Silva AC, Antunes J, Peixoto J, et al. Domestic violence: the impact of a nature-based holistic development program on victims’ well-being. Ecopsychology. 2018;10(3):158-172.
To determine the benefit of a group ecotherapy program for women who are survivors of domestic violence*
A prospective, single-arm study
Thirty-two women (ages 21-66; mean 43.5 years) with a history of domestic violence. In addition to standard physical and mental health screening criteria, participants completed 3 assessments: the Risk Checklist [adapted from the Victims Domestic Abuse, Stalking and Harassment and Honour Based Violence (V-DASH, 2010) Risk Identification Checklist (Richards, 2010) and from the Spousal Assault Risk Assessment] for current domestic violence, the Inventory of Marital Violence, and the Brief Symptom Inventory (BSI), an assessment of 9 symptom areas of emotional disturbance. Women with children were encouraged to bring their children to participate in the program, as social and community aspects were integral components of the program’s design.
A 6-day outdoor group experience (Project CarryOn–Ecosystem services and their role in domestic violence victims’ support processes), occurring in local, regional, and nearby national forests, farms, and beaches of northwest coastal Portugal. The program was led by a team consisting of psychologists specializing in domestic violence care and biologists specializing in environmental education. Specific content instructors were also present to lead participants in a variety of daily activities including the following:
- Native plant and animal identification
- Use of medicinal, culinary, aromatherapeutic, and cosmetic herbs
- Habitat and conservation education
- Mindful walking and sitting in natural settings
- Swimming in the ocean
- Movement therapies such as yoga, Zumba, and Pilates
This was a mixed-methods study that collected quantitative and qualitative data from each participant prior to and upon completion of the Project CarryOn program.
- WHO Quality of Life - Brief Assessment (WHOQOL-BREF): a 26-item self-report instrument with areas of physical, mental, social, and environmental health, as well as composite quality of life (QoL) score
- Outcome Questionnaire (OQ-45.2): a 45-item self-report instrument for measuring mental health function, with 3 subscales: 1) symptoms (eg, depression, anxiety); 2) interpersonal relationships (eg, loneliness, conflict); and 3) social roles (eg, workplace, home, school)
- Rosenberg Self-Esteem Scale (RSES): a 10-item self-report instrument with subscales for feelings of positive and negative self-worth and a composite self-esteem score
- Semi-structured interview assessing participants’ enjoyment, memories, and personal meaning of the program
In addition, the Nature Relatedness Scale (NRS), a measure of nature awareness, was used to assess preexisting connection with the natural world and changes to this measure during the ecotherapy program. The NRS is a 21-item self-report with 3 subscales measuring self-identification with nature, external nature worldview, and personal experience with the physical natural world.
All quantitative outcome measures (WHOQOL-BREF, OQ-45.2, RSES) revealed positive pre-post improvement with medium to large effect sizes. Effect size is a representation of the importance or amplitude of change resulting from an intervention, rather than the statistical significance or validity commonly represented by P value. Effect size is determined using a statistical test called Cohen’s d. Cohen’s d effect sizes are conventionally interpreted as small (d≤0.10), medium (d≤0.30), or large (d≤0.50).
Statistically significant improvements in QoL scores included positive changes in:
- Physical health (P≤0.01; d=0.48)
- Psychological health (P≤0.001; d=0.61)
- Environmental health (P≤0.01; d=0.65)
- Overall QOL (P≤0.01; d=0.62)
Statistically significant improvements in mental health functioning scores including changes in:
- Symptom distress (P≤0.01; d=−0.35)
- Interpersonal relationships (P≤0.05; d=−0.39)
- Social role (P≤0.01; d=−0.38)
- Total Outcomes score (P≤0.01; d=−0.49)
Statistically significant improvement in self-esteem composite score (P≤0.01, d=0.34)
Qualitative data revealed unanimous positive appreciation for the program and benefits in areas such as positive feelings, social support, network development, personal development, mother-child interaction, body and mind activities, and liberation, freedom, and security. Specific feedback included statements such as:
- “The day at the beach. I liked being there, throwing that stone…I felt an immense joy, a sense of liberation. I have not felt like that in a long time.’’
