The perceived multiple benefits of ecotherapy for mental health service users
Andy McGeeney & Dr.Sophie Jeffery (2011)
Summary
Weekly sessions of nature based ecotherapy were offered to mental health service users in North-East London. A sample of nine participants were interviewed and a content analysis of their responses was analysed. This evaluation shows a positive and wide ranging set of responses to using nature as a psychological intervention.
What is Well-being in Nature and Ecotherapy?
Well-being In Nature (WIN) started in early 2010 as a two hour ecotherapy session held in Eastbrookend Country Park in Dagenham, London for mental health service users living in the locality. The sessions were initially and during the period of the research (summer 2011) part of the ecotherapy service provided by North East London Foundation Trust (NELFT).
Ecotherapy is the experience of being in nature and feeling an improvement in well-being. The particular format of the sessions had been developed by McGeeney over many years and it involves a variety of components that make it much more than a walk in the outdoors. The sessions usually begin, after a period of socialising and lunch in a café, with physical relaxation and a short mindfulness exercise. This is followed by a two hour walk around the park.
The walk is interspersed with spontaneous stops to investigate the plants and wildlife or to carry out a mind exercise. The exercises are designed to bring people into closer contact with themselves and the natural world around them. In this way the ecotherapy sessions offer a mix of activities which complement each other.
Context
There is a well established literature base for the positive effects of spending time in a natural setting in terms of improved mood and thinking capability (Peacock et al 2007, Barton et al 2011). There has been less research work done in this area specifically with people experiencing mental health problems (p6 Barton et al 2011). If the research could demonstrate real differences in recovery rates for people experiencing poor mental health then the work already being carried out therapeutically could be expanded and more widely applied. The evidence acquired so far has been generally positive (Roe & Aspinall 2011, Barton 2011).
Research on people not experiencing poor mental health, typically students, who have spent time in natural settings has identified a range of positive changes. Mood (eg depression and anger) and self esteem improve (Hartig 2003), stress levels fall when spending time in nature compared to urban settings (Barton &Pretty 2010) or being indoors (Ryan et al 2010 in Barton 2011).
Work carried out specifically with mental health service users who have spent time in a natural setting has also shown similar improvements in (Barton et al 2011) and in some cases the changes have been more marked among those with poor mental health (Roe & Aspinall).
Restoration is the process of recovery from a depleted psychological, physiological or social resource (Hartig 2007 in Roe). In the field of mental health much of the definition of such a depleted state are personally and expertly defined. In our study the subjects self defined themselves as in recovery from a poor state of mental health and in most cases they were initially referred to the ecotherapy sessions by a clinical psychologist or allied professional from the North East London Foundation NHS Trust. There were nine male participants aged between 21 to 68.
Aim of the research
The aim of the research was to gain a better understanding of what people were responding to and what they got out of the ecotherapy sessions. All participants were regular attenders some for many months. We used a mixture of quantitative and qualitative approaches to record and analyse the responses.
An earlier study by McGeeney (2010 unpublished) using POMS (Profile Of Mood States) and Rosenberg with a sample of over 70 service users had shown positive changes and statistically significant results from questionnaire data administered before and after sessions. Depressive mood was improved, levels of anxiety reduced, and self esteem enhanced as a result of sessions similar to those in this study but with a sample composed mostly of inpatients. All these results are congruent with those of other researchers in this area, see Barton et al 2011 for a summary. After these encouraging results it seemed important to gain a better understanding of what it was people were responding to and what they got out of the sessions. We wanted to add more qualitative methods of investigation.
Method
Interviews were carried out one to one and in isolation, by one of the authors very soon after a session had ended. The interview schedule (available from the authors) was based on one used by Mapes and Hine (2011). The schedule included open ended questions eliciting their experience of the group, followed by structured questions on the perceived outcomes and views of specific elements of the session. Responses were recorded in detailed notes and verbatim quotations. Ethical approval was not required for this routine service evaluation.
Non-parametric Wilcoxon T tests were used to analyse quantitative questionnaire data. The analysis of interview responses followed Braun and Clark’s () Thematic Analysis approach. Each participant’s responses were coded, noting emerging themes. Comparisons were then drawn between individual accounts, and codes clustered into overarching themes.
