Using the Canadian context as a case study, the research reported here focuses on in-depth qualitative interviews with 36 researchers, artists and trainees engaged in ‘doing’ arts-based health research (ABHR). We begin to address the gap in ABHR knowledge by engaging in a critical inquiry regarding the issues, challenges and benefits of ABHR methodologies. Specifically, this paper focuses on the tensions experienced regarding academic legitimacy and the use of the arts in producing and disseminating research. Four central areas of tension associated with academic legitimacy are described: balancing structure versus openness and flexibility; academic obligations of truth and accuracy; resisting typical notions of what counts in academia; and expectations vis-à-vis measuring the impact of ABHR. We argue for the need to reconsider what counts as knowledge and to reconceptualize notions of evaluation and rigor in order to effectively support the effective production and dissemination of ABHR.