Nature matters in mental health

In this blog post, authors Rosa Roberts and Tom Fisher explain the concept of nature-based practice, and discuss the growing body of evidence for its benefits to mental health.

Nature-based practice is an umbrella term that can include making small adjustments to bring nature into existing practice, as well as structured nature-based interventions such as allotment groups, mindful walking or other therapeutic activities within a natural setting (Sometimes offered through ‘Green Social Prescribing’).

There is a growing body of evidence relating to the mental health benefits of connectedness to the natural world.

Good for patients

Engaging with nature is linked to positive health benefits and general wellbeing across age ranges, cultures and social class^1,2, with those reporting lower wellbeing scores initially experiencing the greatest improvements³. Studies have shown that nature-based practices can lead to improvements in symptoms of depression, anxiety, addictions, emotional regulation and difficulties associated with autism ^3,4,5,6,7,8. Nature exposure has also been found to play an important role in child development, benefitting overall wellbeing, cognition and ADHD symptoms⁹.

A 2023 systematic review of 92 randomised controlled trials found significant reductions in depression and anxiety scores with nature-based interventions, as well as improvements in physical health measures such as lowered blood pressure¹⁰.

Nature-based interventions have also been shown to positively affect some of the more profound aspects of the human experience, such as meaning, purpose, belonging, self acceptance and sense of autonomy^{11, 12}. There is a wealth of evidence to show that a person’s connection to nature is key to the physical and mental health benefits of nature exposure^12,13,14, and that interventions which facilitate nature connection have the largest and most sustained positive impacts^15,16,17.

“Especially if you’re unwell - actually it’s really hard to leave the house - and so if you do manage to kind of get out of the house, then actually it does make you feel better, and I feel that you get that sense of perspective a little bit more, it’s easier to kind of … talk yourself down from a ledge if you’re outdoors.”^a

“I have been diagnosed with stress and anxiety, being involved at the allotment and the mindfulness course has been transforming. I cope much better with stress and anxiety, which has meant that my work performance has improved. Whereas before I found it stressful to have face-to-face interactions, now I feel much more comfortable”^b

Participants of nature-based interventions have reported enhancement in the therapeutic relationship and feeling empowered to take an active role in their own recovery¹⁸.

Good for the community

As well as individual health benefits, research shows that nature-based interventions can lead to improvements in social cohesion, social empowerment and social support, reducing feelings of loneliness and social isolation^19,20,21. Contact with nature may have advantages to low-income populations, giving the potential to reduce health inequalities²². The Royal College of Psychiatrists recognises this and states:

“There is clear evidence healthy environments and contact with nature are important for our mental health… equal access to nature must become a priority of the UK government, NHS and Mental Health Services.”²³

“I am very happy to be part of these sessions, it provides me good feeling about myself, coming to nature and involving these sessions at green space, it is so refreshing, It makes me feel better mentally, I feel so much relief every time, I come and involve this.

“This is important for my community who mostly live these local flats to come down and involve these sessions, it is so friendly, and we can sustain in long run. Coming to green space make me feel better and boost my mental wellbeing. Thanks for the Bristol Somali youth voice and green social prescribing project team for doing this and giving us this opportunity to involve.”^c

Good for staff

There are clear benefits to staff wellbeing of working in and with nature, which may help protect against burnout¹⁸. People with strong levels of nature connectedness feel happier and function better than those with lower levels. Increasing the nature connectedness of staff can improve employee wellbeing, with follow-on benefits for staff sickness, performance, and retention²⁴. Studies have shown limitations to employee’s exposure to nature contacts could impact levels of work related stress and stress-related behaviours²⁵.

“… being out of this building was really beneficial for us, it helped with burnout.”^d

“I always come back thinking I’m so glad I got out, you just feel refreshed … a different kind of fresher approach when you’re coming back to your work.”^d

“It restores us too!”^e

Good for the planet

There is evidence that nature-based interventions may be more cost effective than traditional models of care, as well as being a more sustainable and lower-carbon alternative^26,27. Nature-based interventions which lead to increased nature connectedness also lead to increases in pro-environmental and pro-conservation behaviours, which are vital in addressing the climate and environmental crisis^28,29,30.

International and governmental recognition

The integral links between nature and health have been recognised at both International and Governmental levels. The 2020 Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services (IPBES) Report recognised that our mental and physical health is inextricably linked with the health of the natural world³¹. The UK Government 25 year plan includes multiple policies related to “Connecting people with the environment to improve health and wellbeing”, including “Considering how environmental therapies could be delivered through mental health services”³².

Theoretical frameworks for understanding the benefits of human-nature interactions:

Despite the evidence for the benefits of nature-based care, a 2023 Government report on the national state of Green Social Prescribing found that across the country the network of nature-based providers is patchy and diverse, often struggling to cater for those with more significant mental health needs. The report recommended several system changes, including better links into the health service³⁸. This report demonstrates that there is a clear role for mental health trusts in helping to deliver these services, both in collaborating with and providing training for nature-based providers to care for those with significant mental health difficulties, and also training and supporting staff to integrate nature-based care into their service, to provide these evidence-based interventions themselves.

