Dr Catriona Mellor So, I’m Catriona Mellor. I’m a  Child and Adolescent Psychiatrist. I’ve currently   stepped back from clinical practice to contribute  to research and service development in the field   that covers the interface between climate, nature  and child and adolescent mental health. However,   until I stepped back a couple of years ago, I  was working at Marlborough House, an adolescent   inpatient unit in Swindon, and remain very closely  involved with supporting their nature-based work,   that started whilst I was with them. And I’ve got  the last half hour this – with you this evening,   and I’ve been invited to talk to you about that  work, bringing nature into that inpatient unit. So, just a little overview. I’m going to start by  describing the small steps we took to get started,   making changes, and then how the project has  grown, including how we’ve been working with   staff and young people to design parts of the  project, and how we’re trying to evaluate and   disseminate and share our learning. I’m not  going to go through the evidence as I hoped,   and I’ve seen that that’s been covered in the  previous two talks. But I will touch into a   little bit on the difference between nature  contact and nature connection, and the slides   that I’ll share have got evidence summaries on  them, as well, if people are interested in that.   And then towards the end I’ll share a framework  for an approach to weaving nature into CAMHS,   which is emerging from the work I’ve  been doing with Beth and other teams. And, just to say, again, as has been mentioned,  that this is such a new and emerging field. So   it’s exciting, challenging, and it’s a little bit  like laying the road as we’re walking along it,   rather than having a clear destination  in mind sometimes. And, hopefully,   there’ll be time at the end for discussion  and reflections, and it would be great at that   point to talk about any changes that people  here have made themselves, or would like to,   or anything else that’s come up in the  talk, or indeed in the other two talks. So, about the nature work in Marlborough House.  So this project grew out of the longstanding   “Healthy Lives Programme” at Marlborough House.  So this is a 12-bed adolescent unit in Swindon,   and for all young people admitted there, it’s  an average stay of between two to three months,   and young people there have complex,  severe mental health difficulties.   But the treatment not only prioritises  an evidence-based approach to their   mental illness, but, also, tackling the  foundational elements of wellbeing. So,   such as, sleep, physical health,  activity, nutrition, relaxation,   so very much aligns with a lifestyle medicine  approach, from which this diagram has come. But just to say that our nature project was also  inspired and grew out of the “Youth Climate Strike   Movement,” and the “FridaysForFuture Movement,”  of 2018, and a growing awareness among some of   us at Marlborough House of the huge impact of the  climate and ecological crisis on mental health,   on many things, but that was, sort of, almost  calling us to think more systemically and   holistically about health. And when we, sort of,  realised, clocked, that connection with nature,   or time in nature, is – can be seen as one  of these foundational elements of wellbeing,   we committed to somehow bringing that  into the treatment at Marlborough House. However, knowing where to start and what to do  first was really daunting, and I just put this in,   ‘cause I’ve been comforted by this little  quote and this image many times. So it says,   “Might oaks from little acorns grow.” So, there  are a few of us on the ward and we decided to just   start really small, do something, and then  talk about it, and see what happened next. So, over the course of a year actually, staff  and young people met for 20 minutes once a month,   so that’s – that was all it was. It was during,  like I said, whilst I was working there,   it was during the regular community group on the  ward, that happens every week. And the aim was   for 20 minutes once a month, to discuss green and  nature issues and then set monthly goals, and then   we all work together, in various ways, towards the  goal for that month before setting the next one. And this, sort of, led on to many things. So,  initially, things like, cutting down on single   use plastic, then we brought nature artwork  onto the walls indoors, with support from the   Trust Art Therapist and, also, enhancing  biodiversity in the garden. And, sort of,   one conversation leads to another, and we found  loads of different opportunities that we couldn’t   have predicted happening when we started out. So  it’s been one small step at a time and, sort of,   joining with other people as we go along and,  all the time, listening to what the young people   in the group were asking for and, of course,  these young people change over time, that would   be – sort of, with this eye to our care becoming  more sustainable, but, at the same time, something   that’s going to improve patient experience and,  also, obviously, therefore, hopefully, outcomes. And here a few examples of some of the feedback  we’ve been getting from young people along the   way. So this is, sort of, a few years on now, but  these were from earlier on in the project. On the   left was a session with the Regional Participation  Group, young people’s participation group, and,   on the right, it may not be very clear, these  are some suggestions from an exercise we did,   and perhaps a little bit like the ones  Beth was explaining, wi – on the ward,   with young people that were – just happened  to be admitted for that spell of time. So, the little petals are offering  suggestions of, can we have longer walks,   with occasional break, ‘cause a lot of  the young people on the ward are having   treatment for eating disorders, so there’s  a complexity there around physical health   and activity levels. “Enough staff to take  us on trips,” “snacks out while we’re out,”   “planting bulbs.” And then from the  participation group, comments like,   “Being outside in nature is really beneficial and  it’s been lost in our generation.” “It’s good to   bring in other interventions because it feels like  there’s an overemphasis on CBT in CAMHS.” And,   “It’s very calming to be outside, breathing  in fresh air, physically and metaphorically.”   “And it” – the, sort of, theme that was coming  out of what Beth was talking about, as well,   “And it’s a more natural environment for therapy.  Inside it feels very much out of context.” So, we carried on, we introduced what  we called “Wilder Walks,” out into the   countryside for young people, rather than  sticking to the – an urban environment,   which was around the unit. Halfway through  the year, one of our conversations led to an   opportunity to work with Wiltshire Wildlife Trust,  to pilot a multifamily ecotherapy intervention,   in a beautiful local nature reserve. And a  version of this, “Families in the Wild,” had   been running successfully in Bristol adolescent  unit for many years. So we learnt from them,   and then, sort of, changed it to adapt  to our site and our inpatient population,   in partnership with some wonderful Practitioners,  Outdoor Practitioners, from the Wiltshire Wildlife   Trust, and that continues still in the  Easter holidays and summer holidays. And then, I think it was in 2021, 11 members  of the staff team were trained, and this is a   picture of us in the bottom right-hand corner,  of us on this training. It’s the same one that   Beth was talking about, but just a little bit  previously, by the same organisation, so this   is a not-for-profit community interest company  called Natural Academy. And they’ve developed this   training for people working in organisations  that’s called “NatureWell,” and it aims,   over six days, to initially enhance staff’s  own nature connection and then teach nature   connection techniques, so that the people on the  course can then go on to weave what they’ve learnt   into the work that they’re already doing, so  adding it to their experience and expertise. And, as we were doing all these little  changes, all these different interventions,   we were getting a positive sense and some lovely  comments and experiences. So, I’ve put a few – put   in a few photos, put in a few comments, ‘cause  I think the previous speakers alluded to this,   it’s really hard to describe this work with  slides and in a presentation, when people are   sitting at their computers. A lot of the impact  and the, sort of, understanding about how this   work works is through doing and experiencing,  rather than hearing about it. But I think photos,   and like Beth was talking, about a video or  quotes, help to offer a little bit of a flavour. So, the “Families in the Wild,” so  families that had been on that would   just reflect afterwards that they’ve just  noticed a change, and that’s so often what   we’re looking for. When young people come  into the unit, they’ve often had months,   weeks, months, if not years, of feeling like,  you know, high levels of stress, no change,   no shift, and this sense that, actually, “Oh  my goodness, that – after that intervention,   that was the first time he’s fallen  asleep for months,” or, “We haven’t   enjoyed ourselves as a family like that for so  long. I can’t remember the time we did that.” And the “Wild Walks,” very simple, I mean, that’s  jumping in a taxi, or the ward minibus, and just   driving 15 minutes, but up onto what’s called the  “Ridgeway,” outside Swindon, so you’re up high,   you’ve got these views, the wind, and young people  would come back again to the wood. And there’d   been a shift, a real shift, in their mood, but,  also, in their bodies and their posture and their   levels of anxiety, and they’d come back saying,  “Gosh, that felt like freedom,” felt normal   being with staff, not in uniform, walking side-by-  side.” “Coming into the trees was like a big hug.”   And a theme that came up again and again was,  “It relaxed me, so when I got back to the ward,   my anxiety was less, I could eat better,” often  there were fewer, sort of, arguments that evening. So, as – I mean, I think as Beth was  saying, and similarly, our project started,   sort of, from the ground up with little steps,  little changes, but, fairly early on, we reached   out to the Oxford Healthcare Improvement Team,  so that it’s basically the Quality Improvement   Team within the Trust, I work for Oxford Health.  And they’ve been supporting us along the way,   guiding what data we’re collecting, what  evaluation we should be doing, and then helping   us to think how we disseminate our learning,  initially within the Trust, and then more broadly. We’ve had some funding from the  charity, from Oxford Health Charity,   and just recently been linked up with  the Research and Development Team,   but I’ll talk about that a little bit later.  We’re also linked with the University of Bristol,   and being part of a scheme that sends  medical students every year to undertake   a form of research, so that’s a lovely,  sort of, momentum they bring with them. And, so far, the Trust QI Team has helped  us evaluate two aspects of the project.   