Alan Kellas, Psychiatrist

Published in JHH 18.3-Shifting the paradigm

Many holistic practitioners wonder ‘How can I connect with nature in my practice? Would keeping nature in mind make any difference to my own work, whether in the clinic or therapy room, ward or care home?’ Could it change the care to individuals, families, parents, young people, people at the end of life, people with special needs? Some practitioners have a lifestyle, preventive perspective, or even a public health role and know the health-positive role of access to natural green spaces. Covid and lockdown restrictions have highlighted both the serious inequalities of access to them for people and families in urban high-rise housing, and at the same time sparked a deep hunger for the outdoors. But what place does or could nature have in clinical holistic practice?

This article traces some findings on a journey of linking nature and my personal and professional practice: I first worked in general practice and then in holistic health settings and self-help centres like the Bristol Cancer Help Centre. I then trained in psychiatry, specialising in helping people with learning disabilities in community and hospital settings, loving the combination of medicine, neuropsychiatry and applied genetics with the emotional challenges of working non-verbally using creative arts. The social challenges included creating packages of care and support with families and carers for people with complex and challenging needs or risky behaviours, responding to safeguarding concerns, or resolving social crises that threatened exclusion from homes, families or neighbourhoods. There were seldom quick fixes. Holism meant integrating legal, financial, social, family, therapeutic and medical approaches and insights.

Towards the end of full-time NHS community work and after a few struggles with my own mental health, grief and bereavement, I wanted to make the transition to a more sustainable way of clinical practice. I came to realise the personal and transformational value of spending immersive solo time in nature, and found myself drawn to the traditions and practices of the School of Lost Borders, particularly its approach to wilderness questing: this for me combined the insights of meditation with the embodied teachings from which I had gained so much from people with disabilities and my own explorations of dance movement therapy. Reflecting on the deep importance of nature for my own wellbeing and identity, I began studying ecopsychology and realised my own and my patients’ fundamental connection with nature had been a huge missing part of my psychiatric and clinical training. What would psychiatry be like, I wondered, if we honoured the creatures on the crest of our college coat of arms and acted as if nature really did matter to and in mental healthcare?

Around this time in 2014, the sustainability committee at the Royal College of Psychiatrists was applying the principles of human environmental and financial sustainability to mental health services: promoting low carbon, low waste, preventative and empowering approaches to practice. Having done a year’s course in permaculture and sustainability, I joined this group as the ‘green care rep’, and have since then been part of a dynamic network of psychiatrists exploring and promoting the value of nature in mental healthcare. We have been particularly helped by colleagues and innovators in the green care sector, the Wildlife Trusts, community, city and care-farming and therapeutic horticulture, by Forestry England, and woodland wellbeing and forest school networks.

Then came climate protests. Hearing Greta Thunberg speak to 30,000 children and families on Bristol College Green, invited by local school strikers, and realising the breadth, depth and strength of professional concern and rising activism woke me up: experienced and respected medics and colleagues were arrested for non-violent disobedience as part of Doctors for Extinction Rebellion, and it became clear to many of us (inspired by Climate Psychology Alliance) that the climate and ecological crisis is also a psychological and human behavioural crisis.

Eco-apathy and climate denial are one way of dealing with the climate crisis: the illusion that business as usual can carry on. At the other extreme people crash into despair, paralysed by powerlessness at the prospect of the imminent unravelling of all life on earth. Both reactions are bad for mental wellbeing and bad for the planet. The case for psychiatry to address these emotional disconnects is compelling: we have the interest and expertise to take seriously the human, social and personal harms and risks of the crisis, and to help us all deal with these realities and the ever-worsening climate news. In 2020 I was part of a group gathering a wide variety of expertise to inform the Royal College of Psychiatrists’ position statement on the climate and ecological emergency, and was pleased that as well as considering climate, heating, emissions and carbon, the ecological emergency and nature’s particular role in mental health recovery and in nature-based solutions gained more prominence. Globally the outcomes from COP15 and the UN biodiversity conference in Kunming need to link to COP26 on climate. Advocating for nature flows from protest and alarm at the climate crisis: so committing to holistic care and services that are both low carbon and nature rich can build these crucial bridges between human health and biodiversity.