“You’re both in nature together so you’re kind of barriers are down… it’s just like you’re two people out in nature rather than… therapist and this… person that needs help.”^d

Have a look at the podcasts and resources below for more ideas on how to integrate Nature into your own practice as a psychiatrist.

By Rosa Roberts and Tom Fisher

Quotes

1. Mother Nature Project (forest bathing sessions for mothers with postnatal difficulties and their babies¹⁸)
2. Mindfulness through nature connection programme
3. Bristol Somali Youth Voice – Green Social Prescribing Project
4. Bringing Nature into CAMHS^{24 -} 2022 study with CAMHS inpatient staff who had recently undergone nature-based facilitator training²⁴
5. Community Rehabilitation Team - Nature-based practice reflection group

References

1. Pritchard A, Richardson M, Sheffield D, McEwan K. The relationship between nature connectedness and eudaimonic well-being: a meta-analysis. J Happiness Stud. 2019;21:1145–67. doi: 10.1007/s10902-019-00118-6.
2. Bratman GN, Anderson CB, Berman MG, Cochran B, de Vries S, Flanders J, et al. Nature and mental health: An ecosystem service perspective. Sci Adv. 2019;5(7):0903. doi: 10.1126/sciadv.aax0903.
3. Rogerson M, Wood C, Pretty J, Schoenmakers P, Bloomfield D, Barton J. Regular Doses of Nature: The Efficacy of Green Exercise Interventions for Mental Wellbeing. Int J Environ Res Public Health. 2020 Feb 27;17(5):1526. doi: 10.3390/ijerph17051526. PMID: 32120892; PMCID: PMC7084199.
4. Richardson M. Beyond restoration: considering emotion regulation in natural well-being. Ecopsychology. 2019;11(2):123–129. doi: 10.1089/eco.2019.0012.
5. Bratman GN, Daily GC, Levy BJ, Gross JJ. The benefits of nature experience: improved affect and cognition. Landsc Urban Plan. 2015;138:41–50. doi: 10.1016/j.landurbplan.2015.02.005.
6. Grigsby-Toussaint DS, Turi KN, Krupa M, Williams NJ, Pandi-Perumal SR, Jean-Louis G. Sleep insufficiency and the natural environment: results from the US Behavioral Risk Factor Surveillance System survey. Prev Med. 2015;78:78–84. doi: 10.1016/j.ypmed.2015.07.011.
7. O'Brien L. Engaging with and Shaping Nature: A Nature-Based Intervention for Those with Mental Health and Behavioural Problems at the Westonbirt Arboretum in England. Int J Environ Res Public Health. 2018 Oct 10;15(10):2214. doi: 10.3390/ijerph15102214. PMID: 30309039; PMCID: PMC6210670.
8. Vujcic M, Tomicevic-Dubljevic J, Grbic M, Lecic-Tosevski D, Vukovic O, Toskovic O. Nature based solution for improving mental health and well-being in urban areas. Environ Res. 2017 Oct;158:385-392. doi: 10.1016/j.envres.2017.06.030. Epub 2017 Jul 5. PMID: 28688269
9. McCormick R. Does access to green space impact the mental well-being of children: a systematic review. J Pediatr Nurs. 2017;37:3–7. doi: 10.1016/j.pedn.2017.08.027.
10. Nguyen, P-Y. Astell-Burt et al. Effect of nature prescriptions on cardiometabolic and mental health, and physical activity: a systematic review. The Lancet Planetary Health. 2023. Volume 7 Issue 4 E313-328.
11. Pritchard A, Richardson M, Sheffeild D, McEwan K. The relationship between nature and Eudaimonic Well-being: A meta-analysis. Journal of Happiness Studies. 2020; 21(1) DOI
12. Zelenski, J. M. & Nisbet, E. K. (2012). Happiness and feeling connected: the distinct role of nature relatedness. Environment and Behaviour, 14(1), 3-23.
13. McEwen K, Richardson M, Sheffield D, Ferguson F, Brindley P. A Smartphone App for Improving Mental Health through Connecting with Urban Nature. Int J Environ Res Public Health. 2019 Sep; 16(18): 3373. Published online 2019 Sep 12. doi: 10.3390/ijerph16183373
14. Richardson M, Cormack A, McRobert L, Underhill R. 30 Days Wild: Development and Evaluation of a Large-Scale Nature Engagement Campaign to Improve Well-Being. PLoS ONE 11(2) Feb 2016; https://doi.org/10.1371/journal.pone.0149777
15. Arbuthnott, K. D., Sutter, G. C., & Heidt, C. T. (2014). Natural history museums, parks and connection with nature. Museum Management and Curatorship, 1-20. doi:10.1080/09647775.2014.888818
16. Mayer, F. S., Frantz, C. M., Bruehlman-Senecal, E., & Dolliver, K. (2009). Why is nature beneficial? The role of connectedness to nature. Environment and behavior, 41(5), 607-643.
17. Williams, I. R., Rose, L. M., Olsson, C. A., Patton, G. C., & Allen, N. B. (2018). The impact of outdoor youth programs on positive adolescent development: Study protocol for a controlled crossover trial. International journal of Educational Research, 87, 22-35.
18. David Francis Hunt, Mia Morgan, Michéal Connors & Catriona Mellor (2022) Bringing nature into CAMHS inpatient services: reflections for the implementation and integration of training into practice, International Review of Psychiatry, 34:5, 546-552, DOI: 10.1080/09540261.2022.2080530
19. Weinstein N, Balmford A, Dehaan CR, Gladwell V, Bradbury RB, Amano T. Seeing community for the trees: the links among contact with natural environments, community cohesion, and crime. Bioscience. 2015;65(12):1141–1153. doi: 10.1093/biosci/biv151.
20. van den Berg MM, van Poppel M, van Kamp I, Ruijsbroek A, Triguero-Mas M, Gidlow C, et al. Do physical activity, social cohesion, and loneliness mediate the association between time spent visiting green space and mental health? EnvironBehav. 2019;51(2):144–166. doi: 10.1177/0013916517738563.
21. Wild at Heart: A mixed method evaluation of a wildlife-related intervention for older people,September 2016, Journal of Epidemiology and Community Health 70(Suppl 1):A71.1-A71 DOI:10.1136/jech-2016-208064.139
22. Ganzleben C, Kazmierczak A. Leaving no one behind - understanding environmental inequality in Europe. Environ Health. 2020;19(1):57.
23. Nature Contacts: Employee Wellness in Healthcare. Trau D, Keenan KA, et al. Health Environments Research and Design Journal. 2015. Vol 9, Issue 3
24. Hinde S, Bojke L, Coventry P. The cost effectiveness of ecotherapy as a healthcare intervention, separating the wood from the trees. Int J Environ Res Public Health. 2021;18(21):11599. doi: 10.3390/ijerph182111599.
25. A Natural Health Service: Improving Lives and Saving Money (PDF).
26. DeVille NV, Tomasso LP, Stoddard OP, Wilt GE, Horton TH, Wolf KL, Brymer E, Kahn PH Jr, James P. Time Spent in Nature Is Associated with Increased Pro-Environmental Attitudes and Behaviors. Int J Environ Res Public Health. 2021 Jul 14;18(14):7498. doi: 10.3390/ijerph18147498. PMID: 34299948; PMCID: PMC8305895.
27. Yongbo Liu, Anne Cleary, Kelly S. Fielding, Zoe Murray, Anne Roiko,