Qualitative Results
There were seven themes identified in the interviews: ‘Getting out of the house’, ‘Stopping thinking about problems and negative thinking patterns’, ‘Relaxing & physical effects’, ‘Ecotherapy as separate from daily life’, ‘Anticipating and remembering sessions’, ‘Appreciating being in a natural environment’, ‘Safe, trusted and valued social group’. Walking was also often mentioned as an important aspect. This was rarely elaborated on, but may have been used as a shorthand for the whole session.
Getting out of the house
(mentioned by 7 participants)
Getting out of the house was a significant motivator reported for attending the group. This related to the benefits of leaving the home environment to make social contact
“It gets me out of home; I live alone in a big 3 bed house now so it’s good to get out and see people.” (AL)
To get a break from people in the home environment:
“Being with group helps get me out of the house and takes me away from thinking about the problems at my flat with the neighbours and family troubles.” (MM)
As well as escaping the closed in physical environment of home.
“The open air, not shut in by four walls.” (RW)
Stopping thinking about problems and negative thinking patterns
(mentioned by 6 participants)
The participants discussed the impact of Ecotherapy activities in blocking and reducing negative thoughts. At a minimum the natural environment acted as a distraction supporting the ART model of Kaplan and Kaplan that natural settings reduce mental fatigue (Kaplan & Kaplan 1989)
“Don’t have any worries. Don’t have to rush. All my family problems are forgotten” (RW)
“I think about wildlife rather than thinking about worries and stuff.” (NA)
Interviewees also expressed an increased awareness of their thoughts and thought processes. Some group activities were designed by the facilitators to increase self-awareness and reflection on cognitive processes, informed by meditation and CBT principles. The participants’ comments suggest that this was indeed an impact of the group.
“Problems go. Like today we were looking at the things we got out from the pond and just looking at them. I forgot my problems and you know I thought what am I worrying about? I forgot about them all while we were doing that.” (SS)
Relaxing & physical effects
(mentioned by all 9 participants)
Some focused on specific relaxation and breathing exercises,
“The exercises help me, sometimes they make me tired afterwards, but they’re relaxing. I liked that hand tensing thing you showed us, that releases tension.” (DW)
others described it as a general response to the sessions.
“I’ve had big changes doing this. I’ve opened out, relaxed.” (SS)
“feel relaxed then revitalised, full of life. I’ve always felt this on the walks since I began.” (GN)
Some valued the physical effects of walking and exercise.
“I enjoy the walking. I used to go walking everyday until I got heart problems.” (AL)
For others it was the natural environment that they found relaxing.
“Sitting on my own by the stream today was nice and relaxing.” (MMc)
“I like looking at clouds, water and other things – it calms me.” (GN)
Anticipating and remembering sessions
(mentioned by 8 participants)
Some clients spoke about how they hold onto the benefits of Ecotherapy through the week. For some this involved active efforts to retain the session content and what they had learned.
“When we did that interview worksheet the other week, I took it home and was looking at it. I thought about a lot of things and wrote down what I’d learned, like the black poplar, and willow and oak, and that eggs and bacon flower.” (DW)
Others described experiencing a lasting effect of Ecotherapy without active efforts at retention.
“It carries on over time. Like I said, like a battery. I leave here fully charged and ready to do things and over the week it gets lower like a battery running down then I come here again and I feel better.” (SS)
They expressed some strong motivations to come to sessions despite barriers and challenges to coming.
“I’d put anything else off to come here, because I like it.” (DW)
Some valued the impact to the extent that they considered re-creating their own Ecotherapy if they missed a session.
“Wouldn’t be good. I would go for a walk in the park probably” (LW)
“I’d be upset. I’d probably find some others to go with, get a group.” (GN)
Appreciating being in a natural environment
(mentioned by 8 participants)
Participants made reference to the value of being in nature. This was both in terms of the interest they had in these features, and finding a sense of peace and relaxation in the natural environment. Some participants noted environmental features such as fresh air, clouds, space, water.
“It’s nice to be out in the fresh air and nature, and to walk around on grass” (MMc)
Others focused their appreciation on being amongst wildlife.
“I enjoy the walking and seeing what wildlife we come across. I think about wildlife rather than thinking about worries and stuff.” (NA)
Safe, trusted and valued social group
(mentioned by 7 participants)
Many of the participants who regularly attend the group have longstanding mental health problems, limited social opportunities and networks. The group facilitators make active efforts to increase the sense of safety in the group by allowing variable levels of participation, and the group is designed to be primarily experiential rather than discursive. Consequently, it is common and explicitly allowed for group members to attend without speaking to anybody in the course of the session. Many participants nonetheless reported that the group provided a valued source of social contact, a positive and safe experience of trying to be with others, and that this was a motivator for attending.
