Forest bathing in outdoor green spaces: Treating clients with eating disorders

The recent use of non-clinical, outdoor green spaces as an effective therapeutic modality to promote biopsychosocial health and quality of life—a practice sometimes referred to as forest bathing (Li, 2018)—has created new opportunities for occupational therapy practitioners (OTPs). Particularly in an era shaped by the Patient Protection and Affordable Care Act (ACA, Pub. L. 111-148), institutions have found it useful to invest in creating outdoor community spaces such as farmers’ markets, community gardens, and farms that promote preventive health. We (the authors) have used three such outdoor green spaces on our Penn State Hershey hospital campus to facilitate occupational practice at an eating disorders clinic, including forest bathing in the woods, shopping at an outdoor hospital farmers’ market, and harvesting produce from the hospital community garden as therapeutic programming for clients living with eating disorders.  

Forest bathing or forest therapy was derived from the Japanese Shinrin yoku in the early 1980s by Japanese physicians who noticed their urban clients had increasing rates of physical and mental health issues that might be ameliorated by time in nature (Li, 2018). Although the name evokes the wilderness, forest bathing has more recently come to encompass bringing clients into any natural environment or green space and encouraging them to simply be conscious of their surroundings rather than fixated on their illness. Indeed, research has consistently shown that taking in nature through the five senses can have a beneficial impact on heart rate, blood pressure, pulse, blood sugar, stress, mood, sleep, and the immune system (Li, 2018). It allows humans to experience a liminal state and shed the stressors of the day, thereby promoting flow and other positive mental health states, such as relaxation and mindfulness. At a deeper existential level, “being in nature can contribute to one’s sense of connection beyond themselves to a common good” (Delbert et al., 2023, p. 1). This emerging research, as well as recent changes in the U.S. health care system, have created an impetus for OTPs to think more strategically about how green spaces might be used in client care.  

Background 

Since the 2010 passage of the ACA, hospitals have been incentivized to conduct community health needs assessments and implement programs to address chronic disease and mental health issues (George & Ethridge, 2023). At Penn State Milton S. Hershey Medical Center, we established a market (2010) and garden (2014) and are located next to a wooded hillside with 10 miles of hiking trails. Given the benefits of nature exposure, we have sought to explore ways to use these green spaces with Partial Hospital Program (PHP) clients in an eating disorders clinic (EDC). See Table 1 for types of eating disorders.  

Table 1. Eating Disorders (American Psychiatric Association, 2013) 

Implementation 

Community Garden 

In 2023, a dietitian and an OT from the EDC took four clients to the Hershey Community Garden (HCG) and used horticulture therapy as well as integration of garden produce into the clinic kitchen (e.g., to prepare homemade salsa). Client A is an 18-year-old male presenting with avoidant/restrictive food intake disorder (ARFID). He has a longstanding history of only eating approximately 10 different food items and hopes to expand his food choices (especially vegetables) prior to starting college. Client A harvested vegetables from the HCG and worked with an OT on introducing a harvested tomato as a novel food. He progressively increased from bite-sized pieces of tomato to eating an entire serving in occupational therapy treatment, following the EDC ARFID protocol (Lane-Loney et al., 2022).  

Farmers’ Market 

We took five clients to the hospital market where they listened to live music, shopped at stands, and purchased peppers for later use in food preparation. Client B is a 23-year-old female presenting with ARFID. She developed selective eating as a child, and it became more restrictive 2 years previously in the context of severe anxiety resulting in nausea and vomiting. At the market, she purchased tomatoes with a plan to prepare cowboy caviar (a bean salad dip) to return to eating a vegetable she used to enjoy. Research shows that food preferences are developed through tasting (even if the amount is only a crumb) and that learning to like a food requires repeated tastes (Williams & Seiverling, 2018). The occupational therapist encouraged her with a short-term goal of gradual and increased bite sizes and a long-term goal of eating a full serving. By discharge from the program, she was able to tolerate eating small portions of her recipe. 

