Ep 75 - My Published Research on Nature-Based Pediatric Occupational Therapy - Part 3 (Discussion, Limitations & Future Research)
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Laura Park Figueroa: Welcome to Therapy in the Great Outdoors, the podcast where we explore the business and practice of nature based pediatric therapy of all kinds. If you're an outdoor loving pediatric practitioner in the fields of occupational, physical, or speech therapy, social work, or mental health, this podcast will help you start and grow a successful nature based practice or program.
I am the ever honest, always a hundred percent real. You'll hear it all on this podcast. Dr. Laura Park Figueroa. I'm a pediatric OT with over 20 years of experience and I run a thriving nature based practice with profitable locations in two different states and multi six figures in revenue. I also host the free online community at therapyinthegreatoutdoors.
com to help you pursue your nature based therapy dreams too. Are you ready to take action on those dreams? Let's jump in.
Welcome to part three [00:01:00] of the audio book version of my research article, Mechanisms of Change in Nature Based Pediatric Occupational Therapy, the Ecology of Change in Outdoor Therapy Model, ECO Therapy Model for short. All right. If you have not listened to the previous two episodes to this one, This episode will not make much sense.
So if this is your first time tuning in, welcome, I'm so glad you're here. And also don't listen to this one first. Go back to the previous two episodes and listen to part one and two of the article so that you have all the context that leads up to this discussion, because it won't make much sense without that context.
Okay. Again, I said this last week, but I am not certain that this will be just one episode for the discussion. I may need to break it up into multiple parts, but we might get through it all. I shall see. I like to [00:02:00] keep the episodes fairly short for you all. Like, I don't like to do 90 minute episodes. I feel like it's just a lot to put in your ears at once.
So I will keep an eye on the time. And if this gets to be like 30 minutes long, I will wrap up and we will do a part four next week on the podcast for the rest of the discussion. All right. Discussion. The purpose of this study was to develop a new model to explain potential mechanisms of change in the nature based pediatric OT process using the perspectives of OT practitioners currently engaging in nature based practice with children. The result, the eco therapy model, is a preliminary theoretical explanation of potential mechanisms of change at work in nature based pediatric OT. The visual for the model is a symbolic representation of [00:03:00] relationships among actors and phases in the process.
The lower section of the visual depicts the actors, while the upper section of the visual outlines the phases. In the lower section, so y'all, this is going to be a description of the actual model itself. So it might help if you have a picture of the model in front of you to understand what I'm saying, but I am going to try to give you a little bit of context and explain things here.
So this makes sense in the audio version. So the visual is a large spherical circle, like it looks like a kind of water colored earth. And in the bottom, we have some shapes that illustrate the actors in the process. And then at the top, we have kind of a trail map that illustrates the phases in the process.
In the lower section, the spherical shape of the earth background symbolizes nature as both a contributor to the therapeutic process and [00:04:00] the context
encompassing the child practitioner and caregivers. Two overlapping horizontal ovals symbolize the child and practitioner as they are the essential human actors in the process. So the child is a kind of horizontal oval and the therapist is a horizontal oval in the, in the depiction, the visual of the model, and they overlap a little in the center.
Below those two horizontal ovals, there is a heart. The heart symbolizing the caregivers is below and slightly overlapping the ovals of the child and practitioner. This positioning of the heart below the two ovals represents the contributions of the caregivers, while also illustrating that caregivers may interact with the child or the practitioner at different times, but caregivers are not always present during sessions above the diagram of the [00:05:00] actors.
The upper section of the model is conceptualized as a trail map illustrating the six iterative phases as the mechanisms of change in the nature based therapy process. The PI, remember that means primary investigator, that's me who's reading this to you, the primary investigator intentionally designed the maps trail marker icons to symbolize key aspects of each phase and trails were purposefully drawn to illustrate the iterative manner in which nature based intervention may unfold, with returns to different phases throughout the process. Since the model highlights nature's potential influence on the pediatric OT process, it has implications for practitioners interested in using nature based therapy.