“I don’t mix much with people but they seem more real here, not just liars and bullshit.” (DW)
“I’ve got used to being a loner all my life, but talking to the others helps take my mind off the anxiety.”…“It’s the start of learning how to talk to people.”(MM)
One exception to this was MMc, who used the group as an opportunity “To get away to the peacefulness, because I get no time alone at home” (MMc). Therefore, it was valuable that he could come and choose not to engage with the group and have some space.
“Sitting on my own by the stream today was nice and relaxing.” (MMc)
Ecotherapy as separate from daily life
(mentioned by 5 participants)
Some clients expressed a contrast between the sessions and their normal life outside (ecotherapy good, home life bad). Ecotherapy seemed like a positive island separate to the rest of their life, and they did not appear to incorporate their learning into everyday life. They reported feeling positive benefits which gradually diminished through the week. We hypothesised that this may be related to joining the group being a result of referral from another therapist, and consequently the group being viewed as a therapeutic intervention and separate from the rest of their life.
“Modern living is all rushing. This what we do here brings this, the rushing about, down to earth.” RW
“I can rest at home. The feeling lasts a few days, almost until I come back the next week.” MMc
“I’d miss the bit of calm during the week.” SS
The Importance of different elements of the Ecotherapy sessions
Following the semi-structured interview, we asked participants to rate the importance to them of different elements of the Ecotherapy sessions, and to rate any change in various aspects of their well-being before and after the session. These results generally support the qualitative findings above.
We grouped the aspects into five elements: Social, Internal State (emotional & cognitive), Environment (scenery, fresh air, out the house), Physical Exercise, and Nature. The participants indicated that the motives for attending were varied and that across the sample there was a range of benefits with different individuals having different primary reasons for stating why they felt better as a result of the ecotherapy sessions. All elements scored highly underlining the advantages of providing multiple benefits in one ecotherapy session. The same conclusions can be drawn from the interview analysis: all the themes identified from the content analysis are congruent with the ratings. All the interviewees thought all the themes were relevant to them but one or two themes were seen as significant reasons to attend by each individual. There are implications here for the design and marketing of ecotherapy to service users.
Applying a Wilcoxon T test to the before and after scores for each of the above elements produced a significant (5% 2 tailed) positive shift except the one regarding relationships with other people (the scores were skewed by one socially phobic participant).
One possible criticism of the methodology is that the before and after ratings were both collected after the session and that it might have been better to have collected the initial ratings before the session actually started. However we were interested in the respondent’s perceptions at the end of the session rather than any objective measure of change.
Key conclusions from this research
There are implications for the content design of ecotherapy sessions and how they are marketed to potential clients. All the elements - social, physical, psychological and nature contact were perceived positively, although there was a wide variation of individual preferences for the elements.
It as also recognised that there may be a multiplier effect taking place. For example standing and watching a sunset or the amusing activities of ducks can be enhanced when it is shared with others. Further research is required to tease out, and in some cases isolate, the different elements to see their individual effects.
The variation between individuals on what is rated highly also suggests the respondents are being discriminatory and were not rating everything highly just to please the interviewer. For example (DW) expressed his discomfort with being in a group as well as positively rating his appreciation of being in nature and learning about it.
Another conclusion is that no one activity was rated overall as better than another. This suggests more than one explanation; it could be activity and stimulation is lacking in the client group’s lives and that any opportunity to get out of the house is attractive. The Roe study showed that those with poor mental health showed greater improvements in mood than those with good mental health (Roe & Aspinall 2011) and their conclusions were that the former group benefited more from rural as opposed to urban walking on stress and hedonic tone (mood).
An alternative explanation is that because the respondents discriminated between the elements they were identifying real benefits that were not just activities to stave off boredom. There is also evidence from other sources that there are benefits from experiencing the different elements such as socialising, being in a natural setting and doing relaxation exercises (Barton et all 2011). More work still needs to be done to tease out the various elements and their relative importance though. There is less evidence specifically from research with those experiencing mental health problems but there is also no evidence that they would react in a fundamentally different way. Further research may be able to discriminate responses between those with good and those with poor mental health.
Implications and recommendations
GPs often have the limited choice of offering medication which is intended to deal with the symptoms of a patients condition and offering counselling or CBT with a long waiting time, when they would prefer more choice of treatment (Mind 2007).