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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5516_Библиотеки_им_академика_М_И_Перельмана
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42 NATURE THERAPY
In thischapter,
anese healing practice that has been attracting attention in science globally. Forest bathing was developed in 1982 to counter heightened stress
at the national level, which was associated with Japan’s rapid economic
growth. Considering today’s global mental health crisis, it is understandable why this practice now has international appeal. We 1) review
the history, culture, and science (i.e., health benefits) of forest bathing;
2) offer practical guidelines for clinicians; 3) discuss areas for future
research and practice; and 4) provide case examples. Although costeffectiveness, accessibility, flexibility, and eco-friendliness are regarded
as major advantages of forest bathing, more diverse samples must be
evaluated to establish conclusive therapeutic efficacy (and safety) of
forest bathing. Insights offered in this chapter can help health care
workers, researchers, and patients identify safe and helpful ways to implement this treatment.
we focus on forest bathing (Shinrin-yoku), a Jap-
CULTURE, PSYCHOLOGY, AND
CONTEXT OF FOREST BATHING
Perceptions of nature vary by culture (Gierlach et al. 2010), and in Japan, forests are important spaces for religion and culture. Shintō (
Japan’s Indigenous religion, is considered a polytheistic nature religion.
In Shintō, objects, places, and phenomena, including natural phenomena, are believed to be inhabited by kami (
ancient trees, large waterfalls, winds, storms, or fires may be understood to be inhabited by kami. Shintō does not draw hard distinctions
between the physical and the spiritual, and thus many natural places,
such as forests, are also sacred places. Traditional Japanese art also
draws attention to the beauty and interconnectedness of the natural
world, including forests (Ulak 2020). For example, traditional Japanese
haiku (
ence including phenomena or objects found in forests, such as the
morning dew or leaves with changing colors. Paintings, screens, and ceramics also commonly depict the natural world across the seasons as,
for example, the blossoming of trees or the falling of leaves (Metropolitan Museum of Art 2004). This artistic interest in the seasons and the
natural world is reflected in cultural practices too, such as hanami (
flower viewing) and ikebana (
history, Japanese culture has drawn attention to the natural world and
encouraged consciously engaging with and reflecting on nature, in-
俳)—a type of short poem—contains a seasonal, natural refer-
生け花; flower arranging). Throughout
神), or spirits. For example,
神道),
花見;
Forest Bathing 43
cluding trees and forests. Thus, it is perhaps not surprising that Japan is
described as a forest civilization (Li 2018).
Forest bathing, also known as Shinrin-yoku (
森林浴), is a Japanese
therapeutic practice in which participants experience nature in a forest
by using their senses, aiming to harmonize with the forest (Miyazaki
2018). Often involving walking or breathing exercises, forest bathing
has been practiced with various activities such as yoga, meditation,
farming, and cooking (Kotera et al. 2020). In the period after World War
II up until the early 1990s—commonly referred to as the Japanese Economic Miracle—Japan successfully reformed its financial system and
became the third largest economy in the world. This rapid economic
growth was accompanied by technological advances and large-scale
migration from rural to urban areas. Accordingly, people’s lifestyles
changed: consumption increased, and long commutes, overworking,
and disconnection from nature became more common. This period also
saw the emergence of stress- and lifestyle-related illnesses in Japan (Li
2018). Indeed, the term Karōshi (
過労死), meaning “overwork death,”
was coined in 1978 to describe the increasing numbers of otherwise
healthy people dying from strokes, myocardial infarctions, or suicide.
These deaths were seemingly connected to long working hours and intense work-related stress. The Japanese government needed to implement an effective well-being strategy to protect the health of its people.
The word Shinrin-yoku was coined in 1982 by Tomohide Akiyama at
the Japanese Forestry Agency as an antidote to burnout from an urbanized, fast-paced, technology-oriented lifestyle and a way of preventing
and remediating stress-related illness. The first appearance of the term
Shinrin-yoku in literature was on July 29, 1982, in Asahi Shimbun, one of
the major newspapers in Japan. The word shinrin means “forests” and
yoku means “bathing,” implying that you immerse yourself in a forest.
