Connecting Ecotherapy and Well-Being
Ecotherapy utilizes a broad spectrum of systematic interactive nature-based treatments and activities designed to facilitate healthy outcomes in interdependent dimensions of the human experience that benefits one’s well-being.
Nature includes both wildlands and wilderness, managed nature (e.g., cultivate gardens, arboretums), and, to a lesser extent, specific flora and fauna features.
Multifaceted Approach to Health and Well-Being
Increased human population, urbanization, and extractive enterprises around the world result in fewer people having access and exposure to natural places. However, research conducted in developed nations has identified nature interactions that have proved beneficial for multidimensional aspects of health (Hartig et al. 2014). With predominantly indoor living and increased technological media, contemporary societies are significantly detached from the therapeutic benefits of nature. This disconnect is associated with a rise in many chronic, noncommunicable diseases, such as cardiovascular diseases, asthma, allergies, vitamin D deficiency, diabetes, and mental health conditions of stress, anxiety, and depression (Shanahan et al. 2015, 2016; Sullivan and Chang 2017). As urbanization emerges as a global health concern, there is a greater need to understand and harness beneficial connections between direct exposure to and experience with germane nature and its subsequent effects on human health.
Human connection to the natural world offers multifaceted, health-promoting potential for restorative and resilience-building processes essential for holistic lifestyle (Keniger et al. 2013). Centuries ago, indigenous societies and ancient cultures lived in close connection with their natural surroundings, thus nurturing a philosophy of health as a balanced, sustainable state both in relation to the human body and mind in connection to the landscape in which they lived (Reddon and Durante 2018).
During the nineteenth and twentieth centuries, the study of germs provided a focused framework to identify and treat specific ailments, diseases, or genetic factors (Malle 2017), thereby overshadowing the previous eras of philosophical and holistic understanding of health that considered both the intrinsic relationship of all parts of the body and the human experience with extrinsic dynamics. While it is very appropriate to continue to understand disease from an individual and public health perspective, it is also necessary to acknowledge that biophilic tendencies, or innate human-nature relatedness (Kellert and Wilson 1993), are more likely to be disrupted as humans inhabit various modernized settings. In fact, the absence of nature, or significantly reduced contact with nature, can play a role in creating unease or “discord” (Grinde and Patil 2009) to desired human health. On the other hand, biophilic tendencies can be threatened when nature is harmful and poses a threat (forest fires, drought, etc.) that impacts daily living. Further, a recognition of the existing inequities between the most developed and the least developed portions of the world is at the core of the United Nations’ Sustainable Development Goals. Not all nations have equal or safe access to open natural landscapes or contemplative green spaces, thereby making the benefits of ecotherapy not as easily obtainable. This raises additional questions as to whether ecotherapy is an appropriate intervention in areas of the world that are traumatized with issues of extreme poverty and illness, warfare, severe government corruption and instability, and countries lacking basic humanitarian laws.
Health and well-being are multifaceted goals – incorporating physiological, psychological, and social aspects of self. As contemporary thinking about health continues to evolve, health-care professionals who previously had a biomedical, disease-centered model of care are now gravitating back to a focus on the person within a holistic, interdisciplinary, and cross-cultural model of health in which health is a sustainable state of the human ecosystem (Mallee 2017). Additionally, the responsibility for maintaining health is now more collaborative and includes the individual – front and center – as an empowered stakeholder in charge of his/her well-being.
Facilitated and structured
Takes place in a green, blue, or white environment, such as forests, water, or winter ecosystems
Is related to exploring and appreciating the natural environment over time
May involve other people (Mind 2013)
Holistic health care (also called comprehensive care)
Emphasizes treating the individual as whole with emotional, social, and spiritual needs in addition to physical needs (Holistic Health Care n.d.)
Nineteenth-century European “nature cure,” which was a system for treating disease with natural modalities such as water, fresh air, diet, and herbs (Lee and Kemper 2000)
Defined as “taking in the forest atmosphere or forest bathing” (Tsunetsugu et al. 2010)
Animal-assisted therapy (AAT) (e.g., canine, equine, etc.)
