Arts On Prescription

[00:00:03] BC: From the Center for the Study of Art & Community, this is Change the Story / Change the World. My name is Bill Cleveland.

Happy New Year. A while back in we shared a series of episodes dealing with arts, and aging, and arts and neuroscience. One interesting theme that arose was a relatively new healthcare approach called social prescription that provides patients with non clinical services, like exercise programs, volunteer opportunities, community gardening activities, and, of course the arts, aimed at improving mental and physical well-being. In our conversations with Creative Care founder, and MacArthur Fellow Anne Basting, and Atlantic neuroscience Fellow Veronica Rojas they talked about the adoption of social prescribing at the British National Health Service and some pilot efforts taking place in the US.

Then A few months ago I got an email from Jill Sonke the Director of [00:01:00] research initiatives in the Center for Arts in Medicine at the University of Florida (UF), asking if she and her colleague, Tasha Golden Director of Research at the International Arts + Mind Lab at Johns Hopkins Medicine, might come on the show to talk about the field book they have written to support the development of arts and nature centered social prescribing initiatives in the US. So, Of course I said, “Come on down.”

What follows provides a first hand account of emerging movement and introduces a great new resource called Arts On Prescription: A Field Guide for US Communities.

Part One: Arts and Health

Jill Sonke and Tasha Golden, welcome to the show.

So, Tasha when you speak to people who are not familiar with your background and your work, how do you describe your work in the world?

[00:01:49] TC: Oh, if I were to say I research the impacts of arts on health, usually the first things that come to mind for people are things like art therapy and music therapy. So, I have learned to [00:02:00] immediately zoom out from that, or even specifically say, “Oh, this doesn't have to mean music therapy or art therapy. Actually, it's a lot more about, all of the many ways in which art in all of its many forms can affect human brains and bodies both individually and collectively.” But it does seem to help, to tell the story about, where I've come from as an artist, how I wound up doing the work that I do as a scientist, and it brings it together.

[00:02:22] BC: Yeah, so we're going to get to that story next. And Jill, what do you say to folks who are curious about your work?

[00:02:30] JS: I'm Jill Sonke, and, I work at the intersection of the arts and health. I came to this work as a practitioner, as an artist in residence in a hospital, working in both hospitals and in community settings, facilitating the arts in all sorts of ways that promoted health and well being. And now, like Tasha, I'm a researcher, and I study the relationships between the arts and health, both at the individual and the population levels.

[00:02:57] BC: And Tasha, my curiosity now is, given that you've talked about, how you define your work, how in the world did you get into this business?

[00:03:09] TC: Yes, this was never the plan. This was, not what I imagined when I was starting out. From the time I was a little girl, I wanted to be a singer songwriter. I had a dream of traveling and writing songs and performing those songs for audiences. And I got to do that for a lot of years. And that was, from the outside, going really well.

In many ways, we had, songs and TV and film and working with Grammy winning musicians, and it was really lovely and really honored to do that work. But there were a couple things that were happening during that time that sort of set me on a different path. And the first is that I had songs about difficult experiences, like my family's history of domestic violence or my own history of depression….

We come from cigarettes, yeah and old shoes

from moving out every time the rent was due

And penniless old men with guitars

and children in the back room praying in the dark

Tennessee whiskey   

Oh, it's in the blood and bones of me

Hallelujah, hallelujah

Tennessee Whiskey, Tasha Golden, from Over Land, Over Sea, released June 26, 2017 © all rights reserved

And anywhere we went in the world, those were always the songs that people lined up after concerts wanting to talk about. And they would share their own personal stories of difficult histories with me. And, many of them following those stories up by [00:04:00] saying that I'm the first person they'd ever told.

And I started to get really curious about what does that mean for all of the other people in this person's life who may need this information in order to better serve them, whether that's a physician or a therapist or even a friend, a partner. And I began to get curious around; Why is a certain level of communication and disclosure possible in the space of music? And why is it not possible in other places? And how do we bridge that divide? So I developed this curiosity.

And then also the grind of the music industry was wearing me down without my really realizing it. Before I knew it, I was in the midst of catastrophic burnout and major depression. Couldn't get out of bed for many weeks, let alone play concerts, and had to really fully reimagine who I was, my whole identity, my whole trajectory, where I was going with my work and my life.

And what I grabbed onto in that really dark time was this question that kept coming up in my work, which was: What becomes possible in the space of music and the arts? Why does it become possible like that? And how do we use that knowledge and that possibility to improve our lives and our well being in the way that our systems and our society works outside of those spaces, instead of just saying, isn't it cool that this is possible here, can we think about what that means and, infuse it into other spaces.

So I pulled on that thread until I wound up with a Ph. D. in public health, specializing in the effects of the arts on public health. So it's how you found me, how I wound up here.

[00:05:33] BC: Jill, I ask you the same question. How did you come to the intersection of art and well-being.

[00:05:58] JS: So, unlike Tasha, I was actually headed toward medicine as a kid. I wanted to be a doctor because I was really fascinated with the brain. And it started for me, with insomnia. I just couldn't sleep at night.

So I would like crawl down the stairs and read encyclopedias. And in the encyclopedia, everything I wanted to read was about the body and the brain and, babies. all things physical. And that [00:06:00] really, got me headed down a path toward medicine. But then when I was in my junior year of high school, wherein I was a competitive gymnast and one day a dancer came into the gym to help us with our floor exercise routines and I had, my first aesthetic experience.

