Choosing Wisely: Conquering Habit to Achieve Excellence

Introduction

I am extremely happy to be here today. This is really an occupational therapy exploration of the techniques and how they would be applied to occupational therapy. Depending on where you are in the country, right here in the Northeast, it is an absolutely perfect day to engage in a little bit of Shinrin-Yoku and get some of those health benefits of being outside. Whenever I attend a continuing education course, I always want to learn something that I can take immediately and use with my clients. I hope to provide you with that today.

What is Shinrin-Yoku?

What is Shinrin-Yoku? It is the Japanese word for forest bathing or forest air bathing, and the term was really coined in about 1982. The focus is to be outside in nature. Particularly in Japan, this means being in the forest to increase health and wellness. This was one of the first areas where research became really big for Shinrin-Yoku, which is why it is a Japanese term. Another term that is used is Forest Therapy. This is an intentional goal of healing, and it is done with a trained guide. When we are thinking about providing occupational therapy services, we use that same type of forest therapy model. We have an intentional goal to affect the function of the clients that we are working with. We are going to look at some different examples and different settings, and how this might look. Hopefully, by the end, you will see how  Shinrin-Yoku principles or invitations, as we will call them, can align with the intentional goal of affecting function.

One of the basic components of Shinrin-Yoku is that we are using all of our senses when we are out in nature. We want to connect with the environment, with the time that we are in, and also with ourselves. Many of our clients can be disconnected from their environment and from some of the challenges that they may be having. And, they might be disconnected from their senses. If we think about children with sensory processing disorders or with autism, they may be very disconnected from their senses. Another example is the older and long-term care population as they often have a disconnect between the sense of time and place for the environment that they are in. The forest bathing techniques can be really helpful and restorative. And a lot of times, that component of being restorative can allow us, as occupational therapy practitioners, to have more influence on ADLs, IADLs, engagement, leisure, and recreational activities.

Now that we know what forest bathing is, I want to now tell you what it is not. It is not hiking. It is not wilderness survival or outdoorsmanship. Probably the first time you go to your facility manager and say, "I want to try forest bathing with our clients, one of the first things that people might say is, "We can't do that." So, knowing a little bit about what forest bathing is can really help us explain to the powers that be and our colleagues what types of activities we will be doing and what types of activities we will not be doing. I also think relaying the benefits to those administrators, principals, or our colleagues can be a great way to get a little bit of buy-in as well. 

Evidence of Benefits

• Forest bathing has many documented health benefits.
  • Improved immunity
  • Reduced stress
  • Increased relaxation
  • Increased healing speed with decreased need for pain management
  • Increased well being

I was surprised at the amount of research available. In fact, I had to scale back on the amount of research that I was going to include today because there was a really large body of evidence. Much of it is not based in the United States, but the information that they are gathering is really valid to use with occupational therapy populations. First, we are going to talk about some of the documented health benefits, and then we are going to talk about how this would apply to occupational therapy or to populations that we work with.

Some of the areas that have been studied are immunity, reducing stress, increasing relaxation, increasing healing speed, increasing well being, and then decreasing the need for pain management. This also certainly supplies to some of the challenges with the opioid crisis. Decreasing the need for pain management is certainly an area that is really important right now, and if some of these techniques from forest bathing could decrease that need, that would be a really valuable thing that occupational therapy could bring to the table. When we look at some of these benefits, they are very broad. We need to think about how are they going to apply this to occupational therapy as far as engagement in ADLs, IADLs, recreation, and education. If our clients are less stressed and more relaxed, they are more likely to be successful and engaged in ADLs and IADLs. If they have an increased sense of well-being, they are also much more likely to engage in social, recreational, and leisure activities. When someone is healing and dealing with pain that takes the forefront. Using some of these Shinrin-Yoku techniques allows the person to start to move toward increased function. We are now going to look at some specific areas and conditions.

