1.1. Background
Stress
Mental illnesses is a common challenge of the public health sector in the the Euroean Region, and it is estimated that around 25% of the inhabitants are affected each year (WHO, 2013). Stress and stress related illnesses are considered to become one of the greatest threats to public health in western world in 2020 (WHO, 2005). Stress and stress related illnesses are an increasing cause of work incapability and sick leaves in Denmark (Netterstrøm, 2014). Stress can be defined as, “[…] a state in the organism characterized by physiological responses with activation of the sympathetic nervous system, immune system and energy mobilization and mental activation due to strain of a psychological, physical, chemical or biological kind[…]” (p. 14) from a medical perspective (ibid). From a holistic perspective, humans who suffer from stress-related illnesses, can be seen as having their relationship to the world disturbed; Ill individuals lose their undisturbed freedom, which involves exclusion from ‘life’ (Gadamer, Gaiger, & Walker, 1996). In Dahlberg et al. (2008) illness (such as stress-related illnesses) is described: “When we are in pain and weak, our bodies become obstacles that keep us from immediate engagement with the world. Illness alters one’s attachment to the world” (p. 44). There is no official definition of stress as an illness, and stress is not diagnosed as an illness in itself. The ‘stress diagnosis’ is based on multidimensional stress related symptoms (Aldwin 2012), identified by the ICD-10 (WHO, 1992).
The amount of citizens incapacitated to work due to severe stress has reached beyond the capacity of the Danish health care system (REF). Currently there is a waiting time for up to six months.. (REF). It may cause a major burden to the Danish public welfare economy, as well as being a threat to the quality of life of the stressed individual and their relatives (Netterstrøm, 2014; WHO, 2013). WHO reports that if the community could cope the stress-burden, quality of life could be improved, productivity improved and even suicides could be prevented (WHO, 2013). These challenges have led to global, national, regional and local requests for innovative interventions for prevention and treatment of stress (Eplov & Lauridsen, 2008; European Communities, 2005; National Board of Health, 2014; WHO, 2005, 2013). The demand is directed towards evidence-based and effective treatments (WHO, 2013), and the wish is for safe and human evidence-based interventions with a multidisciplinary professional curricula (ibid).
In recent decades a growing awareness, interest, and acknowledge of a biopsychosocial and multispectral approach to human health and treatment of diseases are seen within the population, and in contemporary health science and clinical practice (Nolen-Hoeksema et al., 2014; Pearson, Field, & Jordan, 2009; Taylor & Francis, 2013). Such view was funded from WHO’s broad definition of health from 1948: ”Health is a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity” (WHO, 1948). As a result, human health is today often considered from a biopsychosocial perspective which includes humans’ entire life situation, eg. both the biological, cultural, social and environmental aspects.
Nature, health & design
There is a long history of using gardens in health care (Gerlach-Spriggs et al., 1998; Marcus & Barnes, 1999). Today there is and today there is an increasing interest, prevalence and use of therapy gardens as health facilities (Marcus & Sachs, 2014), and the evidence for positive health outcomes of participating in NBT interventions, e.g. therapy gardens, is increasing in number and across research disciplines (Hartig et. al, 2014; Marcus & Sachs, 2014; Nilsson et al., 2011; Palsdottir, 2014; Währborg et. al, 2014). This has resulted in a political awareness in the Scandinavian countries of using nature in care and treatment settings. In Denmark there is a common demand across the municipal health authorities for efficient and evidence-based treatment in general (Danish Health Authority, 2009), and currently, several Danish municipalities are conducting or planning therapy gardens and NBT in their auspices in accordance with the demand.
An evidence-based approach can yield suitable measures for changes in the health outcome for different patient groups and for the impact and effects from the nature-based care or treatment setting. It gives argumentations for governmental level, and for these reasons several municipalities seek support in the evidence-based design approach, which has developed as a branch in both architecture and landscape architecture – Health Design (HD). In landscape architecture HD is defined as: The conscious design of green spaces and gardens so that they, in a certain way, support health processes and result in improved health outcomes (U.K. Stigsdotter, 2015). The design of the therapy gardens matters, and examples of therapy gardens with negative health effect on patients do exist (ref). Therefor health design within landscape architecture must have an evidence-based design approach (see section XXX).
