Here's why your health care provider may tell you to go take a hike

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Social prescribing allows care providers to connect patients to a broad range of social, physical and cultural services in their communities that may help boost their health and wellbeing. In this episode, Jill Sonke of the Center for Arts in Medicine at UF and Christopher Bailey, arts and health lead at the World Health Organization talk about this approach to good health. Produced by Nicci Brown, Brooke Adams, Emma Richards and James L. Sullivan. Original music by Daniel Townsend, a doctoral candidate in music composition in the College of the Arts.

Nicci Brown: Physicians and other health providers around the world are taking a serious look at the ways physical, social and creative activities boost health and wellbeing. It's called "social prescribing" and today we're going to talk with two experts about what it is, how it works and what evidence exists to show that it works.

Our guests are Jill Sonke, who is the director of the Center for Arts in Medicine at the University of Florida, and Christopher Bailey, the arts and health lead at the World Health Organization.

Welcome, Jill and Christopher!

Jill Sonke: Thank you, Nicci.

Christopher Bailey: Hello.

Nicci Brown: Let's start with the basics. Jill, what does the term "social prescribing" actually mean?

Jill Sonke: So social prescribing is essentially a way that care providers can connect patients to a broad range of non-clinical services in their communities that can help support their health and wellbeing. And in a number of countries, it's become a system that includes structures for referral, and that's the prescribing part. And even for payment of services by the healthcare system, as is the case in the UK. So essentially, a care provider prescribes an arts or social activity or program and the health system pays for it, just like other interventions.

Nicci Brown: I think some listeners might be surprised to learn that this social prescribing, as it's now known, originated in the 1990s. So can you tell us a little bit more about the history behind this approach?

Christopher Bailey: Well, I think in the 1990s, you had, in the UK, for instance, a great interest in how do you incorporate the arts more formally into the national health system. And there was a paper that came out that was groundbreaking and helped catalyze that movement, not just within the UK, but throughout the Commonwealth of Nations. But I think it's a mistake to say that it actually started in the '90s. I mean, even in the UK, you had doctors in the 19th century prescribing specific poems for different conditions that people had. I think the tradition of looking at the whole person and not just drawing on the accepted areas of medical response, but also the full human response, has always been there.

Nicci Brown: Could you tell us a little bit more about your job and why the World Health Organization is backing this approach to wellbeing?

Christopher Bailey: Well, I am the arts and health lead at the World Health Organization [WHO]. And I think in many ways, WHO has been using the arts from its inception, and certainly in the areas of health promotion — and everything from the rollout of the DOTS program and the TB world a generation ago, using radio, soap operas and street theater to "Together at Home" concert at the beginning of the pandemic that we did with Lady Gaga.

And I think what we've always known is that it's more than just simply, in an entertaining way. getting a pro-health message out there, that there's something about the engagement in the arts that creates solidarity, creates community, creates compassion. And I think that's the entry point into looking at what might be underlying this emerging, serious look at arts and health. We've always known that it has this beneficial social effect, but we haven't actually looked at why. And when we start looking at the mechanisms, we begin to understand why we call it "healing" rather than just simply an entertaining form of relaying information.

Nicci Brown: And you mentioned the UK and Commonwealth countries. Could you give us some perspective on the use of social prescribing in other nations?

Jill Sonke: There are established programs, for instance, in Australia and Japan, Ireland, Canada, New Zealand, Portugal and Singapore and, of course, in the UK, where it's most notably engaged as a part of the policy system. And a lot of countries are in conversation about this idea. And this is really stemming, as Chris has alluded to, from the understanding that arts and cultural resources are available resources in communities. Human beings have always recognized the value of the arts in terms of health and wellbeing. They feel good. They connect us. They do so many things for us that are very organic and logical. And in many parts of the world, health systems are struggling with social determinants of health. These conditions that impact not only our health and wellbeing, but our opportunities for health and wellbeing.

The health systems are also struggling, and this is the case in the United States, with what to do with folks who are just simply not thriving — not necessarily people who have overt diagnoses, but people who come to their health providers because they're simply not well. They're not thriving.

