Three major themes were identified in the interviews: 1) mental health clinicians are supportive of NBIs; 2) perceived benefits of NBIs for mental health consumers; and 3) perceived barriers to NBIs within mental health services. Research participants will be referred to as “clinicians” in the results. When quoted, clinicians will be identified by their assigned number.
Mental Health Clinicians Are Supportive of Nature-Based Interventions
All interviewed mental health clinicians were supportive of NBIs and were willing to recommend these programs to their consumers. When asked about their personal experiences with nature and its potential impacts on mental health, many reflected on their upbringing and how their childhood influenced their love for nature and how it became a part of their lifestyle. They described how they found spending time in nature beneficial for their own health and the therapeutic impact it had for them.
Several clinicians described their experiences of growing up surrounded by nature, playing with friends outdoors and exploring and learning about the natural world:
As kids, we lived close to a mountain range. So, we would go bush walking or abseiling or different things like that. And living on a farm, I would always be surrounded by nature or collect wildflowers or different things like that throughout my childhood as well. So, it’s always something that’s been important to me and always been something that’s been part of my life (12).
They had experiences with various natural environments including the bush, costal zones, rivers and lakes, forests, and campsites. The value of time spent in nature growing up became embedded in these clinicians’ lives. Over half of them stated that exercising in nature was part of their weekly routine. Some specifically moved to the Illawarra region because of its proximity to the bush and the beach. They reflected on their experiences of walking in nature, including bushwalks, spending time at the beach or going camping and the impact on their own mental health:
I find [that it] is really supportive for my own wellbeing. It’s something that helps me feel relaxed and recharged and refreshed. Particularly after maybe a stressful period at work…it’s something that I really enjoy and find beneficial for myself (12).
Another clinician reflected on time in nature to allow for a “freeing natural human state of just being” (11) that they actively implement when needing any form of respite. This clinician also stated that when time in nature is spent with others, it generates conversation. Additionally, clinicians reflected on the negative effect that lack of contact with nature would have on their stress levels and feeling overwhelmed. One clinician described the need to schedule more walks in, as a “good balm to both sadness, anger, frustration, general stress, that it just brings all of those emotions down and…promotes happiness” (07), especially when life was stressful. Stepping into nature was described as stepping outside of the human world, and clinicians valued this use of their time. They also reflected on the sensory experiences that come with nature and these include the calming, relaxing, and peaceful aspects of the sights, smells, and sounds. All these personal experiences allowed clinicians to realise the therapeutic aspects of time spent in nature.
As clinicians were prompted to comment on their view of NBIs, some highlighted the convenience of engaging in therapy outside of the normal office setting. They felt that nature pervades the local landscape and access to it can be generally low cost or inexpensive. One clinician stated:
…because of the area we live in, engaging with nature is quite easy. So, whether it’s going to the beach or going to the escarpment…walking around the lake…it’s fairly easy to access something close by, which then also means that it’s low cost (12).
Clinicians also described the structured component of an NBI group as appealing for mental health consumers because the responsibility of navigating the walk lies on the facilitator. Additionally, clinicians perceived that NBIs would provide a space for consumers to “have a break from their internal mayhem and briefly focus on things outside of themselves…and do it in a more relaxed setting with staff” (05). Some clinicians also believed that NBIs would enhance rapport and therapeutic alliance: “it's a way to build better rapport and better relationships that that are more natural than this forced clinical relationship” (09).
Overall, many clinicians already encouraged consumer participation in nature-based activities such as going for walks, with some comparing it to taking compulsory medication. Spending time in nature was described as pivotal for achieving holistic health outcomes and adding meaning to consumers’ lives. As one clinician simply stated, “No matter what else happens, [nature] will still be there in one way, shape, or form” (03). If NBIs were to be organised within their services, clinicians expressed willingness to discuss and promote these programs with their consumers as a valid treatment option.
Perceived Benefits of a Nature-Based Interventions for Mental Health Consumers
Clinicians perceived numerous potential benefits of NBIs for mental health consumers such as relaxation, alleviated mental health symptoms, social connections, confidence and empowerment, and physical exercise resulting in better health.
Mindfulness and Relaxation
Providers believed NBIs would provide space for mindfulness, relaxation, calmness, and restorative sensory experiences. One clinician elaborated on these potential benefits in the following way
…being aware of what’s going on in the environment around me, whether it be that something is flowering or whether it be that a bird flies over. Almost like a calming meditative [experience] and I think people would benefit from that calming meditative feel about it. You feel part of something. You feel part of the environment. You feel part of the world and I think people might find that really useful. And just a lot of awareness of outside yourself (02).