Psychiatric Conditions

• Kellen Taylor states that connection to nature can help people exit feelings of alienation, fragmentation, and isolation that, unpleasant emotions that those with psychiatric conditions are often dealing with.
  • Berger, R., & Tiry, M. (2012). The enchanting forest and the healing sand—Nature therapy with people coping with psychiatric difficulties. The Arts in Psychotherapy, 39(5), 412–416. doi: 10.1016/j.aip.2012.03.009

In the study "The Enchanting Forest and the Healing Sand- Nature Therapy with People Coping with Psychiatric Difficulties," they found that the connection to nature really helped people move away from that feeling of isolation, alienation, and unpleasant emotions that they were dealing with. If we think about someone who is dealing with a psychiatric condition, this is often a place where they might be getting stuck. Even someone who is transitioning to a long-term care facility can sometimes have that feeling of isolation, especially in a new environment. They do not have the same social supports anymore. Shinrin-Yoku techniques were shown to help people to connect and be more open to positive feelings. This can be another tool in our toolbox to bring this population some relief.

Stress

• Studies that used HR, BP and self-report provide the most convincing support for the hypothesis that spending time in outdoor environments reduces the experience of stress and improves health.
  • Kondo, M. C., Jacoby, S. F., & South, E. C. (2018). Does spending time outdoors reduce stress? A review of real-time stress response to outdoor environments. Health & Place, 51, 136–150. doi: 10.1016/j.healthplace.2018.03.001
• Hostility and depression scores decreased   significantly as a result of participation in shinrin-yoku compared with the control day
  • Morita, E., Fukuda, S., Nagano, J., Hamajima, N., Yamamoto, H., Iwai, Y., … Shirakawa, T. (2007). Psychological effects of forest environments on healthy adults: Shinrin-yoku (forest-air bathing, walking) as a possible method of stress reduction. Public Health, 121(1), 54–63. doi: 10.1016/j.puhe.2006.05.024

Two studies looked at stress. Certainly, stress is a wide-ranging issue that pretty much can affect any population. One example might be children in a school setting. Stress might impact their ability to learn. This might also be people in a long-term care setting where they have a loss of control over what is going on in their daily life. The question was, "Does spending time outdoors reduce stress?" This was a review of real-time stress response to outdoor environments. The study used heart rate, blood pressure, and self-report to find that the outdoor environment reduced the experience of stress and improved overall health markers.

In another study, they looked at the psychological effects of forest environments on healthy adults. This was forest air bathing compared with walking as a method of stress reduction. This study made me think about caregivers. They are our healthy adult population, and they often are impacted by caring for their loved ones. This study looked at the comparison of hostility and depression scores, and they compared a Shinrin-Yoku setting with a control day. The control day was just walking, and the Shinrin-Yoku day was an actual forest bathing session.  There was support that forest bathing reduced stress and improved health. I think to be able to offer some of these techniques could have a benefit both for reducing their stress but also for improving their ability to care for their loved one. This might be a way that we can offer some guidance and techniques in occupational therapy that they can use not only with us but then also take these home.

Relaxation

• The present study demonstrated that 15-min “forest bathing,” compared to the urban environment as a control: (1) significantly improved mood, (2) significantly improved positive affect, (3) induced feelings of significant restoration, (4) induced feelings of vitality. In conclusion, exposure to the forest environment in the winter induced psychological relaxation.
• These results provide several implications for forest therapy practice. They indicate that the forest bathing during winter is an acceptable and welcome intervention because it might generate psychological relaxation.
  • Bielinis, E., Takayama, N., Boiko, S., Omelan, A., & Bielinis, L. (2018). The effect of winter forest bathing on the psychological relaxation of young Polish adults. Urban Forestry & Urban Greening, 29, 276–283. doi: 10.1016/j.ufug.2017.12.006

When our clients are relaxed, they are more able to engage in cognitive tasks. This study looked at 15 minutes of forest bathing compared to being in an urban environment. They found significantly improved mood, positive affect, and feelings of restoration and vitality. The interesting thing about this study was that it was done in the wintertime. I am really excited to see these results as I am in the Northeast. This study found that being outside in the winter was acceptable and welcome and that it generated positive psychological relaxation or positive psychological benefits. This shows that access to all types of weather is a really important thing. I heard a great quote from a Czech Republic therapist. They said, "There is no bad weather, only poorly dressed therapists." This applies here as well. We need to make sure our clients are dressed appropriately for whatever weather that we are going out in. The benefits of being outside and being out in nature do not need to be impacted by the weather as shown in this wintertime study.

