Art, nature and mental health: assessing the biopsychosocial effects of a ‘creative green prescription’ museum programme involving horticulture, artmaking and collections

The wide-ranging benefits of social prescription on psychological health have been well established.^1,2 Consequently, there is a growing impetus for social interventions that support psychosocial health outcomes, such as community-based referral to non-clinical provision involving creative and cultural activities, physical exercise or educational opportunities.^3,4 Given that a fifth of consultations with a general practitioner (GP) are for psychosocial rather than medical problems,⁵ social prescribing has become an important means by which healthcare professionals can ‘seek to address the non-medical causes of ill health with non-medical interventions’ (p. 5).³ As an illustration of current interest in the UK in non-medical interventions, a new independent not-for-profit organisation, the National Academy of Social Prescribing, has been set up by the Secretary of State for Health and Social Care. The Academy’s mission is to develop and advance social prescribing to promote health and wellbeing at local and national levels.⁶

As part of the National Health Service (NHS) Long Term Plan, NHS England has published a summary guide to social prescribing, regarded as a key component of Universal Personalised Care – the choice and control that people have over the way their care is planned and delivered.⁷ As part of its Long Term Plan for the next 10 years, NHS England aims to recruit over 1000 trained social prescribing link workers within primary care networks by 2020/2021 and to integrate social prescribing into the personalised care remit with the objective of referring 900,000 people to such schemes by 2023/2024 (p. 25).⁸ Furthermore, social prescribing in general practice, described as the use of referral and signposting to non-medical services in the community, is listed as one of 10 high impact actions needed to release time for GP care.⁹ Other high impact actions related to social prescribing include active signposting that provides patients with a first point of contact to direct them to an appropriate source of help, such as web and app-based portals, and supporting people to play a greater role in their own health.

Arts on Prescription has a long history in the UK and the evidence base continues to grow, demonstrating a range of psychosocial outcomes that include supporting mental health recovery; combatting social isolation for people with mild to moderate anxiety and depression; as well as increased levels of empowerment and improved quality of life.^1,10 A review of Arts on Prescription studies illustrated a body of evidence indicating that participation in creative activities can promote health and wellbeing, quality of life, levels of empowerment and social inclusion, and positively impact people with mental ill-health.¹⁰ Furthermore, the authors proposed that creative arts contribute to the health of the wider community, not just the individual. There is also good evidence to show that creative engagement in museums supports health and wellbeing, quality of life, social inclusion and lifelong learning. An extensive Museums on Prescription study, that carried out 12, 10-week programmes of museum-based sessions in seven central London and Kent museums with 115 participants, found significant wellbeing improvements.³ Participants in the study, who were aged 65–94 and considered to be at risk of social isolation, rated highly the experiences of feeling absorbed and enlightened by the sessions and commented on the opportunities afforded by the museum activities to meet new people, learn new information and develop new skills.

Another type of social prescribing, ‘green prescription’ where outdoor spaces are used to improve health and wellbeing, is beginning to gain momentum, with a potential for impact across the life span.¹¹ Green prescriptions work under the same premise as social prescriptions, focusing on therapeutic engagement with nature-based interventions. A Scandinavian systematic review of 38 nature-assisted therapy programmes located three main types of intervention: horticultural therapy, wilderness therapy and unspecified nature-assisted therapy.¹² The authors found small but robust evidence to suggest that these different types of nature-based therapies were relevant public health interventions. Effects of these therapies included psychological, social and physical goals across diverse patient groups, with reduced measurable symptoms of disease in some cases, for instance, obesity and schizophrenia. An Australian review, using an expert elicitation process, categorised 27 distinct nature-based interventions.¹³ Interventions were split into two categories: those that aimed to promote general wellbeing and prevent chronic health conditions through interaction with nature and those that aimed to treat specific physical, mental or social health and wellbeing issues through behavioural and environmental change. The review found that a key characteristic of nature-based health interventions is that a single intervention can potentially improve wellbeing across a range of domains. Nature prescriptions can promote physical activity leading to positive health outcomes, while contact with nature can have an additional restorative effect on mental wellbeing. As such, nature prescriptions can have significant impact as not only do they have multiple effects, they may have potential in terms of protective factors. Across both reviews, the authors called for more research to investigate the effectiveness of such programmes to promote their wider usage across public health.

