Tracking momentary experience in the evaluation of arts-on-prescription services: using mood changes during art workshops to predict global wellbeing change

There is increasing impetus to develop the evidence base for what has been called ‘arts-on-prescription’ or ‘arts-on-referral’, using the arts in primary care both to improve the mental health of patients and to reduce the burden on the National Health Service (NHS).^1–3 This article reports on an evaluation of arts programmes run by Bristol Arts on Referral Alliance. The evaluation builds upon previous research using pre–post designs, which suggest that arts-on-prescription can improve wellbeing,^4–8 but is novel in that it draws on the experience sampling method,⁹ tracking reports of momentary wellbeing over the course of arts-on-prescription programmes. The aim is to evaluate the extent to which dimensions of mood (hedonic tone, tense arousal and energetic arousal) are affected by art-making, how these change over time, and whether this predicts any long-term changes in wellbeing. A further aim is to test a novel evaluation tool (mood tracking) that is easy to deliver and useful for inferring mechanisms of change.

Arts-on-prescription forms part of the wider remit of social prescribing, where doctors, nurses or other primary care professionals prescribe non-clinical activities with the expectation that this will improve the health and health behaviours of participants, including the arts, as well as gardening, cookery, healthy eating advice, nature walks and sport.^3,10,11 Three benefits of social prescribing have been outlined,³ which are not mutually exclusive: improved mental health; improved community wellbeing; and improved social inclusion. This model draws on a holistic definition of health that is impacted by social cultural factors.¹² With an increasing burden on General Practice (GP), and since it is claimed that one in five visits to GPs are due to social rather than medical reasons,¹¹ social prescription is being explored as a route to reducing the financial burden of patient care, decreasing visits to GPs.¹ Indeed, in England, the NHS Long Term Plan aims to make social prescribing available at every GP practice.^11,13 It is important to evaluate whether such interventions can improve wellbeing, since the primary driver for its use should be patient benefit.¹¹ Evidence for the efficacy of such interventions is especially pressing since the costs of mental healthcare are expected to surge in the next 10 years,¹⁴ and the World Health Organization predict that by 2030, depression will be the main global cause of health loss.²

Art is not prescribed as an alternative to other forms of treatment, but as a supplement.⁴ People are usually referred by a primary care professional due to stress and anxiety, depression and low mood, to help with symptoms of chronic pain and/or to improve self-esteem and reduce loneliness.³ Art-on-prescription is not a form of psychotherapy, and individuals participate in visual art and craft activities, in small groups, led by a skilled arts practitioner rather than an arts therapist.^3,15 Typically, this consists of attending a weekly art-workshop, for about 2 hours, for 10 to 12 weeks, after which there may be an opportunity to join ‘move on’ art groups.⁵ Activities are structured according to individual need and interest, and may include clay work, watercolour, mixed media, drawing, print work, collage, felting, and so on. The emphasis is on process and enjoyment, exploring art materials in a safe, non-judgemental space, rather than solely on the development of artistic skill, a process in which the artist facilitator plays a key role.

Research on art and health more generally supports the view that art making is associated with a broad range of benefits such as: decreased depression, anxiety and stress; and increased engagement, meaning (eudemonic happiness), empowerment, connection with others and self-esteem.^9,15,16 Research on the impact of community art groups suggests an improvement in wellbeing over the duration of the workshops, in both pre–post designs and a waiting list control study.^16–18 However, specific research on arts-on-prescription is more limited and consists of only a few research papers.^{4–8,19–24}

Quantitative outcomes, using pre–post designs, suggest that arts-on-prescription can improve wellbeing (assessed with global wellbeing scales at the beginning and end of art programmes, usually the Warwick Edinburgh Mental Wellbeing Scale (WEMWBS)).^6–8 Qualitative outcomes, from both comments on evaluation forms and interviews, suggest that participants feel that they benefit through connecting with and being with others, ‘losing themselves’ in the art activities (and thereby being distracted from pain or anxieties) and forming positive identities (of self-confidence, agency, empowerment and positive self-regard in relation to ‘being an artist’).^20–22,24 Furthermore, econometric work suggests that arts-on-prescription can reduce the financial burden on primary care.^19,25