And then we're going to get into that in a minute. But I did want to say one thing about this model. So I created the model myself. I actually tried to have someone create something for me on fiverr. And I was so frustrated with the design process [00:06:00] with this graphic designer that I paid several hundred dollars to, and it was just awful.
I ended up designing it myself. So I was very intentional with where everything was placed with the aesthetic aesthetic, another hard word to say of the design, because I wanted it to illustrate. The feel of, of nature based therapy. And I also wanted each of the icons on the map to actually illustrate something about the phase in the process.
So when you look at the model, this is not in the paper, this is just my commentary for you guys in the audio version here, but, the first phase longing for freedom, the words are inside of a outline of a house. So kind of a boundaried restricted thing, the words are inside of it, right? So, that is not to say that indoor therapy is always restrictive and horrible.
I have learned to live in the, in the nuances and the grayness of things [00:07:00] as a therapist, the older I get. and the more I did research, honestly, like, nature based therapy is not, perfect for all kids in all situations. So that was something my, my people always had to remind me of cause I was just so gung ho nature's the best.
But that icon for that longing for freedom phase is intended to show you that there, there are boundaries that therapists and children are longing to get out of when they are in that phase. Embarking on adventure is the words are inside of this like sun that looks like it's rising kind of along the horizon at the top of the little model here.
And the trail kind of comes from the bottom where the actors are where the therapist and child are over to longing for freedom and then goes through embarking adventure. And then the trail kind of splits in different directions. Dancing with nature has a few trees and some birds and then a little like adult and child hiker with backpacks on and,
[00:08:00] little hiking sticks. So that just kind of illustrates all the actors in that space, like nature and the child and the therapist altogether. It's, very central to the design and that dancing with nature is in a, central portion of the map because it is one of the central constructs.
I mean, you have to have nature and the child and the therapist kind of interacting with one another to have the process unfold. so that's in the center and then off to the right side is claiming self agency. And on that one, there is a trail marker sign that kind of has different, arrows on it going different directions.
And that one kind of stands for the child and the therapist being able to kind of take charge and claim their own self agency and learn about themselves and be adventurous in this process. The trail kind of meanders through all of these phases. One of the things that I had to do was add some trails because the way that I originally had drawn the trail, one of the reviewers of the article [00:09:00] pointed out to me that it looked very linear.
It looked like you start on the trail and you just kind of go through all the phases and then you end at growing adaptive capacity and you go, go off on your own or whatever. And I realized that she was right. And so I added some lines, hopefully without making it too busy, to show that there are many different ways that the process can unfold and that it's not a linear process.
That was some of the best feedback that I got from one of the reviewers, honestly, and that was like at the first round of review of the article. So I'm very thankful to you. I don't think that person is probably listening, but if you're listening and you're the person who told me that when you reviewed this article originally, thank you, because it was such helpful feedback to make the visual more accurately represent what we were actually meaning to represent with the model. Okay, and then the last two phases are Braving Real Life Challenges, which also has a central place on the map. There is a mountain range up at the top where the trail in Braving Real Life Challenges kind of traces up a mountain [00:10:00] and then goes down and through a valley and kind of up a mountains before you enter out the top right side of the model where there is a forest of trees and a circle of the trail around growing adaptive capacity.
And then there is a trail that kind of heads off into the distance off the model altogether, symbolizing like the child leaving the nature based therapy process. So that is an explanation of all of the, oh, and the trees for growing adaptive capacity were obviously growth trees change. Like that was a very symbolic choice of an icon there too.
Mountains for braving real life challenges because mountains are challenging to get over when you are out in nature. So yeah, that's the background of why I chose all the icons that I did. And okay, now we can talk a little bit about the discussion section. So again, that last sentence [00:11:00] before all of these kind of smaller points in the discussion was, Since the model highlights nature's potential influence on the pediatric OT process, it has implications for practitioners interested in using nature based therapy.
So these are the implications. These are the takeaways from this research. This section is titled Expanding the natural environment. The eco therapy model may expand the OT perspective of the natural environment to include nature as the overarching context in which all other life contexts exist.