A 2013 review evaluated the published literature on nature-based activities and found reliable evidence of the positive effects of gardening for mental health. The evidence included reduced symptoms of depression and anxiety, and a range of self-reported benefits across emotional, social, physical, occupational and spiritual aspects of the lives of mental health service-users.¹⁴ Studies focused on mental health outcomes give further insight into the multiple effects of nature-based interventions that go beyond the benefits of contact with nature or physical exercise. Indeed, an additional potential positive effect of nature-based interventions is that they tend to be designed as social activities and therefore have the potential to mitigate social isolation and enable engagement with a person’s community.¹⁵ Qualitative studies further consolidate understanding of the psychotherapeutic mechanisms for how nature prescriptions can impact wellbeing, and mental health in particular. The social and occupational dimensions of activities are strongly associated with feelings of belonging allied with decreasing isolation and increasing social inclusion for people experiencing mental health issues.¹⁶ In addition, as meaningful activities with opportunities for knowledge and skills developments, nature-based interventions help to consolidate self-reliance and bolster self-esteem;¹⁷ factors known to improve individual psychosocial wellbeing.¹⁸ Conversely, poor self-esteem can be an indicator for the development of mental health disorders.¹⁹ Improvements in self-esteem can be supported by programme designs that enable self-expression, personal growth and connectedness (with self and others) through meaningful occupation.²⁰

The current UK-based study utilised the trend by museums and art galleries starting to use their outdoor spaces with a wider focus on wellbeing activities.^3,21 Since these activities are designed and delivered by museums, they are able to utilise the unique characteristics of their sites to bring together horticulture and gardening with creativity and culture. This article sets out to examine the potential of such a combination in a mental health intervention with adults, an area of practice not yet investigated. The current research was situated in a park adjoining an inner-city art gallery. It focused on a group project of dual engagement in green activity outdoors (including planting and clearing) and creative, arts-based activities indoors responding to collections with broad links to nature themes (including painting, print making and ceramics). The study was developed as a part of a larger research initiative called Not So Grim Up North, a collaboration between researchers at University College London and two museum partners, the Whitworth Art Gallery and Manchester Museum, part of the University of Manchester, and Tyne and Wear Archives and Museums. The current study reports on a project called ‘GROW: Art, Park & Wellbeing’, delivered by the Whitworth Art Gallery since 2015. The aim of this study was to explore the health and wellbeing outcomes derived from engagement in a combined programme of horticulture and creative, arts-based activities. In this sense, the study is unique and original in considering the dual effects of indoor and outdoor spaces, and the combination of arts- and nature-based activities. It was hypothesised for the quantitative phase of the study that measures of wellbeing would increase significantly reflecting positive improvements, such as social inclusion, that might be identified in the qualitative phase.

For Phase 1, qualitative findings were derived from inductive thematic analysis of participant and facilitator diaries and interviews,²⁶ using NVivo v11, and for Phase 2, quantitative findings resulted from statistical analysis of pre–post intervention scores from UCL Museum Wellbeing Measure,^24,25 using IBM SPSS v25.

The aim of the study was to explore the health and wellbeing outcomes derived from a combined programme of nature-based horticulture and arts-based responses to museum collections as part of a creative green prescription. As Phase 1 produced a range of positive responses, it was hypothesised for the quantitative analysis, Phase 2 of the study, conducted two years later with another group of participants, that psychological wellbeing would increase significantly and reflect positive improvements identified initially through thematic analysis.

Thematic analysis of participant and facilitator interviews in Phase 1 revealed three main themes: building a shared sense of community, decreasing social isolation and supporting self-esteem. Each of these interacted to form the collective experience of the intervention; the sense of community supported a decrease in social isolation while self-esteem was boosted through social interaction. The sense of community was enabled by knowledge of shared experience but notably, this was not the main focus of the programme; rather, it was the types of activity and the non-clinical indoor and outdoor spaces of the museum that supported a sense of community first and foremost. The new learning gained from the programme, across both nature and arts topics, also contributed to a shared sense of community and individual self-esteem, thereby reducing feelings of isolation commonly reported by participants before the start of the project.

