Outside the boxes
By Alex Sakariassen, The Montana Free Press, June 11, 2020
As it does for most high schoolers today, Jocelyn’s world came at her in a rush. The early morning alarm gave way to the crush of classes, and that in turn to the flood of homework, a dizzying flurry of touchscreen activity running through it all like the unending connective sinew of 21st century life. Debilitating headaches and severe chest pains drove Jocelyn to the emergency room, but tests turned up no physical explanations for her symptoms. Her pediatrician, Dr. Robert Zarr with the Washington, D.C.-based practice Unity Health Care, determined Jocelyn’s panic attacks were rooted in stress. The solution he prescribed didn’t come in pill form, but rather in the shape of a hammock in her father’s backyard.
The hammock time that led to the subsidence of Jocelyn’s panic attacks wasn’t just a casual recommendation from a doctor. Zarr sent her home with a literal prescription including a dosage of 60 minutes, a frequency of once a week and a strict condition that Jocelyn take each dose sans digital devices. It wasn’t the first time he’s filled out a scrip for time outdoors, and it’s far from the last. Zarr has spent much of the past decade at the forefront of an international movement to tap the restorative powers of nature, helping to clear a path in the treatment of physical and mental illness that’s become all but overgrown since the advent of modern pharmaceuticals. And he’s adding trailside flourishes of his own along the way.
Earlier this spring, Montana Free Press reported on the surge in outdoor recreation prompted by Montana’s response to the coronavirus pandemic, and how that surge spoke to the connection between wild spaces and mental health. The fact that social distancing and fear of disease transmission are taking a toll on people across the country is abundantly clear, whether the news comes from the Centers for Disease Control as tips for coping with the pandemic or polling by the Kaiser Family Foundation. Speaking with MTFP in April, Whitefish therapist Sara Boilen speculated that the wave of pandemic-induced stress, anxiety, isolation and substance abuse would continue to wear on the public’s mental well-being for some time to come. We’re going to be processing the effects of this pandemic, Boilen said at the time, “for a while.”
Predictions of a mental health crisis following on COVID-19’s heels present not only a challenge for the health care community, but an opportunity to explore seemingly less conventional options more fully. If an hour of hammock time once a week in an urban backyard can ease a 17-year-old’s panic attacks, what role might Montana’s wealth of undeveloped public lands hold for a population looking to heal from social, financial and societal upheaval?
“I see it as being foundational to our recovery, not just on a day-to-day level, but longer term as well,” said Florence Williams, a former Helena resident now living in D.C. and author of the 2017 book The Nature Fix. “I think one thing we’re seeing is that people are appreciating that the outdoors is one of the only safe places they can be, and that it’s in fact making them feel a lot better. These are ripple effects that are going to really last beyond the current crisis.”
“I think in some way what the pandemic has revealed for us is that it’s not just about recreation, it’s really in some way about our survival. Having access to green space, it’s critical.”
INSTITUTE AT THE GOLDEN GATE DIRECTOR DIANE MAILEY
While Zarr’s experience bringing the outdoors into his exam room may seem novel at first, it’s just one example of a trend that’s gained traction in the United States over the past decade. In October 2013, California’s Institute at the Golden Gate, a conservation program run by the Golden Gate National Parks Conservancy, joined with local and national partners in the recreation, conservation and health care communities to develop a model for deploying parks as a physical and mental health intervention. That early experiment with park prescriptions led to the formation of the National Park Rx Initiative, a nonprofit and government agency collaborative designed to cultivate similar prescriptive park programs elsewhere in the country.
According to Institute at the Golden Gate Director Diane Mailey, the initiative’s first National Park Rx Census, in 2018, revealed that in just five years 87 park prescription programs had taken root across 32 states, including Montana. The terminology varies from place to place, with programs adopting titles such as “Outdoor Rx” or “Trail Rx,” and the depth of their efforts ranges widely. Mailey said the movement has also started to evolve beyond an initial focus on the physical health benefits of parks to incorporate the psychosocial benefits as well.
“I think there is definitely growing evidence that the concept is working and it’s gaining momentum,” she said. “Although I would also say we have a ways to go before this could really be seen as some form of systemic change” in the health care industry’s approach to treatment.
In other words, the concept of park prescriptions remains somewhat new, supported locally by community leaders and grassroots coalitions, but still faced with financial hurdles and struggling to gain wider traction with insurance companies and policymakers. Zarr notes that funding continues to be a major issue for the D.C.-based nonprofit Park Rx America, which he founded in 2017 and serves as medical director.
Even so, the organization has succeeded in registering 815 prescribers around the world, offering them an online platform to fill out digital outdoor prescriptions for patients exactly as Zarr did for Jocelyn. The platform serves a two-pronged purpose: to help overcome the potential “woo-woo” reaction some doctors may have to elevating nature exposure to the same dose-and-frequency formulation as pharmaceutical medications, and to encourage patients to take the scrip more seriously than they might take a less formal recommendation.