Offering therapy services for children in natural environments, the places children inhabit in daily life is a long held value and best practice in pediatric OT. Ah, you guys, I forgot to tell you something. I am not. I'm not reading all the citations because it would be very annoying to listen to me say Bysce Byer and Khill 2021, you know, every [00:12:00] time there was a citation.
So I mentioned that in the first part of this, I am not going to read citations throughout. Okay. Best held practice in pediatric OT. Viewing nature as the continual context may raise practitioners awareness to consider children's access to nature during assessment and intervention in any treatment setting.
Access to nature is an issue of occupational justice, especially for children with disabilities who traditionally lack access to outdoor recreation. The ecotherapy model may assist practitioners in advocating for each child's access to nature and to consider incorporating nature in treatment and home programs.
The next section is titled leveling traditional hierarchies. Nature is not bound by human social norms and invites exploration without placing expectations on children. It can be a neutral space in which the child and practitioner come together for therapy. [00:13:00] This neutrality of nature sits in contrast to a built or manicured setting that quote, announces ownership by adults to children.
That's from Hart, 1979. His work is amazing if you read his work. I think he's the guy who came up with the term affordances, but anyway, I digress. Um, manicured setting that announces ownership by adults to children, overtly communicating adults are the ones in control and positions of power. Recent OT research agrees that, quote, tolerant and permissive environments and flexibility of level of engagement are key features that foster participation in effective nature based therapy.
The ecotherapy model illustrates how nature based practice may allow practitioners and children freedom from power dynamics, social hierarchies, and societal expectations that may exist in many built spaces in which therapy traditionally takes place, such as clinics, homes, or schools. [00:14:00] Okay, now we are to the part of the article that I personally feel is the big aha moment that I had in the research and I would love, love, love to hear any and all thoughts about this section, okay? If it makes you uncomfortable, if it You want to criticize it? I am, I am game because here's the thing about grounded theory.
Grounded theory is meant to evolve and change and grow. This is not intended to be the be all end all theory of nature based therapy, okay? So I, I want to hear from you. I want to have conversations about this and interact and talk about this concept. The title of this next section of the discussion is igniting hormesis. So I'm going to talk about what hormesis is, but just so you have a picture of the word in your mind, it is spelled H O R M E S I S. Hormesis is the [00:15:00] scientific concept that low to moderate level stressors or pain cause the human nervous system to generate an adaptive response that leads to long term change.
A key finding in this study was the potential for real life challenges in nature to have a hormetic effect for children and practitioners. Nature may offer ever changing and unpredictable real life challenges that often involve true risk and may evoke a sense of wonder awe or even fear, similar to experiences that may happen in daily life context outside of therapy sessions.
Many nature based practitioners and outdoor educators value challenges and risk taking as important elements of nature based work with children. OT practitioners also promote risky play as beneficial for children. In contrast to interventions in which the practitioner attempts to organize the environment for the child to experience the quote, just right challenge, nature may offer opportunities for the practitioner and [00:16:00] child to problem solve together to co adapt when facing nature's real life challenges during sessions.
For example, if a tree has fallen across the planned hiking route, or a stream is too high to cross, the therapist and child must come up with solutions together and decide how to change their plans accordingly. Participants in this study were enthusiastic about the benefits of nature based OT for children.
At the same time, they seemed to accept the discomfort of braving real life challenges as the main catalyst for growth in nature based therapy. Human adaptation is ultimately a process of being exposed to some level of discomfort, Stress or pain. Too much pain may harm or even kill a human, but likewise not enough pain may not ignite adaptive processes in the nervous system.
The real life challenges encountered during outdoor sessions may be an impetus for maximal adaptive responses to take place, [00:17:00] with the child receiving guidance and support from the therapist to modulate their responses to those challenges. Nora's story at the beginning of the article about the thunderstorm rolling in unexpectedly during a session provides a good example.
During the thunderstorm, children experienced a real sense of fear, but Nora took control to bring the children to a safe place and provided a calming presence. After the storm passed, The lived experience of braving that real life challenge together provided fodder for the therapists, children, and caregivers to process emotions, discuss safety, and problem solve what to do in times when we may feel scared in daily life.