I had always moved athletically, but I found myself moving artistically for the first time in my life. And I had my first truly transcendent and self transcendent experience while having an aesthetic experience. And it was just, it was world changing for me. It really changed everything.

And I knew in that moment, in the elation and wholeness of that moment that I wanted that experience every day that for me was what it was gonna mean to live. And so I immediately signed up for dance class, and then just a few months later, I was spending the summer working as a live in babysitter in northern Michigan near an incredible performing arts [00:07:00] boarding school called Interlochen Arts Academy, and on a whim I auditioned and got in, and then I was just in that arts path.

I studied and Dance at Interlochen and in college. And then I went to New York City and I danced professionally. and then I ended up going to Gainesville, Florida, which was meant to be for a short time. And at that time, the UF Health, Shands Arts and Medicine program was just beginning as one of the first five arts and health programs in the United States.

And they were all bubbling up at the same time. And when I heard about that program. I couldn't believe that I could be an artist in health care, and so I was very excited to become one of the first two artists in residence in that program, and to be able to stay put in Gainesville for a while to explore that path.

[00:07:50] BC: And you have. You've been there for how long?

[00:07:53] JS: So I'm now living in New York City, but I still am employed at the University of Florida as Director of Research Initiatives, but I was in Gainesville for 30 years.

[00:08:04] BC: Yeah. That's a significant, investment on your behalf, but also, and I think when I tell this same story to folks, most of them are very surprised that an institution of higher learning and a major, teaching hospital have invested in this subject area for so long. It's one thing to have one of those little pilot projects, right? But this is,I think, a testimony to the subject of your, book, we're not talking about, an interesting idea here. We're talking about a practice that is serious and rigorous.

Part Two: Not Just A Cool Idea

Arts on Prescription: A Field Guide for U. S. Communities. Could you talk about the genesis of this, the how and why of this manifesting in the world?

[00:08:55] TC: Yes, we owe a lot to Mass Cultural Council, the State Arts Council in the state of Massachusetts, which launched the first statewide Arts on Prescription program in the U. S. in 2020. And they, they asked me to come in 2021 do a, an evaluation of their pilot program. And we learned so much from that program in Massachusetts because even though it was a statewide initiative to link cultural experiences, arts experiences in communities with health care providers each instance of that across the state was really a very hyper local partnership that was set up sometimes between a single cultural organization and a local provider. And that was so different. you can imagine Western rural Massachusetts, that would be very different from what's happening in the city of Boston.

And so there were about 12 of these different kinds of partnerships that we got to look at in that pilot program. Which means that we could see, even in a single state, really different ways of this process emerging, and what were the problems that people face, what were the things that went really well, what seemed to translate no matter where they were, and what seemed to be really specifically helpful in certain regions, things like that.

And we learned so much from it that Mass Cultural Council was like, we would love to pull these findings together in a kind of how-to guide that would help other communities to do this, but not just in Massachusetts, you know, around the country. So we reached out to Jill and the University of Florida because they were doing this massive research about social prescribing in general, and we're, accumulating more and more findings from across the country.

And of course, wrapping that in with ongoing findings from similar kinds of models of care around the world. And so we brought together the findings from Massachusetts from a ton of other pilots around the US. And not just pilots but programs that have been operating for a long time, but just not calling themselves Arts on Prescription, right?

So there's a lot of these kinds of programs that have been both emerging and ongoing that we were able to really tap into and learn from, so that we could create a guide that wouldn't just tell people, like you say, it's not just telling people about this cool idea that isn't this novel and interesting, but saying, this is what the idea is, this is the research and evidence and practice that it's grounded in, and it's possible and you can do it too, and here's how.

So as comprehensive as we could make it, with a ton of really practical resources.

[00:11:11] BC: So, Jill, was there also a demand for this? For those 30 years, I know that you were one of a few programs. Obviously, the field has dramatically grown. So did you have a sense that, oh yeah, there's a ready audience for this. There's are people who are hungry for this?

[00:11:30] JS: Yes, Bill, I think you're quite right. The field has grown quite a bit. When I started in 1994 as an artist in residence, not only were there, just a few programs around the country, people's response in the hospital was sometimes like, "Wait, what? This is really weird. This is a hospital, What are you doing here? The arts don't belong here.” But that pretty quickly shifted because as people gained firsthand experience, they recognize the value of the arts, from very simple, levels of [00:12:00] enjoyment and connection to very profound levels of healing and transformation.

So we did see starting in the 1990s, a very rapid proliferation of arts programs in hospitals. And then over the past 20 years, we've seen that extend more and more into a connection between the arts and health in communities and a recognition among artists of the value of the arts.

And along with that in the past, I would say, it's hard to actually quantify, but I would say around the past 10 years, there's been a growing, recognition of social prescribing as an approach that, has been taking hold in other parts of the world. There are social prescribing programs that are well established now, in at least 18 other countries. And in some of those countries, like the United Kingdom, there's policy and, national health service, governmental level investment in social prescribing infrastructure.

[00:13:00] BC: Isn’t it true though that, given the differences in our healthcare system , the US version is distinctive in a number of ways.

[00:13:10] JS: In the United States, social prescribing has been in place for decades, but it's been framed a little bit differently than it's being framed currently in other parts of the world. Historically, in the US, over the past few decades, as public health systems have been thinking more about social determinants or social drivers of health resources have been allocated, not only to medical interventions, but health resources have been allocated to some of those social drivers.

