Therapeutic Impact of Engagement in Green Spaces

Abstract

Active engagement in green spaces has been shown to improve physical, mental, and social well-being. Blending the topics of forest bathing, therapeutic sensory gardens, and nature meditations, this chapter will unpack the therapeutic effects of active and passive engagement in green spaces. Frequent exposure to and engagement in green spaces has been found to decrease feelings of anxiety, social isolation, and stress levels. Spending time in green spaces can promote restoration and offer recovery from daily stressors. With the perspectives of the authors’ expertise in holistic health as occupational therapy practitioners, the chapter will present how the influence of usage and dosage of green spaces affect stress, social isolation, and a sense of well-being to facilitate occupational balance (flow). This chapter will report how green spaces have been assessed in the current evidence and the questions that remain regarding the impact on personal, group, and population well-being.

1. Introduction

A growing number of researchers [1, 2, 3], mental health advocates [4, 5], and media outlets [6, 7] support engagement within nature and green spaces to promote well-being. The purpose of this chapter is to explore the evidence on the therapeutic impact of engagement in green spaces and supplement the review of the evidence with the authors’ experiences piloting a therapeutic sensory garden intervention to support the well-being of university students.

As occupational therapists, the authors consider well-being within the context of a person’s ability to engage in activities that are meaningful to them. Participating in activities that are meaningful can enhance a person’s physical, mental, and social life. Occupational therapy training is holistic in bridging science and art by adapting, creating, and modifying activities to optimally support the person within their environment [8]. From the inception of occupational therapy as a profession in 1917, its founders viewed people as inextricably tied to their environment [9]. From this holistic lens of a person within their environment, the profession connects deeply with the impact of green space on individuals’ well-being. Records of occupational therapists using gardening as a therapeutic intervention are recorded as far back as 1932. The natural environment has been a context for meaningful engagement in activity, production, and socialization [10].

A common concept within occupational therapy is occupational balance. The occupational therapy practice framework defines occupational balance as “the proportion of time spent in productive, restorative, and leisure occupations” (p. 12) [8]. Occupational balance is an outcome of health and wellness that ensures that the demands of different activities meet the needs of the individual [8, 11]. In 2021, the definition of occupational balance has expanded outside of a Western paradigm utilizing influences from Chinese culture to address humanity’s need for harmony [12]. This philosophy on occupational balance follows the traditional Chinese belief that each human ultimately has the goal of being in unity with nature [13]. Eriksson et al. [14] investigated the impact of using therapeutic gardening to promote occupational balance. The described themes experienced by participants included being absorbed in the present and accepting self as connections to the protective environment of the therapeutic garden [14]. These findings intersect with the basis for this chapter by describing what, how, and why of green space as a means for therapeutic impact.

This chapter is meant to further the discussion of the therapeutic utilization of green space by using references within and outside of the occupational therapy discipline. Intentional questions will be threaded throughout the chapter related to what makes green space therapeutic.

• What defines green space? What has been studied and how does it differ depending on locality, type, and seasonal use?

• How can green space be used therapeutically? What are the intentional means of intervening within green space?

• Why do we use green space? What are the outcomes and impacts of the green space on well-being?

2. Typology of green spaces that impact well-being

Green space has been defined as public ground covered primarily by grass, trees, plants and other vegetation that is open and accessible. The openness of this land allows for recreation and provides places to view and experience nature [15]. Natural green spaces have been connected to small urban parks and larger wilderness areas such as protected national parks or nature preserves [1]. Additional descriptions have included gardens, outdoors, eco-roofs, green infrastructure, wilderness, greenery, and forests [2, 3, 16]. There is no universally agreed definition of green space, and in order to collect evidence, more specific delineation of spaces can assist with comparing impacts of green space on wellbeing [2]. Providing greater detailed descriptions with photographs, maps, and written overviews to the type of green space can provide more comparable reviews of impact of green space on well-being [2].