- ‘‘I really liked to walk outdoors…with nature. Everything was part of me.”
Additionally, participants reported increases in all nature relatedness measures, with statistically significant improvement in the NR-self subscale (P≤0.05; d=0.42).
Domestic violence is common throughout the world. It is defined as “the willful intimidation, physical assault, battery, sexual assault, and/or other abusive behavior as part of a systematic pattern of power and control perpetrated by one intimate partner against another. It includes physical violence, sexual violence, threats, and emotional/psychological abuse.”1 According to the US National Coalition Against Domestic Violence (NCADV):
- 1 in 4 women and 1 in 9 men have been victims of severe physical violence by an intimate partner in their lives.
- On average, 20 people per minute are physically abused by an intimate partner in the United States.
- More than 20,000 phone calls are made daily to domestic violence hotlines.1
Domestic violence has significant health impacts beyond the potential acute threats to health and safety. Chronic lifelong physical, mental, and sexual health effects often result from domestic violence, often causing severe disability and limiting quality of life due to physical damage, posttraumatic stress disorder (PTSD), and increased risk for developing chemical dependency. Treatment and recovery from domestic violence can be difficult because of inability to leave the abusing partner, fear of stigma, feelings of guilt or shame, and other aspects of trauma.
The Project CarryOn program described in this study takes a novel approach to addressing domestic violence. It utilizes aesthetically pleasing natural environments in which women who have experienced domestic violence engage in multiple therapeutic group-based activities. This unique, holistic approach addresses participants’ physical, emotional, cognitive, social, cultural, and spiritual needs within the context of safe and supportive natural settings.
The known mental health benefits of nature exposure and ecotherapy make these approaches a ‘natural’ fit for inclusion in trauma, PTSD, and stress reduction treatment programs.
One of the most important steps in trauma-based therapy is establishing a safe, comfortable, and relaxing environment.2 The process of trauma disrupts central nervous system (CNS) function and (among other things) can create heightened sensitivity to environmental stimuli.3 Part of the therapeutic work with trauma survivors is to gently reintegrate their sensory CNS function, which is best accomplished in calm, relaxed settings. Properly chosen natural environments are well-known for engendering a restorative context for individuals who have experienced stressful events.4 For individuals who have suffered trauma, the environment itself can be an important component of therapy.
Past studies have shown that the context of a natural environment can significantly increase the efficacy of other therapeutic activities.5 This place-based “settings approach” to health promotion contends that ‘‘place and context are themselves important and modifiable determinants of health and wellbeing.”6 It is theorized that natural settings contain evolutionarily adapted restorative attributes that create a “salutogenic” effect on mental health.7 In the Project CarryOn program, it is likely that these salutogenic setting effects were present, based on analysis of the quantitative and qualitative data.
Use of natural environments and activities for therapeutic and restorative psychological and mental health work has been well-reviewed in the literature.8-10 Horticultural therapy has been used for centuries and has demonstrated benefits for addressing clinically significant stress11 and depression.12 Most recently, the field of ecotherapy has been developed to provide direct application of the studied benefits of natural settings for mental health.13
MIND, a British mental health nonprofit organization, has made ecotherapy a major component of its agenda and has advocated for inclusion of ecotherapy in addressing all forms of mental health care.14 Increasingly, ecotherapy is being used in individual clinical therapy sessions by trained professionals.15 And the type of group ecotherapy demonstrated by Project CarryOn has been proven effective in various other populations, including women recovering from cancer treatment and military veterans with PTSD.16,17 The known mental health benefits of nature exposure and ecotherapy make these approaches a “natural” fit for inclusion in trauma, PTSD, and stress reduction treatment programs.
In the United States, incidents of domestic violence and associated sexual assault are common. Societal conversations about these topics are increasing, sparked by the #MeToo movement and the growing number of women coming forward to share their stories of abuse. The Rape, Abuse & Incest National Network (RAINN) support hotline received a 338% increase in calls during the period of late September 2018 following a nationally reported story of such an incident.18 These conversations are happening because the events they relate to occur very frequently, they often cannot be openly expressed, and conventional management and treatment is typically inadequate. This study demonstrates that opportunities to significantly benefit the physical and mental health, well-being, and quality of life of individuals affected by trauma are possible.