But what we see in the United Kingdom and other parts of the world around social prescribing is an even wider framing that considers the social dimensions of health, right? Recognizes loneliness as a barrier to health, and recognizes that we need social connection to be well, right? Social prescribing programs address those social drivers of health, right? Things like, housing and food and transportation and also, and increasingly they are addressing, social needs, connecting people to walking groups, and volunteering, and arts and culture, and nature, to the extent that a lot of these programs… and where we focus in the field guide is on arts prescribing, right?… prescribing arts and culture and nature. So, this is a tide that's been growing in the United States as we've looked to other nations.

And now when we look around in the United States, we've, we have our eyes on more than 25 pilot programs now in the United States. And as Tasha said, some of those are pretty longstanding. So now policymakers, healthcare systems, people in public health and in the arts are really beginning to think about, is this possible in the United States?

[00:15:04] BC: Tasha, Who's this for? Could you describe the universe of folks and organizations that might be interested in this?

[00:15:13] TC: Yes, we did a lot of talking, as this was first taking shape around; who do we imagine as being the initial audience? And then, of course from there, there's always ripple effects, and people who latch onto it who you didn't expect. But initially, we had two primary audiences in mind, which were people who are already working in arts or cultural organizations, or nature organizations.

Like Jill said, the idea of arts and prescription. is that healthcare providers would be able to refer people to arts and culture and nature resources in their community to cultivate their well being for their patients. So we wanted to be able to write something that was for people who are working in that sector, so that they would be able to better imagine, oh, what might my role be in this kind of model of care?

And then of course, right along with that, health care providers themselves, people who are in health care and social care who are aware that there are [00:16:00] needs in their community, and among their patients and clients that they haven't had a way to meet, and who are looking for ways to do that, or who are just open in general to reimagining how they're doing their work.

What are some more creative ways that we can approach our care? Either because we want to be more human centered, or we want to be more whole person about our work, or because we need to be more efficient and economically sound. whatever their motivations might be, they're looking for how to improve care, right?

[00:17:19] BC: So, the manual came out in the fall of 2023, since you launched it how has it been received. Is it having the effect you imagined?

[00:17:31] TG: , Yes as the field guide has been out there, what’s exciting to me as somebody who's often in this position of trying to help people across different sectors join together, and partner, and realize their relevance to one another, what's been so exciting is that the guide really serves as a … it's a jumping off point for new conversations around what health even means; What is well being; Do we want to accept what it already is and just tweak it, or do we want to reimagine how we do health and healthcare? And so, what I love about the guide's existence as a concrete thing to send out into the world is that people can read and share. It becomes so much easier to just ignite new conversations about things.And what I see the field guide igniting is, conversations around; What is health? What is health care? What do I want it to look like?

And then, as you intuited Bill, people who are outside arts and culture and nature, this is just as relevant to them, because guess what? All of us are patients, ultimately. All of us are affected by the health and well being resources that are around us. And people find in this concept of arts and prescription, maybe a new way to imagine, what they want, their own health opportunities to look like in their community, and maybe how they can be a part of effecting that change, even if they don't find themselves in the kind of, specific roles that I mentioned earlier.

[00:17:50] BC: Yeah, so I have a map in my head. There's all these little social prescribing dots on it. They're lighting up. and some of them are on fire, and some of them are very faint. But all of them deal with issues like scarce resources, and short term thinking operating in the infrastructure ecosystem in which they work. All of them, particularly in the areas that you're focusing on, which is arts practice and healthcare practice, have many, many layers and are intrinsically partnership intensive.

The question I have, Jill, is, if someone opens up your book, your field guide, and they realize, I'm totally excited about this idea, but I am not in control of the universe in which I work. Does this, field guide help them deal with the jungle in which they work so that they can navigate it in a way that's healthy, and assess their capacity for engaging in this work?

[00:18:53] JS: We do hope, Bill, that this field guide will be helpful to people in a huge array of positions. I think that was actually essential for us to bear in mind as we were writing because social prescribing, and arts prescribing, it's not one thing in the United States. It's not one thing anywhere. There's a lot of variation in the way these kinds of programs are structured and operated and the players and partners, who are involved.

So, we really had to recognize that we're in a very formative moment in the United States, and that we wanted to be able to flag, not only great examples that could inspire and guide, but some of the considerations that we have found through being a part of pilots in the United States, and through studying programs in other countries, we felt would be important considerations for people in any role in relation to social prescribing or arts prescribing. And, that landscape is not just in a sort of super professional realm, right?

Health is generated in communities and it can be supported through community based resources, things that are very informal, backyards, and parks, and friends, and church choirs and, just the ways in which we live, the ways in which we notice that, the beauty we bring to setting our breakfast table or dressing ourselves in the morning, can be very creative. And, especially when approached with that kind of, mindfulness, can be a component in building our health.

[00:21:31] BC: So, you see social prescribing as much more than a strategy for integrating the arts into health care. as more than a program and policy initiativeS

[00:21:42] JS: we hope that by driving social prescribing, and arts prescribing through this manual that there will be a deeper, more primary recognition of the relationship between the arts and health, and recognition that formal social prescribing programs, wherein health providers are referring or prescribing people to these local community based resources in partnership with us as patients, as Tasha said, that's one avenue. But really, I think the bigger and more important, arena here is just that we, as individuals, recognize that relationship between the arts and health, and recognize how we can engage those resources in our everyday lives. So, I think the prescribing is as an important component.

