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Being in Nature: An Innovative Framework for Incorporating
Nature in Therapy with Older Adults 
Ronen Berger (2009) Journal of Holistic Nursing, 2009, 27(1). 

Abstract

This article describes a creative framework in which nature is incorporated in therapy with older adults. Using an example from practice, it illustrates how the integration of concepts from the narrative approach and the innovative nature therapy framework can help older people expand their perspectives, connect with strength and expand their coping strategies, while gaining a wider sense of acceptance and completion in life.

 Key words: nature-therapy, narrative, older adults, psychological time, creativity, nature

 Introduction

The medical definitions of health in older age refer mainly to physical symptoms, giving only little attention to the emotional and psychological aspects of the personality (Bar-Tur, 2005; Danhauer & Carlson, 2005; Ryff & Singer, 2000). This attitude is also expressed in practice: only a few training programs for counselors focus on this growing population and health maintenance organizations that work with older adults generally offer few psychological services (Bar-Tur, 2005). In most cases, when psychotherapy is offered to older adults, it takes the form of verbal and cognitive activity held indoors, involving little contact with nature (Bar-Tur, 2005; McLeod, 2003).

A review of the literature in psychology suggests that older adults possess unique characteristics and needs, and therefore a specific therapeutic approach is needed when working with this group. The psychological literature on older age indicates that one of the major challenges in this field is to help the clients accept the past and make choices for the future, while constantly adapting their perspective to the changing reality (Bar-Tur, 2005; Kling, Seltzer, & Ryff, 1997; Shmotkin & Eyal, 2003). This is consistent with Shmotkin and Eyal's (2003) concept of "psychological time," which reflects the construction of the self and therefore influences the older person's perspective on life, experience and function and constitutes a key element in any psychological framework that seeks to work with older adults (Shmotkin & Eyal, 2003).

Another element of such a framework should relate to the physical and social aspects of aging, as these shed light on other perspectives that are perhaps less crucial when working with younger populations (Bar-Tur, 2005; Kovacs, 2005). The increasing recognition of this aspect is expressed in the growing number of mind-body group activities (chi-kong, tai-chi, walking, and drama) that are offered in centers for older adults and being incorporated in rehabilitation, nursing and prevention programs (Bar-Tur, 2005).

All these factors are consistent with the concept of positive health, which claims that the involvement of older people in their own lives and their sense of competence strongly affect their well-being, functioning, and happiness (Bar-Tur, 2005; Danhauer & Carlson, 2005; Ryff & Singer, 1998, 2000; Ryff , Singer, Love, & Essex, 1998). This holistic concept is founded on the belief in the strength of older adults and their ability to make choices, develop, and change (Bar-Tur, 2005; Shmotkin & Eyal, 2003).

Based on the relevant literature, it seems that the above approach corresponds with the holistic and mind–body–spirit orientation of the holistic nursing practice (American Holistic Nurses Association, 2007; Frisch, 2003; Zahourek, 2005). Thus, the present article describes an innovative therapeutic framework that uses creativity and incorporates the therapeutic potential of nature in practice (Abrams, 1996; Berger, 2006; Berger, 2007; Author & McLeod, 2006; Beringer & Martin, 2003; Burns, 1998; Davis, 1998, 2004; Hartig, Mang, & Evans, 1991; Roszak, 2001; Totton, 2003). It highlights a mode of work that can be integrated in nursing and healing processes in general, and with the older population in particular. 

The article draws on concepts from the narrative approach (Freedman & Combs, 1996) and from the innovative nature-therapy approach (Author & McLoed, 2006), in applying the concept of psychological time (Shmotkin & Eyal, 2003) as a key reference point in therapy with older people. By means of an example from practice with this innovative theory, the article suggests concepts and methods that practitioners can incorporate and further develop in their work with clients. As the framework presented here is very new and not fully articulated, the article also aims to open a dialogue on the issues, inviting others to add and further develop its basic concepts.

The Narrative Approach

Narratives, or life stories, provide a meaningful integration of the events, actions, and experience that have happened to people in the course of their lives (Shmotkin & Eyal, 2003). Listening to the narratives of older adults helps them bridge the past-present and future and develop an identity and purpose in life (McAdams, 1993; Shmotkin & Eyal, 2003). This article refers to a specific narrative approach developed by White & Epston in Australia (Freedman & Combs, 1996; McLeod, 1997; White & Epston, 1990). The underlying assumption of the approach is that the life of each person is led and constructed by a dominant narrative, which is an integration of stories that individuals tell themselves and social and cultural stories that are told by people and communities around them (meta-stories). According to this perspective, the dominant narratives help people find meaning and locate themselves within the larger social contexts. At the same time, the tension that may exist between the individuals and the meta-stories can cause conflicts and psychological stress and prevent them from living authentic and full lives. The framework based on the approach seeks to extend the variety of the stories (so-called realities) that people tell themselves while seeking to select preferred and alternative ones (Freedman & Combs, 1996; McLeod, 1997; White & Epston, 1990). Based on this postmodern approach, concepts such as constructivism and choice, belief in the ability of people to make choices and change their attitudes towards life, the narrative approach helps individuals extend their ability to make new choices and navigate their personal lives within the larger social matrix.