Although there was no research on forest bathing back then, Akiyama
suggested that individuals can improve their physical and mental
health by immersing themselves in the smell of a forest. Moreover,
Japan is a forest-rich country. Two-thirds of Japanese lands are forests
(as opposed to other countries such as China and the United Kingdom,
where only about 10% of the land is forests), and policymakers intended
to capitalize on this abundant natural resource. Scientific research on
forest bathing was initiated by Yoshifumi Miyazaki, a physiological anthropology professor at Chiba University, in 1990. About a decade later,
Qing Li, a physician and immunologist at Nihon Medical School, advanced forest bathing research. Building on their promising findings,
the Japanese government promoted forest bathing by funding research
into its potential benefits, protecting forests for public use, and making
44 NATURE THERAPY
it part of the country’s health care program (Li 2018). Subsequently, forest bathing became a popular “social prescription” (the referral or linking of patients to nonclinical services by health care professionals with
the aim of promoting patients’ well-being and health) among Japanese
health care professionals. Additionally, in Japan, many medical doctors
are now certified in forest medicine and can provide services directly to
patients (Miyazaki 2018). Forest bathing is also popular in Japan as a
preventive and remedial strategy for illness: 60 official forest therapy
trails are used by approximately 5 million people annually (Miyazaki
2018). In 2010, the New York Times featured forest bathing (O’Connor
2010), reporting on the scientific health benefits of this practice. The
2010 New York Times article is widely regarded as the first step for the
global recognition of forest bathing. Today, forest bathing is being researched internationally because this practice has the potential to address people’s health problems in an affordable and accessible way
(Kotera et al. 2020).
Japanese Forests
Specific qualities of Japanese forest environments may influence the
effect of forest bathing on health. Li (2010) argued that high concentrations of phytoncides or volatile organic compounds (VOCs; compounds emitted by trees and other organic matter into the air) are
partially responsible for the positive effects of forest bathing on health.
The dominant tree species in Japanese forests are cedar and cypress,
which are both conifers. Tree composition affects the types and amounts
of phytoncides, with conifer forests having higher levels of VOCs than
deciduous forests, possibly influencing outcomes (Antonelli et al. 2020).
Indeed, Lee et al. (2015) found that phytoncide levels varied by location
and weather. However, researchers caution that although VOCs may
play a role in the effects of forest bathing, visual, auditory, and social
factors also contribute to the positive effects of forest bathing on health
(Antonelli et al. 2020; Li 2010). Indeed, McEwan et al. (2021) found that
participants in forest bathing activities reported using their visual and
auditory senses more than their sense of smell.
Healing Forests of South Korea
Reports of the benefits of Shinrin-yoku crossed the ocean a long time
ago, and Shinrin-yoku has been enjoyed by people in Japan’s neighboring countries, such as South Korea. Through rapid urbanization and
technological development, 85% of South Koreans live in cities. This development comes with significant challenges, with suicide being one of
Forest Bathing 45
the most common causes of death (Rezaei et al. 2021). According to a recent report, 7 of 10 employees in South Korea experience burnout (SeoHyum 2020), resulting in high levels of stress. Furthermore, alcohol use
and other psychiatric disorders have been identified as a major problem. The Korean Alcohol Research Center studied depression in 92 patients with chronic alcohol use disorder (Shin et al. 2012). The study
found that forest therapy can help reduce symptoms of depression in
patients with alcohol use disorder (effect size r=0.68). This study
yielded promising evidence of the possible effect of the forest environment on depression among people with substance use disorders, a subject that has received little attention in the literature.