There are many people for whom this will be a new idea and a new opportunity and having a prescription will provide a structure in which they can enter that space and for others, it will just reinforce a knowing, an interest in the arts.

Part Three: How Does This Work?

[00:21:54] BC: So there are probably people now who are listening who are intrigued, but also thinking, “How does this work? How does this go?” And obviously, one of the best ways of sharing that kind of thing is to share a story. You have six case studies in your field guide for an obvious reason, which is that it basically, it's not theory, it's a practice, and those are stories of practice. Tasha, could you, describe one of these in a way that gives people a sort of window into, How these things, unfold.

[00:22:32] TC: Sure. And, exactly like I said earlier, the Mass Cultural Council program was a great example of the fact that it has looked really different from community to community. And I say that now because it's so important, I think, in talking about this, that it's okay to be imaginative and creative about what this will be.

would or could look like in a given community and to recognize that's going to be different. Especially at this stage when we don't have a national health care system in the US that would just roll something out that would be maybe a little bit more cookie cutter. But we also might not want that because the experience of arts and culture isn't inherently localized and culture-specific thing.

And there are definitely pros and cons to the fact that things have to be community by community. But one of the pros is that there's a lot of imagination and creativity that can be applied even in that.

I will tell you about in Massachusetts, the program is called CultureRX. So, I encourage anybody to Google that and they have reports, and things like that they've published about that program, you can read much more intensively about it. And we also, of course, have their case study in this field guide that you can read first with links out to their work.

But, as an example, they have had, a physical therapy clinic that is partnered with a dance studio so that, older folks who were maybe dealing with mobility issues, such as Parkinson’s, could be referred out to a dance studio that had dance programs specifically designed for people with Parkinson’s and help with their mobility and balance in that way. And there was, in Western Massachusetts a collection of a few different arts experiences like a theater and Mass Audubon, a park [00:24:00] system.

And some, some museums and other experiences, and that was connected with McKinney Pediatrics like a large system of clinics and the physicians in those systems could offer, any one of those five opportunities to their patients. And, based on what was their interest, what was maybe closest to them, what were they most excited to go to.

And then, I'll tell you a little bit more about, there, there's also the Norman Rockwell Museum that partnered with, an array of private mental health therapists. So rather than being, like an institution, a hospital or a clinic, it was many therapists in the region that all were given access to tickets and things like this that they could share with their clients to come to that museum for a variety of reasons.

And what's interesting about that is that for me, like that was one of the more grassroots examples of a single arts institutions figuring out what their relevance might be to people who are working on mental health in that region and then coming up with these really creative ideas about what could be useful to [00:25:00] these clients.

And so they developed, for example, a really beautiful packet that had, information about the museum. I think sometimes some coloring sheets in there, depending on like the age range of the clients, if they're working with children and then also had coupons for the cafe.

And so, we heard from the mental health therapist saying that they would, send clients to the museum as a way to create conversational pieces like, “What stood out to you? Why do you think that was? or, What was that experience of leaving your home?” like, “Why were you able to leave the home to go to the museum when you haven't been able to get out to do other things, tell me about that?”

So, you see these creative ways that providers are using these experiences to enhance their care. But then, I have to tell you, what they realized with that was that inclusion of a coupon to their cafe was so essential in ways that they couldn't have predicted, but there were so many clients who were making new social connections or enhancing existing connections with their family or with friends or with others, because they could say, [00:26:00] “Come to the museum with me and we can get a coffee while we're there and we can sit down and talk.”

And that was such an appealing intuitive way for mental health clients to try something new to connect with somebody, and to feel like they were having a really organic experience, which they absolutely were and the providers are saying, “You know without this kind of system set up in our community for us to do this, what were our options?”

We can recommend all day that somebody, go make a coffee date with somebody, how can we get you out of the house and go explore some things that you're curious about and that give your life meaning. But we don't have a way set up inherent in our practice that gives us real tools that we can give people to actually go have that experience. And this was exactly that infrastructure that they needed for that.

[00:26:44] BC: Yeah, you're really offering people access to new ways to change their stories, to change or alter a pattern in their life that just isn't working for them. You think about the incredibly short encounters we all have with health care providers. There's so little that they can do, even if they recognize that, “Oh, this is not a good pattern. Maybe you should change it.” But to have that resource, just that little nudge, right? The coupon to go into the cafe. It's like a small window opening into a new world with many ripples. I think ripple is definitely one of the things that happen here.

Jill, I know that one of the aspects of your work, and also of this field guide is that, you have both done a lot of work, asking some very important basic research questions of your colleagues around the world. and, some questions are, “How'd you do that?” But another [00:28:00] important one, which I think people are probably thinking about now is, “Why does this work? What? What actually happens when this resource and enters into a community?” And what have we found out? Because I'm going to say this again this is a field guide for a practice that has a history, and the history is one that is very promising. And so what's so promising about it?

[00:28:23] JS: So, there has been a lot of research. Fortunately, we have seen a lot of investment in research because these programs have been implemented throughout the world. research is, prevalent enough that we can now sort of map it and synthesize it. we recently completed a mapping review of social prescribing outcomes from the 13 countries that are included in the World Health Organization's, social prescribing toolkit. And, we saw that again, in alignment with the breadth of approaches and programming and the innovation that's happening in this space.

