Early intervention services (EIS) aim to reduce symptomatic periods and improve developmental and social trajectories for those who have experienced a first episode of psychosis (FEP).Reference McGorry, Killackey and Yung1 Full recovery and therapeutic engagement may be difficult to achieve.Reference Hodgekins, Birchwood, Christopher, Marshall, Coker and Everard2–Reference Morrison, Pyle, Maughan, Johns, Freeman and Broome4 Green care uses natural environments to facilitate improvements in well-being, with growing evidence to support effectiveness in the general population.Reference Richardson and McEwan5,Reference Lovell, Depledge and Maxwell6 Evaluations suggest that people with mental health problems may benefit proportionally more from such nature-based care.Reference Bragg and Atkins7 Accessing green space may mitigate health inequalities closely tied to severe and enduring mental illness (SMI),Reference Grant8,9 including for young people, among whom nature ‘connectedness’ is low.Reference Richardson, Hunt, Hinds, Bragg, Fido and Petronzi10 Groups in natural spaces may also confer potential advantages for therapeutic engagement and work.Reference Ulrich, Simons, Losito, Fiorito, Miles and Zelzon11–Reference Cooley, Jones, Kurtz and Robertson13 However, there is limited evidence for green care for those with SMIReference Buckley and Brough14,Reference Cuthbert, Kellas and Page15 and, to our knowledge, none in FEP. Green care is a ‘complex intervention’, combining psychological work, physical activity and social interactions,Reference Dures, Rumsey, Morris and Gleeson16 so our study used a mixed-methods approach, as recommended by the Medical Research Council.Reference Craig, Dieppe, Macintyre, Michie, Nazareth and Petticrew17 This mixed-methods evaluation considers potential benefits and barriers encountered in a green care programme delivered in an EIS.
The intervention
The woodland group was facilitated by Circle of Life Rediscovery (CLR), commissioned by Sussex Partnership NHS Foundation Trust for 10 weekly half-day sessions. Two CLR staff prepared and attended groups, collaborating with EIS staff who facilitated transport and supported individuals (up to 15), with an overall staff:participant ratio of at least 1:3.
The group included a short walk, refreshments, contemplative time and activities such as learning about plants and habitats, maintaining the woodland area and cooking.
All participants were aged between 18–30 and had experienced FEP, some demonstrating active psychotic symptoms. Target problems included isolation, anxiety and depression.
Ethics and consent
This study was conducted as a service evaluation and did not require research ethics approval. All participants gave written consent for data to be collected and used within evaluations of the service.
Data collection and analysis
Participants completed the 15-item Questionnaire about the Process of Recovery (QPR) at weeks 1, 3, 6 and 10. The QPR has good internal consistency, high test–retest reliability and convergent validity.Reference Williams, Leamy, Pesola, Bird, Boutillier and Slade18,Reference Law, Neil, Dunn and Morrison19 ‘Reliable change’, an estimate of statistical significance of change in outcome scores, was calculated using the Jacobson–Truax formula with published Cronbach's alpha and standard deviation.Reference Zahra20,Reference Jacobson, Truax and Kazdin21 Participants in the final session also completed a semi-structured service evaluation questionnaire and the NHS Friends and Family Test (FFT).22
Qualitative data were invited through free-text portions of the evaluation questionnaire and through intervention summaries completed by participants and staff. A 20 min focus group (n = 7) was convened in the final session, facilitated by the group leader and transcribed by the first author. All three authors independently performed thematic analysis of the data.
Results
The QPR 5-point Likert scale ranges from 1 (disagree strongly) to 5 (agree strongly). Mean QPR scores increased from 3.4 (n = 3) at week 1 to 3.8 at week 10 (n = 8). Four patients showed reliable improvement and one showed reliable deterioration for those with data at two time points (n = 8).
All participants present at week 10 (n = 5) recommended the group on the FFT.22
Results of the evaluation questionnaire (at week 10) are shown in Table 1.
Table 1 Participants’ (n = 8) scores on the service evaluation questionnaire (at week 10)
a. Scores are on a 5-point Likert scale: 1, ‘strongly disagree’, 5 ‘strongly agree’.