Healing and Pain

• A study of hospital patients recovering from gall bladder surgery found that patients viewing a natural scene recovered more quickly with less pain medication than those who viewed a brick wall.
  • R.S. Ulrich, View through a window may influence recovery from surgery. Science 224, 4647, 420-421, 1984.

This is a study that is probably more commonly known. It looked at hospital patients who were recovering from gallbladder surgery. They compared rooms who had a natural scene with those who faced a brick wall. They found that those who could look out a window and see grass or trees recovered more quickly with less pain medication than those who were just viewing a brick wall or another building. The results of this study have been incorporated into residential types of facilities as exposure to nature, even if it is just visual, has a positive effect on health. One of the invitations that we will talk about in a little bit is a Sit Spot. This is where people sit in a spot by a natural scene. This study showed an improvement in their recovery with a decreased use of pain medication. When we are thinking about the PEO model (people, environment, and occupation), we can affect that environment by incorporating some natural scenes. 

Well-Being

• The examined studies offered numerous examples of the healing power of nature for the health and well-being of older people. Occupational therapists could gain substantial insight from earlier experiences of nature-based activities for application in their practices.
  • Gagliardi, C., & Piccinini, F. (2019). The use of nature-based activities for the well-being of older people: An integrative literature review. Archives of Gerontology and Geriatrics, 83, 315–327. doi: 10.1016/j.archger.2019.05.012

This was a literature review, and it looked at numerous examples of nature for the health and well-being of older people. One of the outcomes for this was that occupational therapy practitioners could gain a lot of insight from earlier experiences in nature-based activities. Thus, it did not just look at Shinrin-Yoku techniques, but it also looked at horticulture therapy, outdoor adventure-based therapy, and a wide variety of other practices. There were many health benefits noted. 

Post Traumatic Stress Disorder (PTSD)

• Generally, the research indicated that physical and mental well-being, as well as the ability to deal with PTSD symptoms, is improved in everyday life. The potential of nature (ranging from gardens to wilderness) is highlighted as a therapeutic resource in the treatment as it provides an opportunity for reflection and restoration.
  • Poulsen, D. V., Stigsdotter, U. K., & Refshage, A. D. (2015). Whatever happened to the soldiers? Nature-assisted therapies for veterans diagnosed with post-traumatic stress disorder: A literature review. Urban Forestry & Urban Greening, 14(2), 438–445. doi: 10.1016/j.ufug.2015.03.009

For those who are working with veterans or those with PTSD symptoms, this research indicated that PTSD symptoms improved in everyday life with nature. They looked at everything from gardens to wilderness as a therapeutic resource. This particular study was a lit review, and it included a variety of different studies. The researchers found that nature provided an opportunity for reflection and restoration. I also think that connection to one's senses is an area that some of our patients, who have troubling PTSD symptoms, might get a bit disconnected from their body sensations between what they feel is going on and what is actually going on. They may get a heart-racing feeling, even when they are in a calm and safe setting, as an example. In a natural setting, there may be time to work through these feelings and body sensations.

Autism

• Results showed that exposure to nature provided motor-sensory, emotional and social benefits to children with ASD, although some of the identified benefits also come with concerns. Participants identified a wide range of barriers that make exposing their children to nature difficult. Among them, inappropriate behaviors, safety concerns, phobias and issues with the public realm emerged as critical hurdles. These findings suggest that practitioners should consider nature exposure as an intervention strategy
  • Li, D., Larsen, L., Yang, Y., Wang, L., Zhai, Y., & Sullivan, W. C. (2019). Exposure to nature for children with autism spectrum disorder: Benefits, caveats, and barriers. Health & Place, 55, 71–79. doi: 10.1016/j.healthplace.2018.11.005

Another study showed that exposure to nature for children with autism spectrum disorders found motor, sensory, emotional, and social benefits. The interesting part of this study was not only that it found benefits, but they also discussed the barriers of this practice with the parents of children with autism. Some of the barriers that were identified were inappropriate behaviors from the children, safety concerns, phobias, and issues with the public realm. Basically, the parents had some concerns about taking their children out into these natural environments. And certainly, the families that I have worked with have expressed similar thoughts, whether this is just to a local park. I think this is another area for occupational therapy practitioners who are working with children on the spectrum or children with ADD and ADHD. We can help parents to find ways to expose children to nature in a safe and controlled way. 