    Nature connection, pro-environmental behaviours and wellbeing: Understanding the mediating role of nature contact,Landscape and Urban Planning,Volume 228,2022

28. Whitburn J, Linklater W, Abrahamse W. Meta-analysis of human connection to nature and proenvironmental behavior. Conserv Biol. 2020 Feb;34(1):180-193. doi: 10.1111/cobi.13381. Epub 2019 Jul 12. PMID: 31251416; PMCID: PMC7027494.
29. Royal College of Psychiatrists: PS03/21: Our planet’s climate and ecological emergency. May 2021
30. University of Derby: Nature Connected Organisations Handbook (PDF)
31. IPBES (2019): Global assessment report on biodiversity and ecosystem services of the Intergovernmental Science-Policy Platform on Biodiversity and Ecosystem Services. E. S. Brondizio, J. Settele, S. Díaz, and H. T. Ngo (editors). IPBES secretariat, Bonn, Germany. 1148 pages. https://doi.org/10.5281/zenodo.3831673
32. A Green Future: Our 25 Year Plan to Improve the Environment. Department for Environment, Food & Rural Affairs and The Rt Hon Michael Gove MP Published: 11 January 2018, Last updated:17 February 2023
33. Wilson, E. O. (1984). Biophilia. Cambridge, MA: Harvard University Press
34. Kaplan S. The Restorative Benefits of Nature: Toward An Integrative Framework. Journal of Environmental Psychology. 1995(15 (3): 169-182)
35. Ulrich R, Simons R et al. Stress Recovery During Exposure to Natural and Urban Environments. Journal of Environmental Psychology. 1991(11 (3): 201-230).
36. Richardson, M., McEwan, K., Maratos, F. et al. Joy and Calm: How an Evolutionary Functional Model of Affect Regulation Informs Positive Emotions in Nature. Evolutionary Psychological Science 2, 308–320 (2016).
37. Mathew P. White, Terry Hartig, Leanne Martin, Sabine Pahl et al. Nature-based biopsychosocial resilience: An integrative theoretical framework for research on nature and health,Environment International, Volume 181,2023, 108234, ISSN 0160-4120, https://doi.org/10.1016/j.envint.2023.108234.
38. National Green Social Prescribing Delivery Assessment: final report. 2023. Department of Health and Social Care.