Research PresentationUKCP Research Conference

Regents College, London22 June 2013

The Effectiveness of Nature Awareness Exercises as a Therapeutic Intervention for Anxiety:

A Hermeneutic Single-Case Efficacy Design Study

Nigel Magowanhttp://www.ecotherapy.eu/

http://www.manchester-psychotherapy.co.uk/

Background

• The research formed part of my Advanced Diploma in Contemporary Psychotherapy

• The research was carried out last year and submitted December 2012

• Single Case Study using HSCED Research Methodology

• Participant attended a 2 day outdoor Ecotherapy workshop

• About me:• Graduate of the Beeleaf Institute of Contemporary Psychotherapy• Solution-focused Integrative Psychotherapist• Also been practicing as a Clinical Hypnotherapist and Life Coach since 2002• Started running Ecotherapy workshops and 1-to-1 sessions ~4 years ago

Research Questions

• Would the research participant change during the Ecotherapy workshop?

• Could any changes that occur be directly attributed to the nature-awareness exercises?

• What else could be responsible for any changes that might occur?

Nature Based Therapies

• Ecotherapy is a collective term for nature-based therapies

• Therapies which utilise a connection with nature as part of the therapeutic process

• Combine the positive effects of nature with modern psychotherapy and counselling

• Often draw on both ancient and modern practices(e.g. shamans are equivalent to the tribes doctors, psychotherapists, advisors and priests)

•Examples: Equine Assisted Therapy, Pet Assisted Therapy, Horticultural Therapy, Walking Talking Therapy, Natural Awareness Therapy

Research examples:•Using CBT with depressed clients in a forest environment produced superior results

•Psychiatric patients working on a farm showed significant improvements in coping ability, reduced symptoms, and improved self-efficiency

Wilderness Therapy• Around since 1960’s

• Evolved from Outward Bound (1940’s)

• Challenges in outdoor environment build self awareness, confidence & self esteem, and relationship skills

• Expedition or Base-Camp based

• Perceived isolation and risk

• Often take place over extended periods of time

• Can involve hiking, camping and other outdoor activities

• Different therapeutic relationship (3 way client-therapist-nature)

• Opportunity for solitude, reflection

• Natural Awareness Therapy is a form of base-camp Wilderness Therapy

Nature-Awareness Exercises• Presented as:

• A series of nature-based exercises and games• Sensory awareness exercises & meditations• Primitive living skills (Fire making, tracking, shelter building etc.)• Solo reflective time• Group sharing• Trance work

• From a variety of sources: • Bushcraft• Tracking/Hunting skills• Aboriginal cultures, particularly North American Indians• Mindfulness / Meditation• Geoffrey McMullan (creator of Natural Awareness Therapy)• J.Cornell (‘Sharing Nature with Children’)• Tom Brown Jnr. (Nature observation)

Natural Awareness Therapy frames these exercises with a therapeutic intent

EcotheraWorkshop Images

The research participant does not appear in these image.

Ethical Considerations• No gatekeeper issues• Participant had previously expressed an interest• Introductory letter• Participant Information Sheet

• Overview• What would be expected• Benefits• Risks• Reimbursements

• General Consent Form• Agreement to take part• Participation is voluntary• Consent to use anonymised results• Consent to recording of follow-up interview

• Consent to record the interview was re-confirmed verbally • Reviewed draft documents at different stages and gave her consent

• Anonymised interview transcript• Rich case record• Draft dissertation

Ethical Issues: Outdoor Workshop Related

Group Related:• Confidentiality (General & Research Related)• Mutual respect• Discussion and mutual agreement• All workshop attendees sign a Terms and Conditions sheet

General Public Related:• What to do if encountering a non-workshop attendee• Discussion and mutual agreement

Natural Environment Related (Risk Assessment):• Natural hazards• Slipping/tripping• Wet/Uneven ground• Falling branches• Low branches• Burns and damage from camp fire and cooking• Weather conditions• Appropriate equipment

