder to come up with sounds without pre-selected words. Someone countered by saying that made it feel easier. It was also discussed how the group came into Day Two with more expectations compared to yesterday as they now knew a bit more about what to expect from the group. After lunch, the group came together and began with the Feldenkrais method. The group transitioned back to the last sound improvisation, where they could taste the fruit prior to the vocalisation. The chosen fruits were a melon and pineapple. Participants did a mixture of walking around, pausing while standing, and sitting down when creating sounds. Some participants walked the whole time, while others would pause, and some sat down. Participants provided feedback stating that since completing the session yesterday, they were at more peace of mind. They reported finding a deeper connection with music, as well as sleeping more the night prior. Participants reported feeling less self-conscious at the end of the course. The session ended with one last sound that consisted of a “fruit salad”. Participants could taste either melon, pineapple, banana, or oranges. Participants laid down with their heads inward and the cellist sat in the middle.

This evaluation was completed with information from eight out of the nine workshop attendees, meaning that most, but not all experiences from the workshop are represented. Participants were fairly evenly split between male and female but were generally older and predominantly of white ethnicity. In keeping with the ethos of the Recovery College, we did not collect formal mental health diagnoses, meaning that it is not possible to identify the extent to which dominant psychiatric illnesses were represented. However, all participants reported challenges that could be considered common within secondary mental health services. Three participants independently volunteered confirmed or pending ADHD diagnosis. Future evaluations should explore how to broaden the demographic reach of attendees, particularly in relation to ethnicity and age as well as broader learning and neurodevelopmental conditions, education and wider sociodemographic characteristics. This is important given mental illness, lower socio-economic status and being of non-white ethnicity are characteristics identified as barriers to participating in the arts (36). Loneliness and social contact may be particularly important to capture given the majority of participants sought social connection as a goal in attending this workshop. It is also important to note the short follow-up period of the study. As the follow-up was done two weeks after completion of the course, we are not able to comment on any long-term impact of course involvement.

The small number of participants meant that we were not able to make any generalisations about the overall effectiveness of the group. Similarly, given the potential for group composition to vary, future groups may be received differently, depending on those attending. Further evaluations using the same measures will aid comparability. While no adverse events or harms were apparent during this evaluation, we did not actively ask about these beyond inviting comments on “unhelpful” factors. Feedback may have been influenced by the relationships formed by researchers with participants during the workshop. However, having researchers as participant observers was in keeping with the ethos of both the workshop and research methodology and meant that a more nuanced understanding could be drawn from the feedback. Researchers were able to experience the workshop first hand and build relationships with participants which may have also assisted in building trust and retaining participants for the two-week follow-up.

The findings from this evaluation map closely onto existing models that explain the benefits of participatory music making on wellbeing, namely through managing and expressing emotions, facilitating self-development (including experiences of accomplishment, promoting agency and confidence), and providing a form of respite and facilitating connections (37). The changes observed in this evaluation appear comparable or greater than other studies that have evaluated wellbeing in similar populations (38–41). To note, these studies have longer intervention and follow-up periods, suggesting that the gains observed here warrant further investigation. The workshop also offered a number of factors facilitative of engagement for people with mental illness: Activities focused on building upon perceived capability, providing opportunities for social interaction and reinforcing motivations to engage (42). The techniques that we mapped in this workshop have previously been used within wider group vocalisation courses that have been developed in various forms since the 1970s (12–18). Features shared across all of these approaches include the use of a warm-up, or a main focus upon breathwork and the body, to then build up to shared group vocalisation. It is not clear to what extent Feldenkrais methods are distinct from or overlap with wider breathing and bodywork techniques, although its application in psychiatry is beginning to be explored (24). Our evaluation found that participants valued these techniques as a means of grounding and preparing their bodies for vocal work, thus further exploration of the role and function would be of benefit to understanding the group offer in the future. Similarly, while use of the cello was experienced as grounding and helpful by participants, relatively little information was gathered on how the cello was used moment to moment in improvisations. Further musical analysis of the workshops would be of benefit to understanding group processes and the instruments’ grounding role.