The next section is titled Lacking Control and Gaining Expertise. Facilitating adaptation in the face of nature's real life challenges requires the practitioner to be skilled as the attuned analyzer and modulator. In nature, the practitioner lacks control over [00:18:00] many variables that would be easily mitigated in an indoor setting, such as changing the room temperature, using specialized equipment, or adjusting lighting.
Due to this lack of control, developing expertise as a nature based practitioner seems to require building analytical skills, practicing therapeutic use of self, and using in the moment clinical reasoning to tune in to the child. Practitioners may need to modify contextual variables with limited equipment on hand during outdoor sessions, and may develop the creativity by using open ended supplies that can serve multiple purposes.
For example, therapists may bring a simple rope, which could be used in a variety of ways in an outdoor therapy session, for playing jump rope or other group games, hanging a tree swing, teaching knot tying, or setting up a tarp for shelter during inclement weather. The next section is titled Staying True to Occupational Therapy Roots.
The ecotherapy model [00:19:00] indicates participants in this study seem to practice nature based OT in alignment with existing evidence in the fields of outdoor education and psychology by utilizing a child led approach, valuing risky play, promoting social emotional development, and fostering childhood nature connection.
Pediatric OT practitioners in this sample attributed the effectiveness of their nature based practice to remaining anchored in the classical roots of their profession, such as activity analysis, contextual analysis, therapeutic use of self, occupation based practice, and facilitating adaptation. The ecotherapy model adds to existing OT theories by explaining how nature based intervention may contribute to increasing adaptive capacity in children.
Engaging in evidence based practice, staying true to OT roots, and focusing on adaptation are ways OT practitioners may maintain their professional identity to bring the distinct value of occupational therapy to be more widely acknowledged [00:20:00] among other nature based professionals and within the literature on nature and children's health.
The next section is titled embracing non dualism. Untangling the relationships among actors in the nature based therapy process required embracing non dualism. Nondualism contends that humans are not separate from their environments, but rather are inextricable from the context in which they live. In other words, all of human life on Earth is messy, intertwined, and complex.
Many OT theories highlight the interdependence of humans and their environments, but nondualism is especially apparent when considering human nature interactions because nature is the broader context that includes all other contexts in which humans live. Human health is directly related to the Earth's health, as humans rely on the Earth for continued sustenance and life.
Human actions affect nature, and nature's actions affect humans. [00:21:00] The ecotherapy model centers the concept that humans are interdependent with nature, not independent of nature. In the model, each actor's primary roles are outlined by the titles that I gave them, which we talked about in the first episode.
But in practice, the roles are often inextricable, overlapping, and parts of one unified whole within nature based therapy. The model also honors the non duality of nature as a treatment setting that is both calming and regulating to the nervous system, yet also wild, always changing, and unpredictable, providing real life challenges that may be taxing.
Participants had an overwhelmingly positive perspective on nature as a therapy setting, but admitted nature is not a panacea. Taking therapy outdoors seems to be a complex and multifaceted decision. Working indoors may be best for some children due to medical or safety reasons, to address specific goals in natural context, or to [00:22:00] honor clients preferences.
All right you guys, I think we're going to make it with this episode because all I have left is limitations and future research so I'm going to plug on through and this will be a three part series. Limitations. There were limitations with this study, obviously. All studies have limitations.
That's not in the article. I'm just, this is my commentary, y'all. This is what you get for listening. My special commentary, which sometimes is meandering. But anyway, children and caregivers were not interviewed, and the model was built from the lens of occupational therapists. Nature based OT is an emerging practice area, so there was only a small existing sample from which to draw participants.
All participants were female and occupational therapists with 17, having less than three years of experience in nature based practice. So to me, that is a commentary again, here, a key limitation of this study. So it would be very interesting to do this study in 10 years when we have more [00:23:00] people engaging in nature based practice and see.
see what has changed or maybe what hasn't changed. It would be interesting. Ten participants had attended the PI's nature based therapy training, my Contigo approach program, prior to this study, which may have led to bias in their perceptions. All participants and authors lived in Western civilizations.
