Employing the Restorative Capacity of Nature: Pathways to Practicing Ecotherapy Among Mental Health Professionals

"It Was Definitely an Eye-Opener to Me"-People with Disabilities' and Health Professionals' Perceptions on Combining Traditional Indoor Rehabilitation Practice with an Urban Green Rehabilitation Context

Research points to the health benefits of rehabilitation in urban green spaces. Nevertheless, more studies indicate complexity of utilising urban green spaces in an established health system context. An understanding of challenges related to rehabilitation in urban green spaces remains unaddressed. Therefore, the aim was to describe and analyse people with disabilities' and health professionals' perceptions on combining traditional indoor rehabilitation practice with an urban green rehabilitation context. The interpretive description methodology was applied supplemented by Edgar Schein's Model of Organisational Culture. Three online focus group interviews were conducted with people with disabilities (n = 4) and health professionals (n = 10). Three interrelated themes formed an understanding of rehabilitation practice in an urban green rehabilitation context: "ambivalence due to contextual change", "negotiating rehabilitation assumptions" and "expanding the frame of rehabilitation". Expanding the frame of rehabilitation to an urban green context may provide a basis for enhancing compatibility to everyday life for people with disabilities and still accommodate structural quality standards of professional rehabilitation practice.

Experiences of outdoor nature-based therapeutic recreation programs for persons with a mental illness: a qualitative systematic review

OBJECTIVE

The objective of this review was to identify, appraise, and synthesize the best available evidence related to participation in outdoor nature-based therapeutic recreation programs for adults with a mental illness living in the community.

INTRODUCTION

Therapeutic recreation is posited to be beneficial for persons living with a mental illness. Research evidence indicates that therapeutic recreation programs can foster mental health recovery. It is important to understand the effectiveness of this from the perspective of persons living with mental illness how outdoor nature-based therapeutic recreation programs are meaningful and helpful for recovery.

INCLUSION CRITERIA

This review considered studies that collected qualitative data on the experiences and perspectives of adults with a mental illness regarding their participation in outdoor nature-based therapeutic recreation programs.

METHODS

The databases PsycINFO, CINAHL, MEDLINE, Scopus, and Informit, as well as unpublished sources in gray literature (Google Scholar, OpenGrey), were searched and reference lists were checked to locate any additional studies. Studies published in English were considered, with a date range from inception to 2019. Three reviewers independently assessed the methodological quality of the studies that met the inclusion criteria using the JBI critical appraisal approach for qualitative research. Data were extracted by one reviewer using the standardized qualitative extraction tool and checked for accuracy by three other reviewers. The qualitative research findings were pooled using JBI methodology. The JBI process of meta-aggregation was used to identify categories and synthesized findings, and a level of confidence was assigned to both synthesized findings.

RESULTS

Eighteen papers met the inclusion criteria and were included in the data extraction phase. A total of 84 findings were extracted and aggregated into six categories based on similarity of meaning and two synthesized findings. The methodological quality of the studies varied, and the overall level of confidence of the synthesized findings was determined to be moderate.

CONCLUSIONS

This review identified that persons living with mental illness perceive outdoor nature-based therapeutic recreation as enjoyable and that therapeutic recreation makes a positive contribution to mental health. Congruent with the literature, therapeutic recreation offers a socially inclusive and psychologically safe environment. The intentionally structured social milieu enhances the formation of social relationships and meaningful connections for persons with mental illness. Elements linked with psychological well-being, such as intrinsic motivation, overcoming perceived challenges, and finding purpose and meaning, are enhanced through participation in therapeutic recreation in outdoor nature-based settings. Increased levels of physical activity, greater self-esteem, and enhanced sense of identity were some of the perceived positive changes. This review provides important insights into the subjective needs of persons with mental illness who undertake therapeutic recreation in outdoor nature-based settings. The qualitative findings can inform health care providers, or those interested in therapeutic recreation programming, to use alongside quantitative evidence of effectiveness to design nature-based therapeutic recreation activities that are meaningful for persons with mental illness. Limitations of the research were that papers published in languages other than English were not searched, and papers not located may have influenced the findings of this review.