Traumatic events such as domestic violence impact health in many ways and can have lifelong effects. Utilization of holistically minded group ecotherapy programs such as Project CarryOn have been shown to have multiple therapeutic benefits that improve health, well-being, and quality of life. Development and expansion of ecotherapy programs for survivors of domestic violence, as well as other potential groups affected by trauma, could substantially reduce the significant physical, mental-emotional, and social burden of these experiences and create opportunities for improving individual and community public mental health.
*Terminology for people that have experienced domestic violence can be controversial, with specific justifications for terms such as “survivor” and “victim.” Until a universally accepted term is adopted, difficulty in language use around this sensitive area will continue. As neither “survivor” nor “victim” is the absolute preferred term, this article uses the former term as it is thought to help promote greater positive individual agency.
- National Coalition Against Domestic Violence. Quick guide: what is domestic violence? https://ncadv.org/blog/posts/quick-guide-what-is-domestic-violence. Published October 4, 2016. Accessed November 8, 2018.
- Levine PA. In an Unspoken Voice: How The Body Releases Trauma and Restores Goodness. Berkeley, California: North Atlantic Books; 2010.
- van der Kolk B. The Body Keeps the Score. New York, NY: Penguin Books; 2014.
- Ulrich RS, Simons RF, Losito BD, Fiorito E, Miles MA, Zelson M. Stress recovery during exposure to natural and urban environments. J Environ Psychol. 1991;11(3):201-230.
- Kim W, Lim SK, Chung EJ, Woo JM. The effect of cognitive behavior therapy-based psychotherapy applied in a forest environment on physiological changes and remission of major depressive disorder. Psychiatry Investig. 2009;6:245-254.
- Dooris M. Expert voices for change: bridging the silos-towards healthy and sustainable settings for the 21st century. Health Place. 2013;20:39-50.
- Beute F, de Kort YAW. Salutogenic effects of the environment: review of health protective effects of nature and daylight. Appl Psychol Heal Well-Being. 2014;6(1):67-95.
- Gascon M, Triguero-Mas M, Martínez D, et al. Mental health benefits of long-term exposure to residential green and blue spaces: a systematic review. Int J Environ Res Public Health. 2015;12(4):4354-4379.
- Bratman GN, Hamilton JP, Daily GC. The impacts of nature experience on human cognitive function and mental health. Ann N Y Acad Sci. 2012;1249:118-136.
- Logan AC, Selhub EM. Viz Medicatrix naturae: does nature “minister to the mind”? Biopsychosoc Med. 2012;6(1):11.
- Adevi AA, Mårtensson F. Stress rehabilitation through garden therapy: the garden as a place in the recovery from stress. Urban For Urban Green. 2013;12(2):230-237.
- Gonzalez MT, Hartig T, Patil GG, Martinsen EW, Kirkevold M. Therapeutic horticulture in clinical depression: a prospective study of active components. J Adv Nurs. 2010;66(9):2002-2013.
- Summers JK, Vivian DN. Ecotherapy - a forgotten ecosystem service: a review. Front Psychol. 2018;9:1389.
- MIND. Ecotherapy: The Green Agenda for Mental Health. 2007.
- Buzzell L, Chalquist C. Ecotherapy: Healing with Nature in Mind. San Fransisco, CA: Sierra Club Books; 2009.
- Nakau M, Imanishi J, Imanishi J, et al. Spiritual care of cancer patients by integrated medicine in urban green space: a pilot study. Explor J Sci Heal. 2013;9(2):87-90.
- Poulsen DV, Stigsdotter UK, Refshage AD. Whatever happened to the soldiers? Nature-assisted therapies for veterans diagnosed with post-traumatic stress disorder: a literature review. Urban For Urban Green. 2015;14(2):438-445.
- Rape, Abuse and Incest National Network. RAINN hotline helps record number of survivors. https://www.rainn.org/news/rainn-hotline-helps-record-number-survivors. Published October 1, 2018. Accessed November 8, 2018.