Hiking Trails 

A group of four clients, one medical student, and the authors of this article took a field trip to the woods behind the hospital. We used a combination of story-sharing, sensory activities, and information about the medicinal value of plants. We recommended that clients use deep breathing and sensory awareness for stress management, and we encouraged the group to pause and take in the Blue Ridge Mountains on the horizon and the surrounding beauty. Participants descriptively used terms such as calm, happy, and peaceful after the intervention, using an important recovery skill of tuning in to their bodies and how they feel, versus the eating disorder tendency to tune out cues. Client C is a 17-year-old female presenting with anorexia nervosa, binge-purge type. She initially refused to eat lunch prior to the field trip; however, she compromised by drinking a supplement which enabled her to participate in the fieldtrip as well as the remainder of the program day.  

What we Learned 

Forest bathing field trips provided opportunities for clients to leave the clinical setting and be outside, allowing a reprieve from their Cognitive Behavior Therapy (CBT) eating challenges at structured mealtime and in snack groups. We asked patients about their anxiety level—both at the beginning and end of the group sessions—using 10-point modified SUDs rating scale (Cuncic, 2023, November 9), with 10 being unbearably upset and 0 being peaceful and calm. We observed that scores changed from 8 to 10 out of 10 at the start, to 4 to 6 out of 10 at the conclusion. Providing client education about interoceptive awareness is especially important. Based on informal observations during 15 years of experience, Amy (first author), has noticed that this patient population tends to have differences in perceptions of body cues. An ARFID patient may be hyperfocused on food texture or the fear that a particular food will make them vomit, and an anorexic or bulimic patient is prone to tuning out body cues and emotions). 

Since one of the main lessons of eating disorder (ED) recovery involves healthy stress management, patients are asked about their best coping activities (both at admission and discharge), and it is beneficial when patients add new activities to include any of the outdoor activities presented to them in during the program (i.e., forest bathing, attending farmers markets, gardening, stepping outside for a breath of fresh air). A foundational component of ED treatment is to work on food variety, which we were able to do via expanding client palates after field trips. For example, client A was exposed to a brand new food and client B independently selected a food to incorporate in a recipe. Clients had increased motivation to participate in clinical treatment in order to return to previously desired outdoor activities. Patients who were underweight and/or had critical signs of malnutrition in their lab work became motivated to gain weight to return to hiking or biking. Instead of just discussing nature therapy as a healthy coping skill, we were able to actually experience it in-vivo. 

In terms of limitations, some clients were not able to participate due to program schedules. We were fortunate to have access to a tour guide, community garden, farmers’ market, and hospital shuttle without cost to our clinic. The activities also rely on people in public places being sensitive to client needs, such as avoiding potentially triggering comments and respecting activity restrictions. Activities are weather dependent and seasonal.  

Implications for Practice   

The beauty of forest bathing is its simplicity. Simply seeking green space can be incorporated as a therapeutic intervention for inpatient and outpatient treatment, as well as group or individual sessions. To implement therapeutic field trips, staff need to identify participants who may benefit—anyone who is open to outdoor exposure and physically capable of movement, interaction, and appropriate conduct in such spaces—obtain field trip destinations, secure funding for any costs, and coordinate client schedules and transportation. As outlined in the fourth edition of the Occupational Therapy Practice Framework: Domain and Process (OTPF-4; American Occupational Therapy Association [AOTA], 2020), all performance components of the tasks, consisting of the required motor, sensory, and social skills, could be adapted to the client and their diagnosis. Forest bathing provides heightened awareness of sensory experiences. Nature therapy could be applied to any setting as wide ranging as occupational therapy settings themselves, spanning the lifespan from young children to older adults, and including both physical and mental health.  

Documentation and reimbursement are site specific. For example, our ED field trips were documented in the clients’ daily group notes and incorporated in daily PHP bundle code. Some ED treatment centers offer nature walks and beach outings, but few appear to make time in nature a central aspect of their programs. Precautions include potential allergies, flight risk, and identifying clients who are unsafe—those severely underweight and/or with critical signs of malnourishment in bloodwork, or clients with active self-harm or suicidal thoughts. Our population required adaptations to limiting the forest presentation to the trail head (versus hiking trails) due to the clients’ activity limitations. These activities could be adapted to other physical rehabilitation issues by considering things like wheelchair accessibility.  