Forest bathing—or forest healing, as it is sometimes called in South
Korea—has been receiving increased attention, and South Korea is now a
leading country using forest therapy (Mao et al. 2017) as part of innovative systems that are being developed to counter the detrimental health
effects of urban living. The Korea Forest Service has designed several healing forests, with the first therapeutic forest opening in 2009. By 2020, there
were 32 specifically designated areas across the country (Park et al. 2021),
similar to Japan’s “power spots” in nature. Public interest in these therapeutic forests increased during the coronavirus disease 2019 pandemic,
with stress levels motivating people to visit nature (Chae et al. 2021).
Cultures Outside Asia
Given the context of forest bathing in Japan and South Korea, the positive effects of forest bathing may be culturally specific. Japanese and
Asian participants reported greater mental health benefits from forest
bathing than did their Western counterparts (Kotera et al. 2020). Possibly, the positive associations with forests in Asian cultures increase forest bathing’s effectiveness for these populations. Research on forest
bathing is limited in non-Asian populations (Kotera et al. 2020). The
preliminary evidence from outside Asia, such as the United Kingdom
and Poland, is promising, with positive results for psychological conditions such as depression, anxiety, anger, rumination, emotions, and
mood disturbance (e.g., Bielinis et al. 2019; McEwan et al. 2021). The
U.K.-based study (McEwan et al. 2021) found that participants receiving a forest bathing intervention reported significant benefits across
many psychological variables, but no difference was seen in the magnitude of effects between forest bathing and an established well-being intervention. Taken together, the positive effects of forest bathing appear
to transcend culture. However, more research is needed, and outside
Asia, forest bathing’s effect on mental health may be similar in magnitude to other well-being interventions. Given that a person’s culture
46 NATURE THERAPY
and associations with forests may affect efficacy and other established
well-being interventions appear to have similar benefits for psychological health, patient preference and interest (Antonelli et al. 2020) may
play an important role in the appropriateness of recommending forest
bathing to a given person.
HEALTH BENEFITS OF
FOREST BATHING
Although research on forest bathing is still nascent, diverse and salient
health benefits of this approach have been reported in the scientific literature. In the physical health domain, immersion in nature increases
the number and activity of natural killer cells, leading to improved
function of the immune, cardiovascular, and respiratory systems. Song
et al. (2016) theorized that the underlying mechanism of forest bathing
is that the restorative effect of nature reduces stress, leading to physiological relaxation and immune function recovery, which protects us
from various illnesses. These relaxation and stress reduction effects
have been identified through salivary cortisol levels, heart rate variability–related sympathetic and parasympathetic nervous activity, blood
pressure measurements, and pulse rate.
Likewise, the mental health benefits of forest bathing have been
identified. Depression, anxiety, and anger were often evaluated in forest
bathing research targeting mental health outcomes by using the Profile
of Mood States; overall positive effects on those outcomes have been reported. Among those three mental health outcomes (depression, anxiety, and anger), Kotera et al.’s (2020) meta-analysis identified that forest
bathing reduced anxiety the most. This can be explained by the calming
effects of forest bathing; however, a scientific evaluation is needed.
Moreover, forest bathing also has been shown to have psychological
and physiological benefits in patients with prehypertension and hypertension. Chronically high stress levels can lead to hypertension, myocardial infarction, or stroke. In recent years, forest bathing has been
adopted as a prevention strategy to reduce blood pressure and stress
and induce feelings of relaxation in hypertensive patients (Mao et al.
2017), and it could be adopted by health care professionals as a complementary therapy for several other physical ailments(Yau and Loke 2020).
Along with these empirical findings, several theories have been proposed to explain how nature heals us. Attention restoration theory posits that our concentration is restored by time in nature because we pay
Forest Bathing 47
attention to items in nature effortlessly. This state of effortless attention
is thought to recover our concentration. Stress reduction theory claims
that being in a natural environment lowers stress levels and strengthens
physiological functions such as heart rate and blood pressure. (See
Chapters 1, “The Wise Outdoors,” and 5, “Horticultural Therapy,” for
more details on attention restoration theory and stress reduction theory.) Recently, forest bathing’s positive effects on mental health were
explained via the affect regulation model. The affect regulation model
theorizes that spending time in nature activates our soothing system
(and the parasympathetic system), which is associated with feelings of
safety and compassion, leading to better mental health (Richardson et
al. 2016). Recent forest bathing studies that evaluated levels of selfcompassion support the positive effect of spending time in nature on
our soothing system (Kotera and Fido 2021; McEwan et al. 2021).
