Nature As Co-Therapist Podcast

Editor's note: This text-based course is a transcript of the Nature As Co-Therapist Podcast, Amy Wagenfeld, PhD, OTR/L, SCEM, EDAC, FAOTA; Dennis Cleary, MS, OTD, OTR/L, FAOTA.

**Please use the handout to complete the exam.

Learning Outcomes

• After this course, participants will be able to:
  • identify the potential outcomes of facilitating therapy services indoors and outdoors.
  • recognize theories that support the relationship between nature and health.
  • identify the role of nature in facilitating physical and mental health and learning.

Podcast Discussion

Dennis: I'm happy to be joined today by Dr. Amy Wagenfeld to talk about nature and its role in occupational therapy. Could you tell us a little bit about how you became interested in occupational therapy?

Amy: Thank you very much. It's a pleasure to be here today. I came into the world of nature and health via a very interesting journey. I am very much a very proud occupational therapist, and I'm also an avid gardener. I love being outside. About 20 years ago, I wondered about the potential connection between occupational therapy and nature and health. We'll talk more about that in our time together today. I set out to learn more about therapeutic outdoor environments and how occupational therapists can be an important part of that process.

My journey has taken lots of amazing twists and turns, but I'm very proud to say that I continue to be a very strong advocate for occupational therapists, being part of facilitating not only nature-based therapy but also being part of design teams of therapeutic outdoor environments.

Dennis: How did you get interested in nature and its relationship to occupational therapy?

Amy: I love to talk about this. As I said, I have always loved gardening. As a very young child, I was sent out to weed, not as a punishment, but as a wonderful activity. I found it very fulfilling and comforting. Wherever we have lived, I have always tried to connect to gardening and nature in some capacity, either in the garden or being involved with master gardening programs. I like figuring out how to blend my professional role with my vocational passions. Coalescing my professional capacities with my personal preferences and loves has been wonderful.

Dennis: How do urban environments affect health and the human experience in positive and negative ways?

Amy: Urbanization and technological advances have had positive impacts, like increased lifespans. However, a lack of outside experience can impact our humanity, if you will. Many who are listening today may be familiar with Richard Louv's amazing book, "Last Child in the Woods," where he talks about nature-deficit disorder. It can negatively impact our ability to think, physiological status, and mental health.

There's good and bad, and I think that particularly since we've dealt with the COVID-19 pandemic. During this time, many felt being outside was a respite. It made many feel connected and less frightened. I think the tide has turned where there's absolute recognition of the value of being outside.

Dennis: During COVID, my family lived in a development with houses on either side of us. It was anxiety-provoking to be in our house. We actually moved during this time to a place that, while it was still urban, had more grass and trees. My blood pressure came down, and the new place was a better fit for me physiologically.

Amy: I absolutely can share that experience. At the outset of the pandemic, we lived in a central business district in an urban city in South Florida. We lived in a condo building with a small balcony. Even though the balcony became my place of refuge, I longed for a more rural place where I could experience being outside and feel safe about it. We took many walks to a local park.

Dennis: This makes me think about people in prisons, nursing homes, or group homes that maybe, you know, are limited in their exposure to nature and just thinking about the impact that that environment has on their overall health.

Amy: It's interesting that you mention nursing homes and prison environments. About a year into the pandemic, we left South Florida and moved to Seattle. I reconnected with the University of Washington Landscape Architecture Program, where I teach now. One of our studio courses I co-taught was designing and building a therapeutic courtyard garden at a skilled nursing facility in Seattle. As you mentioned, this environment was devoid of nature. It had one planter full of weeds, and concrete was everywhere. Our class transformed it into a beautiful nature space. The residents and staff enjoy it so much. Two days ago, a design studio class in Landscape Architecture created a master plan of the outdoor space at the women's prison in Washington. These are examples of bringing nature to folks living in any carceral or long-term care facility that is important for their health and well-being.

Dennis: While we may work in a setting like these, we get to leave. For those there 24/7, what can we do to make that experience better for them? I also think about our history in psychiatric settings at the turn of the century before we were called occupational therapists. Can you talk a little bit about how returning to nature and returning to health is longstanding in our profession and how that connects to your current work?

Amy: When I first became interested in the potential connection between nature and health, and of course, its relationship to occupational therapy, I thought, "What better way to find out if my ideas had any merit than by looking into the archival records of our profession." When searching the Wilma West Library, I found photographs of early occupational therapy practitioners taking patients outside to do "occupational and space therapy."  I thought, without pun intended, "My idea is returning to our roots."  When I began discussing my idea with colleagues, they said, "This is so novel." My response was, "Absolutely not. It's a reemerging practice area, and one that I think we have a lot to add to the world of nature and health." I felt so lucky to learn about our amazing history that included nature as therapy.

