Social prescribing: why purpose is good for your health
GettyIn a bid to improve health and wellbeing, social prescriptions can cover everything from volunteering and art classes to support with household bills. But do they really work?
Akeela Shaikh is a natural carer. After becoming a mother at 19, she realised she loved caring for people and decided to pursue it professionally – first at a home care agency, then in a residential care home. "I just knew, that's me: caring," she says.
But the care jobs she loved so much started to tax her physically. They came with literal heavy lifting: moving patients, pushing beds, being on foot 24/7 to tend to patients' every need. Gradually, the caring took a toll on her back and she realised it wasn't going away; she had developed chronic pain.
Her doctor urged her to rest, and eventually the pain got so bad Shaikh agreed. But instead of making her feel better, Shaikh found resting only made her feel worse, and she found she could no longer get out of bed. "It was a nightmare, and I became a nightmare," she says.
Shaikh couldn't imagine her life without work and became distraught at becoming the one who needed the care. When her husband and kids called doctors and therapists to try to help her, she became even angrier.
When both her mother and mother-in-law then became ill at the same time and she couldn't take care of them, she sank to the lowest she'd ever felt, she says, and began to have suicidal thoughts. "I just kept thinking, 'There's nothing left. I can't do anything anymore, and I don't want everyone to do everything for me. I don't belong here anymore. It's just too much'."
But as she watched her mum suffer, she had a lightbulb moment: "My mum worked so hard for everyone else, but she never listened to her own needs until she became very, very ill. And I just thought, 'Wow, I'm doing what my mum did, and it's not fair to my kids or to my husband'."
The thought prompted Shaikh to finally get help. She tried antidepressants, then counselling although neither worked for her. But then a nurse gave Shaikh a different kind of medicine: "She gave me a card that read 'social prescribing'." The card led to a phone call with Joanne Gavin, at the time a link worker with Bolton Community and Voluntary Services in Greater Manchester in the UK.
Instead of asking "what's the matter with you", link workers ask patients "what matters to you" and find suitable community activities that fit their answer.
Whereas some chronic pain patients might benefit from medication and therapy, others might find that activities in nature or the arts help with their pain. But it was clear what mattered to Shaikh was really another chance to take care of someone.
Gavin intuited this. And when she asked Shaikh what she thought might help her feel better, she honoured her answer: "a job".
Getty ImagesIn 2018, the local healthcare system in Bolton, England, had asked Gavin to help run a pilot programme for this ambitious idea of "prescribing" volunteer work. Her job would be to listen to patients and refer them to spots in charities based on what mattered to them.
At the time, Gavin had never heard of social prescribing, which "was very, very new", she says. But the logic clicked immediately.
"My approach is to listen to someone's story and look at not just what's going on now but what they were like before they started to feel depressed or anxious," says Gavin. "You're still that person you were before you felt ill. It's just a question of how you get back there."
The power of social prescribing – helping patients to improve their health and wellbeing by connecting them to community resources and activities – is increasingly backed by scientific studies. Prescriptions can cover everything from art classes and cycling groups to food and heating bills.
Perhaps counterintuitively, prescribing "service" is proving to be one particularly effective form. Early studies have shown that those in nursing homes who are given choices and responsibilities to serve their surrounding environment (such as taking care of a houseplant) can thrive more than those who are simply there to be taken care of, not to do the caring.
"Helping feels good to the helper, but over time it may make the helped feel incompetent," writes American psychologist Ellen Langer, who led the house plant study, in her bestselling 2009 book Counterclockwise.
Other studies have found taking care of animals can improve our health, with studies suggesting it can help by giving people a daily routine, a sense of purpose, positive distraction, companionship, and emotional support. Another recent study, meanwhile, found that gardening is associated with improved cognitive skills, and can even help stave off dementia.
But beyond taking care of plants and animals, "service" prescriptions also entail taking care of each other through volunteering. Among a raft of benefits, volunteering has been shown to improve quality of life, lead to better health outcomes and reduce symptoms of depression and stress.
One particularly surprising 2019 study of nearly 7,000 older Americans found that life purpose was significantly inversely linked with all-cause mortality. In other words, having a high sense of life-purpose could help you live longer than those who lack one.
For Stephen Post, professor of preventative medicine at the Stony Brook University and co-author of the 2008 book Why Good Things Happen to Good People, these results make perfect sense. "When you volunteer, you get away from the problems of the self, and experience so many internal benefits – you're happier, more tranquil, more resilient," he says.