And so to be able to provide non-clinical prescriptions and non-clinical referrals can help people get out into their communities, engage with others and begin to thrive through not only creativity, but through social activities. Social prescribing systems include referrals to volunteering opportunities, opportunities for being in nature. So social prescribing recognizes all sorts of things that can help us to thrive and can help us to avoid having to step into higher level and riskier interventions, like medications.

Christopher Bailey: I would supplement that by giving a specific example. There was a small program that came out of the UK called "Music for Moms." And in a nutshell, it was using music to help young mothers who may have fallen into postpartum depression. And the evidence of its efficacy was strong enough that Denmark and Romania, through WHO, our Copenhagen office in Europe, started national pilots. And now, Italy has joined on board, the EU is looking at it. And if the numbers are as optimistic as we think they may be, it will become policy across the continent and beyond. So part of WHO's role in that is to help bridge that research and practice gap with policy so that when promising techniques or efforts are identified, we can bring it to the attention of member states and have it benefit the most number of people possible.

Nicci Brown: And I can only imagine that the pandemic brought a lot of this to a head. A lot of these mechanisms that we use to thrive were denied to people.

Christopher Bailey: For me, when much of the world, literally, found itself in isolation, in lockdown, there was a real danger of loneliness, of alienation, of aggravating existing issues that may have been percolating in the background, which would come to a head in a situation like that. And where do the arts and expression come into it? I always go back to this quote from Carl Jung, the Swiss psychologist, who said, "Loneliness is not the absence of people. Loneliness is the inability to express what matters to you most." And to me, that's where the complementary efforts of the arts in health care, and public health as well, can be so helpful.

Because when you think about it, what does a doctor do with a patient? The doctor asks the question, "What's the matter with you?" An artist will ask, "What matters to you?" And that's where Jill was talking about the difference between coming in with an illness that gets treated and yet, that person still may not thrive. It's not enough just to live longer without illness. That life has to be worth living, with moments of joy and the capacity to build your skills, and to create and participate in community. That's what being a human being is about. It's not just the absence of disease.

Nicci Brown: So, what does it say about us that we need to encourage people to dance and sing and learn a new skill or take a walk? Are our societal frameworks sick? If we actually have to push in this area, how do we get to this point?

Christopher Bailey: Oh, in a word, yes. I mean, this was something human beings did naturally and organically for millennia. And I think we saw it beginning in the industrial revolution with the commodification of not just the outputs of our labor, but the people themselves. We saw the breakdown of the family. We saw the breakdown of the intergenerational connections to family. And the loss of musical and dance traditions. And that over-commodification of the arts, where we become passive consumers of an expert doing something rather than we ourselves practicing it, has had a terrible effect on our health and our sense of community.

Jill Sonke: Yeah. I think in the United States, in addition to the over-commodification, we've had an over-professionalization. If, when we're young, we don't feel like we're good at an art, we feel like we should leave it alone because others are good at it. We judge ourselves. And I think that hierarchical nature of the arts in our culture contributes to the ways in which we let go of those health resources. I think we see children being creative because it feels good. It's a way of playing. It's a way of expressing. And one of the things that feels important to me around social prescribing is the recognition that not only do we put down the arts because of the ways in which we judge ourselves, and feel that we do or don't belong, but there are barriers to arts participation, both formal and informal, that can be addressed through social prescribing.

I think social prescribing systems can heighten the recognition among the general public of the health benefits of the arts in ways that can help us reach to them as we saw in the pandemic, we saw at unprecedented levels, people reaching to the arts. Research conducted by our partners at University College London showed that during lockdown, 21% of people engaged in the arts and creativity more than they had prior to lockdown. So people were reaching with that deep knowing that the arts are good for our health. And in the United States in particular, there are tremendous barriers to arts participation -- financial, geographic. We know there's a social gradient in who participates in the arts.

And I'm hopeful that social prescribing systems can help reduce some of those barriers by creating systems that will make pathways toward participation in the arts.

Nicci Brown: Well, let's talk a little bit more about what is happening here in the United States, as far as interest from physicians and others providing their patients with social prescriptions.