Additionally, from a historical perspective, humans are more accustomed to being in nature than in urban environments. In 7 million years
of human history, humans have spent 99.99% of their time in nature
(Miyazaki 2018). This can explain why we do not feel well in urban settings compared with nature. Mortality was 12% lower among women
living in nature than among those living in urban areas (James et al.
2016). The duration of time spent in nature was negatively associated
with rates of depression and high blood pressure (Shanahan et al. 2016).
The levels of awe and prosocial behaviors were higher among participants who viewed a towering tree for 1 minute than among those who
viewed an urban building of the same height (Piff et al. 2015). Another
experimental study compared 3 days of forest bathing with 3 days of
walking in a city and found that the number and activity of natural
killer cells were higher in the forest group than in the city group (Li
2010). Shorter exposure to nature is also reported to be effective. A 90minute walk in nature was shown to reduce the degree of rumination
(negative recurrent thoughts that are related to poor mental health) and
the activities of the brain part that is associated with mental health
problems (subgenual prefrontal cortex) (Bratman et al. 2015). More recently, researchers found that visits and time in nature may facilitate
nature connectedness (Martin et al. 2020)—affective and cognitive connection with a natural environment (Capaldi et al. 2014).
Wen et al. (2019) summarized the health benefits of Shinrin-yoku
(Table 3–1).
Although diverse health benefits of forest bathing have been reported, Miyazaki stressed that it does not cure diseases; it is a preventive practice. The mechanism suggested is that forest bathing reduces
the stress we experience, which strengthens our immune system, pre-
48 NATURE THERAPY
Table 3–1 . Potential psychological and physiological health
benefits of Shinrin-yoku
Psychological Physiological
Improved emotional state
Improved attitude toward things
Improved psychological and
physiological recovery
Improved adaptive behavior
Reduced levels of anxiety and
depression
Source. Adapted from Wen Y, Yan Q, Pan Y, et al: “Medical Empirical Research on Forest Bathing (Shinrin-Yoku): A Systematic Review.” Environmental Health and Preventive
Medicine 24(1):1–21, 2019 31787069. This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/
licenses/by/4.0/).
Improved cardiovascular function
and hemodynamic indexes
Improved neuroendocrine indexes
Improved metabolism indexes
Improved immune and inflammatory
indexes
Improved antioxidation indexes
Improved electrical physiological
indexes
venting us from getting diseases (Miyazaki 2018). Many of us today live
in an environment we are not suited to, which increases our stress level,
in turn increasing our susceptibility to diseases. By connecting with nature through practices such as forest bathing, we are living as we
evolved to live, resulting in a reduction of stress. Therefore, researchers
recommend that if forests are inaccessible (one impediment to forest
bathing; Kotera et al. 2021), people can connect with nature through
items such as plants or essential oils of trees, which have been reported
to be effective for stress reduction too.
More rigorous forest bathing research must be conducted. Many
studies in this field have methodological weaknesses such as a lack of
follow-up assessments and unrepresentative sampling (Kotera et al.
