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12 NATURE THERAPY
Having completed his doctoral studies at Columbia University and
undergone psychotherapeutic training at the William Alanson White
Institute in New York City, Clinebell brings a clinical perspective to nature’s therapeutic potential. Ecotherapy posits that patients experience
despair stemming from an unconscious desire to reconnect with the earth.
The ecotherapist helps patients access their environmental conscience
through psychodynamically informed counseling and nature-based activities. A key component of ecotherapy’s treatment plan involves patients engaging in environmental activities to restore the earth, which
aims to instill hope, foster a connection with nature, and provide a sense
of purpose (Clinebell 2013).
Clinebell also included a spiritual aspect of the human-nature connection. He acknowledged that the transformative potential of the human-nature relationship that he described in westernized language had
long been a part of the ancestral practice of many Indigenous peoples
of the Americas. Although Clinebell valued spiritual wisdom, he recognized that the scientifically minded mental health professionals might
be skeptical of nonvalidated methods. He cautioned readers that the evidence presented in his book was anecdotal and invited collaborators to
conduct more thorough research to explore the salutary effects of nature
on mental health (Clinebell 2013).
Enter the Twenty-First Century
In the decades since Roszak’s call to action and Clinebell’s invitation to
research, a slew of writers, clinicians, and scientists have answered in
kind. Research and publications on the intersection of nature and wellbeing have grown exponentially. A growing body of experimentally
derived and statistically significant evidence has supported what ancestral knowledge had already supposed. Miyazaki’s Shinrin-yoku
(forest bathing) experiments demonstrated stress reduction in both
physiological and psychological measures (Miyazaki et al. 2015). In
2004, the American Journal of Public Health published a study from the
University of Illinois at Urbana-Champaign conducted by Frances E.
Kuo and Andrea F. Taylor that suggested that activity in outdoor green
spaces reduced ADHD symptoms (Kuo and Taylor 2004). The new
wave of scientific inquiry did not focus on the psychodynamics of the
nature experience but rather investigated various forms of nature exposure as potential treatments for a wide range of human ailments, from
reducing cancer pain to modulating trauma responses in PTSD (Kuo
and Taylor 2004; Miyazaki et al. 2015; Summers and Vivian 2018).
The spotlight on the benefits of contact with a healthy environment
brought the consequences of environmental degradation into focus.
The Wise Outdoors 13
Limited access to high-quality green spaces in densely populated urban
areas was found to disproportionately affect socioeconomically disadvantaged groups and people of color. A 2022 working paper from the
National Bureau of Economic Research outlining a large-scale study
from 2003 to 2010 reported that air pollution was an independent risk
factor for suicide (Jennings et al. 2017; Persico and Marcotte 2022).
Technological advances in the twenty-first century brought more
opportunities to disengage from the outdoors. The proliferation of personal electronic devices, diversification of online entertainment options, and widespread adoption of social media meant that people
spent more time indoors glued to their screens than going outside. Richard Louv, an American writer and journalist, expressed concern about
the potential effect on children growing up without regular exposure to
nature. In his book Last Child in the Woods: Saving Our Children From Na-
ture-Deficit Disorder, Louv (2008) synthesized research on the benefits of
nature contact and warned of the opportunity cost for children who
missed out. Louv (2008) advocated for a concerted effort by parents, educators, policymakers, and medical professionals to get children outside.
In 2010, when Louv presented his message as keynote speaker to the
American Academy of Pediatrics, Robert Zarr, M.D., listened. Inspired
to help patients and their families benefit from what nature could offer,
Zarr partnered with the National Recreation and Park Association and
the National Park Service in 2013 to develop ParkRx (or Park Prescription). ParkRx is a national coalition of clinicians, community health organizations, and park departments directed through the Institute at the
Golden Gate. The coalition develops programs and educational resources promoting park activities as part of a healthy lifestyle. Physicians are encouraged to write literal nature prescriptions specifying the
frequency and duration of activity to their patients (James et al. 2019).
