The Outdoor Care Retreat

Maren Østvold Lindheim, Svein Åge Kjøs Johnsen, Åshild Lappegard Hauge, Trond H. Diseth About the authors

Spending time in nature can have a regulatory effect on the body. The architectural design and location of the Outdoor Care Retreat at Oslo University Hospital create a unique therapeutic space.

Illustration: Nina Marie Andersen / Fabel illustrasjon

The Outdoor Care Retreat (‘Friluftssykehuset’) at Oslo University Hospital is a cabin in the woods bordering the hospital grounds. The idea for a retreat cabin was developed by the Department of Child and Adolescent Mental Health in Hospital (S-BUP) in cooperation with the Friluftssykehuset Foundation and the architectural firm Snøhetta. The collaboration arose from a common desire to create an inviting place in nature for patients and their families, and in 2018 the Outdoor Care Retreat was completed. Interdisciplinary follow-up of paediatric hospital patients with serious somatic diseases is important both for an integrated course of treatment and for a quick recovery. Children with serious and/or chronic diseases have a higher risk of developing mental, psychosocial and family-related problems compared to somatically healthy children (1). Moreover, this group is at greater risk of developing symptoms of post-traumatic stress (2). On the other hand, psychosocial factors can affect somatic conditions, for example modulating the impact of stress and inflammatory responses in cases of cancer (3).

Nature as a therapeutic space

Life within the four walls of a hospital entails a considerable loss of perspective, predictability and control, which can result in emotional and physiological strains. In the last ten years, S-BUP has had many positive clinical experiences with incorporating nature into its therapeutic work. These experiences show that taking patients out of the hospital setting allows them to spend time with family and engage in activities that shift the focus away from their illness for a while.

Documented evaluations and feedback from children, families and employees in recent years have been positive. For some patients, regular trips out in nature have been a motivating factor in their treatment and given them positive associations with the hospital. Families have reported that it feels good to get out of the hospital, see what their children can actually manage to do, spend quality time together, take part in meaningful activities and learn new things. This has included, for example, going skiing or sitting in a canoe for the first time. Their positive comments led to a desire to establish a therapeutic space in nature close to the hospital so that patients, who for various reasons cannot leave the hospital area, can spend time in nature. A physical cabin provides a sheltered space and can be used by patients who cannot be outdoors for long periods of time.

Scientific rationale

Several studies show that nature has characteristics that can have a restorative effect on people’s temporarily reduced mental resources (46). In a number of illnesses, physical activity can help to improve a patient’s physical and mental health (7, 8), and physical activity in nature can have an additional positive impact. It has been shown, for instance, that taking a walk outdoors is more vitalising than walking indoors at the same level of intensity (9).

Taking patients out of the hospital setting allows them to spend time with family and engage in activities that shift the focus away from their illness for a while

Spending time in forest areas has been shown to lower cortisol levels, heart rate and blood pressure, increase parasympathetic activity and decrease sympathetic activity to a greater extent than time spent in urban areas (4). Sitting in a room with a view of the natural surroundings reduces blood pressure more than sitting in a room without a view (10). Moreover, several studies suggest that spending time in nature can reduce physiological arousal, enhance positive emotions and minimise negative emotions (6, 10, 11). As a result, time spent in nature may prove to be significant for emotion regulation, and some people deliberately use nature to alter their state of mind (12). A large number of scientific articles discuss the impact of hospital architecture on patients and hospital staff. More exposure to daylight reduces the perceived pain and stress level of hospital patients, minimises the use of analgesics and decreases the length of hospitalisation (13). Patients who are exposed to visual images of real or simulated nature may experience significant pain relief (1416).

Clinical experiences

Helping patients to reduce arousal is an important intervention in preventing and dealing with anxiety and stress-/trauma-related conditions (17). Children who must undergo frightening and painful procedures in hospital need help finding strategies to get through the necessary treatment. Taking patients and their family members to the Outdoor Care Retreat has a positive impact on their perceived level of stress and anxiety. Nature and enjoyable activities bring spontaneous joy, provide a break from difficult hospital experiences and promote relaxation.