Dennis: I did my master's thesis on staff training. It was interesting to look at the history of a particular institution. For instance, many younger individuals with intellectual or developmental disabilities (IDD) would go specifically to learn skills to come back and live independently in their community. People were not allowed to have lifetime confinements. They were there until they were 21 or 22 and then went home after they had the skills to work independently. Institutions changed with Darwinism, genetics, and looking at people with intellectual and developmental disabilities around the end of the 1800s into the 1900s. I always said at the particular place I was studying, "I think they sold the dairy herd in the late 1890s. It was all downhill from there." Back in the day, people worked on the farm and learned those types of skills, and the community welcomed them. It was a positive atmosphere for people to be able to return to health and the benefits that could be gained and then return from there.

Amy: Right. Benjamin Rush, who's considered the father of psychiatry, advocated for mental health facilities to be park-like, and part of his treatment was having patients take strolls outside. Many grounds of early mental health facilities were working farms that were agriculturally and floraculturally beautiful.

Dennis: What type of evidence has been shown to link interaction with nature and physical health?

Amy: More evidence is being published every month demonstrating the significant benefits for physiological health. There's a reduction in blood pressure and heart rate and increased parasympathetic activity. There is very conclusive evidence that physical health is positively impacted by nature experiences.

Dennis: What type of evidence has been shown to link interaction with nature and social-emotional health?

Amy: Again, the evidence is overwhelmingly positive for people who can experience nature independently and in group settings. there are demonstrated improvements in social-emotional and mental health. These have shown a reduction in rumination, anxiety, and stress, which of course, is very connected to our physical health as well. Interestingly, many of the studies are very short-term, looking at one experimental condition at a time. However, more longitudinal studies are now being published, demonstrating that these health benefits are lasting. It's not just a one-time, beautiful nature boost; over the long term, one's mental health improves due to natural experiences.

One caveat I'd like to mention is that all these experiences are personal. What I find appealing in nature may not be to other people. This is occupation-based thinking. We must be cautious about saying "globally" and be more client-centered.

Dennis: What about learning? Does being in nature make you smarter?

Amy: Absolutely. Many studies have been published about the impact of children either learning outside or having the opportunity to actually in their school day to be outside. For instance, recess is so important. Studies have shown that test scores improve when children have regular access to the outside during their school days. Learning outside improves attention, focus, and self-regulation, which, in turn, helps improve the learning process. There have also been studies of older adults, especially those with dementia, that have shown opportunities not to reverse the impacts of dementia but to help them feel more attentive and focused.

Dennis: This makes me think about kids who live in urban settings that do not have as much access to being outside.

Amy: That's right. The lack of equitable access to outdoor spaces is an occupational injustice. Studies have shown that, for people who live in low-income housing, where there is a greater preponderance of nature, trees, grass, other plantings, there is a reduction in crime and aggressive behaviors. These same studies have been replicated on school grounds as well, particularly on high school campuses. An increase in green is correlated with a reduction in aggressive behavior. Other evidence shows that looking out a window at nature-based scenes or even bringing nature into a classroom or any facility helps to improve focus and reduce anxiety and stress. This is contrary to some educators' belief that if we have windows open and children can look out at nature, they will be distracted, while it's quite the opposite. Having that few moments to take a look out the window actually helps to refocus. So I'm a very strong advocate for that.

Dennis: Can you talk about theories that relate nature to health? Do any of these theories have their roots in healthcare?

Amy: There are some really interesting nature in health theories. The first one I like to discuss is the concept of biophilia. The biophilia theory or hypothesis is that people are genetically predisposed to connect with nature. It's part of who we are, and when we are denied opportunities to connect with nature, as we just talked about, it affects our health and well-being. It is important to look out the window at greenery or blue water situation or bring nature in some capacity indoors. This makes us human. 

The environmental psychologists Steven and Rachel Kaplan developed the attention restoration theory. It posits that when we are in situations where we're dealing with long-term hyper-focus, like sitting in front of our computers for hours on end, studying without taking a break, or having a very repetitive job, we can become angry and impulsive and not do our best work. However, according to the attention restoration theory, we can restore our attention when we have opportunities to connect with nature. When I reach my tipping point, if I connect with nature in some capacity by getting outside or looking out my window, I can refocus and then come back in and do much better work.

