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The meaning of the physical environment in child and adolescent therapy: A qualitative study of the outdoor care retreat

November 2023
The Center For Health Design


Why does it matter?
The experience of hospitalization can be extremely stressful, frightening, and even traumatic, especially for children. Children who are chronically ill and staying in the hospital frequently or for extended periods of time will often benefit from psychological therapy as part of their treatment plan. However, in many cases, especially with very sick children, the therapy takes place in the same physical environment where children are receiving care for somatic illnesses. The associations with the hospital environment can have an impact on the therapeutic experience, which in turn can impact the child’s overall treatment, wellbeing and mental health. And despite the evidence that nature-based therapy can be beneficial, it is not always feasible to bring ill children out of the hospital into nature.


How was the study done?
This study took place at an outdoor care retreat cabin situated in the forest adjacent to a large University Hospital in Norway. The cabin is accessible to wheelchairs and even hospital beds. There are large windows and colorful pillows for relaxation or play. There is a fireplace outside and a bridge that crosses over a small stream.

The Researchers used a qualitative approach including focus groups and interviews with three different groups: hospital department leadership (n=7), therapists (n=6), and parents of child patients (n=4). The semi-structured questions focused on the experiences and use of the cabin, and interviews with therapists also focused on the experience of therapy in different settings. Researchers used something called “reflexive thematic analysis” which involved reviewing the data and coding the different themes that emerged, and sharing the initial results with the therapist participants to confirm the categories.


So what do we learn from the study?
So what did they find?  Researchers noticed that when asked about the outdoor care retreat, participants tended to explain their experience in relation to their previous experience in the traditional hospital setting, emphasizing the benefits of the outdoor care retreat. They also found that similar themes came out in each different group of participants (the healthcare leadership, therapists, and parents).

One of the main themes in the findings has to do with where and what users focus on when engaging in therapy in the outdoor care retreat. Therapists discussed the tendency for children to focus on the external, that is, what was happening around them in the outdoor care retreat space, versus an internal focus on illness that came up more often in the traditional hospital space. Further, while the therapists shared that children often seemed overwhelmed by all of the toys in the hospital, they seemed to enjoy focusing on the diverse activities related to nature surrounding the outdoor care retreat. 

Another common theme in the findings is related to body language. Therapists described the children’s energy with words like “relaxed, “vital” and “curious” in the outdoor care retreat, and that their body language was open. This was in contrast to a much more controlled energy and “closed,” “guarded,” and “watchful” body language in the hospital. 

A third major theme in the findings was the ways in which the outdoor care retreat environment seemed to support connection between the child and the therapist. Users shared how the restorative, relaxing surroundings in the outdoor care retreat created a sense of safety. The therapists mentioned that they felt inspired to use metaphors from nature in their conversations where they could sit next to the child, viewing nature together, where they could be on the same level, as opposed to sitting opposite and looking directly at each other as they did in the hospital.


Can we say that the results are definitive?
Let’s talk about some limitations. The authors discuss the need for further research on the outdoor care retreat and similar settings that will help us understand what specific aspects of these environments are producing beneficial outcomes. For instance, the researchers wonder if the benefits of the outdoor care retreat are related to the exposure to nature, or perhaps to the experience of having “therapy in a different place” than where they are receiving their medical treatment. Or if the positive experiences would be similar in an outdoor nature environment without the cabin. The authors also mention the importance of future research should include a diverse patient population, and to include direct interviews with children to understand their experience in their own words.


What’s the takeaway?
So what’s the takeaway? In the hospital, sick children are patients. But taking a break from that space may allow them to be their full human selves again, even briefly. In this study, therapists described how children appeared to remember who they really are when they were inside the cabin, and that the therapist had the opportunity to really get to know the child beyond their illness. Being able to play, to breath fresh air, to explore, and to relax are all essential to our personhood even when we are healthy, and perhaps even more so when we are sick.

Summary of:
Hauge, Å. L., Lindheim, M. Ø., Røtting, K., & Johnsen, S. Å. K. (2023). The meaning of the physical environment in child and adolescent therapy: A qualitative study of the outdoor care retreat. Ecopsychology, in press. https://doi.org/10.1089/eco.2022.0087



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