In the field of HD the landscape architects are primarily working with planning, design and management in relation to health from two perspectives and two types of environments:
1. Natural environments and urban green areas – emphasis is to maintain, nursing and strengthen physical and psychological health (health promotion)
2. Therapy Gardens – alleviation and treatment of ill mental and physical health (treatment)
Present thesis explores therapy gardens, and considers the landscape and natural environments as settings for health care practice.
Evidence-based health design in Landscape architecture
Evidence-based health design within landscape architecture (EBHDL), has evolved from other disciplines that have used evidence-based models to guide decisions and practices in their respective fields (Stichler & Hamilton, 2008), e.g. evidence-based medicine (EBM) and evidence-based clinical practice (EBCP) in which the clinical practitioners makes decisions about the treatment, care and practice of individual patients based on current best evidence from research (EBM) and practice (EBCP)(Gray, 1997; Pearson et al., 2009; Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996). From a design approach a current definition by The Center for Health Design (2017) defines evidence-based design (EBD) as: “The process of basing decisions about the built environment on credible research to achieve the best possible outcomes” (The Center for Health Design, 2017). EBHDL is based on definitions of EBD though has a concrete focus on design of landscape, gardens or natural environments with intentions to best possible contribute for positive outcomes of clients’ health and well-being. However, the work process of EBHDL, does not end when the design has been realised, it calls for systematic and efficient evaluations with the aim to ensure, maintain, and enhance the positive health outcomes. A crucial constituent is a post-occupancy evaluation (POE) of the EBHDL settings. A POE is an empirical evaluation and validation of the design as well as the treatment program (Corazon, Stigsdotter et al. 2010), which aligns the recommendations from WHO and in contemporary health science; that any interventions and practices concerning human health and treatments should be evidence-based and validated to ensure quality and positive effect (Taylor, Francis 2013, Muijen 2013). EBHDL processes is fairly new, and the research group ‘Nature, Health & Design’ at IGN are contributing to develop a model of a transparent process of EBHDL (fig. XX).
Fig xx
The most current model of the EBHDL process to which the NHD research group aim to stay align.
The EBHDL model has four parts. Part 1consists of three equally important components that should initially be taken into account: Aesthetic and practical landscape architectural skills and experience; The specific user-, patient- or target group’s special needs, wishes and preferences. In case of treatment, the treatment program and the patient’s expected rehabilitation process must be included; Research evidence and valid practical experiences. This initial work constitutes the foundation for the next part of the model (part 2), which is the programming that guides the subsequent design. Here, the aimed health outcomes and the objectives of design should be stated; how those will be achieved by the design (design guidelines) as well as the evidence to support the decisions of the design. The EBHDL process does not stop when the design (part 3) has been realized. The design should be continuously evaluated. This is done by a diagnostic post-occupancy evaluation (DPOE) (part 4), which evaluates whether the design fulfills the original aims and objectives (part 2).
EBHDL is a flexible and ongoing design process. A current output will be based on the state of the art evidence, experience and knowledge. New findings, results and experiences from practice and research, are continuously presented and may give good motives for modify, change or adjusting a design to implement and meet most recent and strong evidences of efficient design for a specific user group. As important as it is to follow results from relevant research and practice (‘external evidence’), as important is it to monitor function and use of a current design output (‘internal evidence’) of a EBHDL case. This is to find if the design is used as intended, has the outcome as intended, and to obtain more and new knowledge and experiences about EBHDL for the specific user group.
A POE is an important tool of the process of EBHDL. The findings of a POE can lead to a constructive and continuously regulations of the design to strengthen the design outcome and ensure that the aim of the design is optimally meet in accordance with most reason external and internal experiences and finding – evidence.
