"That Guy, Is He Really Sick at All?" An Analysis of How Veterans with PTSD Experience Nature-Based Therapy

Psychological and functional outcomes following a randomized controlled trial of surf and hike therapy for U.S. service members

Introduction

Exercise-based interventions have established benefits for the treatment of depression and other psychological outcomes; however, limited data exist evaluating psychological, social, and functional outcomes for exercise outdoors.

Methods

The current study sought to expand knowledge about the breadth of effects following outdoor exercise interventions by using data from a randomized control trial comparing Surf and Hike Therapy among 96 U.S. active duty service members with major depressive disorder (MDD). Assessments examining psychological symptoms and functioning were completed before and after the 6-week programs, and 3 months following program completion. Participants also completed assessments before and after each exercise session. Multilevel modeling was used to determine whether psychological and functional outcomes (anxiety, positive and negative affect, resilience, pain, and physical and social functioning) improved for service members receiving Surf or Hike Therapy, and whether improvements differed by intervention.

Results

Study findings showed improved anxiety (p < 0.001), negative affect (p < 0.001), psychological resilience (p = 0.013), and social functioning (p < 0.001) following program participation, with no differences by intervention. Positive affect, pain, and physical functioning did not significantly improve after the program. Within sessions, positive affect (p < 0.001) and pain (p = 0.036) changed, and to a greater extent for those in the Surf Therapy condition.

Conclusion

Study results suggest that both Surf Therapy and Hike Therapy can improve psychological symptoms and social functioning impairments that commonly co-occur among service members with MDD, but Surf Therapy may provide enhanced immediate effects on positive affect and pain.

Clinical trial registration

ClinicalTrials.gov, NCT03302611.

Multisite Agricultural Veterans Affairs Farming and Recovery Mental Health Services (VA FARMS) Pilot Program: Protocol for a Responsive Mixed Methods Evaluation Study

BACKGROUND

Veterans Affairs Farming and Recovery Mental Health Services (VA FARMS) is an innovative pilot program to provide supportive resources for veterans with interests in agricultural vocations. Implemented at 10 pilot sites, VA FARMS will provide mental health services and resources for veterans while supporting training in gardening and agriculture. As each pilot site project has unique goals, outreach strategies, and implementation efforts based on the local environment and veteran population, evaluating the pilot program provides a unique challenge for evaluators. This paper describes the protocol to evaluate VA FARMS, which was specifically designed to enable site variation by providing both site-specific and cross-site understanding of site implementation processes and outcomes.

OBJECTIVE

The objectives of this paper are to (1) describe the protocol used for evaluating VA FARMS, as an innovative Department of Veterans Affairs (VA) agriculturally based, mental health, and employment pilot program serving veterans at 10 pilot sites across the Veterans Health Administration enterprise; and (2) provide guidance to other evaluators assessing innovative programs.

METHODS

This evaluation uses the context, inputs, process, product (CIPP) model, which evaluates a program's content and implementation to identify strengths and areas for improvement. Data collection will use a concurrent mixed methods approach. Quantitative data collection will involve quarterly program surveys, as well as three individual veteran participant surveys administered upon the veteran's entrance and exit of the pilot program and 3 months postexit. Quantitative data will include baseline descriptive statistics and follow-up statistics on veteran health care utilization, health care status, and agriculture employment status. Qualitative data collection will include participant observation at each pilot site, and interviews with participants, staff, and community stakeholders. Qualitative data will provide insights about pilot program implementation processes, veterans' experiences, and short-term participation outcomes.

RESULTS

Evaluation efforts began in December 2018 and are ongoing. Between October 2018 and September 2020, 494 veterans had enrolled in VA FARMS and 1326 veterans were reached through program activities such as demonstrations, informational presentations, and town-hall discussions. A total of 1623 community members and 655 VA employees were similarly reached by VA FARMS programming during that time. Data were collected between October 2018 and September 2020 in the form of 336 veteran surveys, 30 veteran interviews, 27 staff interviews, and 11 community partner interviews. Data analysis is expected to be completed by October 2022.

CONCLUSIONS

This evaluation protocol will provide guidance to other evaluators assessing innovative programs. In its application to the VA FARMS pilot, the evaluation aims to add to existing literature on nature-based therapies and the rehabilitation outcomes of agricultural training programs for veterans. Results will provide programmatic insights on the implementation of pilot programs, along with needed improvements and modifications for the future expansion of VA FARMS and other veteran-focused agricultural programs.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/40496.