Nature-Therapy: An Innovative Therapeutic Framework

Nature-therapy, which takes place in nature, is based on an innovative experiential approach. It seeks to broaden the classical concept of setting as a static, permanent place under the control and ownership of the therapist (Barkan, 2002; Bleger, 1967) to include the dynamic natural environment as a partner in the shaping of the setting and process (Berger, 2006, 2007a, 2007b; Berger & McLoed, 2006). The developing theory, concepts, and methods of this approach to therapy help it operate in the living, open environment and take advantage of its healing elements (Berger, 2005; Berger & McLoed, 2006) to support therapeutic processes and develop in new directions. Nature-therapy is a holistic framework integrating elements from art and drama therapy, Gestalt, the narrative approach, ecopsychology, transpersonal psychology, adventure therapy, Shamanism, and mind–body practices. Its development is based on the personal and professional experience of the author, as well as his research devoted to its conceptualization, analysis, and development as a therapeutic framework and practice (Berger 2007a). It has been implemented with different kinds of clients in individual, group, and family settings in the private, educational, and health sectors in Israel. Trainings are offered in academic institutions in Israel and additional programs are currently being developed in Europe.

The research that examined Nature-therapy’s impact upon different populations shows that its creative operation within nature can significantly support people's healing. It seems like the way it relates to the natural elements within this uncontrollable environment can help people develop flexibility and expand their ability to connect to their imagination and body (Berger, 2007a). These important coping mechanisms may not only help older people deal with the uncontrollable changes that are embedded in their aging process, but also increase their positive health and support their personal development (Bar-Tur, 2005; Danhauer & Carlson, 2005; Lahad, 1998; Ryff & Singer, 1998, 2000). In addition, the connection to the cycle of nature fosters a sense of acceptance and completion, as it links the individual life cycle with the larger universal natural one (Author, 2007a; Author & McLoed, 2006). 

Nature, Narrative and Therapy with Older People

In combining narrative and nature-therapy concepts, therapists will seek to include nature in the therapeutic process in a way that enables the older person not only to voice "quiet stories" but also to connect them with stories of natural phenomena and the nature around us (Berger & McLoed, 2006).

In this sense, the case study illustrates a way in which the incorporation of nature in therapy and the connection to the cycle of nature can help older people gain a sense of continuity and completion of life while associating the personal, limited, and linear lifetime with universal and endless time. The article also presents a creative, nonverbal therapeutic form in which the uncontrolled dynamics of nature can be used as a means to develop flexibility and acceptance that can help older people deal with changes in a more satisfying way. Since these elements relate to the holistic aspects of health and care they can be integrated into the practice of the holistic nursing while expanding its relationship with the environment and widening its existing spiritual dimension (American Holistic Nurses Association, 2007; Frisch, 2003). 

Between Hope and Desperation, Low and High Tide  - Brian's Story

Brian, a 65-year-old social worker, participated in a nature-therapy
workshop designed for professionals held in Scotland. The opening session was set between a forest and the beach. The participants stood in a circle, listening to their breathing, the wind, and the waves. When people were invited to say something about themselves and their reasons for coming to the workshop, Brian shared his feelings of sadness, fear, and queries about the future: "Now that my children have left home and are parents themselves and I have retired, it is difficult for me to find purpose and value in my life. Sometimes I wake up in the morning and do not know what to do. I wonder if this is the time to depart and die."

The next day on the beach, after some mind-body activities using elements from tai-chi, chi-kong and guided imagery and connecting the participants with the wave-whisper and sand movement, I suggested to Brian that he take a meditative-walk imagining each step he took in the sand as a chapter in his ongoing voyage through life. I did not limit this journey in time or space, trusting Brian's ability to navigate this journey in nature in the most worthwhile and supportive manner. When he returned from his walk, Brian had a calm expression on his face, as he told the group that he had reached the conclusion that he was not yet ready to depart.  When other group participants asked him about his tear-filled eyes, he said that he was sad to realize that a few important cycles of his life had been completed and he did not know how to continue or what to do. In order to explore the subject in a creative, non-cognitive fashion, I offered Brian to continue his earlier work by finding a suitable space within the larger group space that had been formed on the sand, and composing a two-faced sculpture: one side relating to the past, and the other symbolizing the future. I asked him to start by closing his eyes and listening to the mantra of the waves, while letting his imagination take the lead. An hour later, as we walked among the participants’ creations, listening to their stories, Brian said, "I really enjoyed this exercise, as I totally lost sense of time. At first, I did not like it since the image of a memorial came up, but then it changed into images from my childhood, when we were playing on the beach and building castles on the sand." When I asked about his creation, he said, “I did not compose anything as I could not control the sand. I tried to build a castle but the sand kept slipping. I stopped and sat down, being present and looking at two sea gulls fighting, watching the tide coming in and the last rays of the sun. It seems this is the first time in many years that I took the time to be – to stop and observe all of this; life is beautiful …"