Deliberate inclusion of an animal in a treatment plan (Nimer and Lundahl 2007)
Nature meditation (also called restoration skills training – ReST)
Mindful awareness focused on the sensory experience of nature – sight, sound, touch, and smell, including thoughts and perceptions (Lymeus et al. 2018)
Horticultural therapy (HT)
Use of plants and plant-related activities such as gardening and related tasks to assist in treatment of people with physical, mental, and emotional problems, such as strokes, Alzheimer disease, autistic disorders, cerebral palsy, etc. (Ackley and Cole 1987; Stigsdotter et al. 2011)
Agricultural-based rehabilitation program (Javed et al. 1993)
National ParkRx initiative (park prescription)
Physician prescribed physical activity in parks to prevent and treat chronic disease and to promote wellness (Zarr et al. 2017)
Ecotherapy engages ongoing, holistic preventive care yet can also focus on specific health purposes such as reducing blood pressure or increasing self-esteem. Ecotherapy may be particularly useful reducing unhealthy and addictive forms of human habits that can contribute to unease or disease. Unhealthy actions that one may seek for short-term comfort and relief from one’s unease may include a multitude of excessive actions such as overeating, social media addiction, movies, video games addiction, alcohol, smoking, drug abuse, and other negative tendencies that divert a person from more healthful life alternatives. Different types of nature exposure generate a variety of human experience, such as a sense of discovery or enchantment, and provide a sense of calming, settling within oneself, or other positive responses that can bring mostly beneficial health and well-being.
Nature Exposure and Human Experience
Nature, broadly defined, includes both wildlands and wilderness (e.g., forests, oceans, deserts) and managed nature (e.g., parks, gardens, trailways) and, to a lesser extent, specific flora and fauna features (e.g., a single historic or landmark tree such as Tree of Life in Bahrain; Major Oak in Sherwood Forest Nottinghamshire, England; or General Sherman Tree in Sequoia National Park, California) (Scholl and Betrabet Gulwadi 2015, 2018). Nature environments also contain its principles of organization – the textures, complexity, whether it is savanna-like or infused with tree canopies, etc.
Cumulative opportunity or neighborhood exposure – refers to the total amount of nearby greenness or the percentage of local area categorized as green/blue space; the amount of green spaces such as parks/woodland and blue spaces such as rivers/coast in the area around one’s home
Duration of specific nature visit – an individual’s visit on a specific day or time for a limited duration (e.g., a park walk)
Visit frequency – frequency of outdoor recreation visits over a period of time (e.g., number of visits during a week, a month, or within the past 12 months)
Distance to green space (e.g., home to park)
Exposure mode – integrating the time spent in nature settings with the type of nature experience (e.g., visual, auditory, tactile, olfactory)
Natural context – the specific climate, seasonality, and daylight at the time of the exposure including nature encounters (wildlife, wildflowers)
Therapeutic landscape experiences are “relational” (Bell et al. 2018) and include many neurosensory modalities that connect the human body to nature’s materiality. Through multiple sensory perceptions (touch, taste, smell, hearing, and vision), the body converts the mechanical sensory energy (information) into stimulated, electrical neurological energy in order to be perceived, assembled, and interpreted by the brain (meaning) (Ackerman 1990). While one is immersed in a natural setting, sensory experiences favorable to individuals are experienced as pleasant (hearing babbling brook, feeling the sun’s warmth, or the amazement of a vista overlooking the Grand Canyon), and those interpreted as unfavorable are not preferred (Frumkin et al. 2017), such as allergic reactions, pesky bugs and ticks, excessive heat, humidity or sun exposure, air pollution, water contamination, or areas affected by natural disaster such as flooding, wildfires, or severe droughts.