The design of green space for therapeutic purposes needs to have components for pathogenesis and salutogenesis. Pathogenesis design focuses on prevention or management of disease, while salutogenesis looks to create and enhance optimal health [17]. Considerations for both purposes are vital to the design and list environmental qualities to include considerations of access, orientation to the space, richness in species, serenity for reflection, and opportunities for social connection [17]. The natural environment is restorative when it is immersive and engaging in order to remove the individual from their typical context and everyday stressors to allow for an experience of escape [3]. Further, with Kaplan and Kaplan’s “Attention Restoration Theory”, green spaces are intrinsically therapeutic due to the decreased cognitive and attentional demand compared to other environments [3, 17, 18].

Green spaces have been defined by different types/green infrastructures with similar benefits to well-being. The definitions and delineations of these spaces have overlapping characteristics which can further conversations about what is integral to the space to maximize therapeutic benefit.

2.1 Garden green spaces

Gardens are a common green space utilized for active engagement in nature. Types of gardens could be individual domestic gardens, community gardens, healing gardens, and therapeutic sensory gardens. Defining characteristics of a garden include planned space for physical movements, cultivation, enjoyment of display, and closeness to nature [19]. Gardens are planned spaces that should address the publics’ accessibility, aesthetic value, maintenance, and safety through appropriate design [19]. Therapeutic gardens, as defined by the American Horticulture Therapy Association, are “A garden designed for use as a component of a treatment, rehabilitation, or vocational program” (p. 3) [20]. Expanding on therapeutic gardens, therapeutic sensory gardens provide an environment tailored to engage all of the individuals’ senses including sight, taste, smell, touch, hearing, and body movement [21].

Gardens as a therapeutic green space have been used in China since the year 717 AD when the first public hospital was created with green settings located in the form of courtyards. Chinese monks would care for individuals with illnesses and disabilities in more remote rural settings where the natural surroundings were considered part of the palliative care [22]. Western counties have histories of use of healing gardens as part of hospital settings since the 1800s, however in the early 20th century during the industrial revolution many green spaces were removed from health care facilities due to increases in high-rise building designs. The revival of healing gardens within healthcare settings in the West did not return until the 1990s [22].

2.2 Urban mixed green spaces

Within urban spaces, the types and settings of green spaces connected to supporting mental health include urban forests, neighborhood green space, parks, and eco roofs [23, 24]. Urban planners often consider multiple factors when designing the space including environmental factors (improving air quality, absorbing noise/creating soothing soundscapes, visual stimulation, mitigating heat), space for activity (physical and social), and intentional design for social cohesion (fostering social capital, neighborhood satisfaction, sense of security, belongingness to space) [23, 25]. Indicators have found based on mental health needs that communities prefer green spaces with moderate vegetation complexity and a tree canopy over a simple open space of grass [23]. Urban green spaces must also consider potential environmental determinants to the use of the space including accessibility, quality and condition of features, and feelings of safety within the environment [26].

2.3 Rural wilderness green space

The key features of rural wilderness spaces associated with improvements in well-being are less structured and defined as compared to garden and urban green spaces where planning leads to more descriptive outlines/graphics and examples. Studies looking at the impact of wilderness on wellbeing have labeled the space as broadly as unfamiliar outdoor wilderness settings [27] to increased specificity related to classes of the natural land cover including: woodland, farmland, grassland, mountain, bog, coastal with either freshwater or saltwater [28]. Skärbäck et al. further defined rural environmental qualities for well-being to include the following characteristics: serene (limited sound, natural view), wild (plants self sown/old paths), lush (richness in species), spacious (removed, enabling feelings of escape) (Figure 1) [29].

Figure 1.

Case study: green space design [30].

3. Therapeutic interventions in green space

Green space and nature-related interventions are utilized to improve a sense of well-being across therapeutic and healthcare disciplines. What is included in the nature experience/activity varies depending on discipline and active ingredients of the intervention [1, 3]. Context, population, and culture can influence how and when nature based interventions are used [3]. Four types of green space therapeutic interventions are addressed in this section: Horticultural Therapy, sensory gardens, nature meditations, and forest bathing.