In the Outdoor Care Retreat and the surrounding nature, the therapist can support the patient’s self-regulation by providing the opportunity to move between qualitatively different therapeutic settings inside and outside. During emotionally difficult conversations, children will often switch between talking and playing while looking out at the forest, and take the initiative to go outside. Therapists have found that children and adolescents who are given the opportunity to do this are better able to tolerate strong emotions and find effective ways of establishing stabilisation and reducing arousal.

Real and imaginary ‘safe places’ are used in connection with therapeutic stabilisation (17). Patients and family members who visit the Outdoor Care Retreat often say that they find it easier to relax and feel good inside the cabin than within the four walls of the hospital.

Many then talk spontaneously about other places and experiences that make them feel good. In this way, the surroundings can facilitate access to positive sensory experiences and memories. Moreover, the therapists are able to help the patients recapture the feelings of peace and joy from the forest when they are in challenging situations in hospital: ‘Do you remember when we were out by the stream, and your bark boat went over the rapids?’.

Curiosity and belief in the future

The therapist’s ability to awaken interest and belief in the therapeutic project is a crucial factor in therapy. Children often react with surprise and wonder when they are told about the chance to visit a cabin near the hospital. This can help the child to come into a state of focused attention, which gives them easier access to their own resources and makes them more open to suggested solutions. Additionally, the therapists find that the environment in and around the cabin helps the child to be more accepting of supportive suggestions such as ‘this will go just fine’ and ‘we will get through this together’.

Children often react with surprise and wonder when they are told about the chance to visit a cabin near the hospital

When out in nature, people are more open to fantasy, wonder and play compared to being indoors. This gives therapists the opportunity to actively incorporate nature into their therapeutic work. Therapists feel that they have access to a wider range of perspectives and creative approaches in the cabin than in the hospital. Let us look at some typical examples: A therapist and her patient saw a grey heron land outside the Outdoor Care Retreat, and the therapist used this to say that herons only come when someone says something important. Another therapist observed that the child was not afraid of handling spiders, and used this as a conversation starter by asking for advice. Through the use of metaphors from nature, children and adolescents have the chance to experience wonder and externalise their problems (18).

Children who are anxious in hospital and find it difficult to trust healthcare professionals often require a long time to feel safe. The therapists meet with patients and family members who have a need to talk about their fears, process difficult experiences or understand their own or someone else’s illness. Many children are tired of ‘talking about it’ and mistrust the hospital staff. Some are in hospital for only a short period of time, so it is important to establish a safe relationship quickly. The therapists find that the children feel safe with the healthcare professionals much more quickly when they are at the Outdoor Care Retreat than inside the hospital. The physical change in the children can be observed immediately when they leave the hospital and walk towards the cabin. They relax, look around freely and begin to talk. The natural surroundings allow for a different, often closer, therapeutic relationship.

Out of the patient role

Disease affects the entire family. Parents, siblings and extended family members all feel that their lives change when a child becomes ill. The children often feel that life is unfair. They may feel different from their peers, and their interaction with parents and siblings can be challenging. Having a place to go increases their motivation to get out of the hospital, and the threshold for joining others out in nature is lowered. Encouraging families to have positive experiences has a therapeutic function in itself. New experiences expand people’s narratives about their own lives, and can bolster self-esteem and the ability to cope (18). The healthcare professionals can experience other sides of the patient and family compared with a hospital setting, and can help to develop positive narratives about the patient and family.

In the Department of Child and Adolescent Mental Health in Hospital (S-BUP) at Oslo University Hospital, we prepare children and adolescents for medical procedures and support them through difficult hospitalisations. Teaching them to cope with stress and anxiety is a critical part of our work. Both empirical and clinical experiences suggest that spending time in nature in itself can have a regulatory effect on the body, in the same way that existing therapeutic techniques are currently used to reduce over-arousal. The architectural design and location of the Outdoor Care Retreat provide a unique therapeutic space. The surroundings awaken patients’ curiosity and creativity, give them access to positive associations and facilitate belief in their coping abilities and positive expectations for change and development.

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