Shinrin-Yoku, an Occupational Therapy Exploration

Introduction

I am extremely happy to be here today. It is great to see we have so many participants here in the classroom. 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. Our older and long-term care population often have a disconnect between the sense of time and place as the environment that they are in as another example. 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. 

Wellbeing

• 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. 

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.