So “Families in the Wild,” and, also, work  that led us to publishing this report about   the nature world training. This is just  a small, excuse me, in comparison to the   previous research we’ve heard about, this is a  very small, qualitative, practice-based paper,   drawing out themes from focus groups of staff  that have taken part in the training. So,   this was – and there were 11 members of  staff in the training and nine, I think,   took part in the focus groups. So, they’d taken  part in the training and they’d started to weave   nature into their work, in terms of taking  any opportunity on the ward to work outdoors. And the main themes that came out of those  conversations, I think pretty well reflect   the previous discussion. So, what they’d noticed,  first and foremost, was the benefits on patients,   and one of the main things they noticed was  in terms of emotional regulation, and how time   outdoors, even – it may be just looking out the  window, but, ideally, opening the door, walking   outdoors, maybe watering a plant, offers the staff  an avenue that offers calm and, also, at times,   an alternative method of de-escalation. Which  is so important in that inpatient environment,   because once that escalation starts, it  can lead to potentially really intense   and quite traumatic episodes of restriction  and other ways of keeping the patient safe. The other theme that came out was the  impact on the staff-patient relationship,   and this had come out of the “Families in the  Wild work,” as well. So, in terms of interactions,   be – when outside, were more open and  less intense, but – and – but, also,   that something shifted between staff members and  young people who’d been outside together, and that   came back into the ward and back into therapy, for  a long time after any time they’d spent outdoors.   And, again, that idea that it – staff loved  the idea that we’re offering these short,   simple techniques like grounding,  sort of, mindfulness, outdoors,   that then young people potentially can take  into the long-term and use into their future. The impact on staff is, kind of, obvious, when  you think about it, but we hadn’t thought about   it before we set out. So, sort of, an unintended  but welcome positive impact on staff wellbeing was   noted by every single person interviewed, and a  reflection of that is that nature-based approaches   have been integrated into staff awaydays since  then. And members of staff still use, sort of,   daily reminders to each other, to, “Come on,  let’s go outside, take a breath of fresh air,”   a walk at lunchtime, something like that, and  just, you know, just reflecting at how much   difference that can make in the middle  of a very busy, intense, stressful day. The other two themes, one  was around practicalities   and challenges. So a challenge of facilitating  groups in this environment, let alone nature   groups and, again, the importance of co-creating  any changes with the young people, to maximise   that engagement. Risk assessing for outdoor work  was something that staff were talking about and,   really importantly, a theme that comes up  again and again is, “Do we have time to do   this?” Particularly in the early days, when  it takes more to establish something new.   And the staff who’d been on the training felt that  there was something beneficial about a number of   them coming from the same perspective now. They  felt more nature connected themselves and that   naturally bled into what they wanted to do in  their days at work, and they had more confidence   and passion to start trying to integrate  nature into the practice – into their practice. In the last few weeks, we’ve gone back to the  patients and staff and asked them what they   think are the benefits still of having more time  outdoors. And, again, similar responses emerged,   this word, “relaxation, calmness, peace,” this  keeps coming up again and again and again,   to the point that perhaps you can dismiss  that, but from experience of having spent   so much time on the wards, the idea that we  could offer these little pockets of a sense   of calmness, peace, sort of, a refuge  or safety, seems vitally important. And the staff talk a lot about the  patient-staff relationship building,   and the young people were bringing out  themes around, “clearing my head,” “helping   me feel sane,” something about feeling normal,  feeling in a, sort of, normal context again,   “be quite therapeutic and offer mental health  clearance.” And then there’s this idea that,   actually, it’s also just quite a nice  distraction and helps pass the time. Since being part of the team of trainees  in “NatureWell” at Marlborough House,   as I’ve stepped back a little bit from the  clinical work, I’ve become more involved as   one of the Trainers of this approach, and I’ve  travelled to other CAMHS teams to deliver. And,   through this, Beth was mentioning  a network of teams is appearing,   so that involves CAMHS Clinicians from Alder  Hey, up in Liverpool, Beth and her colleagues,   down in Cornwall, and now – and also two teams  up in Epsom in Surrey, covering inpatient and   outpatient settings. And there’s lots of learning  coming from this. It’s a – very much a, sort of,   emerging project, the, sort of, question, what  happens if you deliver the same training to   different teams? And just watching, observing and,  sort of, cross-referencing the different changes   that is happening is really interesting.  