Holistic medical skills and nature-connecting insights help us approach individual, family or community healing with broader models of human psychology embedded in a wider ecology: recognising, in our next breath or gulp of water, our indebtedness to the natural world and the mycelium of attachments which affect not only bodies but minds and spirits too.

In psychiatry and medicine advances in pharmaceutics, genetics and neuro-imaging are changing the ways we view brains and bodies, and neuroscience increasingly influences psychology, but place-based ideas of asylum or sanctuary and ancient notions of retreat, respite and the restorative benefits of the natural world also emerge in clinical conversations all the time. And while family and systemic therapies are recognising wider non-human environmental influences, psychotherapeutic and counselling practices now embrace embodiment more explicitly; trauma-informed care keeps attention on our core animal physiological reactions, and mindfulness reminds us of breath, sense and slowing down to be present in the present. The body thus bridges the mind into nature.

As mental health services moved out of institutions and campuses into general hospitals, clinics and community settings, the benefits of closer contact with green spaces, or water, meaningful occupation like therapeutic growing, or animal or pet care, supported work and outdoor activities, even in specialised care settings, are now finding their ways back into assessments and care planning. The traditional skills of occupational therapists are in carefully assessing someone’s function and motivation in their environment, grading tasks on the steps to rehabilitation and tailoring community support for both need and potential. Budgetary pressures and ideology have, however, meant deprofessionalising much of this skill and knowledge, as the commissioning of community connectors, social prescribing link-workers, and peer recovery navigators has brought new energy and ways of engaging the hard to reach or help, finding common ground and a less patronising relationship dynamic of help or ‘treatment’. Ironically this leads many to stumble anew on the long roots of nature-based skills and insights in mental health nursing and occupational therapy developed over decades.

‘…recognising in our next breath or gulp of water our indebtedness to the natural world and the mycelium of attachments which affect not only bodies but minds and spirits too’

Social workers, the other valued partners in the best multidisciplinary teams I have worked in, have had their professional roots in community development and advocacy, family work and support. While more atomised individualised services, brokered and costed care packages and reactive safeguarding protocols dominate practice, the sense of place, the uniqueness of each community, the need to know your ‘patch’, its people and history, their local community provisions and groups, are still important professional skills: training and experience of these may prove to be as valuable to clients as caseload IT data entry skills.

Educators working with marginalised, excluded, disengaged and vulnerable children and young people like those with learning disabilities, or autistic needs, have long known the value of nature-based, outdoor and forest school educational approaches. Specialist referral units and residential campus-style colleges tend to be funded for only the most complex and vulnerable or needy, but the principles of learning from and rewilding childhood in nature with plants, animals, soil, water and trees are universal while few doubt the urgency and value of better environmental education for all. What is less recognised is the value of nature-friendly schooling for child and adolescent mental health.

Even while social care faces gross funding and staffing crises, social prescribing has emerged as a way for prescribers in primary care to access the non-pharmacological benefits of community connections, whether for loneliness and isolation, physical inactivity, stress or housing, financial and social adversity. So prescribing nature (alongside arts, sports and advice) in the form of a green social prescription or referral from a GP or social prescribing linkworker, community care or housing co-ordinator, is now being actively researched within the NHS in a number of test and learn sites across the country. Micro-grants for community groups in disadvantaged neighbourhoods are testing out, for those often alienated or excluded from these opportunities, the benefits of:

• walking groups from local green to blue spaces
• drop-in and supported community allotmenteering and food growing
• walk and talk groups taking courses in anxiety management outdoors in nature, bushcraft and adventure youth work for those in high rise flats
• wild water swim and outdoor yoga groups for multicultural women’s networks
• woodland wellbeing or adapted forest schooling sessions for young families in refuges
• nature recovery conservation volunteering for those in recovery.

