This article presents an analysis of how, in focus groups, people on sick-leave due to common mental disorders (CMDs) and/or musculoskeletal pain narrate and discuss their experiences of participating in Arts on Referral (AoR).

CMDs and musculoskeletal pain are challenging public health problems (Hallman et al., 2019; OECD/European Union, 2018) which often occur concurrently (Dekkers-Sanchez et al., 2008; Outcalt et al., 2015). This public health challenge requires not only conventional care but also complementary efforts from other disciplines (Marmot et al., 2012; World Health Organization, 2009). Since the beginning of the twenty-first century, there has been an increased use of arts in health care as an example of complementary methods, and several studies have been undertaken showing that arts activities have a positive impact on people’s wellbeing, regardless of age and context (Fancourt & Finn, 2019; Lamont et al., 2018; Murray & Crummett, 2010; Van Lith et al., 2013; Williams et al., 2018). For instance, attending arts activities can help ease pain (Murillo-Garcia et al., 2018), reduce stress and anxiety, and can play a substantial role in mental health recovery, particularly in areas of self-discovery and self-expression (Leckey, 2011; Makin & Gask, 2012; Van Lith et al., 2013). The promotion of social effects, such as enhancing feelings of belonging and reducing isolation, are highlighted in several studies (Lamont et al., 2018). Arts activities have shown to contribute to enhancement of resilience and wellbeing (Reed et al., 2020). Furthermore, research has shown an increased sense of personal achievement and a process from being self-critical to being more self-caring (Jensen, 2019) for people with CMD. Their findings showed that participants’ feelings of being re-engaged with life seemed to be mediated by the therapeutic effects of absorption in the arts activities and the creative potential in arts, but also by the social aspects of participating in arts with others. In a scoping review by World Health Organization (WHO), Fancourt and Finn (2019) argue that arts activities can be considered as multimodal interventions while they combine several components that promote health.

Previous studies have provided some understanding of individuals’ experience of arts activities in various settings. Group-based evaluations have been conducted in studies on older people’s participation in arts activities (Lamont et al., 2018; Murray & Crummett, 2010). However, to the authors’ knowledge there are few studies on how people experience participation in AoR using group-based methodology for this target group. Since belonging seems to be one crucial health-promoting aspect of AoR, studies that make use of interaction also when evaluating AoR appear to be valuable. Our study thus uses focus groups to analyse how former participants in AoR collectively remember taking part in AoR.

Previous research suggests that both arts activities as such and those organized as group-based activities help people with CMDs in their recovery (Fancourt & Finn, 2019; Jensen, 2019; Makin & Gask, 2012). Following these findings, we suggest that both the social interaction within the AoR group and the individual relation to arts activities while performing arts activities seem to be crucial in getting a better understanding of this kind of health-promoting intervention. Therefore, to further elaborate our findings, these will be discussed in light of Wenger’s concept of community of practice (Wenger, 1999), and the concept of flow developed by Csikszentmihalyi (1990).

Four categories were identified from the discussions in the focus groups: 1. Place of belonging; 2. Respite from demands; 3. Challenge and reward; and 4. Health-promoting changes. The interactional processes within the focus groups showed different ways of storytelling: self-contained personal stories and co-narrated collectivized stories (Bülow, 2004).

The self-contained personal stories were often told in relation to a question asked by the moderator. In order to be counted as a co-narrated collectivized story, it had to be told collaboratively where at least two people contributed with more than backchannelling comments like ‘mm’, ‘oh yeah’ (White, 1997). By sharing experiences through co-narration, a jointly produced story appears. In the following text, examples of both self-contained personal stories and co-narrated collectivized stories are provided. Excerpts from all focus groups are presented in the findings to confirm the interpretations and strengthen credibility.

AoR seemed to offer a context that enabled self-reflection, which together with balanced challenges contributed to a new mindset, changed behaviour, and increased faith in the future. In the analysis, two dynamic processes were identified: one within the individual and the other between individuals. Individuals’ inner experiences in connection with the arts activities, understood through the concept of flow (Csikszentmihalyi, 1990), seem to interact with the social and common exchange within the group, understood by the concept of community of practice (Wenger, 1999). Both processes were stimulated through attending arts activities in a safe environment, and together they seemed to contribute to the members’ goals of promoting health and personal development.

The category Place of belonging lays the foundation for participation in AoR. Based on Wenger’s line of thinking, the AoR context becomes a community of practice with members who share common experiences and reality (Wenger, 1999). The AoR community of practice is free from demands; instead it entails understanding, which encourages togetherness, all while engaging in the arts activities offered. The participants felt they were “in the same boat”, having similar experiences both in terms of their disease symptoms and the experience of how these were questioned by society’s judgmental and critical eyes. The importance of the social relationship in the group was emphasized in this study, as in many others (Lamont et al., 2018; Makin & Gask, 2012; Murray & Crummett, 2010). The permissive context in AoR, illustrated in the category Place of belonging, was linked to the participants’ challenging doings in AoR, exemplified in the category Challenge and reward, in that the non-demanding environment was a prerequisite for the participants to dare to challenge and expose themselves in the arts activities in which they felt they were allowed to fail. The four identified categories together form a pattern of processes that influence each other within the AoR intervention. Identified categories and how they relate to each other are illustrated in Figure 1.