Hermeneutic Single Case Efficacy Design (HSCED)• Based on processes used by the legal system• Rigourous systematic approach• Cross examination of the data• Affirmative case and sceptic cases are formed• Rebuttals to affirmative and sceptic cases• Positive bias addressed by inviting 2 independent judges

• Uses a mix of quantitative and qualitative data• Gathered from multiple sources:• Interviews• Outcome Measures• Questionnaires• Therapist Notes• Data is triangulated to find convergence

• Attempts to answer the questions:• Did the client change substantially?• Did they change as a result of the therapy?• What was responsible for the change?

The Research Participant

Selection Criteria: • Must be diagnosed with an anxiety disorder• Willing to take part in outdoor nature-based therapy• Not currently participating in psychotherapy or counselling

'Amy'• 51 year old woman• Attended a two hour taster workshop earlier in the year• Anxiety and low self belief since childhood• Parents strict and very critical• Incidents of bullying in 3 of her last 4 jobs

Four separate periods of therapy in her life:• TA for agoraphobia• Counselling for being bullied at work (twice)• GP diagnosed Generalised Anxiety Disorder and referrered her for CBT

Data Collection Process

Case history taken by telephone before the workshop

Start of the workshop:• Outcome measures (GAD-7, HAM-A, WSAS, LSAS)• Personal Questionnaire (Client generated list of problems)

End of each day:• HAT Forms (one for each exercise)

End of the workshop:• Personal Questionnaire

6 Week follow-up interview:• Outcome measures (GAD-7, HAM-A, WSAS, LSAS)• Personal Questionnaire • Semi-structures interview (Change Interview)• Change List

Data then compiled into the Rich Case Record

Results: Amy's Outcome Data

Measure Case-ness Cut-off

  Pre-Workshop 6 Week Follow-Up

Generalised Anxiety Disorder 7 (GAD-7) 

10   17 11

Hamilton Anxiety Rating Scale (HAM-A) 

18   24 18

Liebowitz Social Anxiety Scales (LSAS) 

55   83 76

Work and Social Adjustment Scales (WSAS) 

10   25 21

Personal Questionnaire (PQ)

3.5   6.3 4.8

GAD-7: Range 0-21. Lower scores are better. (Spitzer, Kroenke & Williams, 2006)  HAM-A: Range 0-56. Lower scores are better. (Hamilton, 1959)LSAS: Range 0-144. Lower scores are better. (Liebowitz, 1987)WSAS: Range 0-40. Lower scores are better. (Mundt & Marks, 2002)PQ: Range 1-7. Lower scores are better. Score is the median of PQ items. (Wagner & Elliott, 2004)

Results: Amy’s Personal Questionnaire Data (PQ)Item Duration Start End Follow-up

I am self-critical >10 year 7 4 5

I lack self-belief >10 year 6 4 5

I fear being the focus of attention >10 year 5 4 4

I lose my temper easily 6-10 years

7 4 5

I find it difficult to relax my mind and body

6-10 years

7 5 4

Anxiety affects my relationships >10 year 6 5 4

I am unassertive >10 year 6 5 6

I see the negative first 6-10 years

6 3 4

I give up too easily 6-10 years

7 4 5

I lack direction >10 year 6 5 6

Mean scores   6.3 4.3 4.8

Rated according to how much the problem bothered her.1 – Not at all2 – Very Little3 – Little4 – Moderately5 – Considerably6 – Very Considerably7 – Maximum Possible

Results: Amy’s Change List (From follow up interview)