Several studies back up this idea. In a 2017 study, people who volunteered less had more pain and depressive symptoms, and volunteer activities appeared to have a mediating effect on the relationship between pain and depression. Another study from 2002 found peer volunteers assigned to help others struggling with chronic pain saw their pain intensity scores drop while they were volunteering. But despite the mountain of evidence, says Post, "people can't quite believe that what you really need to do is prescribe some sort of meaningful volunteer activity".
That's especially true for chronic pain, a condition affecting an estimated one in four in the UK and one in five in the US. In modern times, painkillers are often seen as the answer to pain, but both opioids and NSAIDS show a mixed bag around evidence and safety for long-term use. Which begs the question: what else works to treat pain, especially when that pain is chronic?
Getty ImagesThe answer may lie in demystifying what chronic pain actually is. We tend to think of it as a purely physical phenomenon (pain is painful). But in the early 1990s, during an epidemic of chronic pain in America, a doctor named John Sarno famously challenged this idea, suggesting chronic pain may also be a product of psychological factors. In his groundbreaking 1991 book Healing Back Pain, Sarno describes, among many other theories, one called "weekend-vacation syndrome" – a framework which paradoxically suggests that pain is more painful when we're away from work and "resting".
"As long as [people] are on the job, they may be 'burning up' the anxiety, but when they're away from it, supposedly relaxing, the anxiety accumulates," he writes.
That appeared to be the case for Shaikh: when doctors told her to relax and stop working, that's precisely when her back pain – and her psychological pain – got worse.
Pain psychologist Rachel Zoffness has been building on these theories. She argues in The Pain Management Workbook, published in 2020, that pain is always a combination of biopsychosocial factors, which is why pain feels worse when we experience negative emotions, like sadness and anger, or when we're focused on our pain and missing out on our lives.
To help, Zoffness suggests, we should visualise pain as a dial: just as there are things that turn our pain volume up, there are things we can do to turn our pain volume down. To help her own patients discover those things, she sometimes asks them, "Will you tell me about a time you were so absorbed in an activity that you briefly forgot about your pain?"
That's precisely what Gavin did for Shaikh.
As Gavin listened to where Shaikh wanted to be, she picked up on the support Shaikh needed to get there. "A lot of her pain seemed to do with the fact that she wasn't working and she felt like her motivation was gone," Gavin explains. So when Shaikh said point-blank that she wanted a job, Gavin suggested one. It was a volunteer job, but Shaikh didn't care. For her, it wasn't about making money; it was about feeling a sense of purpose again.
Gavin prescribed the perfect gig for Shaikh: a shift at the office of Lagan's Foundation, a non-profit providing caregiving to children with complex needs. "It was a way for Akeela to still be involved with the care inside, without the heavy lifting."
After a few months of volunteering, Shaikh was offered an apprenticeship at Lagan's Foundation, and later a job there, too.
Julia HotzA far stretch from bedridden, Shaikh practically sprints through Lagan's doors to give me a tour of her building, showing me the infant medical dummies that mimic her clientele. She tells me the story of the charity's namesake – a baby named Lagan who died three months after birth from an array of heart complications, and whose mother "created this charity as a way to help every child and parent like her".
Through phone calls and email logging, she makes sure families of children with complex needs get everything they need, from breastmilk and bereavement support to access to specially trained carers. "We can ask questions that parents of the kids don't have time to ask themselves," she says.
Shaikh feels Gavin, the health worker who first asked her a question no other health worker had time to ask and honoured her unconventional answer, deserves much of the credit for her recovery. "If it wasn't for Joanne, I don't think I'd be here," Shaikh says.
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After Gavin intervened, Shaikh says she started feeling more like herself. At home, she is back to being the one who gives care. After her volunteer prescription, she reconnected with her family and friends. And although she still struggles with occasional back pain, she says she's accepted it as "a part of her life", not the ruler of it.
Of course, volunteer prescriptions are not the answer for everyone dealing with chronic pain, depression or other difficult health issues. But for Shaikh, it was more medicinal than antidepressants, painkillers or simply resting. She hopes her social prescribing story can help others, especially if they, too, are in deep pain and don't see a way out.
"People will think they can't do anything anymore, but I want them to know, 'Yes, you can get better'. Take it from me: a person who wanted to kill herself is now living a normal life like everybody else."
* This article is based on an extract from Julia Hotz's book, The Connection Cure, published 11 June 2024 in the US and the UK.
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If you are suffering distress or despair and need support, you could speak to a health professional, or an organisation that offers support. Details of help available in many countries can be found at Befrienders Worldwide. www.befrienders.org
In the UK a list of organisations that can help is available at bbc.co.uk/actionline
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