This series of posts is intended to illustrate how a straightforward, common-sense idea: guaranteeing the simple pleasures of fresh air and access to nature to those in inpatient and residential psychiatric/mental health facilities – has repeatedly fallen victim to a system that fails to change from within.
Lack of common sense, outdated thinking, and “business as usual” politics has led to systemic, repeated failure in regard to rights protection. Fresh air isn’t the only rights issue we face – far from it – but the issue reflects many universal truths about the state of human rights in mental health, how we (peers/survivors) are seen by the world, and the failure of those in power to protect our rights.
Why Fresh Air?
Every human being yearns to be outside; it’s a basic part of life. When we seek solace, we go to nature. We go to the beach to swim and surf, climb mountains and ski them in winter, and take to the rivers, lakes and streams to sail and fish. “Taking a walk” and “getting some fresh air” are common terms in our vernacular to describe seeking refuge, and expressions like “cabin fever” describe the profound isolation of being shut inside.
The weather is the most common topic we discuss with other people. Small talk? Perhaps. But there’s a profound truth to it. We talk about the weather because it’s one of few things we all share. It’s far bigger than us; the ultimate shared experience. Taking away access to weather robs us of this critical shared experience that keep us well. Nature is at the core of almost every major spiritual tradition and practice, and a major part of our spiritual being.
In 1984, the biologist E.O. Wilson coined the term “Biophilia”1 to describe the deep, instinctual connection we all have with nature. It doesn’t really need a formal definition, though – we are of nature and yearn for it.
The “New Nature Movement”
Even the simple act of playing has been taken away from children…something that should be spontaneous and free is now being rigidly planned…When does a kid ever get to sit in the yard with a stick anymore? Do today’s kids even know what a stick is?
– George Carlin
A remarkable movement has caught the public eye in the last several years. Led by journalist and child advocate Richard Louv, the “New Nature Movement” continues to explode into popularity. As described in Louv’s landmark book “Last Child in the Woods: Saving Our Children from Nature-Deficit Disorder,”2 its core thesis is that modern society (especially children) is suffering the consequences of a “plugged in” lifestyle that’s becoming more and more sheltered and increasingly spent inside – a condition he calls “Nature-Deficit Disorder.” Kids are more sedentary, which leads them towards depression and isolation. It also makes them prone to physical problems such as obesity. Louv believes children and adults suffer from a deficit of “Vitamin N.” And indeed, a flood of scientific studies prove, beyond any doubt, that access to the outdoors has dramatic effects on the psyche.
Ecopsychology: Mind and Nature
In 1984, Roger Ulrich, a professor of Landscape Architecture and Urban Planning at TexasA&M University, conducted a landmark study.3 Ulrich examined the records of patients who were recovering from common gall bladder surgery. He divided them into two categories: those whose hospital room windows faced a brick wall and whose rooms had views of trees. The results were dramatic:
- The “wall view” group asked for and received far more strong narcotic, pain-killing medication than the “tree view” group, which usually got less powerful medications (i.e., aspirin or acetaminophen).
- Nurses’ notes reporting negative after-effects of surgery were over 300% as prevalent among the “wall group.” (3.96 negative notes per patient, vs. 1.13 notes per patient for the “tree view” group).
- Length of stay for “tree view” patients averaged about a day less than those in the “wall view” group.
An entire field of practice and study, called “Ecotherapy,” has grown around these ideas. In 2007, the UK Mental Health group MIND published another landmark series of studies4 on ecotherapy.
One of the MIND studies compared how people felt after a half-hour walk in the outdoors to those who walked a half-hour in a large indoor mall. The results4 speak for themselves:
- Feelings of self-esteem increased 90% on the outdoor walk, compared to 17% on the indoor walk. For the indoor walk, 39% reported no change in self-esteem, and 44% felt worse.
- Depression decreased by 71% on the outdoor walk, and 45% indoors.
- Tension decreased 71% on the outdoor walk; and actually increased 50% on the indoor walk. NO ONE reported an increase in tension on the outdoor walk.
- Confusion, anger, fatigue and vigor all showed similar results.
Another study4 asked a peer group to compare ‘anticipated’ benefits (before going out) with actual benefits reported AFTER going outside. And sure enough, the actual benefits EXCEEDED the anticipated benefits.
In all, 94% of those polled said “green exercise” benefitted their mental health. It’s interesting to note that while awareness of nature’s healing power is well-understood in other countries, the United States lags behind.