Diagnostic Post Occupancy Evaluation
Litterature describes different types of POEs, however, in relation to therapy gardens, a DPOE is recommended for a comprehensive and reflecting evidence-based design process (Marcus & Sachs, 2014). Marcus and Sachs (ibid.) recommend that a DPOE is conducted over a longitudinal timespan, using a multiple-methodological approach and multiple sources of data to provide strong and reliable findings. A DPOE will illuminate background and thoughts behind the design decisions to; clarifying the aims and objectives with the design; decide sufficient core area of examination of the specific site; evaluate in accordance with the original aims and objectives of the case. The DPOE for article III was developed to be suitable for therapy gardens in particular. It asses the initial design decisions by examine a therapy garden’s and subsequently the nature-based therapy program’s impact on a specific patient group’s health outcomes. It has an enhanced focus on the participants’ own experiences of the environment, the operations and health outcomes. The DPOE consists of the following steps: 1. Project context, 2. Examination (of the five core points: a. Environment, b. Experiences of the environment, c. Operations, d. Experience of operations, d. Health and well-being outcomes), and 3. Findings. The methods of measuring health outcomes can vary depending on patient groups and of the aimed health outcomes.
Figure 3. A conceptual DPOE model designated for applying cases of therapy gardens and applied in article III.
Research status in relation to therapy gardens
As mentioned, several studies present evidence for positive health outcomes from participating in nature-based therapy (NBT) in therapy gardens (Hartig et. al, 2014; Marcus & Sachs, 2014; Nilsson et al., 2011; Palsdottir, 2014; Währborg et. al, 2014). However, no study on health outcome form participating a NBT program in a therapy garden have been conducted in Denmark, and a resent review of international studies concludes that the available evidence mainly is based on heterogenic user groups and diverse measures (Annerstedt & Währborg, 2011; Hartig et al., 2014). The reviews finds a lack of sufficient assessments of evidence, quality, or causality regarding which specific natural elements (settings, environments, components) are most beneficial for a specific diagnosis-group. They further concludes that a proper quality assessment of the subjects of NBT to evaluate the use and effect (activities, program, outcome) of nature in NBT can be utilized more efficiently and can be targeted at specific patient groups (Annerstedt & Währborg, 2011; Hartig et al., 2014). Since the referred reviews a sufficient qualitative and quantitative study have been made with positive results have been made in Sweden (Grahn i 2016… I public health paper). However, there is still a lack of comprehensive studies of environments, activities, use and outcome of nature-based therapeutic interventions (therapy gardens) in a Danish context. Additionally, there is a request for studies and assessments using measures suitable to several similar cases of nature-based therapeutic interventions, as it would make it possible to compare and validate findings from several cases (U. Stigsdotter et al., 2011).
Together this asks for a comprehensive, systematic and transparent methodological approach (generic applicable) to find evidence and gain knowledge of the environments, activities, use and outcome of NBT interventions.
1.3. Theories on relations between human health and natural environments
The PhD is supported by a theoretic framework, mainly from environmental psychology, on theorizing the relations between natural environments, human health and design.
The Aesthetic-Affective theory
From an evolutionary perspective AAT (Ulrich, 1983) explains that human has not developed biologically since human were adapted to life in a nature as hunters and gatherers. In order to survive, a prompt reaction to possible threats was crucial, and humans relied on their instinctive and immediate ability to promptly assess and respond (effect) on stressors, perils and/or safeties associated with the natural habitat.
According to the theory, humans’ affects are genetically coded to scan, evaluate, understand and find safety in natural environments, opposed to the modern urban environments. Here humans cannot trust their effects for finding safety. The urban environments have unnatural components and constructions, and socio-cultural environments, which requires rational thinking for humans to grasp and eventually find safety. Rational thinking is a demanding process that requires, which may lead to stress. It is therefore important that humans have access to environments that allows the brain and body to relax and regain capacity for rational thinking.