This is also very important to note. So the ideologies of Western cultures influenced the perspectives shared and interpretation of the results. As a constructivist grounded theory, the ecotherapy model is but one interpretation of nature based pediatric OT at this moment in the participant's geographical, cultural, and historical context.
Results may not be generalizable to a wider population in other locations, service delivery models, or contexts. So I want to make a quick note about the western civilizations because I think this is very important to note and I think it [00:24:00] would be very interesting to. Have someone who is more influenced by Eastern culture to, to do this study and see if there are any differences because In America, especially, like I know, I mean, most of the people in this study were in the U.
S. even, so that's, that's even a U. S. culture, right? And I think that in the U. S. in particular, we have this view of independence, right? Like, and I, know that. Other cultures view interdependence as more highly regarded as far as community goes. And so I think it would be interesting to do this study that could be a whole rabbit hole to go down, but I'll just leave, leave that as it is.
So just knowing that this study is not intended to be a study that says this is how you should do nature based therapy. It was intended to be a study to look at what we're doing right now in the field of occupational therapy in particular, [00:25:00] and Think about what is influencing change in the children that are getting nature based OT.
So, all right, future research. This is the final, final part. Future research. The ecotherapy model is intended to be refined as nature based pediatric therapy evolves. I just said that. Future research may test the model for applicability in different populations and settings, develop assessment tools to measure outcomes of nature based intervention informed by the model, or use the model to examine perspectives of children, caregivers, non Western practitioners, or nature based practitioners in professions outside of OT, such as physical therapy, speech language pathology, psychology, or social work.
Research is also needed to examine the efficacy of nature based OT to affect children's occupational participation and performance, particularly in comparison to [00:26:00] indoor treatment settings. Future research on the ecotherapy model may raise awareness of nature based pediatric OT, potentially inspiring more practitioners to support children's long term health and well being through connection to nature.
So just a word here on this future research section. So they actually, the editors wanted me to take out like physical therapy, speech therapy, psychology, and social work, and just say professions outside of OT. And I really advocated to leave it in, which they allowed me to, because I do feel like those are the four professions that this research would be very interesting to, to do a grounded theory study in one of those fields, PT, SLP psychology or social work, because I think it would be interesting to take this model and see if it holds in a, another profession, or are there things that would be different in another profession?
So the other thing I wanted to mention is [00:27:00] that I originally started my PhD with this grandiose idea to do a study that would compare indoor to outdoor therapy. That was what I really, really wanted to do. Again, you may have heard me say it before, I'm a very black and white thinker. I'm much more a quantitative research person than a qualitative research person.
And I pretty much ended up doing like one of the most challenging kinds of qualitative research for a while. For my dissertation, which is hilarious. It means I grew, you guys. It means I learned how to think differently and I'm pushing my growth edge here. I surely was, if you've heard me complaining about how exhausted I've been the last several years, but anyways, I digress once again, this is you guys, it's like nine o'clock at night.
I really, really need to go. I really shouldn't record even if I'm reading this late at night because I get kind of loopy and I start to go down tangents. So anyways what was I saying? I was saying how I wanted to do this study comparing indoor to outdoor, but I think when I was doing [00:28:00] my coursework, I realized that We didn't really, need that right now.
What we needed was something that looked at what was going on. Like we needed some sort of qualitative study to kind of get a feel for what is going on in, The field of OT, at least right now with nature based intervention. Like, what are we doing here is the question, right? So I think there is more and more research coming out about nature based OT and in SLP.
I haven't seen anything in PT yet about nature based work, but I haven't looked in the last month or so. So maybe something is coming out. Um, but I, I do think that once we, once we start to get more people doing this kind of research. That is one study that I would really love to see done and I'm sure all of you would too.
So let me acknowledge some people. I am not allowed to share who was in this study because it was anonymous. Obviously everybody is. is allowed to be confidential about their participation, [00:29:00] and all of the names mentioned in the article as I read it are pseudonyms. But I do want to encourage you that if you participated, feel free to out yourself on social media or whatever.
I can't control if you want to do that or if you want to, you know, if one of these is your quote, you can say, these were my words in the study or whatever. Feel free to, like, Say that you participated. You're allowed to do that. I just can't say who you were. I want you all to hear me though, if you're listening to this and.