Dr. Frances (Ming) Kuo, a leading expert on the relationship between psychology and nature, has extensively studied residents of inner-city housing projects, with equally dramatic results. Her and her colleagues’ studies compared people living in areas with lots of plants and trees (“green” spaces) with those living in barren “hardscapes” (with little vegetation and lots of concrete and asphalt). Among other findings:
- The level of creative play among children living near “green” spaces was much higher than the levels of play near barren spaces5;
- Natural landscaping greatly increased opportunities for social interaction and supervision of children6;
- Those living in buildings near “green” areas reported a 48% drop in property crimes, and a 56% reduction in violent crime.7 Levels of aggression and violence and “mental fatigue” were lower in “green” spaces.8
Pretty convincing, huh?
The MIND report’s Recommendations included, in part:
- “Inequality of access to green space should be addressed as a human rights, social justice and discrimination issue.”
- “All health, social care and criminal justice institutions should be required to ensure access to green space.”4
You’d think that all this evidence, plus the weight of common sense, would make advocating for fresh air an easy sell – but think again…
The “Fresh Air” movement in Massachusetts
Over the years, legal challenges have been raised around lack of fresh air in Massachusetts and beyond.
Public-interest law firms in Massachusetts, including the Center for Public Representation, pushed hard in the early 1990s for outdoor access at two State-run facilities. Attorneys in New York State filed Jean D. vs. Cuomo,9 a major Federal lawsuit, in 1993. This was a class-action suit on behalf of dozens of people residing at eight State psychiatric hospitals in New York. They had not been granted outdoor access for weeks and months at a time. The case was settled, resulting in successful implementation of fresh air policies at at least two hospitals.
Several states have statutes and/or regulations that specifically address the right to fresh air in inpatient mental health settings. Pioneers in health care and design such as Florence Nightingale and Frederick Law Olmsted (designer of Central Park) spoke emphatically about the importance of fresh air in healing settings. From the former’s landmark book “Notes on Nursing”:
The very first canon of nursing, the first and the last thing upon which a nurse’s attention must be fixed…is this: TO KEEP THE AIR HE BREATHES AS PURE AS THE EXTERNAL AIR, WITHOUT CHILLING HIM.10
I was hospitalized 11 times at inpatient psych units between 1989 and 2002. Each time, I was allowed access to fresh air and the outdoors. Around 2003, I discovered that a nearby hospital I had recently been a patient at had abruptly stopped letting inpatient psych patients outside. I couldn’t imagine being stuck on that cramped, claustrophobic unit without fresh air. I decided to look more closely into the issue, beginning an advocacy project that has continued since, at grassroots and legislative levels.
Under the umbrella of a local law firm, I made a round of calls to all (app. 73) public and private psych hospitals in the State at the time (2005). I was able to make an educated guess that 10-12 hospitals in the State were denying fresh air for psych inpatients.
More recent survey work indicates that this number has increased almost fourfold since then. Right now, I estimate that a total of 40 Mass. hospitals don’t allow access of any kind. This number means that app. 1,100 people (the number of beds in their units) are not allowed outside at any point during their stays.11, 12
Fresh Air: Policy Precedents
There are many policies and laws in place calling for all people to be free to live with dignity, in environments as least restrictive as possible.
- The Fourteenth Amendment of the Constitution, (heavily cited by legal experts re: fresh air), states, “No State shall…deprive any person of life, liberty, or property, without due process of law; nor deny to any person within its jurisdiction the equal protection of the laws.”( U.S. Const., Amendment XIV, §1)
- The Rehabilitation Act of 1974, Section 504 –the first civil rights law for persons with disabilities – states that
No otherwise qualified individual with a disability…shall, solely by reason of her or his disability, be excluded from the participation in, be denied the benefits of, or be subjected to discrimination under any program or activity.13
I often point out that prison inmates in Massachusetts and most States – even at “Supermax” facilities – are guaranteed, by law, outdoor time each day.14 (This isn’t a value judgment on prison inmates or the prison system; rather, it speaks of a larger truth: we are seen to be less worthy of this basic right than those society deems deserving of punishment for criminal acts).
Also, USDA regulations require organic livestock to have access to fresh air15. It’s a sad commentary about our civil rights when we are the ONLY group of people who can legally be denied access to fresh air and the outdoors.
Fresh Air: Historical Precedents
Looking back at the history of psychiatric hospitals, there’s no doubt that countless horrific abuses have happened – and still do. But it bears remembering that for a brief period in early-19th Century America trends, “treatment” of the ‘mentally ill’ shifted to a remarkably enlightened model. Started by the Quakers in Great Britain, “moral treatment” stressed the view that patients should be considered as “brethren” – human beings worthy of equality and respect. Their institutions provided patients with ample access to fresh air, clean dress, recreational and educational opportunities, and good food. And a surprisingly large number of “brethren” went on to live full lives, without further institutionalization.
In Anatomy of an Epidemic, Robert Whitaker quotes a popular mid-19th – Century book on health written by a Scottish doctor, William Buchan:
“The patient ought to take as much exercise in the open air as he can bear…A plan of this kind…is a much more rational method of cure, than confining the patient within doors, and plying him with medicines.”16
Yet today, nearly 200 years later, we are seeing exactly the opposite – more confinement and more overuse of medication!