Evaluating the Relationship between Park Features and Ecotherapeutic Environment: A Comparative Study of Two Parks in Istanbul, Beylikdüzü

The impacts of problems related to dense, unplanned, and irregular urbanization on the natural environment, urban areas, and humankind have been discussed in many disciplines for decades. Because of the circular relationship between humans and their environment, human health and psychology have become both agents and patients in interactions with nature. The field of ecopsychology investigates within this reciprocal context the relationship between human psychology and ecological issues and the roles of human psychology and society in environmental problems based on deteriorated nature–human relationships in urbanized areas. This approach has given rise to ecotherapy, which takes a systemic approach to repairing this disturbed nature–human relationship. This study aims to uncover the relationship between the physical attributes of urban green areas and their potential for providing ecotherapy service to users, first by determining the characteristics of ecotherapeutic urban space and urban green areas given in studies in the ecopsychology and ecotherapy literature, and then by conducting a case study in two urban parks from the Beylikdüzü District of the Istanbul Metropolitan Area. The impacts of these parks’ changing physical characteristics on user experiences are determined through a comparison of their physical attributes and the user experiences related to their ecotherapy services.

Navigating a Middle Ground - Exploring Health Professionals' Experiences and Perceptions of Providing Rehabilitation in Outdoor Community Settings

Contemporary practice has started to rethink use of outdoor and community environments for advancing comprehensive rehabilitation outcomes. The aim is to examine health professionals' experiences and perceptions of providing rehabilitation in outdoor community settings. The purpose is to use these experiences to generate practice-based knowledge in using the outdoors as a means to guide community-based rehabilitation. The Interpretive Description methodology was accompanied by social practice theory. Fieldwork was conducted utilizing participant observation, photovoice, and focus-group interviews. Included were 27 health professionals. The analysis revealed how "naturalistic learning opportunities" offered health professionals strategies to empower activity and participation levels and yet invoked "rehabilitation setting tensions." A continuum was engaged in the theme "navigating a middle ground," representing an integrated environment approach; rehabilitation in conventional indoor and outdoor community settings. Development of a sustainable concept for outdoor community-based rehabilitation involves strengthening health professionals' competencies and skills for providing outdoor and community work.

"Recovering With Nature": A Review of Ecotherapy and Implications for the COVID-19 Pandemic

Connection with nature has been considered beneficial for psychological well-being since times of evolution. Differences in Indian and Western thoughts have viewed natural elements in different lights, varying between eco-centrism to anthropocentrism. The intrusion of technology and digitalized lives as a result of globalization has decreased connectedness with nature. Ecotherapy is a novel form of psychotherapeutic technique based on explicit environmental or ecological interventions. Social and therapeutic horticulture, animal-assisted interventions, care farming, green exercise, environmental conservation and wilderness therapy are some of the ecosystem-based approaches used in mental health. Based on the principles of positive and client-centered psychology, ecotherapy-related techniques have been shown to be effective in medical disorders like hypertension, obesity, post-surgical recovery and psychosocial conditions like depression, stress reduction, post-traumatic stress disorder (PTSD), attention deficit hyperkinetic disorder (ADHD) and adjustment disorders. The principles of ecotherapy have been integrated into other psychotherapeutic techniques for better efficacy. This review attempts provides an overview of techniques, applications and challenges related to ecotherapy in psychology. The implications of its use during the ongoing Coronavirus 2019 (COVID-19) crisis, social isolation and consequent psychosocial aftermath are also discussed.

Therapeutic landscapes, outdoor programs for veterans, and public lands

In recent decades, scholars have developed ideas about therapeutic landscapes that explore how social processes, symbolism, and physical features generate diverse meanings. We examine here how therapeutic landscapes are produced and utilized for outdoor programs for military veterans, particularly veterans experiencing post-traumatic stress. Outdoor programs for veterans (OPVs) provide restorative opportunities through nature immersion and outdoor recreation. OPVs involve diverse social settings, activity types, durations, geographic and land management contexts, and degrees of therapeutic intervention. In many combinations they can generate therapeutic landscapes conducive to some degree of recovery. Our analysis relies on qualitative data gathered through semi-structured interviews with OPV providers and participants, mental health specialists, and public land officials. Arguing against a reductionistic approach, we suggest that the diversity of OPVs and disparate character of activities, locations, and dosages may contribute in important ways to the efficacy of these programs. Ironically, the very qualities that present challenges for measuring and evaluating the benefits of OPVs may prove to be advantageous with respect to therapeutic outcomes. We highlight how public lands present a distinctive set of attributes that make them particularly well-suited to provide therapeutic opportunities, and that agency policies can shape the development of therapeutic landscapes.

