Green recovery: using nature to help people with mental health problems

How nature-based practice can become part of the therapeutic process in mental health care.
Abstract
The inclusion of nature into mental healthcare practice has a growing evidence base for its effectiveness in improving patient outcomes, and there can also be secondary benefits including improved staff wellbeing. While there may be a need for some training and clinical governance considerations, there are a range of possibilities that are comparatively low risk and simple to implement. This article provides an overview of potential approaches to try.
Citation: Page M (2024) Green recovery: using nature to help people with mental health problems. Nursing Times [online]; 120: 8.
Author: Mathew Page is chief operating officer, Avon and Wiltshire Mental Health Partnership NHS Trust, Bath.
- This article has been double-blind peer reviewed
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Introduction
There are a variety of terms associated with bringing nature into clinical care. These include ‘nature-based practice’, ‘ecotherapy’ and ‘green interventions’. For simplicity’s sake, this article will use the term ‘nature-based practice’.
In mental healthcare, nature-based practice includes interventions in which the natural environment has a distinct part in the therapeutic process. Often, in its simplest form, this involves moving existing support outdoors – for example, by taking a one-to-one meeting between a mental health nurse and a patient from the confines of a clinic room to a nearby park.
The beauty of including nature is that, for most people, it is intuitive and simple. In their own lived experience, many people will describe going out for a walk to clear their head as highly effective. Being scalable means that the activity can be adjusted to the available resources and levels of symptoms. Nurses who begin using nature-based practice may find that they move on to more sophisticated projects, such as horticultural therapy, in the future.
Over recent years, a number of popular books have emerged with a non-clinical perspective, making the case that nature improves mental health. Texts such as Bird Therapy (Harkness, 2019) and Nature Cure (Mabey, 2005) use a personal narrative that describes the author’s own experiences of how nature helped improve their mental health and, in this way, create interest for patients who want to find out for themselves whether nature could help to alleviate their symptoms.
Background
The County Asylums Act 1808 ensured that every county had its own hospital for the care of people with mental health problems. These were usually large, well-designed buildings with expansive grounds, offering meaningful occupation in restorative activities, such as gardening and agriculture (Nolan, 1993). It would be naive to eulogise too much about this period but, while many of the experimental treatments were brutally ineffective and the concept of moral deficiency led to unjustifiable incarceration, we can track back some positive aspects of our contemporary practice to this era.
As care moved into the community, the access to farms and gardens dwindled. By the 21st century, the large hospitals were closed and much smaller new units had limited access to outside space. Despite there being no national strategy to ensure access to nature, there are a few examples of excellent practice, in which services have found ways to bring nature into practice, often by working with specialist non-clinical organisations in the field.
Evidence base
Children and young people
Unlike adults, children often have routinely planned activities outdoors through their schooling. McGeeney (2016) described the benefits of playing in nature, making outdoor recreational spaces more nature oriented and including planned activities, such as forest schools. Seers et al (2022) noted an overall decline in children’s interaction with nature over recent decades, despite evidence of its helpfulness.
In the clinical arena, research has developed therapies that specifically revolve around nature. Swank et al (2015) created a technique of nature-based play therapy for children in educational settings, which was found, in some cases, to reduce problematic behaviour and improve desired behaviour.
In formal psychotherapy for children and young people, Lane and Reed’s (2023) initial research found that there was likely to be some positive influence by nature on the therapeutic process, but that more research was still needed.
In acute services, Hunt et al (2022) found a number of benefits of including nature-based approaches in child and adolescent mental health inpatient services. These included distinct activities, such as a gardening group that involved some therapeutic components, and integrated activities in which nature became part of existing therapy (for example, by including a natural object as part of a one-to-one session).
Interviews with practitioners found benefits for young people, including improvements in emotional regulation, relationships and engagement. The interventions were also felt to contribute towards a more positive culture of mental health recovery and have a sustainability focus. Hunt et al’s (2022) research highlighted that including nature has the potential for positive impacts on staff, such as improved relationships and reduced risk of burnout.
While there is persuasive evidence for practitioners to include nature in their work with young people, nurses should be aware of the emerging issue of climate anxiety. Hickman et al (2021) surveyed 10,000 young people (aged 16-25 years old) across the world and found widespread issues with climate anxiety, with 59% being very worried or extremely worried. This suggests that, while nature has positive effects, practitioners should be cautious about simply sending young people off to look at the environment in an unmanaged way, as the reality of ecological destruction could cause an unintended reaction.
“The first time a therapy group moved its activities outdoors it was transformational”
Primary care and community mental health
As part of a plan to improve community mental healthcare, in 2021 NHS England launched a green social prescribing programme. Pilot sites were commissioned to develop local community-based services that people with mental health issues could be prescribed. No particular constraints were placed on the pilot areas, with the expectation that the initiatives would promote innovation and diversity.