Despite Montana’s glut of public trails, rivers and forests, a demo of Zarr’s prescription platform showed only 16 prescribable parks and trails, all of them in the Bozeman area where the Bozeman Trails Rx program operates. The national Park Rx website lists a similar Trails Rx program in Livingston, as well as a statewide Montana Trails Rx program spearheaded by Bike Walk Montana, with both promoting healthier lifestyles with walking prescriptions. According to Zarr, there are currently two health care professionals registered with Park Rx America in Montana.
One of the biggest obstacles to mainstreaming the movement is securing buy-in from health care professionals, who may be unconvinced of the legitimate health outcomes of park prescriptions. Numerous studies worldwide have provided compelling insights into the positive relationship between nature and human health, from reductions in negative emotional reflection after 90-minutes walks in a green space near Stanford University to discoveries about the importance of the quality of the nature experience in promoting mental well-being. The latter study suggests that nature’s beneficial effects may vary depending on whether you’re in a backyard setting or a full-on forest environment.
Such examinations, however, are scattered and predominantly small-scale, a point stressed by researchers at Appalachian State University in a 2019 review of park prescriptions published in the Journal of Leisure Research. That review stated that absent a randomized controlled clinical trial — the gold standard for establishing efficacy in medical literature — health care providers “may be extremely reluctant” to recommend nature as a medical intervention. According to the Park Rx Initiative’s 2018 census, a majority of the 71 responding park Rx programs reported working with multiple health care or social services professionals, but public health agencies were noted as leaders in less than 15% of those efforts.
In other words, while some individuals in the health care sector have recognized the potential of such programs, it is public land agencies and nonprofits that have so far led the park Rx charge.
Zarr is in the early stages of a randomized controlled clinical trial now, though he acknowledges the results won’t be available for some time. He and others in the health care field are optimistic the results will reinforce what they have gleaned anecdotally in their exam rooms.
“I have a young mom with anxiety who was having a lot of side effects to anxiolytic medication that I was prescribing, and so one day we tried our park prescription,” said Greg Anderson, a family medicine specialist with Family Care Network in Bellingham, Washington. “It really quickly stabilized her mood and she felt better, and she attributed a lot of her improved mood just to being outside walking with her family on a regular basis.”
These U.S.-based anecdotes line up perfectly with what Williams discovered on the other side of the Pacific Ocean. In The Nature Fix, she discusses the Japanese notion of shinrin-yoku, or “forest bathing,” and the work of physical anthropologist Yoshifumi Miyazaki, vice director of the Center for Environment, Health and Field Sciences at Japan’s Chiba University.
Since 2004, Miyazaki has studied physiological changes in hundreds of research subjects he’s taken on forest walks, recording significant decreases in heart rates and cortisol levels (the body’s natural alarm system) compared to those he’s taken on walks in urban areas. Miyazaki’s research, Williams writes, stems from the belief that because humans evolved in natural environments, nature is where we feel most comfortable. It’s still just a theory, known as “biophilia,” but it’s widely and strongly enough held that Japan’s ministry of agriculture, forestry and fisheries has invested $4 million in funding for shinrin-yoku research since the early 2000s, lending institutional credence to a private initiative that has established 62 certified “forest therapy” sites across Japan over the past 14 years.
When it comes to the “why” behind Japan’s efforts, Williams ties the motivation to some familiar problems: long work hours, intense educational and professional competition, a stubbornly high suicide rate, and the sometimes negative side effects of pharmaceutical interventions, which, based on Williams’ own experience with Zoloft, can include headaches, insomnia and lowered libido.
“There’s so much in modern life that really taxes our nervous systems,” Williams said. “We spend so much time in modern life in our prefrontal cortex, the thinking and planning parts of our brains. We don’t spend very much time in our sensory brains. We don’t spend a lot of time paying attention to what we’re smelling and what we’re hearing, and our perceptual systems were really designed by evolution to hear sounds and sights in nature, to sort of experience the senses in nature. So when we’re able to do that, even on a subconscious level it just makes us feel more relaxed and comfortable.”
Anderson credits his introduction to the park prescription movement to friend and fellow outdoor enthusiast Todd Elsworth, executive director of the nonprofit Recreation Northwest. Elsworth had been inspired by Zarr’s nature prescription work and approached Anderson’s clinic hoping to find an Rx partner in Bellingham’s medical community. Now, some three years later, Anderson regularly discusses the outdoors with his patients, seamlessly working the topic into conversations about possible health interventions.
Anderson’s approach bears a striking similarity to how physicians began to incorporate new discoveries about the role of diet in health during the first decades of the 20th century — the so-called Golden Age of Nutrition. Anderson, whose work helped inform Recreation Northwest’s development of a Whatcom County-specific “parkscription” platform, is especially fond of citing a study linking visual exposure to morning sunlight with decreased stress and improved sleep to underscore the subtle ways in which human bodies react to the natural environment.