We mapped a total of 347 unique outcomes. And most of those were patient outcomes, 278 of them, and 69 of them were system level outcomes. So, mostly those studies are focusing on mental health, and on lifestyle and behavior, and on the experience of social prescribing. And many as well are looking at the economic outcomes. Some studies have shown reductions in burden on primary care and emergency care systems. Some, studies have shown, reductions in cost of care when social prescribing is engaged. And some programs are measuring what's called social return on investment. And that's an approach. That gives economic value to social benefits. And so, there's some really encouraging data around the ways in which people are finding benefit in social prescribing, both the individuals who are participating as patients and end users.

[00:30:00] And the care providers, who now have a new resource. And that we hear about a lot in meetings around social prescribings, when health providers themselves are in those conversations, they describe, frustration at having a limited toolkit that's essentially built in the United States by the third party payers, by the insurance companies.

Our dear colleague, Dr. Alan Siegel once described, as a practicing physician, how he walks into a patient room. He knows he has a limited amount of time with that patient, and because he knows his time is limited, and because he knows that what the insurance providers will pay for is limited, he has a sense that he will fail the patient because he doesn't have a broad enough toolkit to address the holistic and unique needs of his patients.

[00:31:00] So, Alan is now working hard as an advocate for social prescribing because he believes that he and other care providers can be more successful in providing holistic, patient centered care if they can offer non medical, non clinical interventions.

And that's another piece that I think is important around social prescribing, that it's meant to fill a few gaps. One of those gaps is that space that people present to the health system when they're not thriving. We're not always super ill, and we don't always need the big guns of medicine, risky medications and therapies when we're not doing our best. Sometimes we need. simpler interventions in order to thrive. And that’s one of the spaces that social prescribing seeks to fill.

[00:32:00] The other is a space in which every individual has access to wellness and prevention resources, even uninsured and underinsured people. Today in the United States, People who are well insured, have insurance coverage that'll pay for wellness services and prevention services, but when we're uninsured or underinsured, it's really hard to access those kinds of services. So social prescribing is also seeking to address that gap.

Part Four: Connecting the Dots - Who pays and who plays?

[00:32:23] BC: So actually, here's the elephant in the room for me. The programs I've looked at overseas, so many of them are designed and developed within national healthcare systems. This may be getting into the weeds, and I'm sure it's different in almost every single program, but is there an aspiration to, move this American version of this into the realm where, the resource is paid for, where the doctor doesn't feel between a rock and a hard place prescribing something that, that isn't being supported. Is that something on the horizon?

[00:33:09] TC: I think there's myriad ways to answer that question. But I think the first thing to say is that,I think part of your question is could health insurance cover this? How is this covered, et cetera. And we, we do see, interest from health insurance from payers in this kind of care and that is happening. There's some examples with, Horizon Blue Cross Blue Shield in New Jersey that has partnered with the New Jersey Performing Arts Center for a program and that's described in our field guide that you can check that out. There's many more insurance companies that are interested.

And so I think the ways to answer this is that yes, a lot of insurance companies have been interested in this. Yes, there's a path forward to creating policies and opportunities whereby this kind of care can be covered the way that other things are covered. And yes, it's definitely possible to move this from a state by state, method.

[00:34:00]And then also, this is also an opportunity, like I mentioned, to reimagine what health is, and what health care is, and it can be an impetus for that important conversation here in the U. S. Do we need to be working with the system as it is in order to improve care as, as urgently and as soon as possible?

Yes, and then also, can we be imagining how that care could and should operate? And so I'll just mention that at the beginning of the field guide, we describe like what health is, we rely on the World Health Organization's definition of health, which is that it is complete physical, mental and social well being and not merely the absence of disease or infirmity.

And of course, just like Jill said, a lot of the focus has been on reacting to things when things go wrong. Here's the kind of care that we want to exist. And that's so important, but that's ultimately only half of health. There's like the absence of disease and what we do, am I not sick? Am I not suffering? There's that form of health, right?

And then there's also what is present, what kind of wellbeing opportunities do I have? Can I thrive? Can I flourish? Is that even possible for me? And to address that part of health, we not only [00:35:00] need to be able to, expand providers toolkits, which is what this model of care does, and it's urgently important, that we also need to rethink what we think, again, what health is?

How do we create a community where more and more humans have as much opportunity to thrive as possible? What does a community look like that is conducive to human thriving? We don't have those kinds of communities yet in the U. S. or, lots of places around the world. And creating that kind of community is a different project than creating the optimal reaction to, suffering when it happens, right?

And both of those projects are important. So when we're thinking about how to pay for, opportunities for patients to, to be able to heal, to be well, to connect, there's that dual concern of like, how do we do that right now within the systems that we have now?

How do we work with insurance companies? And of course, how do we work with philanthropies and grants and state funding as it exists? And then also, how do we reorient our imaginations around what would it take to make a true economic investment in the kinds of communities [00:36:00] that have to exist for humans to thrive?

[00:36:02] JS: Just to add that I, a couple of thoughts here about, about the financial dimensions of social prescribing. one is that there's a lot of dialogue about the notion of, systems alignment, right? How we can, reorganize or reutilize or connect existing resources in order for care providers to provide these kinds of referrals and prescriptions.