Summary of Benefits Related to Occupational Therapy

• Forest bathing has ancient roots in many cultures.
• Shinrin-yoku is based in Japanese culture and can be seen in anime such as Spirited Away and My Neighbor Totoro
• A contemporary resurgence of nature-based healing practices is happening worldwide:
  • Friluftsliv- (fresh air living) in Norway
  • German Forest Spas
  • Sanlimyok in South Korea
  • Forest Therapy or Forest Mindfulness in the USA

The populations that occupational therapy professionals typically work with like children with autism and ADD/ADHD, adults with mental health issues, veterans, and older adults benefit from exposure to nature. The available research was not provided by occupational therapy practitioners, but the benefits are often areas that OT addresses. Occupational therapists can use the available research, client values, beliefs, and clinical reasoning to utilize forest bathing as an evidence-based intervention. As the research was not done by occupational therapy practitioners, I titled this talk an occupational therapy exploration. This is an attempt to start to look at how we could take the research that is out there and apply it to our philosophy. How would we apply it to our areas of focusing on function, ADLs, IADLs, leisure, recreation, and education? How do we take this information, our clients' values, and our clinical reasoning to provide an evidence-based intervention? We have covered the research component, and now we are going to look at other considerations and how to apply this model in our practice.

Cultural Considerations

• Forest bathing has ancient roots in many cultures.
• Shinrin-yoku is based in Japanese culture and can be seen in anime such as Spirited Away and My Neighbor Totoro
• A contemporary resurgence of nature-based healing practices is happening worldwide:
  • Friluftsliv- (fresh air living) in Norway
  • German Forest Spas
  • Sanlimyok in South Korea
  • Forest Therapy or Forest Mindfulness in the USA

Shinrin-Yoku has roots in many cultures, although the term Shinrin-Yoku is a Japanese term. Forest bathing itself is wide-ranging, and we see evidence from Norway, Germany, South Korea, and then in the U.S. Again, it is referred to as forest therapy or forest mindfulness. When we are looking at benefits and applications, we want to keep in mind the cultural considerations and how we are then going to apply that to our clients. And, when we think about moving from research to practice, we need to keep cultural considerations in mind.

Invitations

• Invitations are not exercises or assignments to accomplish
• They are a flow between the environment as your partner and yourself and can be guided by an OTP
• When done with one client, the OTP can have the client journal, share their story with nature or with the OTP
• When done in a group, people take turns sharing what they are noticing, and the OTP facilitates the discussion and sharing

The application of forest bathing is called an invitation. The term here is selected specifically because these are not exercises or assignments for the client to accomplish. Depending on which population we tend to work with, we typically have a list of goals that we want to achieve in our OT session for the day. These invitations are opportunities for our clients to experience nature and the environment, but they are not necessarily something that the client has to go and complete. There are a variety of different invitations, and the client can find one that works for them. If you are working with children, chances are the child has another idea other than the one we propose. These invitations allow some flexibility and freedom with that. As we are working with the adult population, and whether that is more focused on mental health or rehab, an invitation is a nice, open sort of way of encouraging participation rather than saying, "Okay, this is what we're going to work on today." There is just a little bit of a different feeling. An invitation is a respectful way of encouraging them to participate.

These invitations can be guided by the occupational therapy practitioner, and if it is done in a one-on-one setting, we can have the client journal and share their story. In some cases, they might be sharing the story with nature, or they might be sharing it with us as the occupational therapy practitioner. This can be up to the client. We might be within earshot, or they might be a little bit further away from us where they are sharing that privately. Some people are going to be more comfortable doing this privately than sharing it directly with us. If we are doing this in a group, people can take turns sharing what they are noticing, and the occupational therapy practitioner is there to facilitate the discussion and the sharing. It is a form of a group, and we are taking these invitations as a way to guide us through.

Invitation: Intention

• This is the beginning of the OT session or forest bathing experience.
• The OTP helps the client set a goal or intention for the time in nature.
• This can be helpful in measuring carryover from intervention to goal mastery.