Jill Sonke: Sure. There's a lot of interest in social prescribing in the United States right now. I would not say that it's coming, necessarily, from physicians. I think it's coming from the arts sector. And I think it's coming from the public health sector. There are programs like ParksRX in the United States that have been around for a while, doing what we would generally call "nature prescribing." I think these social prescribing systems in the UK and other parts of the world are becoming more visible, while the evidence base is very insubstantial, right now, around social prescribing. There is a fair amount of evidence out there that's compelling enough that people are really looking. So right now, I'd say we're in a stage of dialogue in the United States. In our EpiArts Lab, our National Endowment for the Arts research lab here at the university of Florida, we are doing implementation science studies over the next two years of social prescribing.

So those are studies that'll help us garner information about whether social prescribing is feasible or would be acceptable to the public in the United States and what financial systems that we might engage. We're working under a collaborator agreement with the WHO to develop a set of key common outcomes and a core outcome set, again, to lay the foundation for strong research to happen. We're also being hosted by the Harvard Design Lab at the end of October for a design sprint where we'll bring policy makers, insurance providers, artists and an array of stakeholders together and we’ll look at a systems design approach for social prescribing in the U.S.

Nicci Brown: Can you tell us a little bit more about that collaboration?

Christopher Bailey: Well, WHO has been working with partners to create an international network of research centers around the world, looking at all aspects of what we're calling arts and health. And it can be randomized control trials of experimental approaches that offer some interesting insights into how we might be able to scale this work to help the most number of people. But it could also be looking at the primary science, the neurology, the biochemistry of how this works, why this works and where it doesn't work equally importantly.

But I would like to say something about the term "social prescribing" because I understand why it's used and if it can, as you mentioned, in our society, things that used to be part of our lives, like standing around the piano and singing songs as a family, which has fallen out of favor in many people's homes . . . If social prescribing can actually get people to start using their abilities to engage, aesthetically and emotionally, with each other and the community and the world around them, then I guess it's all to the good. Especially if it gives it enough of a serious patina that insurance companies pay for it, I think that's all to the good.

The problem with it is that it implies too much of a medicalized view of the arts, too much of a mechanized view. And I wouldn't want people to come away from this conversation thinking that if you have a particular problem, you can read two sonnets and call me in the morning. It doesn't work that way.

It gets back to the WHO definition of health, which states that "Health is not merely the absence of disease and infirmity. It is attaining the highest personal level of physical, mental and social wellbeing." And when we frame it like that, we begin to understand, intuitively, why the arts can play such a crucial, complementary role in all of that.

And I just think it's important to understand there's a difference between curing and healing. I'll give a concrete example in the U.S. that has been mirrored around the world. The Museum of Modern Art had a program with dementia patients, where they brought them in to look at their collection in a moderated, curated way with gerontologists and psychologists and artists. And the evidence that exposure to the arts or music or dance actually reverses the damage to the brain of Alzheimer's, for instance, or prevents it, is debatable. But what it can be measured in those interactions are those moments of peace, those moments of connection, those moments of reawakened memory and feeling, and relationships, which are priceless. That is real. And they're not necessarily sustained. It doesn't reverse the condition, but giving people, managing Alzheimer's disease the gift of those moments of grace. It's not only a huge benefit to them, but to the caregivers as well.

Jill Sonke: I agree that that term is problematic for a number of reasons. In the U.S., in particular, I think the term "social" is problematic in that social services, unfortunately, are highly stigmatized and that's different than in some other nations. I think the notion of prescribing is also problematic because it implies gates. It implies that someone needs to tell you you can or should engage in the arts. And in fact, we should have communities and a society in which everyone has access to the arts and cultural activities as a way of supporting their health and wellbeing. So, while I think that, as a term, is problematic, I think that we need a social prescribing system in which there are benefits to that idea of prescribing in that when a physician suggests something to you, it has weight because you've come to them as a professional and so you, hopefully, trust their perspectives. And you may heed their advice.

Nicci Brown: Are there other barriers that you've come across, that you really can point at and say, "This is a big thing we need to overcome."