The integration of breath and body-based work was suggested as a key factor in generating safety to explore freely. Breathwork has been found to have a small to medium effect upon stress in nonclinical populations although the exact nature of its effects, particularly in mental health requires further research (25, 26) with proposed mechanisms including modulation of the autonomic nervous system to activate the parasympathetic nervous system – the system that enables the body to relax. There is now a wide body of evidence to suggest beneficial effects of singing upon a range of physiological, psychological, behavioural and social factors (3). Riabzev and colleagues (17) outline key benefits of vocal improvisation as requiring no vocal training, reducing anxiety through breathing exercises, providing a playful space to experience the present moment, promote creativity, enhance recognition and expression of feelings and needs and enable an “intimate, safe and reliable” musical environment. These findings are all mirrored in the results of this evaluation. Similarly to this workshop, healthy participants in one (17) study reported the workshops creating an “open space for freeing and exploring one’s voice”, changing participants’ attitudes towards their own voices and enabling meaningful experiences and new self-discoveries” (17).

The Everyone Breathes workshop was noted for its accessibility by its participants. This is important due to the many barriers faced by people living with mental illness in accessing and participating in arts and wider cultural activities (43, 44). Guidance on the provision of arts in health initiatives within the NHS emphasizes the importance of high quality, non-clinical space (45).The provision of the groups by an esteemed arts organization, the NOS, in a non-NHS mental health setting was appealing to group attendees and mirrors feedback from similar arts-based studies located in conservatoire contexts (11, 46, 47).

Finally, the feedback regarding workshop length and focus offers some pertinent questions for any future Everyone Breathes groups. Participants shared the value of what they had gained in just two days of attendance but also noted challenges in the intensity of this. At the same time, participants were curious as to how these techniques might be used to explore more emotionally evocative and personal issues over time relating to their mental health and recovery. Some expressed concern in doing so, noting the potential for the explorations to become uncontained or “triggering” whilst others felt that the current format was powerful in and of itself. When reviewing findings with the workshop facilitators, the idea of a series of regular workshops to build confidence to join (for example) wider choirs was proposed, along with the potential to empower participants to run workshops themselves. Pujol Torras (16) found an increased need for structure and active therapeutic stance when comparing group musical improvisation with vocal improvisation in secondary mental health community patients and participants also noted the importance of a neutral and abstract topic in feeling safe and able to engage in vocal explorations. The care taken by the group to explore possibilities in this focus group discussion underscores the complexity and potential vulnerabilities requiring careful consideration.

This evaluation highlights the importance of the inclusion of the arts in mental health care. The feedback on the Everyone Breathes course was positive and suggests that this type of workshop should continue to be offered within a Recovery College context. Such an offer is in keeping with priorities from WHO (48), UK Government, Arts Council England and the National Centre for Creative Health in prioritizing creative health for all (49, 50). In order to do this, we emphasise the importance of continued clear, unambiguous advertisement of the workshops and high-quality facilitators with the appropriate qualifications to facilitate the group. We recommend ongoing evaluation using the tools from this report to aid comparability.

There is potential to develop workshops in order to meet different stages of the mental health journey and to encourage participation from a wider demographic. Workshops have the potential to be developed into a longer program of work to develop content and relationships or incorporate end products, such as involvement of a composer and professional recording to facilitate a performance and/or sound recording or other artistic artefacts. This approach would enable development of a performative element and have the potential for attendees to have a product with which to demonstrate achievement and remember the experience.

While the workshops were provided by specialised practitioners, there is also potential to adapt the intervention to be led by people with less specialised skills. For example, none of the vocal exercises, warm-ups or improvisations were based on opera classical music and could be led by other trained singers or vocalists. There is also potential in this course to grow and open to larger group sizes, as well as be integrated into community services. Once such developmental work is complete, through example, further case or feasibility studies, formal testing of effectiveness will be possible in a randomised controlled trial.

We recommend coproducing and evaluating these developments with service users in the Recovery College alongside music therapists, dance movement psychotherapists and wider arts therapists, clinical psychologists and psychiatrists to ensure psychological safety.