Despite these encouraging findings, overall, the evidence base is weak.¹ The quantitative work has focused mainly on one cohort (Artlift), there is a lack of control groups (and randomised allocation to conditions), meaning that wellbeing change could be attributed to uncontrolled factors, and attrition rates are not accounted for in analyses.^1,26 A further limitation relates to a lack of process evaluation, examining markers of change across the course of art workshops.²⁶ Due to the ethical and practical complexities of ‘wait-list’ and other control groups in primary care, this study focused on this latter issue, piloting a new method of evaluation that measured aspects of wellbeing throughout arts-on-prescription programmes.

It has been suggested that evaluations of arts interventions could profitably draw upon the experience sampling method and the use of state measures to capture the immediate impact that attending art workshops might have.⁹ This study built upon this suggestion, using a form of event-contingent sampling, where mood was assessed before and after each art workshop of a 12-week-long course. This approach draws on current recommendations for wellbeing measurement, using both global, evaluative retrospective scales and in-the-moment measures.²⁷ Retrospective scales tend to measure beliefs about wellbeing, rather than actual experience. We forget nuances of our affective life and make errors in our recall (e.g. being biased to remember positive moods across a week-long period).^28,29 Measuring immediate experience can be a more reliable measure of wellbeing (but also has its own set of limitations, being temporary, contextual and labile). Based on best practice recommendations,^27,30 both global and immediate aspects of wellbeing (mood) were measured in this study.

It was hypothesised that (1) global wellbeing scores would increase over the course of the art programmes, replicating previous findings;^6–8 (2) immediate measures of mood (calmness, alertness and contentment) would increase after taking part in each art workshop;⁹ (3) mood would improve over the course of the art programmes; and (4) that improvements in mood during the art workshops would predict improvements in global wellbeing.

The current research was innovative in that it applied mood tracking to the evaluation of an arts and health intervention for the first time. This approach enabled the immediate affective response to attending art workshops to be examined as a mechanism driving wellbeing change. The findings suggest that tracking immediate experience is a useful tool in the evaluation of public health interventions.

The significant increase in global wellbeing over the course of arts-on-prescription workshops supports previous research.^5–8 Wellbeing (WEMWBS scores) was generally low at baseline (at a mean level indicative of probable depression, below 40), but was increased to levels above this threshold after participation in one programme. These findings support the efficacy of arts-on-referral programmes for improving wellbeing. However, it is not known what factors might be required to maintain such increases in wellbeing after the cessation of the arts programmes, and longitudinal research is required to explore this.

The most important outcome from this study was the examination of the immediate impact of art making on mood and its relationship with wellbeing change. Mood is conceptualised as multidimensional, with orthogonal factors with different physiological underpinnings: hedonic tone (contentment and happiness); tense arousal (stress and anxiety); and energetic arousal (alertness and wakefulness).^31,32 For example, previous research, sampling moods in everyday life, has reported that physical activity improves both energetic arousal and hedonic tone (but not tense arousal).³⁷ In this study, participating in art workshops was associated with significant improvement on all three dimensions of mood. However, reduction of tense arousal appeared to be most important for global wellbeing. Participants who reported a larger increase in relaxation and calmness after the art workshops, had a larger increase in wellbeing across the arts-on-referral programmes. Increases in feelings of wakefulness and contentment did not have this effect. This finding is important because it suggests that reduction of tense arousal (agitation, tension, stress and anxiety) is one potential mechanism by which arts-on-prescription improves wellbeing, and suggests that engagement with visual arts and crafts is an appropriate prescription for people experiencing anxiety and depression. It provides a direct link between experience during the art workshops and wellbeing change (limiting the interpretation that change could be attributed to non-controlled factors or reporting biases). The finding also concurs with experimental research suggesting that art-making reduces stress and cortisol levels.³⁸ Further research could seek to replicate and extend understanding of this effect and explore issues such as why some participants may not have had a relaxation response to the art workshops; how this response could be optimised in art workshops; and whether participants also use art making as a tool to manage anxiety in everyday life.