Nature was thus viewed as allowing consumers to step outside their own headspace and create a sense of connectedness to something bigger outside oneself. Clinicians furthered explored the benefits of the sensory experiences that could result from NBIs. Many described tactile sensations such as: “walking on grass with bare feet” (02), “bellbirds whistling in the trees” (04), “the smell of the sea breeze” (12), and “the earth in my fingers” (04). These experiences were believed to calm and relax, soothe feelings of sadness, anger, and frustration, and stimulate a sense of resilience and happiness. Facilitators’ skilled guidance of NBIs such as leading nature mindfulness exercises could further strengthen these benefits.
Alleviated Mental Health Symptoms
Clinicians believed NBIs would offer several short- and long-term benefits for management of mental health issues especially anxiety and depression. For example, nature walks would release endorphins and increase feelings of pleasure and enjoyment which can improve a person’s mood. One clinician described it in the following way
People were able to enjoy this walk, and you could see the difference in people [...] every day in the morning, they were able to move away from that environment into nature. And when these people came back, they were totally different. You could see smiles in their face (14).
Clinicians also stated that NBIs could lead to increased self-esteem and self-regulation and building new copying skills. As one clinician explained: “…it also helps them to be able to identify and put words to how they feel, and how they express things, and connect that with what they’re thinking but also what their body is feeling” (09).
Social Connections. Clinicians believed that NBIs would create opportunities for social connections and camaraderie, which were described as vital for mental health. NBIs offered in groups, such as nature walking groups, could help break down loneliness and social withdrawal tendencies which were identified as common among mental health consumers. As one clinician stated: “it might be the only social interaction they get at all” (03). Clinicians emphasised that consumers should not be expected to socialise and talk to other group members if they chose not to. They hoped, however, that by being in the presence of others, consumers would slowly acquaint themselves and create some connections with group members. For example, while walking, consumers could engage in informal conversations without the potentially intimidating eye-contact and intensity of a therapy room. As one clinician explained, walking with others “generates a flow of conversation different to that when you are in a sit-down space” (11). Moreover, they discussed the potential for consumers to meet like-minded people, to motivate each other to take ownership of their recovery and to gain perspective from others who have similar lived experiences and are not closely linked to their personal lives. Group NBIs would thus emphasise the idea that consumers are not alone on their journey and normalise mental health issues in general.
Alternative Intervention. Numerous clinicians have advocated for NBIs as an alternative to the medical model that would entice consumers who struggled with regular sit-down therapy, taking medications, and leaving the house. The presence of clinicians, however, ensures the mental health recovery orientation of NBIs and support in the consumers’ recovery journey. One clinician provided an example of teenagers who may struggle with the expectation to be processing and expressing their emotions in the formal and structured environment of a therapy room. Similarly, one clinician explained: “…I think when they feel like someone’s not staring at them from across a room expecting a certain answer, when you’re just going for a walk, it kind of breaks down that clinical barrier…” (09). NBIs thus alleviate the described feeling of being locked in a room for a therapy session and create “an environment that’s more conducive to mental health support” (09). Group NBIs can also create a familiar, safe, and facilitated opportunities for leaving home regularly, which may be of particular benefit for consumers afraid to go out alone.
Confidence Building and Empowerment
Clinicians considered how structured NBIs such as nature walking groups could support consumers’ functioning and enhance their sense of empowerment and confidence in the recovery. As consumers make the decision to actively look after themselves, they start to recognise their power and ability to make changes in their lives and be successful in achieving their treatment goals. Referring to an existing NBI within a mental health program, one clinician summarized, “Our staff would lead a group walk every morning for consumers. So, the consumers’ comments are that they just feel re-energised. They feel like they have developed some sort of confidence about themselves” (14). Clinicians also specifically described the potential of NBIs for young people given their tendencies to rebel against traditional interventions.
Physical Exercise Resulting in Better Health: Some clinicians discussed the physical health benefits of NBIs as many of them promote exercise: “improving physical health, walking, it's high on our agenda” (13). Clinicians identified that mental health consumers tend to have poorer physical health and thus, any form of physical activity was believed to benefit consumers. Exercise would additionally support management of medication side-effects such as weight gain or lethargy.
Perceived Barriers to Nature-Based Interventions within Mental Health Services
Despite a having a strong belief in, and being supportive of NBIs, clinicians expressed concerns about the development, facilitation, and participation in nature-based activities such as walking groups. They listed several individual and organisational barriers to the implementation of NBIs including consumers’ resistance and mental health symptoms, limited access, and safety risk.
Clinicians believed that mental health consumers may experience 1) resistance, scepticism, and a lack of awareness of the NBI’s benefits; 2) poor physical health and not feeling fit; 3) mental health symptoms (e.g., lack of motivation, anxiety); 4) fear of having to socialize and/or not fitting into the group; and 5) access issues (e.g., lack of transportation), all of which may prevent them from participating in NBIs.