Our first invitation is Intention. It is the beginning of the OT session or the forest bathing experience. We can help the client to set their goal or their intention for the session. This is also a great way to look at measuring carryover from the intervention to mastering their goal. Even with young children, this can be done with the question of,  "What do you want to get out of this today? Is there something specific that you're going to look for?" We might have them record this from week to week, or we might be recording this from week to week if we are doing multiple sessions.

Invitation: Connection

• This is the beginning of forest bathing.  This is the first threshold the client will cross in the session.
• Natural thresholds or ways of entering can increase the special quality of the moment
• Invite the client to be present and connect with the natural environment
• This use of ritual can help mark the session as separate from ordinary time

Our next invitation is Connection, and this is really the beginning of forest bathing. It is the first threshold that the client will cross in the session. We can think about this physically, or we can think about this psychologically. As the OTP, we can set up a natural threshold. It could be a branch, it could be a couple of rocks across the path, or it could be a sprinkling of leaves as a way of entering the space. Again, if we are working children or adults with motor disabilities, we want to make sure that they can clear this symbolic threshold safely. If we are looking at the mental health side of things, this transition is from an ordinary time to a special time where they need to be very present. We want them to be connected.

Invitation: Awareness

• Notice our surroundings
• Notice our body sensations
• Notice how our senses bring us in contact with nature

The next invitation once forest bathing begins is called awareness. It is simply stopping and taking time to notice the surroundings, any body sensations, and how our senses bring us in contact with nature. This could be very broad where we just ask our clients to notice what they are seeing, hearing, or smelling in their surroundings. Can they feel anything from nature like the wind, the cold, or mist in the air? We are asking them to start to slow down, focus, and be present. Figure 1 shows a picture of a Shinrin-Yoku activity. You can see that there are different little bits of nature that are caught in a pine cone.

Figure 1. Example of a Shinrin-Yoku activity.

We often miss images such as this. We are not slowing down to look at a pine cone, let alone look at all the different little plants that happen to be in a pine cone. This is an opportunity to build that awareness. Many of the populations that we work with have limited awareness. That could be self-awareness or awareness of the environment. This is a way to incorporate that Shinrin-Yoku technique of awareness into our occupational therapy goals.

Invitation: Walking

Another invitation is walking. An overview is in Figure 2.

Figure 2. Invitation to walk.

This is very slow walking, and it is noticing what is happening around you. One of the things that clients will often notice first is that there is always movement in nature, and as such, they become a little bit more a part of nature because they are moving. We are asking for a little bit higher level and cognition here. So, if we are working with a population that has had a traumatic brain injury or has an executive function dysfunction, this is an area of intervention where we are starting to ask them what they are noticing. And typically, walking is open for around 15 minutes. It gives the body enough opportunity for movement, and there is a focus on awareness. For those kids with ADD or ADHD, they can have a really hard time sitting still. A walking invitation will allow them to move in the environment. However, we are still getting them to slow down a bit and start noticing their movement within the environment.

Invitation: Possibilities

• Invitations are everywhere, the client should find an invitation from the environment.
• Examples include: I am the grass and I invite you to lay on me.  I am the clouds, I invite you to watch me.  I am the stream and I invite you to wade in me.  I am the rocks and I invite you to touch me.  I am the insect and I invite you to follow me.  I am the dirt and I invite you to dig into me.  I am the tree and I invite you to climb on me.

This is a fun one that is great for all different ages. We are asking clients to find an invitation from the environment. We might change the language up a little bit. If we are working with children, we might say, "Let's go out and see what the grass is asking you to do today." Or "Let's go see if we can find a rock and see what the rock is going to ask you to do." Here are some examples, "I am the grass. I invite you to lay on me." "I am the clouds, I invite you to watch me." And so often, if we give our clients a few examples, they will then go ahead and find an invitation from something in the environment. It could be a stick. It could be something that we have not even noticed. We are letting the client explore the environment. It can give us insight into the client. They may notice things that we do not. It can tell us where their attention and focus are. Is it something on the ground. Do they stop and touch the rocks? What sizes, what shapes, and what is the alignment? As the facilitator, we can make observations. Are they looking down at their feet? Are they looking high up in the sky? What are they attracted to? Is it a sensory component? Is it something that they noticed, and they need to express themselves? This invitation is almost a way of checking in with them during the Shinrin-Yoku.