Another interesting theory that overlaps with the attention restoration theory is the stress reduction theory. When we are in prolonged attentional situations and stressful situations, again, we can restore not only our mental health but also our physiological health as a result of connections with nature.

While these theories are not necessarily directly correlated with occupational therapy, they make so much sense when I think about them through the lens of occupational therapy. We address environmental factors daily, including important connections with nature. We are much more "human" and can reach our full potential by connecting with nature.

Dennis:  My daughter used to hide in our backyard, in her little part of her world. Her creativity was expanded in that environment. Can you talk about sensory gardens?

Amy: One of the gardens I helped design was a sensory garden at an autism foundation at the Els for Autism Foundation in South Florida. I think that my capacity to contribute as an occupational therapist was invaluable. We had many refuge spaces for the children to hide within that space. Providing the children the opportunity to take refuge as needed as a means to self-regulate has been invaluable.

Dennis: I love that you keep mentioning your background as an occupational therapist. How do you connect our theories within the profession to nature and health?

Amy: I continually think about this in my work. The PEOP theory aligns most with the work I do in my design life. As occupational therapy practitioners, we share a strong commitment to the person and environment relationship with our design colleagues. When we dive deeper to think about how one can engage meaningfully and participate and perform occupations, that's the next level that I contribute to the design process. I also think sensory integration factors significantly in the work that I do. No matter the project, I firmly believe in acknowledging our eight sensory systems in design.

Dennis: How would you connect occupational therapy with nature-based therapy?

Amy: It's such a wonderful relationship. Nature-based theory can take on many forms. It can be a therapy that's provided by licensed professionals, like taking clients on wilderness adventures. Another example of nature-based therapy I've been particularly interested in and just published a book about is thinking of nature-based theory as merging traditional allied health practice and mental health practice. It reconceptualizes the idea of providing therapy outside, or if that's impossible because of environmental considerations, bringing nature inside.

Dennis: Can you talk about the relationship between nature-based therapy and some of the factors within the Occupational Therapy Practice Framework (OTPF)?

Amy: When we think about personal factors, which are factors that are not related to our health conditions or our health state, things like race, ethnicity, and socioeconomic status, there is a strong relationship between personal factors and one's access to nature. In the long-term, it can impact our health state. If someone desires to connect with nature, it can positively impact their life despite any potential difficulties. And, of course, negatively when one is not provided opportunities to be engaged with nature. That, again, can reduce our personal factors, if you will.

Dennis: The role of occupational deprivation is huge. What other disciplines are involved in this area regarding nature and health research, and how do we fit into that research picture as occupational therapists?

Amy: Much of the research that's coming out about nature and health is coming out of psychology, particularly environmental psychology, design, and public health. As occupational therapy practitioners, we are tuned into meaningful occupations but have been somewhat of a quiet voice in facilitating nature-based therapy. We can use our skills in this area and become an important contributor to the research on nature and health. I am starting to see more and more research on occupational therapy, which I think is wonderful and needed.

Dennis: Who benefits from nature-based therapy?

Amy: My answer would be people from birth to the end of life. Of course it's always on different levels and client-centered. We must be cognizant of what works at different times in people's lives and what is most impactful for them. Even expectant mothers can be outside to enjoy nature restoring their attention and having moments of refuge. These benefits can be passed down to the fetus.

Research also shows that children who parents who expose them to nature and provide them with nature-based activities grow up to be more positive stewards of the environment and of the land. They are also more likely to engage with nature as young adults and adults. 

Dennis: What is eco-social occupational therapy? How is this an important role for occupational therapy practitioners?

Amy: Eco-social occupational therapy is an interesting concept I only recently encountered. It is an intersection between occupation, occupational justice, and ecology. The intention behind it is meaningful for our profession and a way for us to contribute to planetary health. How can we engage our clients in ecologically friendly activities? Examples could include a gardening group or an active composting system. It could be constructing raised beds from environmentally friendly materials or recycled plastic boards. It could be an occupational activity like cleaning up trash-ridden parks or recycling plastic bottles. It is taking motor-based and social-emotional-based activities and applying these to nature to positively impact our planet.

Dennis: Can you share some practical suggestions regarding how nature can be infused into therapy sessions for clients across the lifespan?

Amy: First, I'll talk about nature inside a therapeutic environment. If you begin to use activities involving nature, plants, or anything that is a byproduct of plants, that is an element of nature-based therapy. In my book, "Nature-Based Allied Health Practice," I advocate bringing therapy outside in whatever capacity the facility offers, like the outdoor garden at the skilled nursing facility I mentioned earlier. 