Attention Restauration Theory
ART explains that humans have two types of attention systems: “directed attention”, and “Soft Fascination” (Kaplan, 1989). The “directed attention” is a process activated when the brain needs to sort large amounts of information, to process only the important and to inhibit the less important. In modern urban environments, or during everyday working situations, human may be exposed to vast amount information to sort in order to commit rational thinking and stay focused. It is believed that the brain receives up to 11 million information stimulus per second in an urban environment. However, the brain can only handle 15-20 information stimuli per second, the sorting process is demanding, thus the brain has limited capacity for ongoing directed attention. It may lead to an overload of the brain causing stress reactions or mental burnout. According to ART, “soft fascination” does not burden the brain, because there is no need to sort information and because this type of attention is considered to be effortless. The soft fascination may be awaken in natural environments with less information for the brain to sort and process, and with no tasks to concentrate. Kaplan & Kaplan believes that staying in nature can restore the brains capacity for directed attention because the soft fascination is stimulated, unlike in urban constructed environments where it may be difficult to achieve similar restoration.
For an environment to give a restorative experience, four components are essential (Kaplan & Kaplan, 1989). The components are pending partly on setting and partly by the individual human’ perception of the environment:
• Being away – The environment leads the user to an experience a respite from everyday life, e.g. stimulates the mind to wander off to another place.
• Extent – The environment gives the user a sense of coherence and provides scope for exploration.
• Fascination – The environment is interesting enough to motivate exploration, e.g. observing natural objects (e.g. flora, fauna, water) and processes (e.g. growth and succession).
• Compatibility – The environmental circumstances must be compatible with the users’ inclinations, for the user to relate to it.
The Supportive Environment Theory
The SET can be seen as an integrated theory combining evolutionary, cultural and personal bases for explaining the positive relations between natural environments, human and human health (Grahn et al., 2010; Palsdottir, 2014). Environment is here understood as a context of natural, cultural and social factors to manage and understand by the individual. An environment is considered supportive when it is experience as comprehensive, accessible, safe and meaningful by the individual. SET explains how human need supportive environments for physical developing (senses, muscles, motor functions) and mental development (being able to feel and think), and it argues that humans need supportive environment to maintain a good health (ibid). Human’s experience of, preference and need for supportive environments (scope of meaning) vary and depend of the individual human’s physical and mental resources and capabilities (executive function) at current time (ibid). As figure XX illustrates, people with low executive functions have difficulties coping the social challenging environments, while still being able to manage natural environments.
Figure xx. The SET pyramid, modified in accordance to Grahn et al. (2010) and Koch et al. (2008)
The SET pyramid shows four levels of EFs, of which the lower part correlates inward involvement, and the higher levels of EFs correlates to more outgoing involvement (Pálsdóttir et al., 2014).
Therapy gardens
In the research group, Nature, Health & Design (NHD) at the University of Copenhagen, a ‘therapy garden’ is understood as a natural environment deliberately designed with the intention to be the premise for a nature-based therapy program and to actively and positively contribute to patients’ treatment and wellbeing by; matching the participants’ treatment process by both supporting and challenging them; and by provide meaningful activities all year round (S. Corazon, et al., 2010; Stigsdotter & Randrup, 2008; U.K. Stigsdotter, 2014). A natural environment is understood as an environment, place or setting where vegetation and other natural features are dominantly present (Steg, van den Berg, & Groot, 2012)
Nature-based therapy (NBT)
NBT is a therapeutic practice, in a special designed or chosen natural environment, using activities implementing nature objects and nature experiences as therapeutic means initiating a therapeutic process (Corazon S., 2012).
Based on the three articles (I-III), present thesis explores the various constituents of NBT for people suffering of stress-related symptoms in a therapy garden specially designed to be a prerequisite for the NBT operations, thus being of possible impact on patients’ experiences of the process, and being of possible impact on the health outcome.
1.2. Aim and main research questions
The overall objective for current Ph.D. project is to yield deeper understanding and develop knowledge of landscape architecture in therapeutic interventions for people suffering from stress-related illnesses in a Danish context. Following research questions will be explored:
A. How do the participants use Nacadia® in general? (I)
B. What type of spaces do the participants prefer in Nacadia®? (I)
C. Do the different seasons and weather conditions have an impact participants’ use and preferences in Nacadia®? (I)
D. How do people suffering from stress-related illnesses experience the 10 week NBT program in Nacadia®? (II)
E. Does the design of Nacadia meet the original aims and objectives of the through the NBTLD process? (III)
1.2.1. Aim of the thesis
Article I – III have different aims and objectives, and each has its own units of analysis (Patton 2015b, Yin 2013) to explore the case from various perspectives.