Effect of nature-based physical activity on post-traumatic growth among healthcare providers with post-traumatic stress

The purpose of this randomized control trial was to observe the effect of nature-based physical activity in achieving post traumatic growth and to estimate the combined effect of nature and physical activity on the psychophysiological outcomes. A 3-month therapy was provided to participants meeting eligibility criteria to receive the walk-in nature (experimental group) or sit-in nature (control group) in the 1:1 ratio. At baseline and 3-month follow-up, participants were assessed with Trauma Symptom Checklist 40, Traumatic Stress Scale, Post-Traumatic Growth Inventory (PTGI), Cortisol, C-Reactive Protein (CRP), Interleukin-6 (IL-6), Brain-Derived Neurotropic Factor (BDNF) and heart rate variability. There was a significant effect of nature-based physical activity on traumatic stress and post-traumatic growth in comparison with the sit-in control. A significant post-interventional difference was observed in the mean PTGI score [F = 5.412, p = 0.022] between the experimental and control groups after 3 months of intervention. All the biochemical estimates, including CRP, BDNF, IL-6, and cortisol levels, were significantly altered in both post-intervention study groups (p < 0.01). Taken together, these results show that nature-based physical activity significantly improves psychophysiological outcomes induced as a result of post-traumatic growth and also reduces traumatic stress.

Mixing Job Training with Nature-Based Therapy Shows Promise for Increasing Labor Market Affiliation among Newly Arrived Refugees: Results from a Danish Case Series Study

The unemployment rate among newly arrived refugees in European countries is high and many experience mental health problems. This has negative consequences on integration and mental well-being. In this case series study we investigated the effect of a 30-week program that included horticulture activities, nature-based therapy, and traditional job training on job market affiliation and mental well-being. Fifty-two refugees met initial screening criteria and twenty-eight met all inclusion criteria and were enrolled. The program took place in a small community and consisted of informal therapeutic conversations, exercises aimed at reducing psychological stress, increasing mental awareness and physical wellbeing. At the end of the program traditional job market activities were led by social workers. Provisionary psychiatric interviews showed that at baseline 79% met criteria for either an anxiety, depression, or PTSD diagnosis. After the program, statistical analyses revealed an increase in the one-year incidence of job market affiliation (n = 28) and an increase in mental health according to two of four questionnaire measures (n_range = 15–16). The results strengthen the hypothesis that horticulture and nature-based therapy can help refugees enter the job market. However, the small sample size emphasizes the need for methodologically stronger studies to corroborate these preliminary findings.

A nature-based health intervention at a military healthcare center: a randomized, controlled, cross-over study

We describe a mixed qualitative and quantitative research study in a military facility regarding the role of nature in well-being. Study intervention included two 20-minute walks. One walk was in an intentionally designed woodland environment (Green Road) and the other was on a busy campus road in a medical treatment facility (Urban Road). Twelve volunteers from a military facility participated in both walks in a cross-over experimental design. The two walking sessions were randomly ordered and preceded by pre-walk instructions appropriate to each road’s characteristics and incorporated focused attention and present moment orientation. A semi-structured post-walk interview, the primary outcome, was conducted after the conclusion of each walk. Qualitative data analyses consisted of sentiments and themes by using NVivo 12 software. The Green Road was unanimously rated as positive (100%). Responses to Urban Road were evenly distributed among positive (33.3%), negative (33.3%), and neutral/mixed (33.3%) sentiments. The Green Road yielded predominantly positive themes such as enjoyment of nature, relaxation, and feelings of privacy and safety. Urban Road produced significantly more negative themes such as concerns for safety, dislike of noise and other noxious experiences. Quantitative assessment of distress and mindfulness with Distress Thermometer (DT) and Mindful Attention Awareness Scale-state version (MAAS) demonstrated that a walk on the Green Road significantly decreased distress and increased mindfulness compared to a walk on the Urban Road. We also observed that pre-walk instructions could direct attention to both obvious and subtle elements of experience and enhance awareness. Results support the notion that an intentional nature-based environment may produce significantly more positive experiences and result in health-promoting benefits in a military health-care setting compared to an urban environment. Future studies with clinical populations could advance our understanding of the healing value of nature-based interventions. The impact of intentional green environments may be enhanced by well-designed instructions for both recreational and therapeutic use.