Although mental wellbeing was not mentioned explicitly by all participants, most of the themes they expressed had positive outcomes with many related to improvements in quality of life and individual, psychological wellbeing; consequently, it was appropriate to use the positive mood UCL Museum Wellbeing Measure for Phase 2 of the study.^24,25 Furthermore, support for self-esteem and allied confidence, agency, ability and sense of purpose are theorised to improve individual psychosocial wellbeing.¹⁵ It was interesting that all of the six mood items on the Wellbeing Measure increased significantly after the 10-week programme, particularly ‘Excited’ and ‘Inspired’, that linked into the overall creative and outdoor experience of the intervention. These increases in positive mood, specifically in enthusiasm, inspiration, excitement and happiness, are conjectured to have arisen through the social, interactive and creative content of the programme. ‘Active’ also contributed to overall wellbeing, which could be related to the physical elements of the programme, in particular the outdoor horticultural activities. As such, and drawing on the wider literature, it can be speculated that the combined programme also had some physical health benefits, though these were not measured directly.

As a creative green prescription for adults with mental health issues, this study focused on engagement with a dual, arts- and nature-based intervention, and found predominantly positive biopsychosocial outcomes. Findings from the research need to be interpreted tentatively, however, due to the small sample size and the lack of a control group experiencing life as usual without the intervention. The unique aspect of this programme was its delivery across two different environments, the park and the museum spaces. A future study, therefore, might compare the effects of a single intervention, arts- or nature-based with the effects of a combined programme. Currently, it can only be speculated that there were specific synergies between the dual aspects of the intervention, most notably in the creative and multisensory engagement,²⁷ that are likely to have supported positive outcomes alongside the social aspects of the project and the opportunities for new learning.

Within the literature, both arts- and nature-based interventions independently have been found to mitigate social isolation and enable engagement with a person’s community.^3,10,11 In this study, these activities were effectively combined to produce similar outcomes. At the same time, there is some indication that this unique combination of physical and creative activities, and the outdoor and indoor museum spaces, may allow for additional benefits, as participants were able to engage in individual and group pursuits. Another aspect of note from this study is the sharing of past and current experiences of mental health that appeared to enhance social ties. While this intra-group sharing did not necessarily improve participants’ relationships with people outside of their groups in the wider community, it could provide an area for further study.

A strong theme from this study was that the intervention bolstered self-confidence and self-esteem, aligning with other research.¹⁴ Given that poor self-esteem can be an indicator for the development of mental health disorders,¹⁶ it seemed pertinent that participants with mental health issues in this study should benefit from improved self-esteem. In addition, a challenge with common mental health disorder (anxiety and depression) is that it can co-occur with other factors such as social isolation, because people are reluctant to leave their homes, which in turn can lead to a lack of physical exercise from not going out. From this perspective, it is relevant to highlight the large significant pre–post increase in the feeling of being active, as shown in the UCL Museum Wellbeing Measure mood item analysis.

While there is limited previous research comparing arts- and nature-based interventions, these two forms of social prescribing appear to bring about similar health and wellbeing benefits, and further research is warranted to explain the underlying neuro-biopsychosocial mechanisms.²⁷ Similarly, the creative and multisensory aspects of these seemingly different types of activity need to be better understood, as do the connections between creativity, health and wellbeing, especially in relation to the neuro-biopsychosocial mechanisms underpinning creative health.

The Creative Health report argues that the arts and creativity can encourage a healthy lifestyle, aid recovery and support major health and social care challenges including ageing, long-term conditions, loneliness and mental health.²⁸ Research on engaging with nature shows similar advantages,^11,12 and here we report on the benefits of an intervention that includes both arts- and nature-based activities. Given the positive improvements for the two groups of participants in this study, held in a museum with adjacent parkland, it appears that green prescriptions, combining creative arts- and nature-based activities, have the potential to significantly impact the lives of adult mental health service users. Museums with outdoor spaces need to recognise the health, wellbeing and quality of life benefits in green prescribing, and the opportunities for combining creative outdoor and indoor activities using their spaces and collections.²⁷ The advantages that museums with outdoor spaces have over single green environments, such as forests or farms, is that they are not necessarily restricted by weather conditions, as collections-inspired activities can be continued indoors. Findings from this study link to the body of research on social prescribing,¹ where community referral can be used to support psychosocial outcomes.^2,3 Further research exploring interconnections between creativity, arts, nature, health and wellbeing outcomes is warranted to fully explain the dual, and potentially synergistic, benefits of creative arts and green prescriptions.

The authors gratefully acknowledge the Whitworth Art Gallery’s Cultural Park Keeper, Francine Hayfron and the Arts for Health Manager, Wendy Gallagher; also the horticultural specialists and museum volunteers who supported the programmes, the community mental health and day centre staff who referred participants to the project, and in particular the participants who consented to take part in the research.