Clinicians perceived that some consumers might not be willing to participate in NBIs due to scepticism and unawareness of its benefits. Clinicians highlighted that some people are oblivious to the natural environment and thus dismissive of its health and wellbeing benefits. One clinician expected consumers may self-sabotage nature walks in advance: “Oh, what’s the point of this, to go on a walk in the middle of nowhere?” (08). Some clinicians believed that their consumers would need to be convinced into participation, and that consumers would not necessarily engage or believe in the benefits even if they did attend. One clinician described her consumer’s response to a recommendation to spend more time in nature: “…the idea of going for a bushwalk just seemed quite weird to her like, ‘Why? Why would you do that? What are we going to do?’ she said” (05). Consumers’ resistance to join NBIs, according to clinicians, may develop around their motivation or physical limitations: “Lack of motivation, lack of energy, lack of belief in the process, just don't like walking. A lot of people just don't like exercise. What else would they stop them? Physical injuries” (01). Clinicians thus believed that consumers who did not enjoy exercise and/or were not physically fit would be particularly reluctant to join.
Mental health symptoms and their management were also raised as potential barriers to NBIs. For example, clinicians worried that consumers with anxiety and social phobia might feel uneasy about being in public spaces and concerned about a potential panic attack in front of others. A clinician described the resistance of a consumer to NBIs in the following way: “the reason she doesn’t want to do it is because she’s socially anxious and she’s worried about people watching her while she’s walking and what they think of her” (07). Clinicians also spoke about the potential for consumers to be preoccupied with the symptoms they experience, and how potential sensory experiences need to be considered, for example: “being a low-intensity kind of sensory environment would be a good match for people with psychosis” (12). Lastly, some clinicians added that special consideration is required for consumers who may have suicidal ideations: “Clearly, if you’ve got a suicidal consumer, you’re not going to walk beside a cliff. You might not want to go into too remote an area with them. You don’t want to get stuck in the bush…” (03).
If structured NBIs such as nature walking groups were to be offered, clinicians believed the group makeup and dynamics may pose challenges to some consumers. For example, younger consumers might not want to join a group with older adults due to physical abilities and levels of fitness which can impact the group’s pace and because socially it would not be considered a “cool thing to do” (11). Clinicians also discussed the presentation and severity of mental illnesses:
Some people that we work with can be quite unwell and others can present as being fairly functioning and fairly well. So also, sometimes, people, young people within that age group, the person who’s sort of presenting well is going to be like, “I’m not unwell like that person, I’m not coming” (06).
Due to existing mental health stigma, some consumers could feel ashamed to walk with the group in a community setting. Finally, some might feel intimidated by a group setting or become withdrawn due to the inability to socialise with others.
Finally, geographic accessibility was perceived as a barrier to NBIs. Many mental health consumers do not drive and/or do not have access to a car. Some clinicians believed that consumers would find accessing NBIs via public transport inconvenient further decreasing their motivation to participate. A few clinicians also mentioned that accessing NBIs may be especially difficult for consumers with limited financial resources and thus providing transport would be essential.
Organisational Barriers: Clinicians also discussed barriers from the perspective of the mental health services and organisations. They listed things such as: “risk assessment” (03), “having the managers see the value in it” (07), and “limited understanding or effort to understand the effectiveness” (11). All clinicians believed that mental health services prioritize the medical treatment model, which is viewed as evidence-based and taking place in a controlled environment. This opened the discussion around the organisation’s doubt and uncertainty of the evidence of NBIs for mental health. As one clinician identified:
I think the service doing anything new is always a barrier because they always want to know, “Is there an evidence base?” and where we’re taking the time from? Like what are the staff not doing instead of doing this group? They don’t want to do anything that doesn’t save them time somewhere else, to make up for the time lost (07).
Many clinicians believed that, like the consumers, the health system is unaware and/or sceptical about the positive effects of NBIs. Clinicians described that within their organisations certain staff members may be unwilling to change or implement new ideas, especially when the intervention is to take place in an uncontrolled environment, such a park or bush. Clinicians worried that running NBIs which would take away time from their current prescribed responsibilities. Overall, the main difficulty was having to justify the value of NBIs, proving that it is a legitimate form of treatment rather than an unnecessary cost that poses risks.
Finally, safety risk was frequently discussed as organisations would require a risk assessment and management to implement NBIs as part of their services. Potential risks included the inability to complete a long walk; consumers becoming unwell; managing behavioural issues; consumer vulnerability and sensitivity; and accidents (e.g., falls). Some clinicians believed that organisational risk management strategies can be so extreme that they may completely block NBIs. As one clinician explained: “If you want to do anything that is outside of the office, it’s just fraught with red tape and barriers, and having to write risk policies and ‘risk this’, and ‘risk that’, because the environment is not controlled” (09). Clinicians emphasised that given the risk averse culture community mental health services, these potential issues would create a variety of obstacles to implementing structured NBIs such as a nature walking group.