Zarr and Anderson have also found that the concept of outdoor recreation as a health intervention is not only easy for patients to understand, but puts them at ease.
“It’s almost universally accepted,” Anderson said. “And you compare that to trying to convince them to take a blood pressure pill — and nobody wants to take pills for blood pressure. This is the opposite of that. You get almost a surprised look on the patient’s face. It’s disarming, and you can have a pleasant conversation and you don’t feel so much like a salesman spouting statistics about statin therapy for cholesterol and blood pressure risk reduction.”
Anderson came around quickly to the practice, partly due to his personal recreational predilections. But for doctors who don’t regularly prioritize time outdoors, he and Zarr understand that such prescriptions may seem utterly foreign. The health care community as a whole has yet to fully embrace nature exposure as a treatment option, and to create the systemic change Mailey hopes for, there needs to be a broader shift in the collective medical mindset — a shift that places engagement with nature on par with dietary, exercise-based and pharmaceutical interventions in a doctor’s toolbox.
To that end, Zarr is developing a continuing education curriculum to give doctors, nurses and other health care professionals a path to expand their knowledge within the process of meeting the licensing renewal requirements of their respective states. He’s also given presentations on the topic to a number of organizations around the U.S., and the story behind Jocelyn’s hammock-time prescription became the focus of a short documentary film released this year by the nonprofit Healthy U.S. Collaborative.
“It’s really about asking the right questions in the right way and engaging your patient, asking them those important questions about where they feel comfortable and safe,” Zarr said. “And that’s going to change from day to day, person to person, visit to visit, and, as you would suspect, during COVID that’s now an even more important question.”
On May 30, D.C.-based news outlet The Hill reported on how ill-prepared the U.S. is to meet an impending pandemic-induced mental health crisis, noting that the national Well Being Trust had recently predicted as many as 75,000 “deaths of despair” if pre-pandemic gaps in mental health and substance abuse services are not improved. The Washington Post similarly noted that the federal Substance Abuse and Mental Health Services Administration’s emergency hotline in April registered a 1,000% increase in activity over April 2019. This attention to the long-term public health effects of the coronavirus supports what a poll conducted in March by Montana State University already indicated: people are stressed, they’re anxious and they’re worried for themselves and others.
While acceptance of the outdoors as a critical component in public health is widespread, efforts to promote nature as a medical intervention remain mostly piecemeal. Some insurance companies have offered support for the movement, as in the case of Blue Cross Blue Shield of North Carolina, which is helping collect data on the effectiveness of park prescriptions for kids and offering financial incentives for prescribing physicians. State lawmakers in New York this year passed an Outdoor Rx Act designed to review and remove financial and institutional barriers facing military veterans who want to seek healing in nature. One of the bill’s chief sponsors, Assemblymember Didi Barrett, boasted to MTFP of her state’s abundant outdoor assets — the Adirondacks, the Catskills, the Hudson River, along with scores of beaches — but noted that during a meeting with stakeholders about the Outdoor Rx Act, veterans advocates said they’d been unaware of a number of programs and discounts already offered for vets by various agencies. It seemed to Barrett as though everyone was operating “in their silo.”
“I’m hopeful that this kind of a crisis, where everything gets put on the table, will be an opportunity for things that really do work to bubble up to the top,” Barrett said.
Mailey, at the Park Rx Initiative, agrees that if there were ever a time to embrace the movement widely, it’s in the face of a looming mental health crisis. Nature prescriptions have long been seen as innovative, she said, “but I think in some way what the pandemic has revealed for us is that it’s not just about recreation, it’s really in some way about our survival. Having access to green space, it’s critical.”
Williams fell into her book-length investigation of nature’s healing qualities the way many authors find their subjects: personal experience. After living in Montana and Colorado for more than 20 years, she found her new environment in D.C. to be noisy and frantic. It was as if a “stress bomb” had gone off in her brain, she said, and she began exploring the ways in which landscapes affect people for Outside magazine. Her research led her to Japan and its popular practice of forest bathing, then to other study sites around the globe. Observing the stressors triggered by today’s pandemic, Williams is reminded of a theory she encountered while working on The Nature Fix, one that builds on the idea underpinning Miyazaki’s research. It’s known as “urgent biophilia,” and posits that when humans are faced with crisis, the impulse to seek comfort in nature is exponentially heightened. That inclination can have a profoundly positive influence not just on individuals, but on the communities to which they belong.
“So often after devastating tornadoes and hurricanes, communities will come together and build parks and plant trees,” Williams said. “It’s this community effort that I think gives people a lot of hope because of the messages and metaphors in nature. It’s where we find resilience. It’s where we take comfort in the cycles of life. And it’s where we can build our health back up.”