Using Practice to Illustrate Theory

Brian's story presents an example of a nature therapy work with an older person, incorporating creativity and contact with nature to support and enrich the process. The present section aims to share some of the theory that underpinned the therapist's choice of interventions, highlighting the ways in which it incorporated concepts of narrative and nature-therapy. The first choice that was made prior to the workshop concerned the location of the first group circle. This choice was guided by the nature-therapy concept of nature as a therapeutic setting using the intermediate zone (Author 2007a, Author & McLoed, 2006), a territory between the forest and the beach, in order to evoke the concept of transitions in life and the narrative concept of constructing continuity between its different phases (Shmotkin & Eyal, 2003). It illustrates a way in which nature-therapy incorporates elements from the environment and landscape to trigger specific therapeutic issues. In this context, the therapist used Brian's narrative to transfer his psychological understanding to the active intervention, the "life span journey."

This choice relates to the concept of the three-way relationship of client-therapist-nature (Author, 2005; Author & McLoed, 2006), another basic nature-therapy concept, which calls upon the therapist to extend the classic therapist–client relationship (McLoed, 2003) to include nature as a third partner. This is illustrated by the therapist’s choice of taking a step back while inviting the client to use the journey in nature as a time for self-reflection. In this sense, the therapist related to the coastline as a symbol of Brian's lifespan and to his footprints as symbols of meaningful episodes in its course. Then, seeking ways to use the impact of the journey to further develop Brian's sense of continuity, trusting the potential of creative and embodied modes of working (Kepner ,1987; Lahad, 2002), the therapist asked Brian to choose a location on the beach and construct a sculpture representing his life journey. The spontaneous play that developed with the sand evoked memories and feelings from Brian's childhood, expanding his personal narrative and helping him engage with his past. In contrast to indoor art therapy modes, where the setting and artistic materials are static and the artist (client) is active, here both are dynamic, as the client does not control the natural surroundings and sand. In this respect, the sliding sand and the unsuccessful building experience led Brian to ask basic questions about the way he deals with uncontrollable changes in his life and the balance between accepting and fighting them. This episode, triggered by nature's independent dynamic, made Brian "stop and be." This unique outcome helped him open himself to the beauty of the world around him and reconnect with the aesthetics of the natural world outside. This experience not only helped him expand his perspective on his life narrative, but also fostered a new sense of hope and meaning in his life.

The Paradox Between the Personal and Cosmic Cycles

In their article on psychological time in older age, Shmotkin and Eyal (2003) argue that "the life course of the individual involves both growth and decline over time [and therefore] human beings are ambivalent in their attitude towards time” (p. 265). They claim that older people focus especially on this issue, exploring how much they have achieved so far and how much they still hope to progress. Following this line, Shmotkin and Eyal (2003) also contend that since "time conceptions", and the question of "what one does with his time" may be a key factor in well-being at any period of life, the concept of psychological time is a vital factor that counselors and therapists should consider in any treatment of people facing normal transitions and developmental challenges and with people of older age, in particular. They also say that “older people seek meaning in their past and observe it from the perspective of their entire life" (p. 261). In discussing the ambivalence around the issue of time and how to address it within therapeutic work with older people, they suggest that "time can be viewed as an objective, physical, and quantifiable entity that exists in and of itself and is not dependent on human perception or consciousness. All (human) events are arranged along a linear axis of time. Human beings exist in time" (p. 259).

This issue raises a question about ways in which therapeutic process, in general, and such that takes place in nature, in particular, can help older adults deal with the paradox that exists within this matrix, the personal and cosmic time.

Brian's story illustrates a way in which cyclic natural phenomena, such as the ebb and flow of tides, sunset and sunrise, migration of birds and the like, can be used to connect people with the universal cycle that we are all part of. This mode of work can help older people broaden their perspective of time and gain acceptance of their past, while gaining a sense of continuity and flow. This spiritual attitude does not seek to scientifically explain or delay the maturation or aging process, but rather to help people relate to it as a natural and normal process, while developing a sense of harmony and unification with their surroundings (Davis, 1998).

Summary and Conclusion

This article presents a creative framework in which nature plays a role in therapeutic and nursing work with older people. This mode of work expands the repertoire of common psychological approaches by incorporating spiritual and creative elements in holistic forms of therapeutic and nursing practices, in general, and in therapy with older people, in particular. It illustrates a way in which a dialectic discourse between the personal time-limited life and the endless cosmic one can be used to extend people's perspective and help them reframe their own narratives. In doing so, it highlights a way in which the connection between the personal story and the natural-cosmic one can enhance clients’ sense of completion and oneness with themselves and their surroundings. It seems that this approach can be integrated in the holistic nursing practice, using creative methods and contact with nature in order to expand the ways in which holistic nursing can help people engage with their surroundings and broaden their overall concepts of health and wellbeing.


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