3.1 Horticulture therapy

Of particular historic interest and predominance in nature-based interventions is Horticulture Therapy. Horticultural Therapy is a defined discipline supported by associations in countries all over the world including Canada, Taiwan, Australia, Peru and the UK [31]. As a therapy, it is known to have roots in psychiatry and occupational therapy particularly following WWII, as patients demonstrated significant improvement in mental health utilizing task engagement with plants and nature to address designated treatment goals [32]. The occupation of horticulture was considered therapeutic in the early 20th century primarily due to the ability of medical patients to be outside of the sterility of a medical institution, and also a means for raising funds by selling produce and flowers [33]. Horticulture therapy developed into an independent discipline in the latter half of the 20th century [32]. Horticulture could be a beloved past time steeped in familial ties, cultural relevance, and cherished memories or depending on the person could bring fear and apprehension due to lack of knowledge and experience [33]. Meaning and emotional attachment placed on gardening could vary however common themes for populations that have experienced benefits to their well-being through this therapeutic medium include:

1. The beauty of the natural environment intrigues, relaxes, and provides an opportunity for reflection on life concerns.

2. The cultivation of nature is intrinsic to supporting the natural world and the planet’s life.

3. Nurturing and attending to the growth of plants can create a feeling of relationship and closeness.

4. Sharing experiences with others in the gardening space supports community building [1, 3, 10, 21].

3.2 Mindfulness in nature

Green space meditation and mindfulness interventions demonstrate positive changes in physical, psychological and pro-social behaviors [34, 35] and are regularly used in treatment of mental health challenges and illnesses. More recent connections in literature report that when mindfulness meditation practices utilize green spaces or nature support, that the positive impact is greater for addressing mental health issues such as depression, rumination, and stress [34]. These meditation practices in green space can be described as introspective awareness or external focus on the present moment. The primary effort of these practices are to connect with the present moment, and reduce the cognitive state of a wandering mind or mindlessness [35]. The cognitive engagement strategies utilize nature as the foreground and an active ingredient for mindful practices [36]. Connectedness to nature is an integral component of meditation practices. As an individual increases the prominence of nature memories the impact of connectedness is lengthened for an individual’s sense of well-being [34, 35, 36]. The individual in the meditative state feels a part of a larger universal state of being as a partner too and member of the natural world [36]. The connection of mindfulness within the green spaces have also been linked to person, group, and population valuation of pro-environmentalism [36].

3.3 Forest bathing

Originating in theory from Eastern cultures, forest bathing (Shinrin-yoku) is walking and breathing in nature to elicit positive psychological and physiological benefits [37]. Forest bathing involves individuals walking slowly within forested nature spaces with a focus on breathing methods and heightened awareness of the natural environment around the individual [37]. The Forest Agency of Japan initiated this wellness initiative in 1982, identifying forest bathing to combat stress and reduced attention caused by fatigue. Since then Japan has been the leader in researching and defining forest bathing as effective for youth and adults in reducing anger, fatigue, depression, confusion and improving positive emotion [37, 38, 39]. Further investigations such as a study in Eastern Europe, suggest that winter forest bathing when the leaves are off the trees is also effective in positive emotions, restoration and vitalization [40]. Some reports have been able to identify the significant difference in urban walking to forest walking, giving support to the need for forest bathing for the increasingly urbanized population and for use in public health [39]. Overall, however, the length, duration, and types of activities, in use in forest bathing are still being determined as well as the most impacted populations for this nature-based intervention [37, 38, 39, 40].

3.4 Sensory modulation in a nature space

Green spaces inherently provide sensory experiences including visual stimuli, variety of touch, movement, sounds and smells. Walking on the ground provides gravitational pull that is countered by muscles and joint sensory adaptations. A person’s ability to take in sensory stimuli and process it optimally for adaptation with sensory integration theory is termed sensory modulation [41]. This relies on an active engagement of the person within the environment of stimuli and assumes that an individual will seek out a variety of stimuli for the duration needed in order to achieve a sense of well-being from successful sensory modulation [30]. Options to engage in sensory modulation are intrinsically designed within therapeutic sensory gardens with populations having the ability to modulate their sense of emotional and physical well-being by choosing to engage in different sensory experiences that are available and easily accessed sensory choices [19, 42]. Figure 2 highlights active ingredients of the designed sensory garden created by the authors.