Nature experiences directly influence the physical and psychoneurological components of well-being through delivering new information through one’s body sensations, thus creating a series of translations by differing neuron combinations of recall or memory. Sensation interpretations, or episodic information, include the memory for things and/or events that happened including one’s perception of experience. Semantic information (or memory) is generalized knowledge such as the familiar information from the past, specific facts devoid of content (Devitt et al. 2017). Memory itself is goal oriented, yet both emotive and cognitive systems are cross-connected. For example, semantic memory is knowing that Yellowstone, the first US National Park, was established March 1, 1872, by President Ulysses S. Grant. Remembering the overpowering rotten egg sulfur smells of the geothermal pools or sighting a gray wolf during a trip to Yellowstone is an episodic memory. Another central human neuropsychological function is the self-generated thoughts of imagination that are also connected to memory and sensation that creates of significance of reality. The multidimensional perception of imagination is active internal processing that allows humans to contemplate matters beyond the immediate present by weighing possible and impossible information or the perception of the invisible and visible for the unconstrained creation of ideas (Abraham 2016; Beaty and Schacter 2017; Gotlieb et al. 2018). Human body systems have evolved in natural spaces; therefore, our brains and minds inherently respond to a sense of primordial landscape. Because of the connection between sensory experience and brain activity, emotions can also be experienced during nature experiences. For example, a pleasant odor signals the amygdala in the brain (responsible for emotional responses) and then transmits to the hippocampus, a region of the brain crucial that links relevant information into a new memory. When a human experience evokes a strong emotion, the hippocampus also links the emotion to memory of a past experience. A strong connection is established between olfactory processes and emotional processes that are cognitively generated (Keller 2016).
For most, however, human vision is the primary sense receptor to appraise and understand the world (Ackerman 1990). The benefits of visual and physical access to “green” environments can be traced back to established practices such as shinrin-yoku or forest bathing experiences in Japan. These kinds of benefits have been identified in various domains such as environmental psychology, environmental epidemiology (Fong et al. 2018; James et al. 2016), city and urban planning (Douglas et al. 2017), health geography (Bell et al. 2018), and neurosciences (Beaty et al. 2018). The most studied experiences are the salutogenic gains/effects of visual experience and especially with “green” and “blue” landscapes (Gascon et al. 2015; Pearson et al. 2017). Rarely studied are the effects of human interactions with brown, gray, and white aspects of natural settings (e.g., rock or snow environments) – especially the non-therapeutic aspects (Finlay 2018). Few studies have examined other sensory modalities such as the auditory (e.g., bird song – Nishida and Oyama-Higa 2014), olfactory (e.g., plant scents in urban smellscapes – Quercia et al. 2016), and tactile ways in which human bodies can connect with nature and derive therapeutic benefits.
Restorative influences of ecotherapy
General physical well-being
Positive changes found in dexterity, mobility, resilience, and stamina through exercise, reduced blood pressure, reduced headaches, reduced cortisol levels, and enhanced immune system
A sense of physical health also contributes to psychological well-being. For example, reduced BP and allergies and lower mortality from cardiovascular disease also improve one’s self-perceived general well-being (Shanahan et al. 2016)
Psychological and cognitive well-being
Improved concentration and memory and numeracy; improved academic and learning performance; relief of depression/anxiety, the lack of negative judgment and of trust in oneself, pride, and self-esteem; and reconciliation with events/people/situations through the use and understanding of the interpretation of nature metaphors (Shanahan et al. 2016)
Self-management, self-esteem, improved social relations and skills, employability, sociopolitical awareness, and higher eco-ethical consciousness (Frumkin et al. 2017; Pedretti-Burls 2007), enrich human life with meanings and emotions; fulfill important noncommercial and non-consumptive human needs (Sandifer et al. 2015)
Other ecotherapy outcomes
A sense of synergy with nature (sky, animals, plants, and the cycles of the life/seasons); a sense of freedom in the outdoors; a sense of discovery and surprise, skills development, and employability; and an enhanced sense of place (Pedretti-Burls 2007)
These health benefits are identified after experiences in nature whether it is through physical or visual access. During these experiences, it is the human perception and interaction with specific objective characteristics of nature that has been studied. For example, an individual perceives the surrounding landscape as either green, blue, or white, whether there is sufficient exposure to light, and how much contact is desirable. The following paragraphs outline the findings under green, blue, and white objective/subjective characteristics.