Article III adds up with findings, and is further a result of converging the data and the findings from article I-II.
The main aims are:
A. To study participants’ use, preferred locations and experiences of locations in Nacadia®, with focus on seasons’ and weather’ possible influence, during NBT for people suffering from stress-related illnesses. (I)
B. To describe the phenomenon of participants’ lived experiences of the NBT in Nacadia® during the course of a 10-week NBT program. (II)
C. To apply a DPOE examining the therapy garden Nacadia’s design, subsequently including the NBT program’s impact on the patients’ health outcomes, in order to identify successes and failures in the design in relation to the original aims and objectives. (III)
The objectives are:
• To illuminate the participants’ use, preferences and experiences of spaces, places and the natural components in Nacadia® (I, II)
• To study which variable factors may have an impact on participants’ use, preferences and experiences in Nacadia® during the NBT (I, II)
• To study if, how and why the participants’ use, preferences and experiences in Nacadia® develop from the beginning to the end of the NBT program (II, III)
• To explore if and how components from the NBT have been implemented in participants general life (II, III)
• To evaluate if the design of Nacadia® is used and understood by the participants as originally aimed during the EBTLD process of Nacadia® (III)
• To evaluate if the environment and the spatial characteristics in Nacadia® actively and positively contribute to the NBT program and to participants’ treatment and health (III)
The above research questions, aims and objectives will be addressed in article I-III basing this thesis.
2. Methods
2.1. Study design
Figure 1. Current study is the explorative part of NEST. (SKAL OPDATERES)
Present PhD project is the explorative part of a major study, Nacadia Effect Study (NEST), which is a randomized clinical trial (RCT) comparing nature-based therapy (NBT) (n42) with cognitive behaviour therapy (CBT) (n38) (fig. 1).
The explorative part of NEST is a qualitative study aiming to examine, analyse and understand the subjects of a specific group’s behaviour in the given complex context (Bryman, 2012; Creswell, 2013). It is conducted as a case study exploring in depth the contemporary phenomenon (Creswell, 2013; Yin, 2013) of a NBT intervention (the case), using mixed-method research (Creswell, 2013; Venkatesh & Brown, 2016) for obtaining a variety of data from various sources during several NBT sessions at the location (The Therapy Garden Nacadia). It consisting of three case units (article I to III) (Patton, 2015; Yin, 2013), initiated with an overall inductive approach, with focus on the subjects’ meanings, supplied with measures, of the various constituents of NBTN. The therapeutic setting constituted by multiple components and factors, and the subjects’ interactions with it, is considered and explored as a contextual whole (the case) to explore. The thesis is based on a biopsychosocial acknowledgement that all individuals’ experiences subjectively based on personal, cultural, historical and biological background (Nolen-Hoeksema et al., 2014; T.P. Melchert, 2015). Such understanding of human represents the general view on human health found in contemporary health care science and clinical practice (Pearson et al., 2009; Taylor & Francis, 2013; Melchert, 2015), concerning the individuals’ experiences in relation to their entire life situation (including biological, cultural, social and environmental aspects). It further represent the holistic understanding of human health which was originally adapted when developing and designing the Nacadia therapy garden and developing the NBT program (Corazon et al., 2010; Corazon et at., Schilhab, & Stigsdotter, 2011; Koch et al., 2008; Stigsdotter et al., 2011). In health care science an overall open and inductive approach is recommended to study and assess patients’ experience of a given health care treatment and/or setting, eg. a medical doctor’s office, a psychologist’s therapy room, or a setting used for NBT (Pearson, Field et al. 2009, Taylor & Francis 2013). For this reason the first case unit (article I) was originally intended to have an open approach from an inductive perspective (Patton, 2015), aligning constructivist grounded theory (Charmaz, 2006; González et al., 2006; Taylor & Francis, 2013) to explore and develop understanding of the constituents of NBT in Nacadia®, though without developing new theory. It was done merely to gain an overall understanding of the case, to be studied further in the following sub-studies. To understand the meaning of the participants’ use and experiences, data collection was conducted as mixed method research (Bryman, 2012; Patton, 2015; Venkatesh & Brown, 2016).
Second case unit has a lifeworld perspective (Dahlberg, Dahlberg, & Nytsröm, 2008) with the aim to illuminate patients’ experiences and understandings of NBTN to build on a deeper understanding of the case. During the study the SSIs was the main source of data. Findings from previous case unit (article I) and data from other methods and sources were used corroborating for the researchers to gain more insight into the context of NBTN prior to the analyses of the SSIa.
The third case unit uses the methods of a DPOE to examine the quality and efficiency of the setting, the Therapy Garden Nacadia. Multiple components and factors are thought to have influence on patients’ use, preferences, experiences, and on the health outcomes of a NBT setting. To develop more knowledge of those factors most comprehensively, the DPOE is conducted using mixed-method research and triangulation to provide reliable findings, as recommended by Guinther et at. (2014), Marcus & Sachs (2014), and Venkatesh & Brown (2016). Mixed-method research and triangulation are acclaimed rigor approaches within health science (Taylor, Francis 2013). Hence a methodological triangulation of several methods is applied in the third case unit (article III) to cross-check and converge data sources and create stronger conclusion (Bryman, 2012; Patton, 2015; Taylor & Francis, 2013). Conduction of a methodological triangulation aims to strengthen trustworthiness of the variable data, findings and conclusions (Taylor & Francis, 2013; Venkatesh & Brown, 2016).
Figure 2. Flow and relations within the embedded case study of NEST (SKAL OPDATERES)
The setting
The specific location for the case is the Therapy Garden Nacadia situated in an enclosed area in the Arboretum in Hoersholm 30 km. north of Copenhagen. The main setting to be explored is the NBT for people incapacitated to work due to stress related illnesses in the natural environment of the Therapy Garden Nacadia.
The Therapy Garden Nacadia®
Nacadia® was designed through an EBHDL process form 2008-2011. It was designed with the purpose for supporting NBT for people suffering of stress or stress-related illnesses.
The EBHDL process was founded on the assumptions that:
• Nature-based therapy in a designed natural environment, will lead to increased health and well-being for people incapacitated due to stress related symptoms. This assumption is based on research showing a correlation between presence and activities in natural environments with specific characteristics and human health, in particular in relation to stress (Annerstedt & Währborg, 2011; Hartig et al., 2011).
• The design of the therapy garden does not only support use and accessibility of the garden, but it directly strengthens the health promoting processes by facilitating restorative nature experiences. This is supported by knowledge of how design have an influence on humans well-being (Stigsdotter & Grahn, 2003), which are related to the field of ”Health Design” and the landscape architect based movement within ”Health Design” (Marcus & Barnes, 1999)
As a result of multidisciplinary collaborations and workshops the architects developed a set of criteria to meet the aims and objectives with a therapy garden suitable for NBT of people suffering of stress and/or stress related illnesses. Those criteria were based on state of the art theories (some of which are described in section x.x.), evidence and experiences from best practice regarding relations between nature and human health in therapeutic settings. The design criteria developed are (Koch et al., 2008; Stigsdotter, 2014):
1. Spatial structure
The garden should be demarcated from its surroundings. It consists of a large “outdoor room” with several smaller rooms, with walls created by shrubs or green fences, the floors are made of grass, stone or wood and the roofs are formed by treetops, pergolas with flowering climbers, and the open sky.
2. Living building material
Vibrant and constantly changing plant material is essential for the garden. The amount of greenery is important in relation to its health supporting qualities.
3. Easy to interpret
The patients must be able to understand what the garden can offer them, and what they can and may do.
4. Security
The garden should provide a sense of total security. The garden’s green walls help to achieve this by obstructing outsiders’ visual or physical access. This demarcation must not make the patients feel like they are trapped, but instead that it shuts out problems and worries from the outside.
5. Levels of Safety
During the healing process, the patients must be exposed to less safe areas at a slow pace. Nacadia’s location within the arboretum offers an extra semi-safe zone, which the patients can visit as they get stronger.