Some teams are designing discreet nature   connection interventions and some weaving a  nature strands into their treatment as usual. We’re learning about how difficult it is to  embed a change in practice. There’s something   about initial momentum can be reasonably easy to  gather, but something about how to keep going,   keep embedding a change so that it sticks,  is tricky. And we all know what pressures   people are working under at the moment,  but certain elements are appearing that,   sort of, facilitate the change. So, having a  critical mass of people in a workplace helps,   including people within senior positions, working  with external partners who have experience in   nature and, again, this importance of  developing a community of practitioners   who meet regularly in some way to share their  progress, share resources, support each other. So, that’s a little bit about how our project has  developed and grown. I’m going to talk – I’m going   to, sort of, move into a slightly different  discussion, bec – about an interesting part   of the work I feel, which the other speakers  have touched on, as well. And it’s, sort of,   how hard it is to work out what we’re actually  facilitating when we’re outdoors with people,   and where the mechanism of action is  around the benefits that people experience,   and how we can use those, sort of,  theories and that knowledge, to then   try and design and target interventions to be as  acceptable, feasible and successful as possible. So, I wanted to just touch on some thoughts around  nature contact, nature connection and nature   therapy, recognising that there’s a lot of overlap  and lots of people use different terms for these,   so just in the spirit of starting a conversation  and discussion. So, one part of this work is   increasing the amount of contacts people have with  nature and blue and green spaces, and the positive   health and wellbeing impacts of that. So, this may  be by bringing natural objects or pictures onto   the walls of the inpatient unit, for example, by  developing a nature garden, onsite, or by working   with families to support more time outdoors when  they’re at home. And there’s a well-referenced   webpage on the Dose of Nature website, as well  as the – lots coming out of Exeter University,   about evidence in this category, and this  is where a lot of attention is currently. An example of the benefits of nature contact  is the positive impact on our immune system of   phytoncides. I don’t know if you’ve heard about  them, that’s the name for the compounds that   trees, particularly pine trees, use to communicate  between each other and it’s what causes the smell   that we smell in a forest environment. And  these compounds have been shown to boost human   immune cells, so natural killer cells, as well as  anti-cancer proteins, so it’s a direct impact on   our bodies. There’s the positive impact of vitamin  D, or the finding that natural sounds boost the   parasympathetic nervous system, adding to that  sense of relaxation, these are examples of that. And then there’s this idea of nature connection,  or connectedness. So we may be in a forest just   passing through, on our way to a busy meeting and  we’re busy and distracted, maybe anxious. So we’d   still inhale those compounds, those phytoncides,  which would impact our natural killer cells,   but what would be the difference if we paused,  took a mindful moment and came into connection   with the beauty of the forest, perhaps visited  that same spot regularly through the season,   so we came to know it as a familiar place of  refuge and relaxation? And this is a slightly   different area and this is an area of burgeoning  research, and one centre’s at Derby University. And then, thirdly is this idea of nature  therapy, that perhaps one of the questions   touched on, which overlaps with the other two,  but, also, potentially, brings something new and   different. So, it could be walk and talk  therapy, where the natural environment is   acting as a Co-Therapist, but, also, wilderness  therapy, horticultural, animal-assisted therapy,   there’s so much learning and wisdom in those  therapies that could augment the work we do. So, I’m really interested in the difference  between nature contact and connection   and this is a definition of nature connectedness.  So, “nature connectedness captures a relationship   between people and the rest of nature. It’s  a measurable psychological construct that   moves beyond contact.” And this is a pictorial  scale that’s used pre and post-interventions,   to see if someone’s nature connection has shifted.  And a lot of work at Derby University, led by   Miles Richardson, has been around measuring this,  finding methods and activities that consistently   boost people’s nature connectedness.  And also showing that, if that happens,   there’s this idea that, actually, other elements  of their wellbeing may be impacted positively too,   things, such as a sense of vitality,  meaning and purpose, and life satisfaction. So, I’m going to move on, there’s more  to say there, I’m going to move on,   as I’m just aware of time. And just a  little bit more on this idea of connection,   something that’s coming out of the broader  realm of nature connection research,   as well as actually in the psychedelic-assisted  therapy research, which is where Ros Watts works,   is this idea that the construct of connectedness  could be of transdiagnostic importance, so it   could be important in lots of different diagnoses.  And if we think of the connectedness as being   opposite to, sort of, alienation, isolation,  loneliness, that possibly makes sense,   and that boosting one possibly has  the potential of boosting others. The connection to self includes awareness of  our senses, emotions and ability to self-soothe.   Connection to others, that we know is critically  important to our sense of self and wellbeing,   but this is also introducing this third aspect  and asking, “Can we see that maybe connection   to nature is as critically important  to our sense of self and wellbeing?   