As part of our State House defense of fresh air, we referred to “moral treatment.” The opponents of the proposed “fresh air” bill (hospital lobbyists) responded with:
“It is easy to romanticize a nineteenth century institution in a bucolic setting…this is hardly the model we should seek to emulate.”17
This comment misses the point entirely; no one wants to emulate the distant past – but it’s unquestionable that institutions have forgotten what truly heals.
Coming up in Part Two: the legislative effort to make “fresh air” a right – the obstacles it has faced from the hospital industry and lobbyists; the failure of public policy to stand up for our rights; the (substantial) influence of money, corporate power and political donations; and the “status quo” mentality that keeps peer/survivors disempowered and allows rights violations to continue unchecked.
1“Edward O. Wilson’s Biophilia Hypothesis.” Wilderdom: A Project in Natural Living & Transformation. Wilderdom website, 2004. <http://www.wilderdom.com/evolution/BiophiliaHypothesis.html>
2Louv, Richard. Last Child in the Woods: Saving Our Children from Nature-Deficit Disorder. Chapel Hill: Algonquin Books of Chapel Hill, 2006. Print.
3Ulrich, Roger S. “View through a window may influence recovery from surgery.” Science, 27 April 1984. Vol. 224, April 27, 1984. 1-3. Web. <http://www.geocities.ws/avisolo3/ulrich.pdf>
4“Ecotherapy: The green agenda for mental health.” MIND [UK], 2007. Web. <http://www.mind.org.uk/assets/0000/2138/ecotherapy_report.pdf>
5Faber Taylor, Andrea, Angela Wiley, Frances E. Kuo, and William C. Sullivan. “Growing up in the inner city: Green spaces as places to grow.” [Abstract]. Environment and Behavior 30.1 (1998): 3-27. Web. <http://eab.sagepub.com/content/30/1/3.short>
6Coley, Rebekah Levine, William C. Sullivan, and Frances E Kuo. “Where Does Community Grow?: The Social Context Created by Nature in Urban Public Housing.” [Abstract]. Environment and Behavior. 33.3 (2001). 343-367. Web. <http://eab.sagepub.com/content/29/4/468.abstract>
7Kuo, Frances E., and William C. Sullivan. “Environment and Crime in the Inner City: Does Vegetation Reduce Crime?” Environment and Behavior, 33.3 (2001). 343-367. Web. <http://www.outdoorfoundation.org/pdf/EnvironmentAndCrime.pdf>
8Kuo, Frances E., and William C. Sullivan. “Aggression and violence in the inner city: Impacts of environment via mental fatigue.” [Abstract]. Environment and Behavior, 33.4 (2001). Web. 543-571. <http://eab.sagepub.com/content/33/4/543.abstract>
9Jean D. v. Cuomo. 90 Civ. 0861 (SS). United States District Court, Southern District of New York. 1993. Obtained from New York Mental Hygiene Legal Service.
10Nightingale, Florence. Notes on Nursing: What it is, and What it is not. New York City: D. Appleton and Company, 1860. UPenn Digital Library, “A Celebration of Women Writers.” Web. <http://digital.library.upenn.edu/women/nightingale/nursing/nursing.html>
11”Massachusetts Hospitals Directory.” Massachusetts Hospital Association, 2012. Web. <http://www.mhalink.org/Content/NavigationMenu/AboutMHA/HospitalDirectory/default.htm>
12Testimony of Massachusetts Association of Behavioral Health Systems, David Matteodo, Executive Director, in Opposition to H. 1430. Massachusetts Joint Committee on Mental Health and Substance Abuse, September 13, 2011.
13United States Code of Federal Regulations, 29 USC § 794 – Nondiscrimination Under Federal Grants and Programs (Rehabilitation Act of 1973, Section 504). United States Department of Labor, 1973. Web. <http://www.dol.gov/oasam/regs/statutes/sec504.htm>
14Commonwealth of Massachusetts. Department of Correction. “Inmate Recreation and Leisure Activities.” 103 DOC 472.02. 2003. Web. <http://www.mass.gov/eopss/docs/doc/policies/472.pdf>
15United States Department of Agriculture, National Organic Program. “Livestock Living Conditions,” 7 CFR 205.239. 2010. Web. <http://ecfr.gpoaccess.gov/cgi/t/text/text-idx?c=ecfr&sid=cfa264613b2e21b263960440e78f71d0&rgn=div5&view=text&node=7:126.96.36.199.32&idno=7#7:188.8.131.52.32.3.354.13>
16Whitaker, Robert. Anatomy of an Epidemic. New York: Crown Publishers, 2010. Print.