6. Strength of Mind
The design should accommodate patients at all different levels of emotional and cognitive strength and the associated different experiences of environment and demands.
7. Mental and physical accessibility
The design should motivate and attract the patients to the different spaces in the garden by minimizing barrier in between, e.g. by making some attractions visible from the other spaces. All parts of the garden should be accessible, and by using different natural paving materials and varied terrain the patients’ body awareness should be improved.
8. Flexibility and Participation
Flexibility concerns the patients’ possibilities to be creative and participating in planting, maintenance and harvesting, and putting their own stamp on the garden.
9. Perceived Sensory Dimensions of Nature
A combination of the nature characteristics ‘refuge’, ‘nature’ and ‘rich in species’, and a low presence or absence of ‘social’, have been interpreted as the most restorative natural environment for stressed individuals (Stigsdotter & Grahn, 2011).
10. Opportunities for nature-based activities
The garden should offer opportunities for meaningful activities year-round. There should be activities of both practical character, such as picking fruit and chopping wood, and activities of more symbolic values, such as balancing over a stream to be used as a therapeutic metaphor for starting something new and leaving worries behind. Activities of interactions with nature may provide health supportive nature experience.
The area of Nacadia is separated from the rest of the arboretum by a fence partly hidden and covered by plantings. To access Nacadia, patients must walk 600 meters through the arboretum to the entrance of the garden. From the entrance a wooden trail leads down the briefly sloping terrain and into the garden. Nacadia has character as a forest garden. 2/3 of the garden area are covered by canopies, the remaining part is open to the sky. The natural objects in the garden (various types of terrain, trees and shrubs) create distinctive spaces within the overall area of the garden. As an example, one space is defined by tall and dense trees surrounding a pond that reflects the silhouettes of the trees and the sky. The spaces all have different characteristics. Several seating facilities can be found in the garden. Some are more visible, such as the staircase leading up to the office building. Others are more hidden, such as the bench in the small closed space (13 on fig xx). A little stream trickles through the garden into a lake with a small island (15 on fig. xx). A wide wooden terrace surrounds the office building and offers a view over the garden. A part of the terrace leads to a four meter raised platform over the lake. A greenhouse facilitates a number of spaces with facilities for sitting of laying (hammock). It further hosts some basic kitchen facilities – possibility for having water, tea of coffee, and has storage space for div. tools and equipment for garden activities and exercises. Current study merely concerns the outdoor environments.
The Nature-Based Therapy in Nacadia
NBT is defined as an intervention initiating a therapeutic process with activities implementing natural elements and nature experiences in a special designed or chosen natural environment ( Corazon et al. 2010, Stigsdotter, Jensen, & Nilsson, 2010). The NBT program used in Nacadia® (NBTN) was developed as a treatment program targeting people incapacitated to work due to stress and/or stress related symptoms. It builds on elements from NBT and from mindfulness-based cognitive therapy (Corazon et al., 2010). A prerequisite for conducting NBT is that the garden design and the therapy program are closely related. Both the design of Nacadia and the NBT program have a salutogenic (health creating) focus (Corazon et al., 2010, 2012; Stigsdotter & Randrup, 2008). The emphasis is on what is strong and healthy within each participant, and to enable the participants to restore their physical, psychological and mental capacity. The wish is to reinforce and develop the strength and capabilities of participants to cope with illness, and improve their quality of life (Antonovsky, 1996).
From an explorative perspective NBTN can be describes as consisting of 5 components with an inter-supportive aim (fig. 2): 1. Individual conversational therapy (ICT) that uses mindfulness-based cognitive therapy; 2. Physical- and mental awareness exercises (AE), eg. meditation and body scan; 3. Garden activities (GA), e.g. chopping wood and collecting herbs; 4. Own time (OT); 5. Home work, to practice the different techniques and methods from ICT, AE, GA, and OT.
Figure 2. The components in NBT programme conducted in the natural environment of Nacadia®.