Conceptualizing the Human Health Outcomes of Acting in Natural Environments: An Ecological Perspective

Human-nature interactions have been presented as important for promoting and sustaining wellbeing and health benefits. Research has shown that pictures of nature, interacting with nature, physical activity in nature, immersion in nature and even feeling connected to nature can improve health. While considerable research supports this notion that nature can have positive health impact, theoretical and conceptual frameworks that help explain how the natural environment provides benefits to human health and wellbeing have proved limited. In extreme cases, theoretical approaches reinforce a problematic notion where nature is viewed as a separate entity, as a treatment to be taken as prescribed to remediate health problems that arise. Such approaches are limited as they fail to address how beneficial person-nature relations may be captured in interventions. There is a need for a deeper understanding of the processes underlying the observed benefits of the person-nature link in order to design effective research and interventions. It is especially important to consider the implications of research on person-nature relations for people living in urban contexts. In this paper, we present an ecological perspective building on James Gibson's conceptualization of human behavior. Specifically, we outline a framework that emphasizes the person-environment system as the most appropriate scale of analysis. We present three relevant concepts from the ecological approach: form of life, affordances and niche construction, as helpful for appreciating how acting in natural environments might benefit human health and wellbeing. This approach urges policy makers and urban designers to rethink environmental designs to provide and support a landscape of affordances that makes use of the richness of natural environments.

'Into the Wild': A meta-synthesis of talking therapy in natural outdoor spaces

Time spent in natural outdoor spaces has physiological and psychological benefits, such as reduced stress responses and improved mood. Mental health practitioners have begun to harness nature's restorative capacity by challenging convention and taking talking therapies outdoors. This review synthesises the experiences of these practitioners and their clients, with the aim of establishing a framework for best practice. A thematic synthesis was used to provide a systematic and integrative exploration of multiple therapy professions. Articles (N = 38, published from 1994 to 2019) comprised 322 practitioners and 163 clients. A mixed-method meta-synthesis resulted in a framework of higher and lower level themes. The outdoor context for therapy ranged in intensity from sitting or walking in urban parks and woodland to remote wilderness expeditions. The outdoors provided either a passive backdrop to therapy or was more actively incorporated through behavioural analysis, relationship building, metaphor, narrative therapy, role play, modelling, and stabilisation. Practical, therapeutic, and organisational issues were mitigated through assessment and formulation, informed consent, process contracting, enhancing predictability where possible, and awareness of professional competency. Therapy was subsequently enriched by added mutuality, freedom of expression, mind-body holism, interconnectedness with the natural world, and practitioner well-being. The question of whether therapy in natural spaces should become a more mainstream option for clients and practitioners is discussed.

Reconsidering McKenzie's Six Adventure Education Programming Elements Using an Ecological Dynamics Lens and Its Implications for Health and Wellbeing

Two decades ago, McKenzie's meta-analysis of literature provided six fundamental elements of adventure education programme design still used to guide research and practice today. While the value of McKenzie's early work should not be underestimated, adventure education has undergone considerable changes. Adventurous activities are now available in urban and indoor contexts and used to facilitate a growing health and wellbeing agenda. The use of risk as part of adventure education programming has also been critiqued. This paper reflects on contemporary notions of adventure, risk and the emergent narratives emphasising the associated psychological benefits. The Ecological Dynamics framework, along with representative design delivery, are presented as a viable way of building on McKenzie's work. Both consider how effective outcomes in adventure education programmes are achieved through designs that focus on the unique relationship between the individual and their environment. While McKenzie's six elements recognise the importance of human relationships, Ecological Dynamics forefronts relational elements, not just between participants but, importantly, the task and the environment. Individual participant needs in relation to their everyday life therefore become the focus of adventure education expanding beyond the traditional long-standing narratives of risk and danger. Through these two important concepts, this paper advocates an approach to the design of adventure representative of a participant's everyday environment. In this way, adventure education outcomes translate beyond the adventure-specific context and align more holistically with the needs of individual participants while also assuring emphasis on individual health and wellbeing.