Various parts of social prescribing may or may not require new resources. Ultimately, I think we would be well served by new resources coming in to support innovation. Right now, the Federal Reserve Bank in New York is convening dialogue around social prescribing and has committed to an 18 to 24 month period of time, of strategic planning and, bringing in, finance experts to help strategize around the economic part where they'll have economists at the table, to help innovate with folks who are working on the possibility of social prescribing.

[00:37:56] Tony Davis, Federal Reserve Bank of New York: Hi, I’m Tony Davis, Director of Community outreach and Health here at the bank. For this afternoon, we're looking forward to explaining exactly what is social prescribing. We're trying to identify new ideas, new partnerships, and new sources of capital to really help low income neighborhoods flourish. There are roles for insurers, community health workers, non profits. various forms of government and many others to be a part of making this movement more widespread in the United states.

[00:36:02] JS:And as Tasha, is alluding to as well, there's, tremendous strength in really hyper-local systems and structures and programs as well. And I think, in, in the spirit of our U. S. culture, we're going to see a lot of unique innovation. I don't envision a moment where suddenly if A switch is flipped on for national policy that enables social prescribing all over the United States. I think what we're seeing now, which is innovation all over, from different partnerships and leaders and different sectors and different kinds and [00:38:00] scales of communities.

I think we'll see that continue, and I think as research comes to bear to look, at the outcomes of those programs, that some trends will develop. there will be replicable programs that can develop. Even in the United Kingdom, where social prescribing has been policy for, I think, since 2012,

Tasha, at least … I forget the year, with the NHS investment in social prescribing, there is not one way in which it happens. The NHS pays for link workers, but they're not paying for the end services. Individual programs are structured differently and they bring different financial structures to bear.

So all over the world, we're still very much in a formative place with social prescribing, and I think even with all the interest and eagerness, to make this happen, we have to be patient and support innovation. So that we can really see what [00:39:00] the outcomes are.

And I keep joking too. It’s an, if we build it, will they come? I think we don't yet have enough perspective from the population that we seek to serve with these programs. In our EpiArts lab, we're doing implementation science studies right now. So we're doing surveys and interviews and learning from a whole range of stakeholders involved in these social prescribing pilots in the United States.

And we feel that at this stage, it's really important, to hear from all of those voices so that, we're not just romanticizing the potential outcomes, but we're really looking at the realities of engagement and outcomes, and, making sure that investments, can happen based on that kind of evidence.

[00:39:45] BC: So one of the things that just rises up for me, and it actually is one that I think that you, yourself Jill, experienced at the hospital a lot. And that is that if you think of an artist in residence in a hospital, that's not the same as an artist in residence in a school. It's certainly not the same as an artist in residence in prison systems that I worked in.

So there's a skill set for these partnerships that you're talking about and that at some point, and this, the reason I'm bringing this up, is that pilot programs often rely on existing resources, and an existing infrastructure, and ecosystems to be able to do proof of concept, you know… can an arts organization partner with, a mental health organization. Can that most basic relationship get established? But at the end of the day, sustainability is dependent on the creation of common language, and a common skill set that is at a high level across sectors. And that's where the resources come in. and obviously the hard part is one size does not fit all. So, you know, critical training or cross sector [00:41:00] collaborative, mortar building, wall building often takes place at the hyper local level, where everybody's doing those things.

So, the other thing I wanted to mention is that in almost every non arts field that I work with, the artist and the arts organizations are seen as an interesting but not central additive. And in the ones that have managed to sustain themselves, the creative sector professionals have become co creators and co leaders.

And when this happens, the arts presence often transitions from just a service provider to become a real strategic creative partner. And I've seen this happen in public safety, and in community planning systems where artists were invited to be fun partners, and actually end up creating entirely new strategies, new innovations, new ways to think about how to get particular things done.

And I'm hearing that could very well be an outcome of this. That it's not just sprinkling a little art on our patients. It's these artists, these arts organizations are actually going to end up being collaborators in designing, helping to change the way we think about what health care is in America.

Which to me, that's the revolution we're talking about here. It's not an additive. It's a principle driving force of a healthy community.

[00:42:37] TC: Yeah, and I think that you see some of that re-imagination and that transformative work that happens is both the inclusion of the artists and the creatives and the folks that are invested in nature, in the systems of care, just like you're saying, but also the way that the inclusion of those organizations lets us tap into and learn from our community members in a different new way.

[00:43:00] And it's their insights, it's their contributions and engagement that wind up, informing how to overhaul systems of care. But the limited ways or the norms around how they interact with community members limit what they can learn from those community members, the kind of feedback that comes back in. In the field guide, we are very clear in there that it is really difficult to create these partnerships across sectors. That, you know, it's not just rainbows and butterflies in this work as much as you might believe in it.

It's not just oh, I had a good idea. So we went and did it. All of the examples that we give share the hardships that they face, the barriers that they faced, if you're entering this kind of partnership, you're going to be encountering those difficulties of language barriers, of differences in values, differences in the ways that you do things.

Sometimes it's about all of the different sectors that are involved learning how to make themselves legible to, to community members, to one another, so that we can partner better.

And it's one of the things that I've been most passionate about, is that it's not necessarily a problem that [00:44:00] there are people who specialize in the arts, and then there are other people who specialize in medicine, The fact that silos exist is not itself a problem.

The only problem is if we don't know how to bridge and talk and communicate. And that is something that we can learn. It's something that we give some advice about in the field guide. It's something that I've been happy to train organizations in. But there are ways that you can reach out across what you already know to access what other people know.

