I contributed a long article to the summer issue of Prospect, about wilderness therapy and the impact of nature upon mental health and the treatment of mental illness. In it, I profile the work of Scottish charity Venture Mòr, an amazing organisation led by outdoor instructors turned counsellors, which has been working to bring the field of ‘wilderness therapy’ to a wider audience in the UK.
Full text can be found on the Prospect website here,
The nature cure: how the great outdoors is transforming treatment of mental health
We need the tonic of wildness. Poets know it. Gardeners know it. Dog walkers know it. Why did it take the medical profession so long to figure it out?
by Cal Flyn / Prospect magazine / July 17, 2019
In the summer of 1901, the Manhattan State Hospital—the largest psychiatric hospital in the world—was facing a crisis. Tuberculosis was sweeping New York. It was the leading cause of death in the city that year, and many patients being admitted into the asylum were also physically sick with TB upon arrival. What could they do with all the contagious, “tuberculous insane”?
Alexander Macdonald, the hospital’s superintendent, had an idea. He set up two huge canvas tents in the grounds of the hospital, which was located on Wards Island, a small, sparsely populated island between Manhattan and Queens. Each tent was large enough to house 20 beds. At that time there was no known treatment for tuberculosis, but many doctors subscribed to the idea that clean, cold air could be of benefit—hence the proliferation of mountain sanatoria in the latter half of the 19th century. “In pleasant weather one side of the tent was kept constantly open,” the psychiatrist Clarence Floyd Haviland recalled later, “so that the interior was literally flooded with pure air.”
The results of the Wards Island experiment were encouraging. After a year, 62 of 81 residents of this outdoor ward had survived—far more than would have been expected given the advanced state the infection had reached in these patients. And more intriguingly, the outdoor lifestyle seemed to be bringing with it other, psychiatric, benefits. Many campers showed marked improvements in their mental state.
So noticeable were the effects that the next year, the hospital extended the encampment fourfold so as to offer beds to non-TB sufferers. Patients gained weight and improved in muscle tone. Their cheeks grew ruddy. “Their delusions became less prominent, their hallucinations less vivid,” said Haviland. Suicidal, homicidal, manic and destructive behaviour dropped away.
“Camping,” concluded Haviland in retrospect, “exerts a most health-giving influence… In the restoration of mental health, the effect of the unrestrained life in tents appears to be of vital importance.”
The vogue for “tent therapy” in psychiatric hospitals that followed these experiments seemed like a novelty, but the concept of nature as a restorative force has been around for millennia. It is invoked in Daoist and Ayurvedic texts, and touched upon in the work of Hippocrates; it is threaded through the thinking of the Romantics and the Transcendentalists. As Henry David Thoreau wrote: “We need the tonic of wildness.” Poets know it. Spiritualists know it. Hikers know it. Dog walkers know it. Gardeners know it.
But, for most of the 118 years after Macdonald’s impressive New York experiment, doctors, scientists and healthcare managers, in the UK at least, have been remarkably slow to wake up to the effect that nature—or the dearth of it—can have on the human health and the psyche. There are various reasons why that might be: not least, that “nature” is a somewhat nebulous concept, and thus defining and measuring exposure is an experimental challenge. The mechanisms by which it might work too are not obvious, especially in relation to physical health.
Whatever the reason, it is beginning to look as if British medicine—and psychiatry in particular—has been missing a trick. Researchers have recently been piling up the evidence. A view of a natural scene from a hospital window—the benefits of which were stressed by Florence Nightingale back in 1859—has now been statistically demonstrated to speed up a patient’s recovery from surgery. Conversely, living in a more urban environment has been linked to raised blood pressure. More recent scientific studies have linked exposure to “nature” with reduced stress, raised mood, improved concentration and memory, improved self-esteem, and feelings of good health and energy. As the scientific consensus strengthens, medical professionals are increasingly willing and able to advocate time outdoors as a curative measure.