The importance of urban natural areas and urban ecosystem services during the COVID-19 pandemic

Urban, peri-urban forests and other natural areas provide a wide range of material and non-material benefits to people known as ecosystem services. Access to these areas has been linked to benefits for physical and mental health of local populations. In the spring of 2020, the COVID-19 global pandemic forced many governments to impose a set of restrictions including the closure of businesses, cancelation of public events and schooling, social distancing, limitations on the size of social gatherings, and travel restrictions. During this period of restrictions, we conducted a study assessing the importance of urban and peri-urban forests and other natural areas to people living in and around the city of Burlington, Vermont, USA. We evaluated the self-reported use and changes in personal importance related to these natural areas before and during the period of restrictions. We received over 400 responses to our field survey. The results show that 69.0% of the respondents had increased or greatly increased their visitation rate to our natural areas and urban forests, and 80.6% of respondents considered that the importance of these areas, and access to them, either increased or greatly increased. Moreover 25.8% of the sample had either never, or very rarely accessed their local natural areas before the pandemic, but 69.2% of the first time or infrequent visitors reported that having access to these areas during COVID-19 as ‘very important’. People reported that these areas were important for a wide range of activities from exercise to birding, but also reported values related to reducing stress in a time of global chaos. Our results indicate the increasing demand and value of such areas in times of crisis such as COVID-19. Experts in zoonotic disease predict the potential for more frequent pandemic events, thus predicating the importance for continued funding for, maintenance of, and improved access to, natural areas to our largely urban civilization.

Therapeutic Nature Activities: A Step Toward the Labor Market for Traumatized Refugees

BACKGROUND

Globally, the number of refugees is growing. For many refugees, entering the labor market in their new country of residence is challenging. Some remain forever dependent on welfare services, and this not only weakens their chances of integration, but also harms their health and well-being.

METHODS

This qualitative single case study focused on a group of war-stricken refugees in Denmark. The study investigated the impact of an eight-month horticultural vocational program aimed at improving their ability to complete an education program or to work. A total of 29 interviews were conducted and analyzed using the interpretative phenomenological analysis (IPA) method.

RESULTS

The natural environment in the eco-village evoked a feeling of safety as well as positive memories in the participants, in contrast to the traumatic memories they had of their flight. Horticultural activities and the positive and respectful attitude from staff initiated a recovery process. New skills were achieved at an individual pace, and feelings of isolation decreased. These findings can be implicated in future interventions.

The importance of urban natural areas and urban ecosystem services during the COVID-19 pandemic

Urban, peri-urban forests and other natural areas provide a wide range of material and non-material benefits to people known as ecosystem services. Access to these areas has been linked to benefits for physical and mental health of local populations. In the spring of 2020, the COVID-19 global pandemic forced many governments to impose a set of restrictions including the closure of businesses, cancelation of public events and schooling, social distancing, limitations on the size of social gatherings, and travel restrictions. During this period of restrictions, we conducted a study assessing the importance of urban and peri-urban forests and other natural areas to people living in and around the city of Burlington, Vermont, USA. We evaluated the self-reported use and changes in personal importance related to these natural areas before and during the period of restrictions. We received over 400 responses to our field survey. The results show that 69.0% of the respondents had increased or greatly increased their visitation rate to our natural areas and urban forests, and 80.6% of respondents considered that the importance of these areas, and access to them, either increased or greatly increased. Moreover 25.8% of the sample had either never, or very rarely accessed their local natural areas before the pandemic, but 69.2% of the first time or infrequent visitors reported that having access to these areas during COVID-19 as 'very important'. People reported that these areas were important for a wide range of activities from exercise to birding, but also reported values related to reducing stress in a time of global chaos. Our results indicate the increasing demand and value of such areas in times of crisis such as COVID-19. Experts in zoonotic disease predict the potential for more frequent pandemic events, thus predicating the importance for continued funding for, maintenance of, and improved access to, natural areas to our largely urban civilization.

Emotional Exhaustion and Health Complaints as Indicators of Occupational Diseases Among Civil Servants in Spain

Occupations focused on helping others, guaranteeing people’s security, and defending societal values can be stressful and risky for the workers involved. Emotional exhaustion and health complaints usually emerge as indicators of the stress suffered by these workers in undertaking their roles. This research aims to explore the effects of psychological contract breach on both emotional exhaustion and health complaints among three kinds of Spanish workers, namely firefighters (n = 80), professional soldiers (n = 77), and prison officers (n = 107). The predictor variables include job tenure and psychological contract breach. Criterion variables are employees’ emotional exhaustion and health complaints. Our findings showed that job tenure and contract breaches significantly explain both emotional exhaustion and health complaints. Despite these general findings, some differences emerge as a function of the organizations. Significance levels were higher for prison officers than for firemen and Spanish soldiers. Results are discussed, suggesting conceptual integration and direction for future risk prevention in this kind of public organization.