While the benefits of nature for everyone might seem self evident, and hardly in need of any expertise, the realities of many people’s lifestyles, the complexity of their difficulties and the barriers of access and the weirdness of these ideas to some, require more than a signpost, weblink or leaflet. Nature’s potential for radical healing and transformation of complex physical and emotional distress means that it can be a soulful multifaceted partner in many therapeutic settings. No wonder then that a full training in nature-based specialist practice can take years. The quality of provisions and projects, training, accreditation and support for practitioners can be key issues, not only for commissioners. Some have years of experience in green care, others in working to bring nature into mainstream settings, while others may be starting out and wanting to gain accreditation as a specialist green care provider. Training to be a volunteer community walk leader, a weekend introduction to forest bathing, a two-year immersive course in nature-based ecopsychotherapy practice, forest school accreditation, or qualifications in animal care or social and therapeutic horticulture are all different. But for all of us, nature provides deep and continuing professional development for our whole careers. Creating or joining a peer group circle can provide the critical reflective cycles of action learning with immersive experiences that are needed.

‘Eco-apathy and climate denial are one way of dealing with the climate crisis: the illusion that business as usual can carry on’

Those wanting to incorporate nature into their existing practice often want to learn about evidence and theories of mechanisms of benefit to their client groups or conditions, the basics of ecopsychology or simply exemplars of good practice. A recent trial special choice module for second-year medical students curious about nature and integrative medicine took them to sessions in a city farm; joining a walking group; considering how neighbourhood spaces link schools and play spaces for young children; experiencing forest bathing and the Way of Council (see for example https://waysofcouncil.net) for themselves; studying biodiversity of wildlife and ecosystems with human health; water cycles and rewilding in rural farmland and adventure and outdoor educational challenges (like first-time camping for some). Time for private study and research allowed a range of projects and literature searches on attention restoration theory, equine-assisted therapy for children with special needs, and an enquiry into modern versions of medical rituals and potential applications of shamanic teaching.

So where does this leave practitioners? Holistic assessments focus on medical, drug, nutritional, structural, psychological and social needs, as well as family and spiritual needs, but they should surely now incorporate nature connectedness.

The key clinical approach I usually take with patients or anyone wanting to explore their own connections with nature is to pause and consider their own evolutionary, ancestral, remembered cultural family history of connections to place and land. ‘Does nature matter to you? How was it important in your childhood or to your family? What contact do you have with nature each day or week; in your home, neighbourhood, work, leisure or learning?’ Tracing back through our grandparents, and our own childhood experiences of play and place, many people find that a disconnect or dislocation happened in the past when natural states of play in childhood and connectedness to the natural world changed over the generations, with migration, travel, technology, and globalisation of food each playing their part. And paying attention to someone’s story, and the language and metaphors they use relating to the natural and the elemental world, often reveals a precious truth or picks up an important relationship, eg to water, the sea, mountains, trees, plants, animals, birds, dogs. This can open up a conversation about close nature, shoots on a window sill, a local park or pond, the daily, weekly or annual times, places and ways people get their nature fix and restoration. The view of a tree from a waiting room, a shell by the tissues in the consulting room, hearing sounds of the sea from the bodywork couch or agreeing to make one group or team meeting a ‘walk and talk’ with a moment of finding and pausing for a sitspot, simply lighting a candle…all can be ways for nature’s magic to appear.

Small rituals from preparing for the next client to marking life transitions call on nature too. Not only the passage from child to adult, but other seasons of life, or the transformation of identity that comes with disability or an empty nest, grief and loss or coping with a trauma. These might need a single witness or a whole community to honour us and are how nature and place support humans with art and ceremony to remember we are not alone.

As we face our current threats, distress and uncertainty together, we might allow nature to restore both itself and us. Extending holistic practice from body, mind and community to keep nature in mind might be one way to explore this deeply alarming and mysterious adventure we share.

Links

Ecopsychotherapy www.confer.uk.com/eco.html

Green social prescribing https://beyondgreenspace.net/2021/07/09/new-green-social-prescribing-resources

Nature matters resources www.rcpsych.ac.uk/improving-care/workingsustainably/nature-matters

Nature based trainings www.naturalacademy.org; https://circleofliferediscovery.com/cpd-training

RCPsych Position Statement www.rcpsych.ac.uk/improving-care/working-sustainably/college-position

UN Convention on Biodiversity www.cbd.int/convention

Ways of Council https://waysofcouncil.net

Wilderness questing https://schooloflostborders.org