Figure 2.

Case study: active ingredients [30].

4. Therapeutic outcomes: Impact of engagement

Green space engagement provides a variety of outcomes for individuals, groups, and populations. Evidence demonstrating the effects of nature on psychological or physiological health and well-being includes longitudinal studies, experimental studies, observational studies, controlled laboratory studies, and studies done in nature itself. Outcomes from time spent in nature have come from self-reports, psychological measures or assessments, and the assessment of biomarkers or measurable physical substances (such as blood pressure or temperature).

4.1 Passive/active engagement

Nature can serve as the context, or the background in passive engagement. In this way, passive engagement refers to being in, or simply experiencing nature [43]. This can include listening to birds, smelling flowers, feeling sunshine, or looking at a landscape. Positive health outcomes can be felt from passive engagement [44, 45, 46, 47, 48]. Of particular interest, passive engagement does not always have to be in nature for positive effects to be felt. For instance, passively viewing or hearing images and sounds of nature can have a positive impact on one’s psychological and physiological health [48]. Viewing nature from a window can result in fewer workplace ailments and higher job satisfaction overall [47].

Nature can also be a partner, a collaborative means or ends. This type of active engagement refers to doing in nature [43]. Active engagement may involve participation in activities such as exercising, socializing, gardening (including weeding, sowing, harvesting, picking flowers, etc.), or tending to animal life such as birds. It is a holistic process of both mind and body with intentional use of natural space [30]. Positive health outcomes can be felt from active engagement in nature [1, 49, 50, 51, 52, 53, 54]. Bengtsson and Grahn identified qualities of the environment that can offer varying degrees of active and/or passive engagement opportunities. Table 1 provides an overview of the environmental qualities and identifies whether the qualities align with active or passive engagement [17].

Environmental quality	Description	Active	Passive
Joyful and meaningful activities	Engagement in enjoyable, preferred, or needed activities within nature. It can include active engagement such as physical activities, exercise, gardening, and social activities. It can also include passive engagement such as relaxing, reading, enjoying a meal, or contemplative walking.	X	X
Contact with surrounding life	Observing nature and what is happening in nature; a passive viewing of one’s environment.		X
Social opportunities	Socializing with others or socializing with nature itself. It can include active gatherings, meetings, and interacting with others and nature. It can also involve more passively being by oneself, even when with others.	X	X
Culture and connection to the past	Areas that demonstrate human culture, or environmental elements that may spark personal or societal memories.		X
Symbolism/reflection	Spark a connection or symbolism between life and nature; passive observing of nature and seeing it as a metaphor for something in one’s own life.		X
Prospect	Well-maintained or groomed green spaces. Can offer opportunities for active or passive engagement as the space itself can be inviting and provide an environment for one to engage the way they need.	X	X
Space	The environment allows for the feeling of calm, tranquility, and rest that can transport one to another world.		X
Rich in species	Refers to the types and numbers of different plants or animals within the ecosystem. Can provide a backdrop for passive engagement of viewing and observing.		x
Sensual pleasures of nature	The active engagement within a natural space, can involve all senses such as seeing, feeling, hearing, smelling, tasting, and moving.	X
Seasons changing in nature	Identification of changes in nature with each season. This might involve passive engagement such as admiring the changing colors of the leaves, or active engagement such as jumping in a pile of leaves.	X	X
Serene	Areas with calming elements that can provide opportunity for quiet, relaxation, or calm. This can include passive engagement such as listening to a soothing stream.		X
Wild nature	Areas in nature that are not groomed, maintained, or developed.	X	X
Refuge	Areas in nature that offer seclusion, space to be safe and alone.	X	X

Table 1.