2020). In forest bathing randomized controlled trials, randomization
and blinding often were not maintained. Relatedly, many researchers
have used a crossover design with no or short intervals and did not
conduct intention-to-treat analyses. Moreover, key figures such as
Miyazaki and Li were often involved. This may have meant that participants who believed in forest bathing received the intervention with
high expectations, which could have exaggerated the effect. Lastly, because forest bathing can include a variety of activities such as yoga,
meditation, and other recreational activities, the practice of forest bathing must be controlled in scientific research. For example, mindfulness
is often used in forest bathing, but that blurs a boundary between those
two; whether the positive effects were derived from forest bathing or
Forest Bathing 49
Neurodevelopmental Disorders
Heart Failure in Older Adults
50 NATURE THERAPY
ture-based intervention contributing to the physical health of older
adults with chronic heart failure. As shown in Figure 3–1, patients with
chronic heart failure who took part in a 4-day forest bathing trip had
lower levels of brain natriuretic peptide levels, a biomarker of heart failure, compared with older adults in the urban control group or the baseline level before the experiment. Such findings provide evidence of the
positive effects of forest bathing in patients with heart conditions and
lay the groundwork for further research into this adjunctive treatment.
Cancer Treatment Side Effects
Conventional treatments for many cancers include surgery, radiation,
and chemotherapy; however, such treatments can cause some unpleasant side effects depending on the type of treatment administered. Connecting with nature can reduce treatment side effects, with improved
cognition, memory, and attention, as well as improved quality of life for
patients with cancer. Therefore, forest therapy could prove beneficial as
an adjunct to standard cancer treatment (Kim et al. 2015).
Forest Rx
The number of clinicians practicing nature therapy is unknown. However, an increasing number of clinicians are actively prescribing nature
therapy to their patients. La Puma (2019), the author of “Nature Therapy: An Essential Prescription for Health,” believes that clinicians
should prescribe nature therapy for people who have nature deficit.
Emerging evidence suggests that nature-based activities can have a
positive effect on health and well-being. Therefore, mental health charities and community groups have been working with health care professionals to actively encourage nature therapy prescriptions (Applied
Research Collaboration South West Peninsula 2021).
The growing field of nature therapy is becoming more widely recognized as an alternative to traditional medicine for the treatment of a
number of ailments, and it is gaining popularity among clinicians. It is
already recognized as an approved clinical therapy in some countries,
such as Japan, where it is available by prescription for the treatment of
mental and physical health.
PRACTICAL GUIDELINES
The fact that forest bathing has no definite methods of practice is both
an advantage and a disadvantage; every practitioner finds their own
way to connect with nature. However, it is often helpful to pay attention
Forest Bathing 51
0
100
200
300
400
500
600
700
800
900
1,000
Baseline Postexperiment
BNP (pg/mL)
City Forest
Figure 3–1. Effect of forest bathing on brain natriuretic pep-
tide (BNP) levels in patients with chronic heart failure.
Source. Adapted from Mao G, Cao Y, Wang B, et al: “The Salutary Influence of Forest
Bathing on Elderly Patients With Chronic Heart Failure.” International Journal of Environ-
mental Research and Public Health 14(4):368, 2017 28362327. This article is distributed under
the terms of the Creative Commons Attribution 4.0 International License (http://
creativecommons.org/licenses/by/4.0/).
to one’s senses, particularly vision, hearing, touch, and smell. Patients
often report that getting in touch with the senses is one of the most helpful aspects of this therapy because, in their busy daily lives, they are often asked to use their heads instead of noticing their senses. Indeed,
noticing one’s senses is helpful in stress reduction (Ahmed et al. 2017).
Forest bathing supports this process.
Forest bathing can take a variety of forms, including walking, meditation, and yoga. Patients need to find their own way that makes them
feel comfortable and supports their healing. If they want to see rays of
light between leaves, then they can do so. If they want to hear the
sounds of a river, then they can get closer to it. This inner sense of what
your body wants is the central guidance in this treatment to heal from
mental distress. Developing this inner sense can take time, and thus
sharing common ways or activities to facilitate forest bathing is helpful
to some patients, especially in the beginning. One of us (Y.K.) had a patient who was not familiar with “noticing” and “sensing,” and this patient struggled with engaging in forest bathing. If Y.K. asked the patient
about his feelings, the patient responded, “Nothing” or “I don’t know.”
Y.K. decided to take a walk with the patient in the forest. As the patient
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