Jill Sonke: I think one of the biggest things we need to overcome in the United States is the question of the financial structure. Many of the places where social prescribing has been implemented are places where there are more public health care systems, where there aren't third-party reimbursement systems like that of the United States. So we've got a big and, I think, very exciting question, in the U.S., around how will this system work financially. How will we link healthcare, public health, arts and culture, and other social sectors together to create more access for people to resources that can benefit health without huge investments.

There's much research that shows us the health benefits of engaging in the arts, right down to mortality. There's studies that have been replicated now, in multiple countries, that show at a population level, people who engage in arts and cultural activities live longer. And they're highly controlled for things like socioeconomics, the things you would think of, education and income, but these studies point more to the immune response that's involved in the arts.

Christopher Bailey: And I think to both of those points, we've seen, for instance, some of the largest public art collections are in hospital systems. And there's a reason for that. When you start having on the walls visual objects that you can focus on, that can bring about a creative impulse. You can measure some of the biochemical effects. The lower cortisol levels, lower stress. And we know how that aids recovery, et cetera, but it's more than that. All of us have been to the hospital at one time or another, so we've experienced that feeling of dissociation, of fear, of suddenly your body doesn't feel like it's a safe place for your spirit anymore. And to try and bring that back in. Objects in the room, whether it's a vase of flowers or a painting on the wall or being able to see trees out the window act as almost a tether to bring you back to yourself, to the people around you, to the world. And it's incredibly important. And I think the question isn't, "Can we measure why that's useful." That's part of it. The question is, why did we stop doing it?

Nicci Brown: What do you both see as some of the biggest opportunities and wins, I guess, that we might realize in the coming years, in terms of wellbeing and health that could come from further accepting of this notion of social prescribing?

Jill Sonke: I think the biggest win, Nicci, would be if the general public gains a greater recognition of the connection between the arts and health, if people generally recognize and valued the arts as a resource that we have available every day and in our own communities to be healthier and to be better connected and, of course, then I think the health benefits are tremendous as a result. And I also recognize that the arts aren't for everyone, so not everyone will choose the arts. But I think, because of all the reasons we mentioned earlier, the hierarchies around the arts and our culture around the arts, we're missing a resource that is very much at our fingertips.

Christopher Bailey: Yeah, actually it is a terminology question, isn't it? Because I've had people come up to me saying, "Why the arts? Why not sports?" And I said, "Well, as a baseball fan, are you telling me that baseball isn't an art?" Of course it is. It's not just about physical movement. It's about the arc of that home run, going to the outfield stands. It's the pop of the ball hitting the glove. It's this sensory experience of the whole thing and the strategy, the story, the emotions.

Jill Sonke: And Nicci, I'd like to add one more thing that we haven't talked as much about today that I think is very important. And that's that a system like this, I think, has the potential to offer significant cost savings to our healthcare system. We've seen that in the United Kingdom, for instance. And I think that we engage in, especially, at this sort of low levels of care. Again, people coming to health systems with low levels of mental illness, not thriving. We engage in a lot of costly testing and prescription that may not be necessary. Not that we want to avoid anything that's necessary, but I think our health care system can benefit financially. The flip side of that, that I want to acknowledge, is that artists and arts programs, the arts sector also need to be fairly compensated for the services that they provide.

Nicci Brown: I understand that you're both participating in a conference on social prescribing next month. Could you tell us a little bit more about who is going to be presenting and what the aim of that conference is?

Jill Sonke: So, we're hosting a national convening called "Creating Healthy Communities" in Orlando, October 10 and 11. That's a convening that focuses on arts and public health generally, but a lot of our dialogue will inevitably be around social prescribing because it is such an interest. Christopher will be there with us. He's one of our three keynotes. We'll also have Dr. Maria Rosario Jackson from the National Endowment for the Arts and Hannah Drake from IDEAS xLab. We have speakers from all over the world we’ll bring. While we will be focusing on the connections of the arts and public health in the U.S., we'll be bringing global perspectives. So it'll be two days of curated dialogue that, we're sure, will generate forward momentum around social prescribing in particular.

Nicci Brown: Listeners, thank you for joining us. Our executive producer is Brooke Adams, our technical producer is James Sullivan and our editorial assistant is Emma Richards. I hope you’ll tune in next week.