Dennis: Can you give some examples of how you might convince potentially skeptical administrators of the value of infusing nature into therapy?

Amy: I think the best way to overcome some skepticism is to share with administrators the evidence that supports improvements in mental and physiological health, social and emotional health, and learning. Come prepared with the evidence when you submit your proposal.

Dennis: I think some of these added features, like a garden space, would make the facility more attractive to caregivers.

Amy: That's interesting that you bring that up because I've long thought that if one could actually quantify the benefits of or a "return on investment" of a thoughtfully designed therapeutic outdoor environment, perhaps at some long-term care facility, then I think that would unto itself make having these spaces be the standard operating procedure if you will.

Dennis: This is especially true when you look at the generations of people that are getting older. Many say they do not want to be in these congregate settings. How do we create those settings so that people can access assistance when needed, but still are in an environment that they find pleasant?

Amy: Absolutely. Making spaces more relatable to them would help them to make the transition.

Dennis: Other than this podcast, how can therapists learn more about this aspect of our profession and some trends in this area?

Amy: Literature searches can be beneficial as it is ramping up in this area. Occupational therapy is beginning to focus on the impact of nature and health. There are also various occupational therapy practitioners who are now advocating for nature-based practices. Organizations like the Children and Nature Network are just a veritable treasure trove of information. This one focuses on the benefits of bringing children outside in nature.

Dennis: Tell me again about the program you teach.

Amy: I teach in the Landscape Architecture Department at the University of Washington. Go Huskies.

Dennis: There you go, and welcome to the Big 10. As a Buckeye, I'm excited to come to Seattle for a game. What is that like to teach landscape architecture students? I assume they're interested in the outdoors, to begin with, but how do you combine your background as an occupational therapist to teach these students?

Amy: That's a great question. On a personal level, every time I enter our building, the College of the Built Environments at Gould Hall at the University of Washington, I almost pinch myself and think, "I am an occupational therapist who is teaching in a landscape architecture program." Our students are so receptive to what I have to offer regarding my thinking and contribution to design. People always come first in the design, and sometimes that might not always be the case with some designers; it's more thinking about the design rather than the person in the place doing what they want and need to do.

The students are very open and receptive. I've had the pleasure of not only teaching design studio courses, but I'm now teaching seminar courses, which are special topics focused on therapeutic design. I just finished a remarkable seminar class on sensory design this past quarter. The seminar classes are interdisciplinary. I have landscape architecture students, students from all the other design disciplines in our college, and students from other majors and programs throughout the campus. So it's a wonderful opportunity to build bridges and to create new interprofessional collaborations.

Dennis: Do you ever have any occupational therapy students in that?

Amy: I have. They have added the most wonderful dimension to the class.

Dennis: Could you talk a little bit about your book? 

Amy: The book is titled "Nature-Based Allied Health Practice." It was published by Jessica Kingsley Publishers and was released in mid-October. My co-author is occupational therapist, Shannon Marder. It's intended to be enjoyed by all allied health practitioners, mental health practitioners, and even the lay public. The book makes the case for the general benefits of nature and health. We also have a chapter that's focused on ethical practice because when you bring therapy outside, you are dealing with different conditions in terms of confidentiality. We also discuss building outdoor or nature-based therapy practices, beginning with infancy and childhood all the way through the end of life. I'm a researcher, as is Shannon, so the final chapter asks, "How do you evaluate and assess your programs so that we, as allied health practitioners, are able to generate evidence and contribute to the world of nature and health in a very meaningful way?"

Dennis: From a nature standpoint, what outcomes do you want to achieve?

Amy: I think would be fascinating to do a comparative study of patients who are receiving rehabilitative care inside versus outside. Are they able to meet their goals faster? Are they more engaged and interested in their therapies? And also, for the therapist or the practitioners themselves, are they actually, you know, their impression or experience of facilitating therapy inside versus outside? I would highly encourage some of our listeners to think about doing this. We could also look at other benefits, like mental health. Is their mood improved if therapy is provided outdoors or in an indoor environment that's more biophilic and has more nature-based qualities? I think the sky's the limit, and there's so much that we can do.

Dennis: Participation in therapy might be another outcome. I think the administration would certainly be interested in it. How do you address the weather?

Amy: I think that you have to be realistic in some ways depending on the client population. If the weather is very inclement or unsafe, like for falls, you need an alternative plan. If your indoor clinic has been naturefied, it will still be beneficial. As an aside and living in Seattle, children at all childcare facilities have full rain suits and boots ready. They go out and play in the rain and get muddy.