Invitation: Sit Spot

• Find a place that feels right and sit there, take about 20 minutes
• Clients are awakened and relaxed from Possibilities and Walking
• Often the longer you sit, the more you notice, this is called the Reveal
• The Sit Spot is a practice that can be taken home and accomplished by clients in their home environment

I referenced this a little bit earlier. This is usually about 20 minutes. For some people, this can feel like a long time. However, hopefully, we have moved into a place where clients tend to be a little bit more relaxed. We have them pick any spot in the environment that we are working in. Again, this can be a playground, a park, or a forest. We want them just to sit. The longer that they sit, the more that they notice. The first things they may notice are the sounds of traffic or a plane going overhead. But the longer they sit, the more natural things come to the forefront. "Oh, there's a bug crawling beside me." Then, when they look from the bug, then they see plants and other things in their surroundings. This component is called the reveal. The more time that they are looking, the more time they have to see all these different components. It is a practice of mindfulness or meditation, even though we would not call it that. It is a way of being focused and present at the moment.

If we think about our population of children with autism, the ability to stay in one spot for a period of time could be done with a partner, the occupational therapy practitioner, or with a parent. It is a positive way that we can use some of their perseveration. It is a positive challenge and way to direct their attention. For our older adults, right, it is a way to be present in time and to take in everything that is around them. And, it is not physically exerting. If they have done a walking invitation, this can be a nice follow-up. They can take a bit of a break, but they are still engaging in the forest bathing session. This is also one that we recommend that clients take home with them. They can find a place that is right near their house. It can be on their front porch, on their back porch, or on a balcony to practice this component of relaxation.

Invitation: Tea Ceremony

• An informal sharing of a drink at the end of the session
• A “trail tea” can be made from native plants or traditional herbal tea can be offered
• The tea ceremony begins the segue from forest bathing back to ordinary time

This one is called Tea Ceremony. This can be an informal sharing of a drink at the end of the session. Many of my pediatric clients come with a water bottle. This is an opportunity to have a drink and segue out of forest bathing back to our OT session or back to ordinary time. If you have experience in plants, you may be able to use native plants for an herbal tea, or we can have the family bring tea that they like with them as well. This can be prepared by the family and occupational therapy practitioner during that Sit Spot time so that it is ready for the gathering at the end of the session. No matter what type of population we are working with, the opportunity to transition is really important. We do not want to start right in with questions like "What did you see? What did you learn?" But rather, we want to give everybody a chance to come back, to hydrate, and to start to make this transition.

Invitation: Re-Entry

• The OTP chooses a formal way to end the forest bathing session
• This helps clients transition back to ordinary time and is often marked by snacking and consideration of the intentions
• The Re-entry or Threshold invites the client to consider the deep awareness gained during forest bathing

As we wrap up, there is Re-entry. This is a formal way to end the forest bathing session. This might be going back over the threshold. We might offer snacks, or if the family has come with snacks, this might be part of our occupation-based part of our intervention.
We want them to process the sensations that they became more aware of when they were in the environment. This could be psychological processing. We may want them to process some of the emotions that they came across when they were in the environment. Or, this could be a physical processing. "How do I feel in my body?" "How do I feel after being outside?" "Am I cold or am I warm?" "Did I get a little winded walking around?" "How do I feel after sitting for a little period of time?" 

Muddy Spots

Muddy Spots is an opportunity to ask clients if they are stuck with something that they experienced. "Is there anything you experienced while you were going through the invitations?" "Was this a little challenging?"

Occupational Therapy Examples

Here we have some examples.

How would you approach this? How would you bring this up to an administrator? What resources do you have in your own community or in your own school setting that might work for this? Here are some of the answers that are coming in:

• Incorporating a windowsill garden
• Completing part of our session outside
• Improving attention to task by going outside to observe bugs and different types of leaves.
• One person stated that they have an administrator that is very open to the natural setting.
• Gathering leaves and pine cones or asking them to bring them from their yard or parks.
• Someone who is working in an urban environment suggested bringing materials inside such as rocks, leaves, and sticks.
• Going to a park
• Observing the weather. There is always weather surrounding us so that is something that everybody has the opportunity to experience.
• Community garden in a forest area with a walking circle for the public.