And when we do that, we create all this fertile ground for new conversations and transformative work.

[00:44:31] BC: So one of the aspects of this program and other places is often these linking, actually, functionaries, people whose job it is to build bridge, do translations, and, know the systems well enough so that they can help people navigate them and, and translate across. I know that they exist in the U. K. Are some American programs working with, with that level of commitment?

[00:44:59] JS: They are, the link worker is one of the kind of primary features of social prescribing, generally speaking, and one way I just want to note in which that position is really an essential in actualizing social prescribing as a co production. It's really important that there's someone… and, sometimes care providers don't have this kind of time, practically speaking, …but that someone can sit with the patient and talk about what's important to you. You know, what's well, what's good in your life, what's important to you? what are your goals? What are your interests?

And so that process of listening and dialoguing and, deciding together what kinds of activities would be supportive. And then as you say, Bill, yes, the link worker would be someone who knows the local landscape of resources, knows the community and, can say, there's a dance studio over here, or there's this amazing woman [00:46:00] who does quilting in her home, and she loves to invite people in. So whether they're formal or very informal, local, resources, that person can help make the connection. That person also serves as a link to the health system and can, not only receive the referrals and then facilitate the referral, but in many instances can report back to the health system about, our folks taking up these prescriptions. What are the barriers? What needs to change to make this more possible? What kinds of new partnerships do we need to make to broaden, the arena of resources that can be prescribed all of those sorts of things.

And then in the US, we see a big variety, around that role, in some programs, there are link workers called link workers. but we also see this beautiful trend toward community health workers playing this role. There's more and more community health workers in this country …this is a role that can be played by social workers or patient navigators. care coordinators. There's a list of about, almost 20 different titles that can be used for this sort of link linking role.

[00:47:14] BC: Two other examples. in Quebec, there is a profession called the Mediateur Culturel, the cultural mediator, that is often a civil servant working to advance Quebec’s cross-community, cross-sector approach to art-based community development. A person who’s job is to link cultural resources to pretty much everything else in the community.

In France there's a similar role called the Culturel Animateur which has a similar role. These are both places with a whole community orientation where connecting and integrating parts of society is a priority. Which is clearly your orientation.

Part Five: What's Next

So one of the byproducts of doing something like this that is useful in a thoughtful and rigorous way is that you're probably going to generate more demand, more demand for information, for more advice, for unique solutions to unique challenges. Given that, uh, since you're both connected to institutions that have supported this research, and this field manual, what's next? Is there an agenda for, uh, meeting the demand and for pushing and advancing this further?

[00:48:23] TC: Jill, I'll let you start there.

[00:48:26] JS: Okay. the answer to that question is yes. we do have, an agenda, a research agenda set out in relation to. Arts prescribing and social prescribing, in our EPI Arts Lab, which is a National Endowment for the Arts Research Lab at the University of Florida, in which we partner with Dr. Daisy Fancourt, and her amazing team at University College London. We're doing implementation science studies of about 20 pilots in the United States. We've completed case studies on 15, and we've got 4 more in process right now. So we are very committed to carrying out those implementation science studies over the next 12 to 18 months.

We're also, doing a lot of work to elevate the potential for really high level research. we're building resources that we hope can advance the quality of research in the United States on social prescribing as quickly as possible, because we recognize there's a lot of interest. And we really want to make sure that we can get high level research in place quickly, so that programs that develop can be evidence based, and so that investment as well, can be grounded in evidence and guided by evidence.

So we're developing a set of key common outcomes for social prescribing in the United States. So that's a recommendation of outcomes that should be studied, among others. So not saying just these outcomes should be studied, but if you're going to study stuff, please consider studying these outcomes.

And that will allow for evidence synthesis, systematic reviews, and meta analyses. And those are the kinds of evidence reports that tend to influence policy and investment. So we want researchers across the nation to be able to do those kinds of studies. studies as quickly as possible. We're also engaged in, Tasha is one of the principal investigators, in a national project that we're developing, that we're undertaking to develop five core outcomes sets for engagement of the arts in, studies of racism, collective trauma, social isolation, mental health, and chronic disease. So we're hoping that core outcome sets for engagement of the arts to address those issues can also help elevate the research base.

[00:50:51] TC: And I'll just jump on that to say, there's so much exciting research to follow and for any of our fellow nerds out there who want to, dig deep into this, there's plenty to dig into. And then, at the practical level, this field guide is really at the center of the work that we want to see implemented on the ground, helping to translate what we already know into new programs. Organizations that are seeking, what is the, how to, how can I do this? We hope that this resource can be useful to you. And, there are also other things that you can do to prepare for these kinds of partnerships.

Like the field guide mentions, there are trainings that you can take in diversity and equity inclusion. There's trainings in trauma informed practice that's really close to my heart, given my background with mental health, I do trainings for arts organizations and artists in mental health and trauma informed practice. But there are things that you can be doing really practically on the ground, including also learning about how to partner, learning about how to make your work legible to other people so that when you pitch a partnership or when you begin one that you're not, it's not falling apart as soon as the first thing goes wrong, right?

There are ways to, at a really practical level, prepare you to do that. And what, something that is really important to, to us and our work together and also [00:52:00] to my other work at the International Arts and Mind Lab at Johns Hopkins is, how do we make sure that people have tools at their disposal so that they can move this forward on the ground.