Dennis: Which is good for all of us. This makes me think of Australian children often wearing hats when playing.

Amy: It is all part of facilitating nature outside and thinking about all the precautions and considerations one needs to take. For example, for proper interoception, you need ample shade and water on hot, sunny days. 

Dennis: I don't think I've ever been in a therapy gym that I felt was large enough. If you have access to outdoor spaces, it's a nice way to expand the size of your therapy gym. I have a buddy who has a house in San Diego that's about 800 square feet, but as he says, "It's San Diego." He has converted his outdoors to make several additional rooms so now his house is much larger than mine. Do you have any slogans that you use?

Amy: I like to say, "Take it outside." That little statement could have some negative connotations, but if you think of it only in the purest sense, our health is improved when we can take our clients outside and ourselves outside. So take it outside, be bold.

Dennis: If people were interested in purchasing your book, is it available on Amazon?

Amy: It's available on all the online booksellers and directly through our publisher, Jessica Kingsley. We're excited about it because both Shannon and I believe in the positive outcomes that can be experienced for everyone when outside.

Dennis: I think this generation of students is very interested in nature and being in the environment. I think would be a great thing to add to someone's curriculum. I think I will get your book for an anniversary gift.

Amy: Well, thank you, and congratulations. I think there is tremendous interest, and I certainly get a lot of emails from interested students. It makes me feel so happy that this area is becoming more mainstream. Nothing could make me happier than to see this continue to grow. As we begin to wrap up today, I thought I'd go into a little more detail about some examples of nature-based therapies in general and, typically, the clients they're intended to serve. We have a bit of a long list, but I think it's pretty exciting.

One would be having therapy activities outdoors, as nature-based therapy can absolutely reference the location of therapy. Traditional therapy interventions such as strengthening exercises, cognitive rehabilitation, or activities of daily living could happen outside. Clients that would typically be appropriate for this type of nature-based therapy would be across the lifespan and probably applicable for most of the practice areas.

Therapy could include ecotherapy walks, guided walks, or hikes in natural settings where individuals are able to immerse themselves in the sights, sounds, and sensations of nature. Typically the client group most appropriate for ecotherapy walks would include youth and adolescents and adults and older adults as environmental conditions permit.

Outdoor group activities, somewhat akin to therapy activities outdoors, are therapy groups or sessions conducted outdoors. Doing so fosters a sense of community and connection among the participants or the clients. Certainly, the clients that could be appropriate for this type of intervention would cross the lifespan if there are appropriate modifications to meet their needs. Wilderness therapy tends to be longer outdoor expeditions. They often involve camping or backpacking, physically and emotionally challenging individuals, and promoting personal growth and resilience. The clients most applicable to wilderness therapy models are adolescents or adults. Typically, this type of nature-based intervention is used successfully among the adult, adolescent, and young adult populations as well as with veterans.

Therapeutic horticulture involves engaging in gardening and plant-related activities to promote relaxation, stress reduction, and a sense of accomplishment. Again, the clients most applicable for engaging in nature-based therapeutic horticulture intervention go across the lifespan and are applicable for most practice areas. You can use nature-based materials when a situation doesn't allow going outside for nature-based therapy. There are absolute benefits to bringing natural materials inside, and is particularly impactful for older adults. Additionally, being close to a window and including nature images, plants, and indoor water features in the clinical environment are evidence-based benefits.

As we begin to wrap up, I have included in your resource packet a list of some examples and organizations that are aligned with nature-based therapy. They cover sort of a broad range of connections with nature. One has to do with becoming a forest guide practitioner. The Children and Nature Network, which I have already mentioned, is a wonderful resource for discovering more about nature-based interventions and research about the benefits of engaging children, particularly with nature. The Environmental Physiotherapy Association is an interesting advocacy group that promotes not only nature-based intervention but also planetary health. Nature-Based Therapy Australia is an excellent resource for discovering more about the opportunities associated with nature-based therapy. Park RX America, which I did mention before, is an example of nature prescribing and one that's very applicable for healthcare practitioners to learn more about and even to become a certified nature-based prescribers. Physiopedia, which is an international organization, has a wonderful resource section about nature-based therapy. And for those of you who are looking at sort of academic models of certification, there is a wilderness therapy certificate available through a university in Maine.

I want to thank Dennis very much for the opportunity to spend time together, and I wish you all the best. I would encourage all of you to take it outside and enjoy the benefits of nature.

References

Please refer to the outline and handout.