In 2022, the American Academy of Pediatrics published a press release
outlining recommendations for parents to bring their children outside.
Nature prescriptions caught on internationally. Japanese doctors have
been prescribing forest bathing since the 1980s, and New Zealand has
had a Green Prescription program for outdoor activity since the 1990s.
The nature prescription practice was picked up by South Korea, Finland,
and Canada. In 2020, as part of its coronavirus disease 2019 (COVID-19)
recovery plan, the U.K. government allocated £4 million ($5.2 million) to
fund a 2-year green prescription pilot program (Broom 2022).
Nature prescriptions for children not only increased physical activity and psychological well-being but also fostered positive early interactions with nature. Louv echoed Roszak’s concern that nature was
imperiled by human indifference to ecological harmony. Louv argued
14 NATURE THERAPY
that the antidote to the unabated destruction of the environment was to
ensure that the coming generation was invested in its preservation.
Louv’s hunch is supported by a cross-sectional study from Universidade Estadual de Santa Cruz, which found that pro-environmental behavior in adults was associated with formative nature experiences
during childhood (Fyfe-Johnson et al. 2021; Rosa et al. 2018).
Environmental health concerns extend beyond access to municipal
parks. Breathable air, potable water, stable shelter, and nutritious food
are the physiological basis of Maslow’s hierarchy of needs and are inextricably linked to planetary environmental health. The COVID-19 pandemic, which claimed the lives of more than 6 million people between
2020 and 2023, highlights the extreme consequences of disregarding
ecological interdependencies. Shrinking wildlife habitats and the black
market bushmeat trade have led to increased conflict between wildlife
and people. Endangered animal populations that are concentrated in
certain areas can harbor zoonotic illnesses that can be transmitted to humans through contact with poachers who bring infected animals to
market. Like HIV, Ebola, and severe acute respiratory syndrome before
it, COVID-19 is believed to have a zoonotic origin. The tragic toll of the
pandemic has spurred the international community to examine the systemic failures that enabled its spread (World Health Organization 2020).
In 2020, the World Health Organization (WHO) declared nature as
the greatest source of health and well-being. The first item of their sixpoint manifesto for a healthy recovery from COVID-19 was to “[p]rotect
and preserve the source of human health: nature” (World Health Organization 2020, p. 4).
This declaration lent institutional weight to Clinebell’s hypothesis
that people who participate in preservation of the environment are also
contributing to their own health and well-being.
The scope of nature therapy is as vast and diverse as nature itself. It
can be practiced through formal sessions or integrated into daily life as
spontaneous activities. Nature therapy encompasses cognitive exercises that reduce stress and restore attention through sensory exploration of natural elements. Some may practice nature therapy as a means
of ensuring a sustainable future for nature, allowing future generations
to derive their own benefits. The WHO declaration acknowledges the
importance of nature to human health and well-being, but it does not
guarantee the execution of conservation plans. The future of nature depends on motivated people who understand the significance of preserving nature and advocate for its protection. As Dr. Seuss’s (1971,
p. 58) mythical Lorax once said, “Unless someone like you cares a
whole awful lot, nothing is going to get better. It’s not.”
The Wise Outdoors 15
LIMITATIONS
Although a growing body of evidence supports the psychological benefits of nature-based interventions, limitations to the evidence prevent
nature therapy’s adoption into conventional medical practice.
One limitation is the high amount of variability in the methods of
nature delivery, which makes direct comparisons between studies
nearly impossible. Additionally, most studies on nature therapy are
cross-sectional, survey based, or case control in design.Although these
types of studies are useful in generating hypotheses and identifying potential associations, they cannot definitively prove causation by nature
therapy for improved health outcomes.
A few cohort studies have been done on nature therapy, but they
have limited statistical power because of the small number of participants. Randomized controlled trials (RCTs) are the gold standard of evidence-based treatments. RCTs can compare experimental treatments,
such as nature therapy, with care as usual to assess for comparative efficacy. To date, one RCT has investigated the application of nature therapy for a psychiatric condition.
