Humans have a natural affinity to nature and are eased in its presence. Forest bathing uses our 5 senses to connect to, or ‘bathe’ in nature. It is a mindful practice that calms the stress response by reducing cortisone levels. Forest baths last from 20 minutes to 3 hours and are led by guides who invite us to notice and sense the forest, or indeed any sort of green space, even at home or work.
Forest bathing guides offer ‘invitations’ to participants to notice nature in different ways and the sharing of what has been noticed. General conversation is avoided so that participants stay mindful. A simple example might be to notice the changing of the seasons.
The practice may be extended with the addition of yoga, a Japanese tea ceremony, foraging and eating food and breathing exercises.
Relevance to primary care
Social prescribing is now a central part of primary care. It is defined by NHS England (2020) as ‘an approach that connects people to activities, groups, and services in their community to meet the practical, social and emotional needs that affect their health and wellbeing.’ Based on what matters to the person, link workers or general practice nurses (GPNs) themselves can discuss the idea of ‘green social prescribing’ to support wellbeing. This is termed ‘ecotherapy’: there are multiple definitions, but MIND (2021) describes it as ‘a formal type of therapeutic treatment which involves doing outdoor activities in nature’ of which forest bathing is one area of practice.
The emerging evidence suggests that ‘prescribing’ nature can have a positive effect on wellbeing (National Academy for Social Prescribing, 2023)
Theoretical underpinnings
As a species, humans are creatures of nature, but have gradually separated from it – a condition sometimes referred to as ‘nature deficit disorder’. We now spend over 90% of our time indoors, when historically the reverse was true. This concept that humans have a biological need to connect to nature is called biophilia, from the Greek ‘love of life and the living world’.
We impact the environment, and the environment impacts us. This human/nature connecting is thought to be essential for our psychological wellbeing. Nature allows deeper thought into the cycle of life and death and the sensory nature of being in a forest allows deeper exploration of thoughts and feelings (Berger and McLeod, 2006).
Being mindful by living in the present moment and noticing surrounding is a core part of ecotherapy. Noticing improves wellbeing more than simply visiting nature (Richardson, 2021).
Trees produce not only oxygen, but chemicals called phytoncides (essential oils or tree oils) that protect them from infection and insects. When we breathe in phytoncides, the body increases natural killer cell activity, which is associated with better immunity and resistance to tumour formation (Li, 2009). The soil contains friendly bacteria called Mycobacterium vaccae that may protect against stress, reduce inflammation and improve immunity (Smith et al, 2019).
The blue sky and green forest colours focus our primitive minds towards the presence of food and water. Observing patterns in nature are called ‘fractals’ can lower the levels of the stress (Taylor, 2016). Examples include symmetrical veins in leaves or patterns of petals. According to the 19th Century philosopher William James, these soothing sights attract our attention in a natural, involuntary way compared to the required effort demanded by computers, traffic etc. He called this ‘soft fascination’. Others have researched how this soft fascination can enable better attention, an approach called ‘attention restoration theory’ (Berman et al, 2008).
Although generally not categorised as a ‘walk’ – rather taking time to gently stroll and notice nature – the exercise effects can lower blood pressure by reducing the levels of serum N-terminal pro-B-type natriuretic peptide (NT-proBNP) and urinary dopamine (Li et al, 2011). Being outside can help people with seasonal affective disorder by exposing them to natural light. Forest bathing with others can also help to alleviate loneliness.
The origins
A national health programme for forest bathing was started by the Japanese Ministry of Agriculture, Forestry, and Fisheries in 1982. This was based on an intuitive idea that people could be healed by nature and was influenced the teachings from the Shinto and Buddhist religions. Two thirds of Japan is forest, but the overpopulated urban life in Japanese cities is stressful; characterised by techno-culture, and a phenomenon called karoshi meaning ‘death from overwork’. Today, there are over 60 official Shinrin-yoku trails in national forests and it is ‘prescribed’ by the Japanese health service.
Dr Qing Li and his team at Nippon Medical School in Tokyo are credited with the earliest research into the benefits of forest bathing, which started in 2004 and is summarised in his book Forest Medicine (Li, 2012).
The evidence
A systematic review (Wen et al, 2019) found that forest bathing can
- reduce blood pressure
- lower stress
- improve cardiovascular and metabolic health
- lower blood sugar levels
- improve concentration on memory
- lift depression
- improve pain thresholds
- improve energy
- boost the immune system by increasing the body's natural killer cells
- increase anti-cancer protein production
- help with weight loss.
A further systematic review however (Kotera et al, 2020) found the potential for research bias:
- randomised control trials (RCTs) focus on comparing activities in nature to those in urban environments, which are likely to be more stressful
- there are no RCTs comparing forest bathing to other therapeutic approaches such as cognitive behavioural therapy.