In addition to exploring the impact of mood change pre and post each art workshop, analyses of mood scores on arrival showed significant increases over time. Participants reported feeling more content, calm and energetic across the 12-week-long arts-on-prescription programmes. This supports the increase in global wellbeing and could be interpreted as being indicative of improved immediate subjective experience in everyday life. However, an alternative interpretation is that participants may have been feeling more relaxed in the art group only. Future work could sample mood at random points in everyday life, drawing on the experience sampling method,⁹ in order to explore how long such boosts in mood last outside the safe space of the arts-on-prescription room and group. Such an approach has been used recently to explore the treatment impact of psychological interventions.³⁹

The findings of this study support the use of the arts-on-prescription as an effective intervention, reducing tense arousal and improving the wellbeing of participants referred with anxiety and depression. Nevertheless, the study had several limitations. In order to be minimally invasive, only mood was measured. However, other aspects of experience could also contribute to wellbeing change, such as feelings of mastery, connection to others or states of absorbed concentration in art making.^9,15,18,19 Furthermore, it is possible that the completion of mood measures could be affected by demand characteristics. Participants may expect to feel better at the end of the workshops and mark the form accordingly. However, it is unlikely that response biases could explain either the interaction between mood and wellbeing scores, or change in mood across the art programmes, since this would require the memorisation of complex scoring patterns. Finally, it would be useful in future work to assess the impact of the number of sessions attended on wellbeing change, as well as to evaluate the efficacy of arts-on-prescription for different reasons for referral.

Future research could develop the approach outlined in this article, using computerised experience sampling methods to explore the impact of arts-on-prescription on wellbeing in everyday life, both across and beyond the referral time-frame. There is also the potential to track physiological data with this approach to augment self-report data.⁴⁰ However, perhaps the most crucial issue is to further explore who arts-on-prescription works best for, and why. For example, in relation to the current findings, what factors contributed to some people finding the art workshops relaxing, and others, not? Mixed methods approaches could be useful here, for example, interviewing people with different relaxation responses about their experiences of arts-on-prescription. Finally, it would be useful to apply theoretical models about why and how arts-on-prescription might work to future research (e.g. stress reduction, distraction and social models). Appropriate state variables (such as absorption and social connection) could be included, but also further potential global outcomes, both for the individual (e.g. social isolation, being better able to manage care) and health and care system (e.g. reduced consultations with GPs).¹¹

The current research supports the efficacy of arts-on-prescription programmes for improving the wellbeing of people referred for anxiety, depression and social isolation.^5–8 The use of a mood tracking component, drawing upon the experience sampling method,⁹ was demonstrated to be a useful tool for the evaluation of public health interventions, helping to understand processes of change. This study found improvements in immediate subjective experience after art workshops (contentment, wakefulness and calmness), experiences that are crucial components of psychological wellbeing.^27,30 Reductions in tense arousal during the art workshops significantly predicted global wellbeing change, making a direct link between experiences during art workshops and subsequent wellbeing for the first time. This strengthens the evidence base for arts-on-prescription and helps to suggest mechanisms for its efficacy. However, more complex theoretical and empirical work on mechanisms for change is required, as well as understanding of the longitudinal impact, of the arts-on-prescription.

The authors thank Julie Matthews and Barbara Disney, the artists who led the arts-on-prescription workshops, through the CreativeShift service for Bristol Arts on Referral Alliance. The project also benefitted from student volunteer research assistants who helped to input data; thanks for this work go to: Susannah Disley, Flora Strange, Sophie Ashton and Abigail Rickards.