17Testimony of Dr. Marc D. Cohen, M.S.W., Ph.D., CHE in Opposition to H.2871. Massachusetts Joint Committee on Mental Health and Substance Abuse, July 11, 2005. Print.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
Fresh air, nature – so important to our well-being, healing.
What a great topic.
What a great blog post!
Thanks so much, Duane. I feel very lucky to have ‘stumbled’ on an issue that is so unique and ties in to our struggles on many different levels!
Jonathan, thank you for such a “refreshing” look at our innate connection to Mother Nature. I completely share your views, and have seen first hand Wilson’s Biophilia Hypothesis, in how working with animals can transform one’s experience of learned helplessness, worthlessness, hopelessness into a sense of confidence, and inspire great change. Something about the deep instinctual connection to nature that promotes understanding and healing for so many. IMHO your work is an excellent contribution to therapeutic and preventive alternatives, as well as an adjunct to bio-medical model psychiatry (that are really not alternatives; rather, life’s energy permitted to breathe!).
Its a disgrace that something as natural as fresh air has to be fought for, but thankfully you have played such a positive role in making change for those who suffer in your state.
I completely support your position, and will share your good article with many friends and networks.
Please keep writing about this!
Thank you PC for your very kind words. It is one of the things that’s important but isn’t necessarily seen as so! I have Part Two on the way in about two weeks, and then possibly some of my own reflections about what I myself have learned from this project.
My wife and i SO resonate with this excellent point. We have faced this issue “up close and personal” with our daughter, who was deprived of the most basic therapeutic benefit of fresh air and sunshine during two extended psychiatric hospitalizations. In one case, we got results after my wife threatened to file a civil rights complaint and the attending psychiatrist (one of the better ones we dealt with) put her “neck on the line” to approve some time (with us) in the hospital’s large enclosed courtyard. In the other case, after three months total confinement and our repeated requests, hospital staff finally made arrangements for her to go outside in a small courtyard within the hospital, shortly before her transfer to a state hospital where she quickly had outdoor privileges. I made the same point at a court hearing (initiated by my daughter) during the latter hospitalization that Jonathan makes in this article: that even a convicted felon gets time outside every day! It’s deplorable that psychiatric patients are regularly deprived of this in many places!
Thank you Russerford. I’m so sorry your young daughter had to go through what she has, and applaud your advocacy on her behalf. One of the points raised by the opposition to the bill has been, “people’s entrust us (hospitals) to keep their loved ones safe” (Thereby implying that fresh air isn’t ‘safe.’) But in my opinion, that’s a weak argument, because they are not mutually-exclusive things!
Thank you for this excellent article, Jonathan. I really learned a lot from your review of the subject, which I had not thought about much before.
You haven’t yet written about your advocacy for inmates to get time outside, but you have indicated that the system has been very resistant. While sort term this must be very disappointing, I can see this kind of resistance to even the smallest change can in the long run be something we can use to discredit the system. This kind of extremism in the long run exposes our adversaries for what they are.
I’m looking forward to your future articles about this campaign.
Thanks Ted for your kind words. I will be following up in Part Two (a few weeks at most) about the “nuts and bolts” – the struggles to make change at a public polcy level. Stay tuned!
This is a fantastic article about a really important topic. I work with folks (teenagers and adults) with autism, and we have found that the outdoors and hiking is wonderfully therapeutic for all involved (staff as well!).
In years past we have hiked (in small groups and small chunks) every section of the Midstate Trail running through Central Mass, we are out at state parks every weekend and time permitting every day on the trails near our school. Walking is one thing we can do without too much prompting, and the movement and the peace dispells all manner of stressors.
I am looking forward to hearing more from you!
Thanks for your kind words and doing the work you do! The next piece will be out in about a week and a half.
Jonathan Dosick, thank you for your work on patients rights to fresh air.
Authorities view the loss of freedom of a person in a (cement) hospital, is different than the loss of freedom in a (cement) prison. It’s a different kind of cement.
Farm animals have more rights than inpatient psychiatric prisoners !!!
§ 205.239 Livestock living conditions. [PARAPHRASED]
(a) The producer of an organic livestock operation must establish and maintain year-round livestock living conditions which accommodate the health and natural behavior of animals, including:
(1) Year-round access for all animals to the outdoors, shade, shelter, exercise areas, fresh air, clean water for drinking, and direct sunlight, suitable to the species, its stage of life, the climate, and the environment…Yards, feeding pads, and feedlots shall be large enough to allow all ruminant livestock to feed simultaneously without crowding and without competition for food. Continuous total confinement of any animal indoors is prohibited…
(4) Shelter designed to allow for:
(i) Natural maintenance, comfort behaviors, and opportunity to exercise.
Link to USDA Regulation: