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Nature: A Key Ingredient for Mental Health

December 8, 2023 By: Robert Zarr, M.D. & Winnie Chan, Ph.D. Read time:

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Nature: A Key Ingredient for Mental Health
A growing body of research shows how being in nature helps people contending with mental illness.

When was the last time you went to a park? Do you take breaks during your day to go outside? Is your home or office filled with green plants? It turns out that all of these things are good for our mental health.

A 2015 study by researchers at Stanford University, published in Proceedings of the National Academy of Sciences, found that compared with participants who walked in a high-traffic urban setting, people who walked for 90 minutes in a nature area showed decreased activity in a region of the brain associated with depression.

Nature-rich experiences can also reduce stress and restore attention, including our brain’s ability to focus. While workers in the U.S. are largely praised for their ability to efficiently multitask, doing so can result in brains that are overworked in discerning what to focus on and what to ignore, which can lead to fatigue and poor mental health. But recent science shows us that nature can help rest and restore the neural pathways that underlie our focus and attention. For example, using an experimental design, researchers from the University of Michigan found that people who completed a difficult cognitive task and then took a walk through an arboretum reported a happier mood and better working memory than those who did the same task and then walked around an urban setting.

Interactions with nature can also promote overall well-being. Researchers in Israel surveyed 776 adults in 2021, during the COVID-19 pandemic, to understand the association between nature exposure and positive feelings. They found that viewing nature from windows, living near nature, and being outdoors were associated with high levels of self-reported positive emotions. Moreover, the participants able to view nature from their windows reported feeling happier. In the U.S., researchers from the University of Iowa who conducted an online survey during the pandemic found a similar benefit: Among the 558 adults who completed the survey, those who had greater access to nature reported higher levels of well-being.

A growing body of evidence shows that spending time in nature bolsters our mental health, promotes positive emotions, and helps reduce negative thoughts—all of which has led an increasing number of health professionals to prescribe nature as a cure or treatment for a variety of ailments.

But what does it mean to prescribe nature? Nature prescriptions (Nature Rx) fall under the larger umbrella of social prescriptions—like healthy sleep habits, eating fruits and vegetables, or even reading to your child at night. And they are synonymous with park prescriptions (spending time in an established park) but are broader and more encompassing—especially for people with limited access to safe and quality outdoor spaces. There is a diversity of park prescription programs in the U.S., and several organizations and agencies—including the Centers for Disease Control and Prevention, the National Park Service’s Healthy Parks Healthy People program, the National Environmental Education Foundation, and the Institute at the Golden Gate—have all contributed generally to the nature and health movement and specifically to nature/park prescriptions.

And early studies are showing the benefit: A randomized trial of park prescriptions, conducted by researchers from the University of California, San Francisco; the University of California, Berkeley; and Cornell University found that weekly park visits reduced stress and loneliness in low-income parents after three months of participation. Stress was measured by saliva cortisol, and loneliness was measured by the modified UCLA Loneliness Scale. Seventy-eight parents were enrolled in the study, and all participants received counseling from their physicians about the value of nature, along with maps of local parks. Fifty of them received additional support, such as additional text and phone call reminders, free transportation, food, and structured programming at the parks. Participants who received additional support did not report lower stress levels than those who did not receive additional support.

Park Rx America (PRA), a nonprofit founded in 2017, has gone a step further to establish a community of health care professionals who share the common goal of issuing nature prescriptions to their clients as part of patients’ treatment plans. Among PRA’s 1,700 registered health professionals, nearly 15% work in the mental health field as psychiatrists, psychologists, licensed social workers, or counselors.

PRA’s nature prescribing platform is accessible to all, regardless of geographical location or type of practice. After providers watch a short instructional video to train themselves, they can begin immediately prescribing nature within the confines of a comfortable “architecture”—with each prescription including a place, activity, frequency, and duration. Since providers are already adept and comfortable with the structure of medication prescriptions, nature prescriptions are similar enough. However, there are some fundamental differences.

Medication prescriptions don’t require much conversation with the patient, except to clarify allergies, potential drug interactions, and side effects. And as a general rule, patients don’t have much say in terms of which medications and dosages they’re going to take. In contrast, when writing nature prescriptions, providers ask patients pertinent questions to better understand their readiness to make a behavioral change, as well as potential social and structural barriers.

PRA’s nature prescription comes with standard prompts that put the patient in the driver’s seat while capitalizing on the provider’s medical expertise to safely maximize therapeutic potential. For example, let’s look at the case of Mr. Jimenez, a 75-year-old Mexican-American with a history of long-standing diabetes, hypertension, and congestive heart failure, who was recently diagnosed with depression after the recent loss of his life partner. Here are a few clarifying questions the provider might ask:

Will you walk alone or with someone, possibly even a pet? Might there be a body of water nearby, like a river, lake, or pond? Do you intend to listen to music or a podcast while walking?

These help the provider take into account the patient’s health status (especially his congestive heart failure and depression) as well as the potential benefits of social contact, the positive effects of a nearby body of water, and the calming and attention-restoring effect of engaging his sense of hearing—especially the rustling of leaves and the chirping of birds. After a few minutes of consultation, the provider can write a nature prescription that considers how Mr. Jimenez can safely and comfortably spend more time in nature:

Walk along a trail near a pond, with a neighbor or friend, without earbuds, for a half-hour, every day.