Researchers from the University of Copenhagen, Denmark, compared
nature-based therapy with a specialized form of cognitive-behavioral therapy (CBT). Inclusion criteria required patients to have a functionally impairing diagnosis of adjustment disorder or acute stress reaction. The
primary outcome was the mean aggregate score on the Psychological
General Well-Being Index. The study found no statistically significant
differences between the treatment groups. Several drawbacks to the
study design may have affected the results. As with the cohort studies,
the number of participants was low, with 39 randomly assigned to the nature-based therapy group and 37 to the CBT group. Additionally, bias may
have been introduced by the inability to blind participants to the type of
therapy they were receiving. Nature-based therapy involved 3 hours of
therapy per session with three different therapists, and CBT involved
1 hour of therapy per session with one therapist (Stigsdotter et al. 2018).
Another limitation of the evidence base for nature therapy is that
many studies use measures of “wellness” rather than clinical psychiatric
symptom scales. This validation measure probably reflects the choice to
study how nature affects mental well-being in a generally healthy population rather than treating a diagnosed psychiatric disorder.
Although measures of wellness can provide valuable insights into
the subjective experiences of participants, their results may not be generalizable to improvements in psychiatric illness. Nature’s effects on
16 NATURE THERAPY
patients, much like psychiatric symptoms, are phenomenological,
meaning that they are based on subjective experiences and perceptions.
Review papers and meta-analyses examining the available literature
suggest that although observational studies indicate a small to moderate effect size, more powerful and rigorous studies using standardized
clinical psychiatric symptom scales are needed to assess nature therapy’s applicability to psychiatric treatment (Annerstedt and Währborg
2011; Bonham-Corcoran et al. 2022).
Clinical research on nature therapy is conspicuously absent from psychiatric literature, with most articles on the subject appearing in journals
of environmental psychology, landscape and architectural design, and
tourism. Although researching novel therapeutic modalities is not explicitly discouraged in psychiatry, receiving support for such experiments can
be difficult. Large-scale clinical trials are funded by private industry, which
expects a return on investment. Pharmaceutical companies can patent and
market their medications, but no equivalent market incentive is available
to promote greater use of nature, which is freely available to the public.
Not-for-profit research, such as in academics, often relies on obtaining grants, primarily through the National Institutes of Health. However, the grant approval process is highly competitive, with only a 20%
approval rate. Grants are more likely to be awarded to proposals that
conform to currently trending topics of interest rather than unconventional or unproven hypotheses.
Academic psychiatrists also may feel pressure to rapidly produce a
high volume of publications for professional advancement, which can
be easier to accomplish by continuing work in an established line of research rather than constructing a new experimental paradigm from
scratch (Lilienfeld 2017).
At the time of this writing, one large 5-year RCT is underway
through Kaiser Permanente investigating health outcomes of the
ParkRx nature prescription program. The study is expected to be completed by 2025. More RCTs with larger sample sizes and standardized
measures of psychiatric symptoms are needed to definitively establish
the efficacy of nature therapy and identify which populations and conditions are most likely to benefit from this approach (Zarr et al. 2022).
GUIDELINES
Even without the backing of large-scale, double-blind RCTs, the available evidence suggests that nature has a positive effect on overall wellbeing. The following chapters discuss a variety of therapeutic nature
The Wise Outdoors 17
interactions that vary in breadth, intensity, and scale. Although there is
some overlap, the various nature therapies each carry their own sets of
risks and benefits. Nature therapies are typically nonpharmaceutical,
noninvasive, and highly customizable to meet individual patient needs.
Identifying patients who could benefit from nature therapy and selecting the best approach to recommend relies on various patient factors, such as their attitudes toward nature, mobility level, and access to
nature. Physicians can perform a comprehensive nature history as part
of the biopsychosocial evaluation to determine these factors. The following suggested questions can investigate the patient’s relationship
with nature.
• How would you describe your relationship with nature?
• How much time do you spend inside?
• When inside, how often are you near an uncovered window? What
is the view from the window?