Effects of experiences in green settings: Operationalizing therapeutic effects of “green” experiences varies widely and includes measuring different scale, texture, color, and context. Despite these variants, there is a strong consensus in the benefits of “green” settings – distilled into three pathways: (a) reducing harm (by reducing exposure to negative environmental stressors such as air pollution or excessive heat), (b) restoring capacities (attention restoration and psychophysiological stress recovery), and (c) building capacities (physical activity or social cohesion) (Markevych et al. 2017, p. 302). Moreover, benefits of “greenness” have been established across a person’s lifetime through prenatal development, childhood activity, adolescence, adulthood, and later life (Douglas et al. 2017). Some benefits of exposure to green spaces include lower depression (Fong et al. 2018; Bezold et al. 2018), better respiratory health (Feng and Astell-Burt 2017), and enhanced attention (Sullivan and Chang 2017). Hartig and Kahn’s (2016) overview of “living in cities naturally” suggests that providing opportunities for green nature experiences within cities will create associated health benefits; however, there is a lack of medical agreement among health professional of the duration and exposure baseline of what is considered nature exposure across the different generations. Longitudinal or cross-sectional studies on the lifetime benefits of nature exposure may be difficult as much of society experience fewer nature contact opportunities due to lifestyle choices or due to increasing number of extreme climate change weather episodes.
Effects of experiences in blue and white settings: While green spaces refer to trees, ground cover, and vegetation, there are other aspects of nature such as the blue spaces referring to surface water bodies – lakes, rivers, beaches, and coastal areas – and white spaces referring to winter snow and ice environments. Studies exploring human connections with bluescapes (see review in Gascon et al. 2017) are very few and do not provide conclusive connections between access to bluescapes and health outcomes. A few health-promoting aspects of staying near coastal areas such as higher physical activity levels, less stress, and happiness (Grellier et al. 2017) have been identified. Also, links between visual access to blue space and recreation opportunities (Pearson et al. 2017) and improvements in reduced obesity rates and improved cardiovascular-related outcomes are prevalent (Gascon et al. 2017). Other studies have examined the mental health benefits of listening to nature sounds including ocean waves (Nishida and Oyama-Higa 2014) and recorded enhancement (mental tranquility) on indexes of mental health.
Although the study of ecotherapy as it relates to blue settings continues, there is very little research on the ecotherapy effects of experiences and activities in white snow-clad settings. One known study by Finlay (2018) investigated the experiences of older adults in a winter city and their challenges in navigating snow and ice with their diminishing health and abilities. In studying the effects on physical, mental, and social well-being in Minnesota, Finlay found that participants demonstrated resilience, pride in their continued adaptability, and strengthened social bonds through indoor winter activities. However, the white conditions with snow and ice accumulation heightened a fear of falling, a sense of isolation, seasonal affective disorder, feeling defenseless, and boredom or stress.
Effects of exposure and experiences with light: Ecotherapy experience of nature includes exposure to light – natural or sunlight has been associated with beneficial health outcomes such as maintaining healthy circadian rhythms, vitamin D production and calcium metabolism, hormone levels (e.g., cortisol, melatonin, serotonin), alertness, mood, and reduction in depressive symptoms (Veitch and Galasiu 2012; Webb 2006). Especially when modern schedules confine most human activity indoors, the daily light doses received by the human eye might not suffice, especially in northern winter environments. At such a time, artificial lighting, especially full-spectrum lighting, serves as a surrogate for the beneficial experience of direct exposure to sunlight (Mccoll and Veitch 2001). However, the presence of dark is equally important in health (Chepesiuk 2009) because light pollution, especially in urban areas, has the capacity to shift circadian rhythms in humans. Misalignment of these rhythms due to the nature of shift workers has been discussed as detrimental to health, specifically in terms of melatonin production (Hurley et al. 2013) and sleep fragmentation or disruption, which in turn influences the capacity of the human body to fight and keep diseases at bay (Uth and Sleigh 2014).
Dose-response relationship between nature and individual health and well-being: Current research indicates a multiplicity of associations by which ecotherapy can improve health and well-being outcomes, yet the ability to provide guidelines as to the type, duration, and frequency of exposure to nature may vary (Frumkin et al. 2017). For example, Shanahan et al. (2016) suggest that if urban residents were to visit outdoor green spaces for 30–75 min during a week, cases of depression would decrease by 7% and high blood pressure would decrease by 9%. Duncan et al. (2014) found that children who experienced “green” exercise had statistically significant lower systolic blood pressure 15 min post-exercise than children not exposed to green exercise.