These were a lot of good ideas. For those of you who are in a more urban environment, having that ability to bring some of the natural materials inside is a great way to have kids have that experience when getting outside might be a little bit harder. These invitations could still be used with some of these natural materials inside. And in most areas, even a very small patch of greenery, a tree or patch of grass, might work. We are still going to see bugs in that little bit of grass and different types of plants. Having children gather around to look at those textures and different types of leaves are good for them to get a little bit more grounded and more aware of how they are feeling. 

Here are some ideas:

• Indoor planters
• Herb gardens
• Potted plants
• Windowsill gardens.
• Find out why they are staying inside so much.
• Encourage time for them to go outside and maybe make a small garden.
• Gardening for the senses with different sensory types of gardens, flowers, and "touchables"
• A long-term goal could be something like a community garden
• A lot of community gardens are very thriving places so it would certainly be applicable for this particular person to move from an indoor planter or windowsill planter to maybe an outdoor garden with a long-term goal of having them engage in a community garden.
• Visiting a greenhouse is a good idea.
• Sit Spot idea of having them come out and just be around a plant or some plants that are planted nearby to your outpatient setting, and then seeing if they can recreate that when they go home.

Again, these are really nice ideas. It definitely seems like everybody is able to take some of those thoughts about Shinrin-Yoku and some of the invitations, and then take them and apply them to some specific populations or some case studies here.

Training

• The Association of Nature and Forest Therapy Guides and Programs offers a certification program.  The certification process consists of:
  • A weeklong intensive
  • A six-month mentoring practicum
  • Approval for certification from your mentor
• Guides must be CPR and First Aid certified

https://www.natureandforesttherapy.org/guide-training/certification

If you are interested in learning more, the Association of Nature and Forest Therapy Guides and Programs has a certification program. The certification program is extensive. It begins with a weeklong intensive, and there are ones offered in the United States as well as abroad. After you complete your weeklong intensive, then you are matched with a mentor for a six-month practicum. During that time, you have specific forest-bathing activities to complete with different populations. And after you have completed your six-month mentoring, then you get approval for certification from your mentor or a recommendation that you need to practice a particular invitation more or work with an individual versus a group more. Your work closely with your mentor and have this support which is really nice. As a side note, guides must be CPR and first-aid certified.

References

Educational References

Clifford, M. A. (2018). Your guide to forest bathing: Experience the healing power of nature. Newburyport: Conari Press.

Miyazaki, Y. (2018). Shinrin Yoku: The Japanese Art of Forest Bathing. Storey Publishing, LLC.

Research References

Berger, R., & Tiry, M. (2012). The enchanting forest and the healing sand—Nature therapy with people coping with psychiatric difficulties. The Arts in Psychotherapy, 39(5), 412–416. doi: 10.1016/j.aip.2012.03.009

Bielinis, E., Takayama, N., Boiko, S., Omelan, A., & Bielinis, L. (2018). The effect of winter forest bathing on psychological relaxation of young Polish adults. Urban Forestry & Urban Greening, 29, 276–283. doi: 10.1016/j.ufug.2017.12.006

Gagliardi, C., & Piccinini, F. (2019). The use of nature-based activities for the well-being of older people: An integrative literature review. Archives of Gerontology and Geriatrics, 83, 315–327. doi: 10.1016/j.archger.2019.05.012

Kondo, M. C., Jacoby, S. F., & South, E. C. (2018). Does spending time outdoors reduce stress? A review of real-time stress response to outdoor environments. Health & Place, 51, 136–150. doi: 10.1016/j.healthplace.2018.03.001

Li, D., Larsen, L., Yang, Y., Wang, L., Zhai, Y., & Sullivan, W. C. (2019). Exposure to nature for children with autism spectrum disorder: Benefits, caveats, and barriers. Health & Place, 55, 71–79. doi: 10.1016/j.healthplace.2018.11.005

Morita, E., Fukuda, S., Nagano, J., Hamajima, N., Yamamoto, H., Iwai, Y., … Shirakawa, T. (2007). Psychological effects of forest environments on healthy adults: Shinrin-yoku (forest-air bathing, walking) as a possible method of stress reduction. Public Health, 121(1), 54–63. doi: 10.1016/j.puhe.2006.05.024

Poulsen, D. V., Stigsdotter, U. K., & Refshage, A. D. (2015). Whatever happened to the soldiers? Nature-assisted therapies for veterans diagnosed with post-traumatic stress disorder: A literature review. Urban Forestry & Urban Greening, 14(2), 438–445. doi: 10.1016/j.ufug.2015.03.009

R.S. Ulrich, View through a window may influence recovery from surgery. Science 224, 4647, 420-421, 1984.