If unable to incorporate field trips with clients, park prescriptions, similar to a prescription for medication, can be used to recommend time spent in nature (Golden Gate National Parks Conservancy, 2023). A formal prescription is unnecessary; one can simply recommend clients step outside in their backyards or go to a local park. If the client is on bedrest, nature can be brought inside by placing a table near a window containing plants, rocks, and nature photos, to create a naturescape.  

Conclusion 

Consistent with prior studies on the effects of outdoor activities on well-being, our preliminary programs had a positive impact on the physical, mental, social, and spiritual health of participants, for example, by increasing food exposure and variety, introducing patients to new ideas for stress management, providing opportunities for socialization within the field trip setting, and increasing motivation to recover in order to return to previously enjoyed activities. Nature-centered activities that guide people out of clinics and into green spaces can be incorporated into occupational therapy interventions to demedicalize the health care experience and positively impact patient health. There may be particular benefits in intergenerational activities that partner younger populations with assisted living residents or master gardeners.  

Although a significant amount of research has demonstrated the health benefits of nature, there are a lack of studies examining the role nature plays in eating disorder recovery (Siber, 2022). Future research might focus on the benefit of simply stepping outside the clinic by collecting longitudinal data such as blood pressure, cortisol levels, weight scores, and mood scores to explore the effects of outdoor opportunities on treatment.  

References 

American Occupational Therapy Association. (2020). Occupational therapy practice framework: Domain and process (4th ed.). American Journal of Occupational Therapy, 74(Suppl. 2), 7412410010. https://doi.org/10.5014/ajot.2020.74S2001 

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Author. https://doi.org/10.1176/appi.books.9780890425596  

Cuncic, A. (2023, November 9). SUDs rating scale for measuring social anxiety. https://www.verywellmind.com/what-is-a-suds-rating-3024471  

Delbert, T., Stepansky, K. E., & Bucey, J. (2023). Cultivating well-being and connectedness: A university based therapeutic sensory garden study. American Journal of Occupational Therapy, 77(Suppl. 2), 7711505158p1. https://doi.org/10.5014/ajot.2023.77S2-PO158  

George, D. R., & Ethridge A. E. (2023). Hospital-based community gardens as a strategic partner in addressing community health needs. American Journal of Public Health, 113, 939–942. https://doi.org/10.2105/AJPH.2023.307336  

Lane-Loney, S. E., Zickgraf, H. F., Ornstein, R. M., Mahr, F., and Essayli, J. (2022). Cognitive-behavioral family-based protocol for the primary presentations of avoidant/restrictive food intake disorder (ARFID): Case examples and clinical research findings. Cognitive and Behavioral Practice, 29, 318–334. https://doi.org/10.1016/j.cbpra.2020.06.010  

Li, Q. (2018). Forest bathing: How trees can help you find health and happiness. Viking.  

Patient Protection and Affordable Care Act, Pub. L. 111-148, 42 U.S.C. §§ 18001–18121 (2010). https://www.govinfo.gov/content/pkg/BILLS-111hr3590enr/pdf/BILLS-111hr3590enr.pdf 

Siber, K. (2021, March). How nature helped me recover from an eating disorder. Outside.  https://www.outsideonline.com/health/wellness/nature-eating-disorder-recovery  

Williams, K. E. & Seiverling, L. J. (2018). Broccoli boot camp: Basic training for parents of selective eaters. Woodbine House. 

Amy E. Ethridge, MS, OTR/L, is an Occupational Therapist and Clinical Psychiatric Specialist who is passionate about bringing creative programming to the Penn State Hershey Medical Center Eating Disorders Clinic.  

Daniel R. George, PhD, MSc, is a Professor of Humanities and Public Health Sciences at Penn State College of Medicine, and has been involved in the leadership of the Farmers’ Market in Hershey and the Hershey Community Garden.