Evaluative or reflective SWB – This refers to how well individuals’ think their life is going overall. The measure, life satisfaction, tends to be used frequently in neighborhood nature exposure studies.
Eudaimonic SWB – This addresses whether individuals think that their behaviors/activities are meaningful/worthwhile. Most common measures of this SWB are feelings of vitality and/or prosocial behaviors, following single nature exposures. Few studies have used this variable in nature-related studies.
Positive experiential SWB – This refers to emotions of pleasure (e.g., happiness) that individuals regularly experience. This is found to be a typical variable in “specific site visit” studies.
Negative experiential SWB – This addresses emotions of pain (e.g., anxiety) that individuals’ regularly experience and is most commonly measured in “specific site visit” studies.
White et al. (2017) found that evaluative or reflective SWB was positively related to amount of neighborhood green exposure and visit frequency. Individuals who had neighborhood nature exposure everyday were nearly 2.5 times more likely to report eudaimonic SWB than individuals who never visited nature. Self-reported eudaimonic well-being increased with each increase in nature visit frequency. Finally, a recent nature visit was positively associated with positive experiential SWB. More studies on the variety of current ecotherapy activities and its objective and subjective effects on individual health and well-being and the factors that influence those effects are needed.
Ecological, Economic, and Social Well-Being Effects
From a broader social-ecological perspective, “good health and well-being” is one of the 17 United Nations Sustainable Development Goals outlined for the next two decades. Impacts of specific green, blue, and white settings can be scaled up to a regional, national, and global (biosphere) level. All inhabitants within an ecosystem have intersecting and interwoven determinants of personal and public health that influence and are influenced by the sustainability triad – ecology, economy, and equity. Human biological and psychological factors come into play on a personal level, but ecological and global systems are also involved, as are economics and access to health care, which determine the social vulnerabilities to disease. These external connections and intersections play out in people’s everyday settings in various ways to impact their daily experiences. Government and community development priorities can influence whether and how beneficial human-environment interconnectedness occurs.
Urban greening integration projects through parks, street trees, and gardens (sometimes rooftop gardens) enhance aesthetic appeal but is also associated with urban revitalization benefits (Haase et al. 2017). Moreover, urban greening initiatives increase opportunities for relational/transactional exposure to nature, thereby improving social capital, but not always in an equitable or safe manner. The greening efforts are typically clustered around higher-income neighborhoods, and a lack of proximal green space raises environmental justice concerns (Wolch et al. 2014). Moreover, there is a balancing act between social equity and ecological preservation and development. Positive social effects of urban greening at individual, community, or national scale include increased or facilitated social interaction, increased opportunities for interracial interaction, reduced level of fear, fewer incivilities, and less aggressive and violent behavior (Sandifer et al. 2015). The type and species of the urban “green” can differ – serving ornamental, utilitarian, or both purposes – for example, fruit trees planted in crowded slums in southern India not only provided “greening” but also food (e.g., Gopal and Nagendra 2014).
Sustainable ecosystems, such as canopy trees, help regulate local temperatures, prevent heat concentrations, and reduce energy demands. Native prairie plants retain the soil structure of watersheds. Additional ecological benefits of vegetation are the promotion of pollination and wildlife habitat, sequester and storage of carbon, and reduction of urban noise (Frumkin et al. 2013). Street trees and sustainable infrastructure such as bioswales with regional planting in parking lots help manage stormwater runoff and control erosion of topsoil. Nowak et al. (2014) found that the health benefits of trees and forested areas were different in rural areas versus urban areas within the USA. Trees and forests in rural areas had beneficial effects on air quality by removing gaseous pollutants. The greater the tree cover, the greater the pollution removal. In urban areas with numerous trees, acute respiratory symptoms were reduced compared to urban areas that lack trees.