Questions

Is the Sit Time 20 minutes from the start or is it increased gradually?

If we are working in that long-term care population, twenty minutes might work really well for them. However, twenty minutes for children may be too long. This may be something that we are going to work up to. We might only get a minute or two at the beginning, and we might try to increase their self-regulation to enable them to sit for the 20 minutes. Think about upgrading or downgrading that invitation based on the population that you are working with.

Do you need special consent forms to take patients offsite?

That would depend on your particular facility. A lot of facilities require special consent if you are taking somebody on a field trip due to liability concerns. How are you going to get there? Is the facility transporting them? 

For the walking segment, do you give directions or is it at their discretion?

The beginning of the invitation is that "We are going to take about 10 to 15 minutes to walk around the environment. You want to walk slowly and notice what is around you." If we are working with children, we might have to provide them a little bit more guidance as far as what the boundaries are for how far they can go. We do not want them going too far from where we are. We want to be able to keep everybody in sight. If we are working with people who are a bit older with decreased mobility, this might be more of a challenge. We might say, "Walk as you are able and if you need to stop and take a break, go ahead and do so." If we are working with people more with mental health issues, we might say, "We really want you to focus on your breathing." Or, "We want you to go ahead and take your shoes and socks off and feel with all of your senses." So, we can make some modifications to the walking component depending on how much direction we want to give.

How effective have you seen this be used within the VA system? Have you seen this be effective with that population, or do you have any research about this?

We do have the one research study that is included in this presentation that was specifically looking at veterans with PTSD. As far as being incorporated by the VA, I am not aware of it. I know there is a lot of emphases right now on adaptive sports, and some of that includes outdoor experiential types of things. However, I am not sure that Shinrin-Yoku or forest-bathing specifically has either been provided by VA practitioners or has been particularly studied. But, there is evidence out there looking at veterans and Shinrin-Yoku.

Is there research with videos of nature for homebound clients?

There are some Shinrin-Yoku videos available. I think on Amazon Prime. They are about an hour-long, and they are scenes of nature. They were actually exhibited at a film festival, and there are a variety of different nature scenes. If you were with somebody who was homebound, that would be one way to offer that. Even if someone is homebound, perhaps we could alter the environment so that they at least have a view outside. Even if we are in an urban environment, we can put a bird feeder up outside the window. There are ways to incorporate nature even in a very urban environment where somebody cannot get outside. And if you are in a suburban environment, could they get out to the front porch? As far as research, I did not come across any research specifically looking at patients who were homebound.

I have used forest walks without this approach. Without the certification, do you have any particular things that you recommend?

I do not think that this is excluded from our scope of practice. I think that this is something that we can incorporate into occupational therapy practice. I think that certification is a great opportunity to add to your practice. However, I do not think that that should exclude anyone from beginning to use some of these techniques and invitations with the populations that they work with. Again, the focus of this particular presentation was an occupational therapy exploration. I think there is a lot out there that we just do not know yet how this fits into the model of occupational therapy. I think it is important to be mindful but have some structure to it. 

I primarily work in a long-term care setting with all cognitive and mobility levels. What would you suggest for the walking portion with someone that is in a wheelchair or non-ambulatory?

There is always movement in nature and in our bodies. Even though we might be using a wheelchair for mobility or our mobility is not what it used to be, I think asking that client to notice movement is the best way to really incorporate that walking invitation. "As we are out here today, I want you to start to notice movement." And then, we could bring it back to their body to wrap it up. We could say, "Now that we have seen what is moving in the environment, I want you to notice what in your body is moving. We always have our breath with us." I think that would be a great way to adapt that invitation to that population.