An electronic prescription reminder allows patients to log their time and keeps the provider and patient connected from one visit to the next. And at his next visit, after Mr. Jimenez is asked the same series of questions about place, activity, frequency, and duration for his follow-up, his blood pressure is rechecked, and he undergoes a quick depression symptom inventory, his prescription could easily change to:

Visit a Japanese garden, sit near a pond, and notice the sounds and smells around you for 20 minutes, twice a week.

Rather than focusing solely on a patient’s “problem list”—literally a list of medical problems that health professionals use to frame the encounter—nature prescriptions focus on what is positive, fostering hope and possibility and finding creative ways to improve health and help individuals feel better. In this way, nature prescriptions can be viewed as a tool to empower patients to improve their health in their own way, imparting a feeling of control—patients can rely on their assets rather than focusing on their deficits. And as every person is unique, individual circumstances will help providers formulate a unique plan for their patients’ interactions with nature.

Just as clinicians consider an individual’s readiness to initiate behavioral change, it is useful to look at the larger context within which patients live, work, study, entertain, recreate, and sleep—the social and physical determinants of health. Imagine recommending that your patients eat more fresh fruits and vegetables when they are unemployed, disabled, or live in a neighborhood that is a food desert. Furthermore, layers of structural racism and inequities create additional barriers that prevent individuals from marginalized communities from accessing the resources necessary to follow evidence-based advice. Keeping in mind an individual’s readiness and capacities, as well as social and structural environments, will only help the patient realize improved health.

Nature-rich experiences can reduce stress and restore attention, including our brain’s ability to focus.

Some might be wondering why prescriptions for nature are even necessary in the first place. After all, isn’t it just common sense to spend more time outside, given all the obvious health benefits, especially the mental health benefits of reduced stress; increased focus; improvements in depression, anxiety, and ADHD; opportunities for awe; increased creativity; and a sense of connectedness to the larger world? Yet, most of us spend upward of 90% of our awake and asleep time indoors. Many of us would in fact benefit from receiving not just a recommendation but also an actual prescription to spend more time in nature.

After several decades of research showing the obvious connections between positive health outcomes and time spent in nature, why haven’t we changed our routines to include more time in nature? Those who live within the structural confines of racism, poverty, ageism, ableism, and heterosexism can justifiably explain the lack of nature inclusion. Many people still don’t have access to safe and quality nature-rich spaces. Some may not have the resources, such as transportation and time, to participate in nature-based activities. People in some communities, such as those that include immigrants and refugees, may not know how and where to access nature-based activities. Nature prescriptions that do not address these structural barriers are less effective. Asking individuals to incorporate nature into their lives and daily routine without structural support is not the best path forward.

How might policy changes in our workplaces and schools affect the likelihood of our spending more time in nature? How might new policies dictate the degree of designs that connect us to nature in our built environment? What does a healthier and happier workforce mean for productivity from an economic standpoint? These are questions that science may not yet have answers for but that could be prioritized in research agendas. Rather than expecting individuals to make these changes in their lives, perhaps it’s time to take more seriously system-level changes that make the “right decision” become the “easy decision.” 

And what about health care providers? Of the 18 million health care providers in the U.S., why the embarrassingly low level of adoption of nature interventions into their practice? So many providers continue to work in rooms with no sunlight and no indoor plants and have no inclination to issue nature prescriptions or similar nature intervention in their practices. This is because nature and health curriculum in health professional training is largely absent. Continuing education courses for providers rarely, if ever, include the preponderance of data linking improved health outcomes to time spent in nature. For many mental health professionals, nature as therapy simply isn’t on their radar.

Nevertheless, there are examples of innovations—like walk and talk therapy, where therapists literally take their clients on walks to reap the therapeutic advantages of both movement and nature. Jennifer Udler, licensed clinical social worker—certified, the author of Walk and Talk Therapy: A Clinician’s Guide to Incorporating Movement in Nature Into Your Practice, writes, “the physical act of moving forward seems to trigger a mental movement toward open mindedness.” In her guide, she shares many client anecdotes that illustrate how people’s observation of the natural world can serve as a metaphor for what they experience internally. Although this type of practice is encouraging, it remains rare among mental health professionals. 

Research in this area remains in its infancy. Not only do we need to better understand the change in health outcomes as a result of issuing nature prescriptions, but we also need to better understand through implementation science (the study of methods and strategies that facilitate the uptake of evidence-based practice and research into regular use by practitioners and policymakers) where, exactly, the tipping point lies within the health professions to fully embrace nature interventions in practice settings.

If the topic of mental health and nature resonates with you, consider self-reflection as a first step. Given the low side effects of nature prescriptions and their relative ease of use, doing this yourself—for yourself—can provide meaningful insight into many of the benefits nature can bring for mental well-being.

Meaningful change, whether it be individual or systemwide, is more likely to be realized when we have a deeper understanding not only of the barriers to change but also an appreciation of our assets. Whether you are a health professional or the client of one, this kind of experiential knowledge can take you closer to improving your own mental health and that of the world all around.

The Takeaway

A wealth of new science shows that being around nature benefits our mental health by reducing stress and negative emotions, restoring attention, promoting positive well-being, and helping us feel happier—and some doctors are now even prescribing time outdoors.

Robert Zarr, M.D., holds a master’s degree in public health and is a physician researcher and public health pediatrician as well as the founder of Park Rx America. He is also a certified nature and forest therapy guide.

Wing Yi (Winnie) Chan, Ph.D., is a community psychologist and serves as the senior program director for the education program at Child Trends, a nonpartisan research center promoting the well-being of children, youth, and families.

Illustrations by Briana Okebalama/The Pew Charitable Trusts

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