Communities that have overlooked the benefits of nature-community connections are more likely to experience cost consequences. Economic burdens are associated with ill-health, particularly chronic conditions such as cardiovascular and respiratory diseases, and other diagnoses such as diabetes and cancer. In industrialized countries with national/social health insurance and universal health care, costs are managed through higher taxation. These costs are experienced at various scales of reference depending on how costs are incurred and shared – international, national, regional, and local. They may only serve to create greater divides between those who can afford health care and those who cannot (Jan et al. 2018). A recent review of costs and benefits of urban forestry (Song et al. 2018) found that this area of research is dominated by studies conducted in North America and with deciduous trees. The existing research identified that economic benefits were clearly associated with aesthetics and shading qualities but less clearly with the ecological benefits such as water regulation, carbon reduction, and better air quality. Vogt et al. (2015) report that there is emerging research on understanding the costs of not maintaining the urban forest. Recognizing these the human-environment engagements within a dynamic spatial-temporal biosphere influence additional for ecotherapy opportunities.
The previous sections help outline the integration of nature as an individual health and well-being change agent. In our modern lives, a sense of place and a sense of human connection to place has been eroded by decreased use of outdoor public space, increased interior living, and overshadowed by recent technologies and services that do not require one to leave home (Solnit 2000). Ecotherapy interventions are aimed at reconnecting the physical, physiological, social, and emotional links with nature with a holistic emphasis on human intrinsic experiences. As we continue to develop a better understanding of the multisensorial characteristics of ecotherapy as therapeutic, palliative, or salutogenic (health-supporting), it is necessary to include multidisciplinary modalities to investigate the many interacting variables and influencing factors.
There are many gaps in our understanding of ecotherapy exposure, experiences, and effects. While there is some perspective on the physiological connections between sensory perception and cognitive and emotional manifestations, we are yet to understand specific types of nature spaces (e.g., indoor, urban, production landscapes, or wildlands), the types of nature exposure (e.g., duration, frequency, mode, or context), and the full measure of human engagement of mind-in-body experience. Each individual’s levels of affinity with nature are influenced by innate feelings and sensations (Kellert and Wilson 1993; Grinde, and Patil 2009) and learned interactions through cultural and socioeconomic contexts.
A clearer understanding of the negative impacts of nature contact – allergic reactions and excessive sun exposure – is also needed (Frumkin et al. 2017) in cases of contraindications of ecotherapy. For example, the emergence of tick-borne diseases or viral infections will influence the type, level, duration, and location of nature contact. Today’s adverse risks however are different than in the remote hunter-gatherer past – contemporary societies may be creating and facing new risks by not going outside to have enough beneficial encounters with nature. For example, there is a significant rise in allergies and loss of immune function in the worldwide population, partially attributed to declining nature contact (as reported in Frumkin et al. 2017). Research agendas in the future might benefit from identifying if there are vulnerable populations who most would benefit from ecotherapy interventions especially during childhood to boost one’s immune system. Research has yet to make clear which of the reported benefits of interacting with nature are universal and which are culturally and racially specific (Keniger et al. 2013; Frumkin et al. 2017). In addition, a person’s sense of place or ecological agency will determine whether they have a stake in their landscape and the landscape has a role in health and well-being.
Methodology for studying human experience in nature is evolving; studies have explored natural versus contrived settings. Virtual experiences versus actual experiences using quantitative and qualitative methodology will utilize innovations in technology to measure ecotherapy outcomes (such as wearable cameras and bio-monitoring devices/fitness trackers) and various age groups of research participants. There is an additional need for research in blue and white spaces and other sensory modalities of experience. With a fuller view of holistic, person-centered ecotherapy, better individually tailored health and well-being outcomes can be realized.
More research is necessary to identify the differences in value of ecotherapy between most developed and least developed nations. As we face an increasingly technological, urbanized world, connections between the individual, local, national, and international contexts must be viewed and interpreted from a variety of lenses – public health, spatial configurations, individual experiences, and policy. Alongside this systemic approach, the interactions between the physical, psychological, physiological, and social justice aspects of health must be studied. Finally, for ecotherapy benefits to be realized, there is a need to maintain the quality, diversity, and sustainability of the biosphere including an emphasis on equity among the world’s populations.
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