Though all NBTN components are intended to apply to the whole group of participants, each component is flexible, optional and adaptable for the individual participants’ needs. The person-nature relations possible during the NBTN, contribute with sensory experiences and nature-related stories and symbols, and are thought to enhance the relaxation potential and to increase the participants’ experiences of being. AEs and GAs were implemented the NBT program with the intentions to help participants to bring their awareness to an acceptance of the present circumstances by paying non-judgmental attention to their thoughts’ and feelings’ needs (Corazon et al., 2010). Homework is recommended the participants in order to maintain the techniques and methods, to implement those to everyday routines. NBTN is a 10 weeks program, 3 days a week, 3 hours a day. During current project there were maximum 7 participants per group and minimum 4. The NBT is the same all year-round, and the framework is the same every week and day. However, every week has a specific theme in accordance with the expected progress. The daily therapy was performed and managed by two authorized psychologists, both trained in NBT. The therapists were supervised by the medical responsible psychiatrist. The GAs were initiated and assisted by a professional gardener in Nacadia.
Subjects
Inclusion and exclusion criteria
Potential participants were informed of the project from announcements in newspapers, online, and through collaborations with social workers, psychologists, psychiatrists, general practitioners, and job centres. The inclusion criteria were: 20-60 years of age; one of the following International Classification of Disease (ICD-10) codes (World Health Organization, 1992) as the primary diagnosis: psychiatric diagnosis of adjustment disorder and reaction to severe stress (ICD-F43.0-9, minus 1 = PTSD). In current study this level of stress was considered to correspond to 3-24 months of incapacitation to work. The exclusion criteria were: Other significant diseases or mental disorders, suicidal, social phobia, drug- or alcohol abuse. Prior to admission to the project, an assessment procedure was performed to ensure that the inclusion criteria were fulfilled by each potential participant. In total, 43 participants were found suitable for NBT and 42 participated.
Sampling
With regards to demographics recruitment was done with the strategy to capture maximum heterogeneity of the participants (Bryman, 2012; Patton, 2015). However, the inclusion criteria aimed ensuring homogeneous sampling of subjects, with regards to the particular diagnostic group of interest of the study (Patton, 2015). The complete group of participants was in focus during observations to gain a broad picture. Though for interviews and logbooks an outlier sampling strategy was used to select subjects, to gain stories from opposite representors of personalities within the group of participants (ibid). The thesis considers seven groups of participants (N=42) participating NBT in Nacadia in the period from 8th of August 2013 to 27th of March 2015 (table 1, table 2).
Group Date N=42
1 05.08.13 – 11.10.13 6
2 14.10.13 – 20.12.13 5
3 03.02.14 – 11.04.14 6
4 22.04.14 – 27.06.14 7
5 11.08.14 – 17.10.14 7
6 13.10.14 – 19.12.14 7
7 19.01.15 – 27.03.15 4
Table 1. Seven groups of participants
Nacadia nature-based therapy N=42
Danish nationality 42 (98%)
Other nationality 1 (2%)
Age, mean 47.9 (SD=7.8)
Female gender 31/7
Married 19 (49%)
In relationship 8 (21%)
Basic education (7-10 years) 2 (5%)
Bachelor education 10 (26%)
Higher education (˃15 years) 19 (50%)
Months of sick leave due to stress related illness prior to
treatment start 7.5 (SD=3.6)
Disability pension
Previous treatment
GP 22
Psychiatrist 11
Psychologist 22
Psychotherapy 6
Antidepressant medication? 9
Table 2. Demographic data for the participants in the explorative study
2.3. Ethical considerations
The study has followed the ethical principles of the World Medical Association’s Declaration of Helsinki (World Medical Association, 2013). It was approved both by the Danish Data Protection Agency (J.nr. 2013-54-0344) and by the National Committee on Health Research Ethics (P.nr. H-1-2013-038) prior to beginning. The participants received both verbal and written information about the project and have signed to acknowledge informed consent before participation. Information of participants’ right to withdraw from the study at any time was given and the participants were guaranteed confidentiality regarding the data. During the data collection and data analysis, ethical principles for qualitative studies were taken into account (Fog, 2004; Nielsen, 2003). The sources in all quotations used in article I-III and in current thesis are anonymous.