Research evidence therefore suggests that forest bathing has intuitive and biological benefits, but also that further research is needed to discover just how much and in comparison to what.
Who might benefit?
Forest bathing is suitable for a range of people with long term physical conditions affecting the cardiovascular, endocrine, respiratory and immune systems as well as those with neurodiverse and mental health issues.
Fit to primary care
From its inception, primary care has been about caring not sense nature
- Can be practised at home or at work
- Figure 1 offers a basic guide that you can give out to people to try.
- Forest bathing at home or work
- Some people that you support may be housebound or have limited mobility. The benefits of forest bathing can still be promoted by:
- Looking at nature through the window – studies show that recovery in hospital is hastened when people can see nature (Ulrich, 1984)
- Growing and tending houseplants, bulbs and seeds
- Trying aromatherapy using essential trees oils to get the phytoncide effect using room mists, diffusers or massage oils. Cedar, juniper, eucalyptus, sandalwood and pine are good. Make sure essential oils are diluted correctly in carrier oil, water, witch hazel etc. so that they don't burn the skin
Case study: Forest bathing in Trafford
In Trafford, Greater Manchester, BreathChamps CIC, a social enterprise offering holistic activities for people with breathing problems, has been practising forest bathing for the last 12 months.
Supported by Trafford Housing Trust, 10 volunteers have now completed an online diploma in forest bathing and have tested out various forest bathing invitations in public parks and green spaces. Five clinicians are amongst the volunteers and this helps to reassure very vulnerable people, such as those on oxygen therapy or those with a history of panic attacks, that they are safe. Permission was sought from landowners and easily granted due to the non-destructive nature of the activities. Although primarily aimed at people with moderate to severe respiratory conditions, these forest baths are open to everyone and particularly attract people with mental health problems. The activities are advertised on Eventbrite, via social media, though social prescribers and via email to other community organisations.
Three regular forest bathing sites are now in operation in the north, central and south localities of Trafford, guided by volunteers working in pairs.
Measuring impact
The profile of mood states (POMS) test, (McNair et al, 1981) is the recommended tool to use to assess the impact of forest bathing. As this has 34 questions which may be off-putting, BreathChamps CIC uses the Office for National Statistics 4 wellbeing measures of anxiety, life satisfaction, happiness and a worthwhile life (ONS4, 2018) to measure impact. Early results show small improvements in all measures other than life satisfaction. Low or unchanging satisfaction with life may be due to outside factors such as the rising cost of living or family issues.
People who come to the organised forest bathing activities are invited to complete a simple clinical assessment sheet so the clinicians leading the session know how best to support them. They answer the 4 ONS questions and describe how connected they feel to their community.
Anecdotal feedback
Feedback from forest bathing participants (figure 2) is that it offers them calmness, tranquillity, peace and stillness. Most notable is that people with serious respiratory illness seem to overcome the challenge of being outside to take part. Whereas normally they would that say that it's too far, too cold, too windy or too hot they will turn up, even in the pouring rain, to watch raindrops and listen to them fall.
Tom
Tom (name changed) was 90 and had idiopathic pulmonary fibrosis. He drove to the park every week and trundled his oxygen to the picnic bench 10 yards away. He was cheered by the support of others waiting there, each with their own issues. Everyone set off together on a journey of 900 paces to the back of the park, where there were woods. Tom had to stop 3 times on the way to get his breath back. He then sat on a camping chair in the wood for at least 20 minutes.
On the way back to the picnic bench, Tom didn't need to stop for breath. He regaled others over a cup of tea and biscuits (or fruit!) with stories of his life as a local milkman and described the history of the area.
Jane
Jane (name changed) came with her social prescribing link worker to the park. She spoke only to her and could not look at or speak to anyone else. Jane had bladder cancer and wrote on her clinical assessment form that she had ‘been through hell’.
By the third week, Jane had made friends with a retired schoolteacher who had revealed her utter loneliness and the link worker no longer needed to come. She suddenly loudly declared one day that she could ‘really breathe here’. Jane could be seen sitting in a camping chair, sunbathing over a cuppa and looking like she didn't have a care.
Jane and Tom have recently passed away. Their families recalled the joy they got from their forest bathing activities.
Summary
Forest bathing is highly accessible for people with a wide range of long-term conditions that GPNs may support in primary care. The evidence base is still emerging but the anecdotal experience in Trafford has provided positive feedback. The basics of forest bathing (figure 1) are simple to learn and can easily be socially prescribed. Activities can take place both outside, indoors and at work, using some simple tweaks such as the addition of plants and looking mindfully out of the window.