“Their delusions became less prominent, their hallucinations less vivid”
This should be welcomed. A need for new approaches is obvious—in the UK, prescriptions of antidepressants are at record levels, and counsellors and therapists are seeing unprecedented demand. Meanwhile, new practices in the health service—such as “personal budgets,” which allow patients to direct the resources earmarked to treat them—are also likely to bolster nature cures. Public interest is already growing. A number of new books on the topic have appeared, including Emma Mitchell’s The Wild Remedy, released in December; Isabel Hardman and Lucy Jones will each publish on this topic early next year.
So what is wilderness as therapy? And how might it work?
It was Easter 2017, and trouble was brewing. Andy Hardie, a fresh-faced, sandy-haired outdoor instructor-turned-therapist in his mid-thirties was brooding on the best course of action. Hardie was on the remote Ardnish peninsula on Scotland’s west coast with four teenagers in his charge, all with behavioural or emotional difficulties, plus three staff members looking to him for guidance.
They were three days into a pioneering 21-day “wilderness therapy” programme—the first of its kind in the UK—and things were not going according to plan. In fact, a rebellion was underway. “We were stuck,” Hardie says now, looking exhausted at the memory. “Anything imposed by us, the staff, that appeared structuring or controlling was being rejected.”
Many of the young people referred to Venture Mòr, Hardie’s social enterprise, have issues with authority; they can be oppositional, difficult to manage. Others are depressed or anxious, self-harming, or suffer from eating disorders or addictions. Their parents approach Venture Mòr after trying more traditional treatments such as counselling or psychotherapy in vain—and are still desperately seeking a way to change their child’s behaviour and alleviate their distress.
The young people themselves had agreed to attend; they knew what they were there for. But it didn’t mean they were easy to deal with—something that became abundantly clear during that first attempt. “When we offered space for group sessions, they wouldn’t engage, or they might tell us to fuck off, or say they weren’t interested,” Hardie told me over coffee. “They were responding to the power we were representing in the only way they knew how. They needed to feel in control again.” Hardie and his team had plenty of experience of challenging clients, including young offenders and ex-prisoners, but this time they weren’t sure how to turn the situation around.
“After days of brewing dissent, the four teenagers threatened to abandon the programme”
“It was dramatic,” recalled Richard Tildesley, a gregarious outdoors instructor with dreads that, when loosed, fall to his ankles. “Before we left, we’d said: ‘we’ll pool all of our experience in youth work, all our experience in outdoor programmes, they’ll love it.’ And then they were like”—he brandishes his middle fingers at me forcefully—“no. They literally ran off. It was too much.”
After days of brewing dissent, the four teenagers threatened to abandon the programme. Then an unlikely breakthrough materialised. “The young people called a group meeting,” says Tildesley. “They told us exactly what they thought of us. They didn’t hold back.” “After that we said, ‘OK, good. How do we move forward? What do you want to do now?’”
Their answer: nothing. But that was OK too. Now that Hardie and Tildesley came to think of it, there may be no better place on earth to do nothing than in the wild and beautiful west Highlands. So they tore up the schedule. They hung around the bothy, an old stone cottage with a green corrugated roof. They watched the tide come in. After a while, it went out again, exposing the white sand beach, and the mussel beds laid out across it. They wandered down onto the foreshore, and picked their way across the sand. They listened to the waves as they washed and withdrew, washed and withdrew. They watched the shadows of the clouds sweep across the islands in the bay and the curving hills of Moidart beyond.
Once they’d had enough of nothing, they set out in canoes—for days. They paddled the length of Loch Shiel, and down into Loch Moidart, around Eilean Shona. They camped for a few nights down by the ruins of Castle Tioram.
Polly Sisson, then aged 15, was one of the participants. At the time, she says, her parents were divorcing, her mother had moved far away, and life had become very difficult for her to deal with. “I was spending my days smoking pot and being sad, I guess. I wasn’t doing very much.” Suddenly, with no phone, no distractions, she found herself alone with her thoughts. “There was a bit when we were camping for nine days straight. So I had a lot of time to think. It could feel quite overwhelming,” she said, “but I realised a lot of things.”
The staff too found time for reflection: “We’d fixated on keeping people busy,” said Tildesley. “Then we remembered why we were in the wilderness to begin with. Space. Autonomy.” As the sun swept the sky and the wind riffled through the grass, for the first time in days, they felt peace.