All authors were concordant on two higher-order themes from the qualitative data. The first was connection with others and nature. Participants described reduced isolation and improved relationships:
‘It's therapeutic to sit round a fire with other people […] it's nice to feel connected.’
‘The difference […] I'm not isolated […] I can feel normal. You go to doctor's appointments, you're not part of the 9–5 but we are still here.’
‘I feel […] awe/curiosity for the natural world.’
A second overarching theme was of positive change in self, including skills development and emotional change. This was expressed as feeling ‘confident to do things’ or ‘I enjoyed the cooking […] it helped distract me more, and it's skills I have used at home’. Participants appreciated creativity and the chance to ‘take something away’ – including physical objects, memories and new skills. They described feelings of calmness: ‘100% impact. I feel better about myself […] I feel supported, I feel able. I have found stillness, calmness […]. It is very healing’. Staff noted that participants appeared more relaxed in the woodland group than in other settings.
Particularly relevant to this group were repeated suggestions that the group enabled changed perspectives on psychosis. One participant wrote ‘[it] showed me what's real in my […] psychotic state’ and another ‘[it] helps me understand other people's perception of psychosis’.
Barriers to participation included short sessions and poor weather. No adverse events, near misses or concerns regarding risky behaviour were reported.
Discussion and conclusions
This evaluation offers promise for green care as an intervention in FEP. Unusually, group attendance improved over time and all participants recommended it. Sequential QPR measures showed positive trends across all recovery domains; additionally, attendees described increased insight and contextualisation of difficulties, alongside distraction from problematic symptoms. Participants spontaneously discussing their beliefs and experiences, potentially enabled by the attention-restoring and stress-reducing properties of the woodland environment, seems to have encouraged reflection and reality testing. The group was therapeutic, with features of universality, development of socialising skills and interpersonal learning.Reference Yalom23
Feedback for improvement was sparse. The location, with associated travelling costs, and the intensive EIS staff involvement were cited as barriers to re-commissioning. CLR staff reported that the ‘scaffolding’ provided by NHS support enabled them to facilitate the group. Without this early input, successful engagement of this patient group seems less likely. Full economic (and carbon) costings, including staff resource, should be part of future evaluations and commissioning for such groups, as within the wider social prescribing context.24
The findings are limited by small sample size, areas of incomplete data and use of patient-reported outcome scales only. We have no data from those who chose not to attend the intervention. Although qualitative analysis allows themes to emerge from the data, defining components and aspects of the intervention which may be poorly understood,Reference Campbell, Fitzpatric, Hanes, Kinmonth, Snadercock and Spiegelhalter25 thematic saturation was likely not reached, and participants may have felt constrained by facilitator presence in the focus group. Further exploration of the increased reflective ability on personal psychotic experiences that participants reported feeling within the grounding and supported woodland setting would be particularly helpful.
Initiatives to boost green prescribing are expanding.Reference Eustice26 This is a preliminary report, indicating promising features for green care as a sustainable intervention in EIS. As a community-based intervention it is empowering and there is potential benefit from developing nature connectedness, which is associated with increased conservation behaviours.Reference Mackay and Schmitt27 Although further exploration of the benefits of green care, including its influence on psychotic experience and longer-term outcomes, is needed, the experiences this group describe suggest that nurturing opportunities for patients to access nature could promote recovery and rebalance relationships with the environment.
About the authors
Sharon Cuthbert is a consultant psychiatrist with Sussex Partnership NHS Foundation Trust, based at Millview Hospital, Hove, UK. Harriet Sharp is an Academic Clinical Fellow in psychiatry with Sussex Partnership NHS Foundation Trust, Hove, UK. Clio Berry is a lecturer in Healthcare Evaluation and Improvement in Primary Care and Public Health at Brighton and Sussex Medical School, Brighton, UK.
Data availability
The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available owing to potential compromise of the privacy of those who contributed.
Acknowledgements
Thanks to Marina Robb, Circle of Life Rediscovery, and to the Hailsham Early Intervention Service.
Author contributions
S.C. gathered and analysed evaluation and focus group data and produced the first draft. H.S. and C.B. contributed to qualitative analysis and contributed to subsequent drafts. All authors meet ICJME criteria for authorship.
Funding
This research received no specific grant from any funding agency, commercial or not-for-profit sectors.
Declaration of interest
None.
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