Active and passive engagement based on Bengtsson and Grahn list of environmental qualities [17].

Typically healing gardens are associated with more passive natural experiences, while horticultural therapy is representative of active engagement [55]. Both active and passive engagement can exist within the same space. For instance, healthcare gardens describe garden environments that provide both passive and active engagement opportunities within nature [17]. Grahn’s triangle of supporting environments provides a model for understanding active and passive engagement with the environment based on a continuum of well-being [17]. This model posits more passive types of interaction (contemplation, passive experiences of nature) occur when one’s sense of well-being is low, and more active and outward-directed engagement (active experience with or in nature) occurs when one’s sense of well-being is high. A similar mechanism of action can be seen within sensory modulation wherein the way an individual engages with the environment (the types of activities or stimuli sought) depends on their sensory needs driven by the need for a sense of well-being [41, 56]. The type of active or passive interaction with nature that occurs impacts outcomes [1].

4.2 Dosage

Since 1982, clinicians in Japan have been prescribing time outdoors for health benefits [54]. In Finland, government funded research in 2005 resulted in recommendations of five hours a month being the lowest amount of time needed outdoors to result in health benefits from nature [57]. New Zealand was the first country to begin using the term green prescription to describe healthcare providers prescribing time outdoors to patients. The Green Prescription Active Families survey in 2018 reported 89% of participants who received a green prescription noticed positive health changes, including needing less medication [58]. Healthcare providers in Europe and North America have also been prescribing time outdoors to improve physical and/or mental health [59]. Healthy Parks Healthy People is a movement that started in Australia and is now worldwide that encourages the exploration of parks and nature for health benefits. Rakow and Ibes identified other similar programs including Park Rx, Nature Rx, Walk with a Doc, Campus Nature Rx, and Nature as Medicine that are used to provide exposure to nature as a way to impact physical and mental health positively [59]. Despite all of these global trends towards time spent in nature, less is known about the specific impact that nature exposure has on health given the duration and frequency of nature engagement.

Studies have sought to investigate the relationship between health outcomes (through subjective assessment such as self-report measures or through objective data such as assessment of biomarkers like blood pressure, heart rate, stress hormone level) and the duration of time spent in nature [52, 60, 61]. A duration of 20–30 minutes in nature three times a week has been found to be most effective for providing physiological and psychological benefits [52, 59]. Interestingly, the duration of 20–30 minutes may represent a point of saturation, as additional time spent in nature beyond 30 minutes still has benefits but those resulted at a reduced rate [52]. Smaller increments of 1 and 5-minute green “microbreaks” within a greenspace on campus also resulted in stress relief among college students [60]. Other research suggests that health benefits have been seen from people spending two hours a week in nature, whether time was continuous or accumulated across the week [62]. These benefits were found regardless of personal characteristics such as age, gender, medical conditions, ethnicity, or socio-economic status. White and colleagues also observed that benefits peaked at 200–300 minutes per week with no additional health gains seen after that point [62]. Overall, an adaptive management approach may be beneficial as it allows individuals to change the amount of time and duration spent outdoors while still reaping the benefits of being in nature [52].

4.3 Outcomes related to stress, social isolation, and wellbeing

There is considerable evidence supporting the positive benefits of natural environments on health and well-being, though benefits may vary depending on personal factors such as culture, gender, age, and socioeconomic status and environmental factors such as the location of residence. How each individual receives, and processes sensory information also affects the type of differentiating results. A summary of current evidence outlining the various types of psychological health benefits related to stress, social isolation, and well-being is provided in Table 2.

Outcomes related to stress	Decreased stress	[50, 52, 63, 64, 65, 66, 67]
	Decreased anxiety	[53, 54, 68, 69, 70]
	Decreased depression	[25, 51, 53, 69, 71, 72, 73, 74, 75, 76, 77]
	Decrease in mental distress	[78, 79]
Outcomes related to social isolation	Sense of belonging/positive social interaction	[21, 64, 80, 81, 82, 83, 84, 85, 86]
	Greater happiness or life satisfaction	[44, 49, 71, 87, 88, 89]
Outcomes related to wellbeing	Emotional wellbeing	[1, 68, 90, 91, 92, 93]

Table 2.