Therapy, whether it be through wilderness or any other method, is perhaps the last thing that stiff-upper lip Brits of the Empire era would have wanted to be associated with. But at least some of the insights that Hardie hit upon in Ardnish would have occurred to Robert Baden-Powell, who dreamed up the scouting movement in 1907. Or to Kurt Hahn, a German living in Britain, who founded Outward Bound in Wales in 1941 as well as the Duke of Edinburgh Awards and Gordonstoun, the rugged Scottish boarding school favoured by the royals (once described by Prince Charles as “Colditz in kilts”). Both men believed outdoor activities to be “character forming”—a corrective for young minds in an increasingly industrialised world. When their movements, with their underlying philosophies of self-improvement, expanded into America, they found a ready audience with an existing summer camp culture. Camp Ramapo opened in upstate New York in 1922, staffed with psychiatric social workers and counsellors, with the aim of reforming “delinquent and problem children”; a trickle of similar ventures would follow, including the influential Dallas Salesmanship Club Camp in Texas in 1946. There, youths with emotional or behavioural problems would live without electricity or running water at a forest camp for weeks or even months.
By the 1960s, American psychiatric hospitals were again experimenting with rustic living, as doctors came to realise that locking their patients away in secure wards was causing them more harm than good. The Oregon State Hospital, then at the cutting edge of mental health care, instituted hiking trips and in 1972, with the help of Everest mountaineer Lute Jerstad, sent 51 of the most unresponsive patients—many of whom had exhibited violent or delusional behaviour—on a 16-day camp-out in the Cascade Mountains.
What would happen when these patients were removed from the security of their ward, with its strictly-policed schedule, and taken to a place “with no perimeters”—the outdoors? They flourished. They rafted down rivers, fished, and climbed rockfaces. “As the days went by and they learned they could survive, the symptoms disappeared,” one psychiatrist told Life magazine, which had sent a correspondent on the trip. It wasn’t a magic solution; not all symptoms vanished, and they didn’t all stay gone. But 14 of the campers recovered enough to leave the institution soon after.
In the US, “wilderness therapy” is now a well-established field with an estimated 500 programmes promoting outdoor “experiential” therapy; perhaps 40 of these offer extended stays of three weeks or more in what Americans call the “back country”—the mountains, the prairies, the badlands, the untracked deserts of that enormous country—places far from cities, roads, phone masts, and the stress and excess of modern life. In a self-styled “frontier nation” the value of self-reliance and being able to live away from modernity fits naturally with the national script.
By contrast, in the UK—and especially in England, where only 14.5 per cent of land is considered in a “natural” or “semi-natural” state —it can be difficult to find a sizeable enough chunk of the countryside to immerse yourself in. Perhaps for that reason, we have come much later to the idea of wilderness therapy. But Hardie is determined to help us catch up.
Your daily routine, your way of life, is upended. It takes a lot of effort to stay dry and warm and well-fed. Poor decisions—like camping on bad ground, or failing to zip up a midge net, or packing too heavy a rucksack—have natural consequences. Wild places don’t listen to excuses, or cut anyone slack; in that way, they’re the most consistent teacher.
To begin with, says Hardie, it can be a painful experience. “You can’t just take people outdoors and expect them to be suddenly happy and calm and easy to deal with. It takes our young people time to figure out how to manage themselves. They don’t pay nature much attention in the first week.” After a few days and nights in the wild, the practical difficulties of hiking and camping grow less bothersome, and they begin to find the capacity to open themselves to the landscape, and see that their surroundings are beautiful.
The staff must deal with the same physical demands; for them, too, it is a 21-day, 24-hour-a-day, experience. They too are camping in bogs or slogging up mountain passes in the hail. But this helps the young people see them as rounded individuals, with experience and strength. Over three weeks, the group grows into a tight-knit community, whose members support and respect for one another can help them to build self-esteem. “It takes time to get into that space, but once they’re there the value is profound.”
Hardie first realised the therapeutic potential of wild expeditions when working as an outdoor instructor. He helped take ex-offenders camping, and “realised that being out in that environment with people for a prolonged period of time—hours not minutes—led to some really deep conversations about what had happened in their lives, and how they learnt to survive,” he recalls. After these experiences, he decided to train as a counsellor and explore the nature cure in more depth.