Let me tell you a big thank you, a big, big thank you for taking time out of your busy lives to contribute to this research. I also want to give the acknowledgements that I have at the end of the article. I want to thank Hannah K. Burke for her assistance with peer coding. She was one of the people who took a few of the interviews anonymized and she
helped me and then I kind of checked her codes matching to my codes. And I really appreciate her again, taking time out of her busy schedule. She was a [00:30:00] PhD student too, at the time. And I can't express to you how grateful I am for her, because I know that when you are a PhD student, you don't have much time. I also wanted to acknowledge Corry Wagner and Elisabeth Meikle for their valuable feedback as expert reviewers of the preliminary model.
So I sent them an initial visual of the model once I had kind of circled back to participants and created it with them. And They helped me check for relevance, and also Chloe Muntefering for her assistance with revisions. So Chloe was my employee here in Madison, Wisconsin, in the second branch of my practice, and she was also a PhD student at the time and I should say a huge thank you to her. But she was very, very helpful with helping me to look over all of the feedback from the reviewers when I had submitted to the journal and helping me think through how to word things. And, and just, I'm so thankful to Chloe.
And I also [00:31:00] acknowledge here all of the practitioners, as I said previously, who shared their experiences and insights for this study. So, I should say, this research, again, was not funded or sponsored by my company. I didn't pay people to, to this wasn't a part of my business. This was, this was done for my PhD. there is a declaration of interest at the end of the article because I do, it says the primary author runs a business that offers a multidisciplinary nature based pediatric therapy course and a membership site for nature based pediatric practitioners. And the coauthors have no conflicts of interest to report. I did have to put that in there because they wanted to be very clear about my work and the biases that I may have had, that I obviously had, because everybody has biases. You just need to try to bracket them when you do qualitative research. So, I think that's it. I would love, love, love, love to hear y'all's
thoughts on this. So you can always reach out to me in the therapy in the great outdoors community. There is a DM kind of [00:32:00] way there. You can also reach out to me on Instagram. I'm trying to be better about not looking at Instagram on the weekends and feeling like I have to work all weekend. But yeah, in the therapy in the great outdoors community, you can find me there and comment on this post.
We always make a post for each podcast episode. So anytime you listen to a podcast, if there's followup you want to do or questions that you have for me, that is how to get in touch with me, comment on the post inside of the TGO community. And I will see that and I will respond there. I really, really appreciate when people comment on those posts because it helps the, posts get seen by more people in our community and makes it feel like a community.
Like, I don't want this to be just me talking at you all, like, even though it's a podcast. I really hope that this brings up thoughts for you and things that you feel like you have to contribute to the discussion about nature based therapy with kids. So, I want to hear from you. That's what I'm saying.
Alright Before I hop off, I just want to remind you that [00:33:00] registration closes for the nature based business retreat on August 1st. So I am doing a nature based business retreat in Santa Cruz, California. It's one of the most beautiful places on earth where redwoods and the ocean are like right all around us. And we are going to work on our businesses together for four days in the redwoods.
So if you want to come to that and get your 2025 plan in place for your business so that you enter next year knowing that your nature based business will be successful. Go to therapyinthegreatoutdoors.com/retreat and sign up before August 1st. That's a firm deadline y'all. Okay. I will talk to you next week.
Bye.
Wait a second. Don't go yet. Do you want 120 ways that you can take your pediatric therapy work outdoors into nature? I wrote the free, big, huge list of nature based therapy activities just for you. The Big Huge List will give you quick ideas for nature based sessions. [00:34:00] In the Big Huge List, there are activities for gross motor, fine motor, visual perceptual, executive function, balance, group collaboration, and team building, social, emotional, and self regulation skills, as well as speech and language, and a whole section just for swing activities.
So go on and get your free Big Huge List so you can get started taking kids outdoors or have some new ideas if you've been doing this a while. You can download your free copy at therapyinthegreatoutdoors. com slash list. So until next time, get outside, connect, reflect, and enjoy therapy in the great outdoors.