And does it make sense that there are  parts of us that need nature connection   and nature contact to be fully developed  physically, psychologically and emotionally?” And, in some cases, in nature work, we  see how young people find it very hard   to make the social connections, that  therapeutic connection, but, actually,   they can start by relating to the natural  world. And that’s almost like a gateway   into then stepping into a relationship with  other people in a group, and/or the Therapist.   So, a question to mull upon, could nature  connection be as important to our wellbeing   as social connection? And it wasn’t that  long ago that systemic and interpersonal   factors weren’t considered important in models  of child development. We only have to go back   60/70 years. So, is it time to expand slightly to  considering the ecological in our formulations? So, I’m just going to whiz through this.  I’m going to run out of time, I think,   sadly. This slide is showing a fra – it’s  an emerging framework about diff – ways of   describing how we could bring nature into CAMHS  work. We could think about this mindset shift,   and bringing the sense of the ecological  and nature contact and connection into our   history-taking, our formulation, our treatment,  and how we talk to families, so that could be   introducing this perspective. We could increase  contact with nature by bringing nature indoors or   improving our green and blue spaces. Beth was  talking about facilitating nature contact and   connection to enhance what we’re already offering,  perhaps, adding a nature-based grounding to CBT,   or trauma-informed work, to just add an extra  ingredient to what’s already being offered. Or is there scope for actually designing  specific nature therapy interventions for   some other particular groups of young people  who would benefit particularly? And can we   even start measuring connectedness, including  nature connectedness, as one of our primary   outcomes of importance? And that last bit is  what’s informing our work in Marlborough House,   the next step of our work that we’re  doing with the Bristol medical students. They asked the young people there, just a  few weeks ago, if they’d be interested in   a dedicated nature connection session, and  there’s – so I think there were nine young   people they asked. One was neutral and  the others were positive and they said,   “Yes,” they’d like a dedicated nature  session on the ward. And so, the students,   supported by other members of staff, and  also people from the local Wildlife Trust,   are developing a succession programme, based  around some of the nature connectedness work   that’s coming out of Derby University. And they’ve  worked very closely with the young people from the   beginning, checking in what activities and  exercise they would work – they think would   work and then running proposed session plans by  the young people. And then on Tuesday, so just   a couple of days ago, they piloted their first  session, which included games and activities,   to help participants notice nature through  tuning in via their senses. They included   a nature mindfulness session and then a guess the  natural object game, and a best leaf competition,   and if anyone wants to know details  about that, I can go into some of it. They just designed a beautiful session that was  really fun, had an element of competition in,   the staff got involved, as well, and they felt  there was really good engagement from the young   people. That not only, I think, impacted  their nature connection, but opened up quite   free-flowing conversation, which is really  quite uncommon in the groups on the ward,   and discussions that touched into emotions  and feelings. So, the plan is to co-develop   and test run six sessions, in preparation  for a formal pilot and evaluation that   we’re hoping to run next year in co-ordination  with the Research and Development Department. I’ve got a little bit of feedback here, which I  probably don’t have time, and I’m looking for Abby   to jump in and – yeah, wait, I think I’ve got  2 minutes left, I’ll just – I’ll flick through   it very quickly. So, this is – the young people  had the session on Tuesday, the students talked   to them yesterday, in the community group, “What  did you enjoy?” So, lots of things they picked up,   “loved collecting my rock,” that was their  favourite object that they – that other people   then had to guess from a description. “Being  outside, even though it rained,” “not being too   lesson-y,” “winning,” and “the leaf game was fun,  and just nice to be out in nature with everyone.” “I feel I appreciate the beauty of nature more  after the session,” two neutral, everyone else   agreed. “I felt my mood improved,” agree, strongly  agree. “I felt more connected,” all but one,   one disagreed. “What do you think could have  been improved?” And the answers were really,   basically, “we wanted longer,” and “to  be outside,” “in a bigger space,” there   is limited space on the ward. And,  “Any more comments?” Mostly positive,   and then this one person who didn’t feel  more connected, said, “I don’t really feel   like the start of the session helps, e.g.,  let’s stand for a bit and look around,”   that was the mindfulness session at the be  – the mindfulness exercise at the beginning. So, that’s me finishing up. We’re going to  continue working with the QI Team to support   other, different, sort of, smaller changes, such  as improving one of the seating areas outdoors,   which is being funded by the Oxford Health  Charity. And, also, with linking up with   the Trust Volunteer Service, to try and  get some volunteers visiting regularly,   as the st – sort of, lack of staff time  is the thing that comes up again and   again as one of the main barriers. So, thank you, I hope that’s given   you a flavour of the work on Marlborough  House and the wider “NatureWell” project.