Change How expected/surprising the change was

How likely without therapy

How important is it to you

Improved Perspective 5-Surprised 1-Unlikely 5-Extremely

Change of Focus 2-Somewhat Expected 1-Unlikely 5-Extremely

Improved Self Worth 5-Surprised 1-Unlikely 5-Extremely

Better Relaxation 1-Expected 1-Unlikely 5-Extremely

Lower Blood Pressure 5-Surprised 1-Unlikely 5-Extremely

Improved Sleep 3-Neither 3-Neither 3-Moderately

Reduced Alcohol Intake 2-Somewhat Expected 1-Unlikely 4-Very

Tolerance of Own Flaws 5-Surprised 1-Unlikely 5-Extremely

How expected/surprising the change was: Range 1-5. 1-Expected, 3-Neither, 5-SurprisedHow likely without therapy: Range 1-5. 1-Unlikely, 3-Neither, 5-LikelyHow important to you: Range 1-5. 1-Not at all, 2-Slightly, 3-Moderately, 4-Very, 5-Extremely

Affirmative and Sceptic Briefs

Affirmative Case

Change in stable problems:• All of Amy's problems were long standing. 6 of the 10 are over 10 years in duration• All but 2 of the problems she lists have improved• Mean PQ dropped from 6.3 to 4.8 over six weeks • Still within clinical range but substantial given the duration of the problems and shortness of the workshop

• All of Amy's outcome measure show a drop• HAM-A reduced to the clinical cut-off point• GAD-7 reduce to 1 point above the clinical cut-off point

Sceptic Case• Client Compliance played a part• Relaxation may have been a contributing factor• Evidence of all or nothing thinking which may have exaggerated her responses• At a natural point of change in life

Participant Comments

Improved Perspective: ‘It was a clear metaphor for how looking at the wider picture

helps ‘dilute’ obsessional thoughts about negative things, and allows you to be

aware of other things which in turn give you a better sense of perspective about

problems in your life.’

Change of Focus: ‘For me, the lesson was that I should try focusing my attention

on my objectives and goals, rather than obstacles in my path.’

’The ultimate lesson I learned was that I spend so much time and effort dwelling

on the perceived obstacles and disabilities in my life that I am blind

to the bigger picture.’

Participant Comments

Improved Self-worth: ‘The compassion I felt for the tree was, in effect, compassion

for myself, and this was an immensely moving experience because I am the last

person in the world I have compassion for.’

Better Relaxation: ‘When I eventually stopped fidgeting and sat still, a Robin flew

down and sat on a branch in front of me…It sort of illustrated that sometimes you

have to stop running around or else all your flapping and shouting frightens

people away. If you are quiet and calm you are more likely to attract people to

you because you are literally more approachable’

Participant Comments

Greater Tolerance of Own Flaws: ‘…my compassion for the damaged tree

helped me recognise and acknowledge areas of my own life and personality

which have previously been buried or are in need of repair’

‘In a positive sense, this interpretation of the tree helped me realise that,

despite being past my prime, and no longer attractive, I still have the ability to

be useful and even flourish.’

Adjudication Results

Judge A Opinion:

To what extent did the client change during the workshop? 70% (Considerably)How certain are you?80%

To what extent did the client change due to the natural-awareness exercises? 80% (Substantially)How certain are you?70%

“Client compliance may have had some effect on the scores. Though from her account she seems to give an authentic response and she was able to say there were still aspects that hadn't changed.”

“some of the changes may have started only post workshop”

“the client states “its an equal combination of the environment, how everything was directed, and support from the other people”

Conclusion• Both myself and the external judge believe that Amy did make a considerable change.

• The changes can be directly attributed to the nature-awareness exercises.

• Both the judge and myself believe there may be some element of client compliance.

• The judge wondered if daily relaxation contributed to some of the post workshop changes.

• Plenty of evidence both quantitative and qualitative to show Amy did change.

• Were the changes stable?

Changes are all the more remarkable: • Given the brevity of the workshop• Given the long duration and stability of Amy’s Anxiety

• Shows that Nature-awareness exercises have potential to be an effective intervention for Generalised Anxiety Disorder

Questions?

Nigel Magowanhttp://www.ecotherapy.eu/http://www.manchester-psychotherapy.co.uk/