The programme was not limited to any particular age group or condition, although local projects could be designed for those for whom existing service models were not accessible. Initial evaluation of the programme showed positive improvements in mental health and wellbeing (NHS England, no date). The programme has demonstrated particularly strong engagement in communities experiencing high levels of social inequalities that affect health and wellbeing (NHS England, no date).
The Department of Health and Social Care (DHSC) (2023) evaluated perceptions of green social prescribing and found high levels of motivation by clinicians looking to find support for people. Summary research of clinical effectiveness is soon to be published, along with evaluations of specific interventions, such as the effectiveness of outdoor swimming for people with depression (NHS England, no date).
The opportunities for innovation and diversity of approach are considerable when working at a community level. The Bristol, North Somerset and South Gloucestershire Integrated Care System’s green social prescribing programme offers a directory of its commissioned services (Healthier with Nature, 2022). This includes dozens of opportunities – primarily for people with anxiety and depression identified via primary care services operating at local community level. Opportunities include:
- Forest bathing (mindfully exploring woodland);
- Nordic walking;
- Sea swimming;
- Mindful photography.
Short films showing several of these activities are available at Bristol, North Somerset and South Gloucestershire Integrated Care Board’s website (bnssg.icb.nhs.uk/health-and-care/healthier-with-nature). These activities are all provided by non-clinical organisations, run by facilitators with the necessary specialist training for the activity.
Rose and Riley (2023) have recognised that nature connection can be harder to provide in the urban environment, but observed that there are still opportunities using facilities, such as zoos. These green spaces filled with flora and fauna can become part of wellbeing facilities in their local community. White and Scott (2021) encouraged the further development of equine and other animal-assisted therapy as having a positive emerging evidence base across a range of demographics and mental health conditions, including those requiring psychotherapy. In the adult mental health context, Cappelen et al (2023) found that equine-assisted therapy had a positive impact for people diagnosed with schizophrenia, helping to improve depression and anxiety.
One prevailing characteristic of this area of innovation is that it is often contextual to the locality. A feature that is universally present is the practitioners’ passion for the activity and the impact this has on patients. This has led to the development of activities such as surf therapy, which is being found to have positive effects (Ponting, 2021); several specialist organisations are being formed in UK coastal areas. One of these is Surf Therapy (surf-therapy.org), which works with men with mental health problems in South Wales.
“Practitioners should be cautious about simply sending young people off to look at the environment in an unmanaged way”
Specialist services
In a well-functioning health system, all the activities available at community level should be able to be used by patients receiving care from specialist mental health services. When people need more specialist interventions for a period of time, nature-based practice can form part of that offer. Bonham-Corcoran et al (2022) assessed the available evidence base from the perspective of including nature in occupational therapy for patients, and found that, although it was not universal, there was positive support.
As evidence and enthusiasm develops, professions that work in the specialist part of the mental health services spectrum have identified the part that nature could play. As an example, the Royal College of Psychiatrists (2021) argued for more proactive inclusion in specialist care.
Hospital settings
Hospitals, by definition, care for the people most affected and disabled by symptoms of mental health conditions and, therefore, those with the greatest potential to benefit from nature connection. Staniewska (2022) noted that, in some cases, the historic gardens of hospitals still remain and can be repurposed for nature-based practice. While acres of hospital land have disappeared, there are still some green areas that could be transformed from unimaginative mown grass into therapeutic spaces.
Page (2008) described a project in an NHS low secure unit, which was part of a larger hospital site, where the team identified a redundant and neglected garden that was brought back into daily use by patients, many of whom had been in long-term institutional care without any access to nature. The effects were positive for the patients, but also demonstrated positivity for the whole service in the improved relationships with staff.
Implementation considerations
Workforce, training and governance
Organisations that have a positive culture of innovation will be well placed to include nature-based practice in their service delivery. Given the high levels of motivation among clinicians (DHSC, 2023), it is likely that nature might start to be included in practice independently and without any particular policy decision. This should be encouraged because much of what is possible is low risk and scalable.
Where the planned activity is something new, then consideration of risk will be necessary. Moving a community therapy group out of a building and into a park should not need major policy changes, but beginning a horticultural therapy programme on a ward garden must be assessed and relevant risks (such as use of tools) be appropriately managed.
In planning any nature-based activity, nurses should be aware of dynamic factors that can affect risk assessment. These mostly involve having less control of the environment and can include:
- Weather;
- Reduced confidentiality;
- Mobility on unfamiliar surfaces.
Training clinicians can be a consideration, but the training needs to be proportionate to the scale of the activity. Nobody needs to go on a course to take a patient who is on hospital leave for a walk, but if there was a desire to take a group into the mountains, training would be essential.
Risk management will need consideration as plans may mean additional staffing is needed, which could become problematic. When there is a desire to embark on nature-based practice on a larger scale or with greater level of complexity, then services must decide whether to train existing people or deliver the activity with someone who is already appropriately qualified, possibly through partnerships with other organisations. Given the positive value that nature connection has been found to have for employees (The Prince’s Responsible Business Network, 2021), it is important to consider how clinicians might continue to be part of any programme, even when it is delivered in partnership.