• Are there any images of nature (pictures, paintings, or posters) in
your indoor areas?
• Are there any plants or animals in your indoor areas?
• What sounds, sights, and smells are most common in your indoor
areas?
• Are there any nearby public natural settings such as parks or gar-
dens that you feel comfortable visiting?
• What are your preferred types of natural environments?
• Do you engage in any outdoor activities, such as hiking or gardening?
• Are there any specific natural environments that you find particu-
larly calming or rejuvenating?
• Have you ever experienced any positive or negative emotional re-
sponses to nature?
• How do you typically feel after spending time in nature?
• Have you ever used nature as a coping mechanism during a difficult
time in your life?
• Do you have any concerns or barriers that prevent you from spend-
ing time in nature?
• How accessible is nature for you? Do you have transportation or mobil-
ity issues that may affect your ability to access natural environments?
• Do you have any physical limitations that may affect your ability to
participate in nature therapy activities?
• Do you feel comfortable spending time in nature alone, or do you
prefer to be with others?
• Have you ever had a negative experience in nature? If so, can you
describe it?
18 NATURE THERAPY
• Have you ever tried any nature-based therapies before? If so, what
was your experience like?
• Is there anything else you would like to share about your relationship with nature?
KEY POINTS
• Nature is an umbrella term that describes Earth's environment, geology, and inhabitants, including people,
and the forces that govern their interactions.
• Experiences in nature have been valued for their profound spiritual and emotional effect across cultures
since the earliest recorded history.
• Parallel revolutions in psychiatric medicine and environmentalism converged in the late twentieth century to inspire scientific examination of nature’s phenomenology.
• A growing body of observational and correlational
studies suggest significant mental health implications
of nature interactions, but higher-powered and more
specific clinical trials are needed to test applicability to
clinical populations.
• Nature is a finite resource vulnerable to depletion by
human activity. Measures for nature conservation can
be incentivized by recognizing the long-term benefits
at both the individual and the population levels.
QUESTIONS
1. Which of the following activities most aligns with Clinebell’s principles of ecotherapy?
A. A family trip to the zoo.
B. Watching birds through the window.
C. Sunbathing at the beach.
D. Buying flowers.
E. Planting a tree.
Correct answer: E. Planting a tree.
Clinebell’s ecotherapy emphasizes a reciprocal relationship between people and nature. Of the available options, planting a tree
The Wise Outdoors 19
is the only activity that involves participating in environmental
conservation or restoration.
2. After reading Rachel Carson’s Silent Spring, a gardener continues to
spray insecticides on their crops. Which theory considers this activity a pathological response?
A. Maslow’s hierarchy of needs.
B. Humboldt’s Naturgemälde.
C. Roszak’s ecopsychology.
D. Wilson’s biophilia hypothesis.
E. Bowlby and Ainsworth’s attachment theory.
Correct answer: C. Roszak’s ecopsychology.
The gardener continues using toxic pesticides even after reading
about how they harm people and the environment in Silent
Spring. Ecopsychology sees environmental destruction as counter
to human interest and survival and reflects a self-destructive
societal psychopathology. Maslow’s hierarchy of needs (A) is a
theory of human motivation. Humboldt’s Naturgemälde (B) recognizes the interconnectedness of the planetary ecology. Wilson’s biophilia hypothesis (D) theorizes that people evolved to be
interested in other living organisms. Bowlby and Ainsworth’s attachment theory (E) describes the infant-parent bond.
3. According to the World Health Organization manifesto on global recovery from the coronavirus disease 2019 (COVID-19) pandemic,
what is the most important source of human health?
A. Nature.
B. Pharmaceuticals.
C. Clean air and water.
D. Medical education.
E. Nutrition.
Correct answer: A. Nature.
In 2020, the World Health Organization declared nature as the
greatest source of health and well-being. The first item of their
six-point manifesto for a healthy recovery from COVID-19 was to
“[p]rotect and preserve the source of human health: nature”
(World Health Organization 2020, p. 4).
20 NATURE THERAPY
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