Evidence supporting nature exposure health benefits related to stress, social isolation, and wellbeing.

4.4 Physiological outcomes

There are currently limited standardized measures and assessments that reflect assessment of the influence of green spaces on health outcomes [43]. Development in this area is needed to support a robust understanding of the specific features and dosage within outdoor spaces that can result in positive health benefits. Nonetheless, data in the form of biomarkers, self-report measures, observation, or second-hand reporting are utilized to understand the overall health benefits of nature exposure. For example, patients post-surgery in a hospital room with a window view of nature recovered faster and used less pain medication compared to patients post-surgery without window views of nature [94].

While there are variations in research related to dosage (the amount of time spent in nature), the specific type of nature engagement (active or passive), and the exact form that nature takes (wilderness, well-maintained garden, nature view through a window, etc.), current evidence supports many physiological benefits from nature exposure. Table 3 provides a list of evidence that resulted in physiological benefits. Figure 3 illustrates the outcomes from the authors’ case study.

Outcomes related to the nervous system	Increased cognitive functioning	[1, 95]
	Increased memory and attention	[1, 96]
	Improved sleep	[43, 78, 97]
	Improved pain control	[98, 99, 100]
Outcomes related to circulatory system	Reduced blood pressure	[101, 102, 103, 104]
Global physical outcomes	Improvements post-surgery	[45, 94]

Table 3.

Evidence supporting nature exposure physiological health benefits.

Figure 3.

Case study: outcomes [30].

5. Conclusion

This chapter reviews what, how, and why engagement in green spaces can be therapeutic for well-being. The case study threaded throughout this chapter is representative of how the impact of engagement in green space can be seen in urban environments. While the case study was based on an organic farm, the participants who utilized the space lived in an urban environment. This demonstrates how active or passive engagement in green space is the desired catalyst for physiological and psychological well-being. In any setting, garden spaces that are urban or rural can have positive health benefits. When considering the what, how, and why one must consider the habits and routines of individuals and populations. Nature provides a mechanism for health for individuals, groups, and populations that require a systemic look at how we nurture ourselves and the natural world. Nurturing nature in an urban context can be an opportunity to support health by routinely optimizing nature’s benefits. Understanding the science and study of occupational balance resulting from engagement in green spaces and how that impacts individual and population health and well-being outcomes may robustly add to the science and study of urban horticulture.

Acknowledgments

The authors would like to thank the following individuals for their support in their work within active engagement in green space: Tony Miga, farm manager at Eden Hall’s campus, for his insight into vegetation, layout, and design to keep a sustainable garden space. Numerous undergraduate and graduate Chatham University students and Eden Hall’s farm staff who have supported the sustainable mission of the therapeutic sensory garden at Chatham University’s Eden Hall campus. The Chatham University Occupational Therapy program for their support of internal University well-being initiatives. We would also like to thank Chatham University’s internal research funding, which has supported the initial construction and longevity of the therapeutic sensory garden, as well as the publication of this chapter in Open Source.

Conflict of interest

The authors have no conflicts of interest to declare.

Notes

It is critical within the review of the literature presented in this chapter and when highlighting the authors’ pilot study that the reader know the identities and lived experience of the authors. All three authors are heterosexual, white, female, North Americans from working class families. They have all been trained as occupational therapists and have their doctoral degrees. They work at a University in Northeastern United States. Since the literature reviewed in this chapter bridges both Eastern and Western health traditions, traditional and alternative medicine, it is important to note the assumptions and implicit biases present in the review. The authors primarily utilized peer-reviewed journal articles in English which could limit the scope of knowledge presented. The intent of outlining these characteristics is not to eliminate knowledge, biases, or expectations, but to illuminate potential inaccurate assumptions and acknowledge the presence of how experience and privilege may influence the chapter.