And for all of you out there who are listening, who are doing this work in your communities, when you do this, you learn from us in order to do this, but then we learn from you as you do it, and it becomes this really beautiful, virtuous cycle as we move forward. So please dive in wherever you can, whatever resources are available.

You can make something happen, even at a very grassroots level. And then let us know what you're doing and how we can help, because we want to both learn from you and support you how we can.

[00:52:34] BC: So if they want to let you know. Where do they let you know? How do they connect?

[00:52:40] TC: Oh, great question. There are so many ways. I think the Field Guide has lots of links for how to reach us. You're welcome to reach me at TashaGolden.com, that's just me personally or through the International Arts and Mind Lab website at Johns Hopkins. Or of course the University of Florida Center for Arts and Medicine has many ways to reach out and I'm sure that Jill has other ideas for getting in touch.

[00:53:05] JS: Oh, on all the socials. we do post research as it's released there and have a monthly newsletter as well. So that's a great way to stay connected to our work as well.

[00:53:15] BC: So do you see, a network in the making that will have, more formal, structure and communication capacities and, learning capacities?

[00:53:26] JS: I would say though, we don't have any concrete plans right now to create a formal network for social prescribing. I think there are folks organizing in the United States. Dan Morse, who leads Social Prescribing USA is a phenomenal resource. People can sign up for a newsletter on the Social Prescribing USA website and reach out to Dan.

And, again, the Federal Reserve Bank, Other universities are engaging in social prescribing. There are a couple of National Endowment for the Arts research labs working on social prescribing, so, the National Endowment for the Arts can also be a good resource. Americans for the Arts is one of our partners now, and is another great resource. So yeah, there's just a lot happening in this space.

[00:54:12] TC: I can just add that if you are interested in the intersection of arts and health broadly, the NeuroArts Blueprint, which is a partnership between the International Arts and Mind lab at Johns Hopkins and the Aspen Institute. They have combined to create a blueprint that's also a free document that also developing networks and resource hubs that you can join eventually and connect with other people and projects that are doing work at these intersections. So, if you are interested in that, you can, go to neuroartsblueprint.org

[00:54:40] BC: So just one final thing to throw in here, it's my soapbox. And it's that, having been involved in what was once called the community arts movement, back in the, 80s and 90s and aughts, it, it has always been both ironic, and wonderful to me to understand that in fact, all of this reconnecting is a re, it's not new. And at every turn, every, indigenous community that I engage with, around these kinds of ideas, that are taking hold in, in westernized, structures and policies and ideas and research. usually the response is what took you so long, to realize that all these things are connected and how important they are.

And this is the same wisdom that we're going to need to heal the earth. This is just another example, another layer of coming back into things that humans have known for a long time, but, in the structures and the systems that we've created. And in some cases, like the criminal justice system, it's, it's a devolution rather than a revolution. it's taking things apart so that some of these new sprouts can have air and sunlight to breathe, I think.

So I just want to say, you are heroines to me. You're doing what great artists do, which is you're learning how to fly, while you're designing the wings. And you're trying to share the knowledge and the wisdom of what you're learning as you do it.

Actually I, I would ask each of you to, in addition to, the wonderful thing that, that you've just published. Are there other, resources, that you would recommend to people who are wanting to, dig a little deeper. After they've poured through the field guide five times, what else should they see?

[00:56:42] JS: I would mention, Bill, that the World Health Organization published a social prescribing toolkit. And that is a really lovely resource. and I would also, just note that in November of 2024, we'll be hosting our third Creating Healthy Communities convening at the New Jersey Performing Arts Center. I'm not sure that we've landed on an exact date yet. But again, that information will be on our website and that is a two day dialogue, which will have a lot of content and opportunity to engage around arts prescribing and social prescribing.

[00:57:21] BC: Great.

[00:57:22] TC: And the field guide itself, once you get it, has an absurd number of appendices and so many things to go exploring, so many rabbit holes to go down. There's a list of publications on my website that are all related to, arts and health.

And because I do care so much about people's mental health and your capacity to rest, I would just like to plug a book called, Rest is Resistance by Tricia Hersey and the Knapp Ministry. And an accompanying book called, by Dr. Devin Price called Laziness Does Not Exist. And I've been recommending these to others who are in this transformative work your rest matters as well. And your mental health and wellbeing is what will make you able to sustain this work over the longterm. So take care of you.

[00:58:03] BC: Yeah. And, thank you for the prescriptions. I'm sure our listeners will take them to heart.

Thanks, Bill.

[00:58:08] JS: Thank you

[00:58:09] BC: Alright, bye bye. And so long and thank you to our listeners for tuning in. And please be aware that links to resources mentioned in this episode are available in our show notes. And as always, you can refer to the transcript for this episode for a double dose of our conversation. Also, if you have some comments, questions, or ideas about how we can expand the ART IS CHANGE community, or people you think we should be talking to, please drop us a line at csac@Artandcommunity.com art and community is all one word and all spelled out.

ART IS CHANGE is a production of the Center for the Study of Art and Community. Our theme and soundscape spring forth from the head, heart, and hands of the maestro, Judy Munsen. Our text editing is by Andre Nebbe.Our effects come from freesound.org. Our inspiration rises up from the ever present spirit of UKE235. So, until next time, stay well, do good, and spread the good word. And rest assured, this episode has been 100 percent human.