Participants’ personal processes were stimulated both by their experiences of flow and by the social exchange within the group. Together, these processes seemed to contribute to health-promoting changes in the participants. Our findings concerning participation in a community of practice (Wenger, 1999) implies opportunity for personal development, while findings related to flow experiences (Csikszentmihalyi, 1990) imply the promotion of wellbeing and development. Further, the permissive environment in AoR enabled a self-reflection process within the participants. This inner process was stimulated by feelings of succeeding in the challenges offered by the arts activities, illustrated in the category Challenge and reward. Since AoR was about participating in arts activities not chosen by themselves, some were outside their comfort zone and challenged their skills and beliefs about what they could do. However, the arts activities offered in AoR seemed to have presented a balance between challenge and the participants’ perceived ability. This kind of balance is the core element of flow and is argued to promote development (Csikszentmihalyi, 1990). The fact that they succeeded in the balanced challenges confronted the participants’ previous beliefs about what they could achieve, which seemed to contribute to personal development. The personal development demonstrated by new mindsets included self-realization, increased belief in their own abilities, as well as feelings of reduced obligations for people around them, illustrated in the category Health-promoting changes. These changes can be regarded as a development that was linked to the process of testing and expanding their boundaries as described in the category Challenge and reward. Our findings confirm those of Jensen (2019), who also identified an increased sense of achievement and a process from being self-critical to being more self-caring. Similar findings were also showed by Margrove et al. (2013) in their study. Csikszentmihalyi (1990) has also identified similar effects in people experiencing flow.

Our findings also provided examples of participants who in some sessions did not feel a balance between challenge and perceived ability. Instead, the experience was that the challenge became too great, which made them feel too tense to achieve a flow state (Csikszentmihalyi, 1990). This finding, presented in the category Challenge and reward, underlines both the importance of adjustable activities in AoR and a safe and permissive environment without requirements. These prerequisites, presented in the categories Respite from demands, and Place of belonging, seem to increase the chances of being able to experience flow. As illustrated in the category Challenge and reward, experiences of flow (Csikszentmihalyi, 1990) were identified in the analysis, similar to those found by Makin and Gask (2012). These experiences included changed perception of time and absorption and concentration during some of the arts activities, which led to rewarding experiences of the disappearance of both mental ill-health and pain symptoms. The participants seemed to have lots of fun during the AoR sessions. Even if the challenges through the arts activities provided the participants with a certain excitement, they also contributed to eased inhibitions through humour and laughter. Attending these joyful sessions improved their mental wellbeing and became something they looked forward to and longed for, which suggests that AoR included autotelic experiences. Lamont et al. (2018) showed similar findings of this flow characteristic in their study.

Reflecting on the results focusing on the concepts of community of practice (Wenger, 1999) and flow (Csikszentmihalyi, 1990) further contributes to the understanding of the health-promoting processes in AoR. AoR as a community of practice emphasizes and explains the importance of sharing activities and experiences with people in similar situations and with related goals, while flow points towards positive psychological processes and individual experiences.

The first author was involved in the AoR project on a strategic level and therefore had a pre-understanding. Although familiarity with the research field was an advantage, it could also be viewed as a disadvantage potentially affecting data collection and analysis (Hsieh & Shannon, 2005). Critical attitudes were present among all authors throughout the research process to balance any risks that might arise due to the first author’s strategic role regarding AoR. The second author conducted the focus group discussions, thus avoiding the first author affecting data. All three authors were involved in the analysis and continually discussed the different steps.

The focus group methodology provided a good basis for creating conversations between the participants related to the research questions. A weakness with focus group methodology could be that participants influence each other, and that those who have a different opinion do not dare to express it. However, none of the focus groups seemed to have problems with a certain participant dominating the conversation. On the contrary, everyone took a lively part in the discussions and there were rarely any long or short episodes of silences, indicating that the participants were expressing their personal experiences freely in the focus groups. The method provided rich content with varied statements about their experiences, and while the participants expressed different opinions, they usually filled in each other’s stories. Except for the lack of male participants, which was a limitation, variations in the sample have been achieved in terms of age, country of origin, diagnosis, and length of sick leave. Reflections from male perspectives could have provided further insights. However, the majority of the participants in the AoR project were women, and according to the Swedish Social Insurance Agency (Försäkringskassan, 2019) more women than men are on sick leave due to health problems such as CMDs in Sweden.

Findings suggest that AoR can be helpful in improving mental wellbeing and feelings of belonging. Aspects highlighted as important components for the health-promoting changes were perceived belonging, a permissive environment, and challenging but manageable arts activities.

There are still unanswered questions about AoR’s impact on health and wellbeing in the long term. Future longitudinal studies are needed to examine lasting effects for the target group in terms of mental wellbeing as well as health-promoting changes.

The authors report no conflicts of interest.