The conversations that come out of such an experience are very different to those arising in a conventional hour-long counselling session. Wilderness therapists are not booked into a fixed slot, but instead are there to speak to when the moment is right; it can be easier to broach difficult topics while semi-occupied by other activities, like walking, or skimming stones, or sitting around a fire. These are conditions that lend themselves to epiphanies.
“It can be very powerful,” says Tildesley. He recalls another wilderness therapy course, this time at Arisaig, near Mallaig on the Scottish west coast. They were sitting watching the sun going down behind the Small Isles, the sky awash with blazing colour. A silence fell, until one of the participants spoke up. “He said he wanted to apologise for how he’d been acting. That started an outpouring.” All the participants had something to say—an apology, or a reflection on their own behaviour. It culminated in a group hug—a gesture of support and community, a proof of something they had come through together.
Of course, there are drawbacks. It’s time consuming, for one thing. Not everyone is willing to vanish into the hills for days or weeks at a time. And it’s expensive.
Venture Mòr recently moved from a three- to a two-week programme, which comes in at just under £4,500, while the Essex-based Wilderness Foundation runs short courses in (rural, though not strictly “wild”) Chatham Green starting at £240 for a weekend camp and rising to £900 for a five-day, four-night course. For this reason, the intake skews towards the well-off, although as more research attests to the effectiveness and even cost-efficiency of the approach, health service and social care commissioners could begin to procure these services for the wider population.
Already there are moves in this direction. In 2016, Natural England commissioned a study into what it called “green care” (nature-based mental health programmes) which rated the evidence for their efficacy as “strong,” noted growing interest among commissioners, and gave providers tips about how to gear their offerings towards them. The same report highlighted other approaches including the 173 “care farms” around the UK that see more than 5,800 visits from patients suffering mental ill-health each week, where they are taught animal husbandry, woodland management or agriculture. Other projects offer gardening or animal-assisted therapies—spending time with trained support dogs, or learning to ride and care for a “therapy horse.” (Developing a bond with an animal, and learning to stabilise emotions and communicate clearly, is thought to impact on self-worth, trust and calmness.) Last October, doctors in Shetland were formally authorised to prescribe activities like birdwatching, hillwalking and beachcombing to those struggling with mental illness—the first UK health board to do so.
A new approach to mental health in this country is, by common consent, long overdue. Mental health services are deteriorating at the same time as a rising tide of mental health problems is being reported. Severe mental illness has been on the rise since the 1990s, while detentions under the Mental Health Act rose by 34 per cent in the decade between 2006 and 2015.
A walk in the woods cannot cure serious conditions like schizophrenia. It is not a substitute, either, for psychiatric medications like antidepressants or antipsychotics. But it could act as an important intervention for those suffering from stress and anxiety-related conditions.
Back in Lochaber, a tentative equilibrium had been reached. One of the four teenagers dropped out, but three decided to stick it out to the end. On the last day, as a way to mark the end of their journey, Hardie suggested that they climb Ben Nevis. One declined, but two of them agreed, including Polly, who found that their journey had reawakened in her a love for the outdoors.
They set off mid-morning on a cloudy, overcast day. As they rose up the mountain, the weather deteriorated. They climbed through sleet and heavy rain. They stopped for lunch, and when they started again the clouds had closed in on them: zero visibility. They trudged on. They staggered above snowline, lost the trail.
“I remember the sweat on my brow, rain on my face. It was tangible, visceral, a huge experience”
They were high now—over 1,000 metres—and squinting into the wind and the sleet. But finally, as they reached the summit, the wind dropped and the clouds let up. They saw the gullies and the cliffs falling away on all sides. “I remember the sweat on my brow, rain on my face,” says Hardie. “It was tangible, visceral, a huge experience.” He gave the teenagers his phone, and—from the top of the tallest mountain in the country—they called their parents.
On the way down, they followed a zig-zagging path down the north west face, and as they did so, the clouds began to lift. They looked out over Loch Linnhe, and Loch Eil. They could see the hills of Ardgour, and beyond lay Loch Shiel where they had paddled and camped. It gave them perspective, made sense of their journey: they could see how far they had come.