Understanding the effectiveness of nature-based practice will mean ensuring that evidence-based outcome and experience measures are used.
Cost and economic value
Hinde et al (2021) assessed the available published evidence and concluded that there is the potential for ecotherapy to be cost effective, but further research is needed to properly demonstrate this. A report from The Wildlife Trusts (2023) has been bolder and claimed potential savings to the NHS of £635m per year through the use of nature-based intervention programmes. Healthier Together (2024) has estimated that, of the services it provides, for the cost of one hospital bed for a year, 883 people could access a green social prescribing programme.
Green therapies in action
Specialist community recovery services
Inner City and East Bristol’s Recovery team covers one of the integrated care system localities in the city. The team provides care to around 1,000 people with serious mental illness and multiple complex health and social issues. It now has an allotment adjacent to its resource centre, with a dedicated facilitator to run it.
The clinicians use the allotment in a variety of ways, such as behavioural activation, a therapeutic technique with a growing evidence base (Ekers et al, 2014) that encourages comforting behaviours to replace troubling thoughts. The Recovery team’s mental health and wellbeing practitioners run groups using this approach at the allotment. Growing, crafting and cooking opportunities are all on offer. Single-gender groups have proved popular and opportunities for carers are being developed. The groups uphold the principles of coproduction and have provided opportunities for those who have used the service, two of whom have become paid ‘involvees’.
Hospital services
Callington Road Hospital provides services including acute inpatient care and psychiatric intensive care. Despite being close to the centre of Bristol, the hospital sits between a nature reserve and community allotments. A group of staff began a range of green interventions and formed a partnership with the local wildlife trust, giving the group expertise in activities like nature identification. Clinicians adapted and developed therapeutic provision, such as grounding techniques for anxiety, in which natural surroundings can be very helpful (Schuldt, no date).
The team collected extensive feedback, which is positively summed up in the words of one patient:
“Being in nature helps me put everything into perspective, the sun will always rise no matter what is happening for me.”
Another patient commented:
“Being here [in nature] is more therapy than therapy.”
Psychological services for refugees and asylum seekers
The Hope Service in Bristol, North Somerset and South Gloucestershire provides specialist psychological support to refugees and asylum seekers. The team has embraced green interventions into many aspects of its practice. A clinical team leader, Mary Griggs, said the first time a therapy group moved its activities outdoors, it was transformational.
Practitioners noticed that, when encouraging people to imagine positive images to alleviate distress, the visualisations were very often landscape based. When it can feel too soon for therapy, the range of green interventions the team offers through a network of partnerships – such as with Bristol’s city farms – can pave the way for further support and interventions.
Box 1 offers some practical tips on how to use nature-based practice for both clinicians and managers/leaders.
Box 1. Tips on how to use nature-based practice
For clinicians
- Try taking whatever you are doing with patients outdoors
- If that is not possible, try bringing nature – for example, plants, flowers and other natural objects – indoors
- Use your personal passions
- Remember that most nature-based practice is scalable, so try something small and see if it works
For managers/leaders
- Give permission for people to innovate
- Help capture outcomes data to monitor for patient improvements and service effectiveness
- Think about how nature might have benefits for staff and build it into your workforce wellbeing strategy
- Look at how you use estates and buildings to find opportunities for nature connection
Opportunities
The benefits for patients are uncontentious. This leads to the conclusion that there is an opportunity for improvements at greater scale by:
- Undertaking additional research to prove the value more scientifically;
- Forming networks of clinicians and organisations to further raise awareness.
For many providers, in particular NHS trusts, there are many possibilities of forming partnership arrangements with organisations that have access to outdoor space, such as wildlife charities.
Conclusion
Nature-based practice is not routinely used in all mental healthcare, and yet, where it is in place, it offers a high likelihood of outcome and experience improvement. There is a need for more research, but clinicians should be encouraged to start trying to work with nature on the basis that it is mostly low risk and likely to be helpful. The success of national programmes, such as green social prescribing, should mean that nature forms a much more central component of mental healthcare in the future.
Key points
- Nature-based interventions can be simple and easy to implement
- Such interventions can be used with people of all ages
- The practice is cost effective and may improve staff wellbeing
- Working with nature is mostly low risk and likely to be helpful
- Many nurses will be motivated to try this approach
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Cappelen H et al (2023) The effects of an equine-assisted therapeutic intervention on well-being in persons diagnosed with schizophrenia. A pilot study. Issues in Mental Health Nursing; 44: 2, 104-111.
Department of Health and Social Care (2023) Exploring perceptions of green social prescribing among clinicians and the public. gov.uk, 30 March (accessed 25 June 2024).
Ekers D et al (2014) Behavioural activation for depression; an update of meta-analysis of effectiveness and sub group analysis. PLoS ONE; 9: 6, e100100.
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