Would you accept a prescription for Shinrin-yoku?

Also translated as "forest bathing" or "taking in the forest atmosphere," does it deserve a place in the treatment tool box of MD's? Are there risks?

This post is a reply to Dr.

Cassandra Quave

, a fellow writer here on Substack. In a recent article she writes about the beneficial health effects of taking some time to immerse oneself in nature. The Japanese call this shinrin-yoku, but it doesn’t have to be anything fancier than walking into a pocket of the natural world, experiencing the green with our eyes, the birdsong with our ears, and the textures of the forest with our hands and footfalls.

As she states: Forest bathing is grounded in the belief that nature possesses healing properties that can restore balance and harmony to our lives…. By immersing yourself in a forest environment, you can experience a sense of tranquility, rejuvenation, and connection with the surrounding ecosystem.

She presented me with a good writing prompt: I’ve heard of ND’s (naturopathic doctors) actually prescribing walks in the forest as part of the wellness plan for their patients. Do you think that this could ever have a place in allopathic medicine?

My short answer is Yes. But my better examined answer goes like this.

Any time allopathic medical doctors (MD’s) make a recommendation to patients we try to weigh three key concepts - risks, benefits, and alternatives. We consider ourselves well-informed medical practitioners, with expertise gleaned through rigorous training, scientific evidence, and continuing education. Naturopathic doctors… I don’t know enough about them. However, as far as mutually prescribing a walk in the forest as part of a wellness plan, we would both agree that the benefits outweigh the risks.

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Risks of forest bathing

The articles you find online about shinrin-yoku do not review the downsides of being in the forest. It kind of spoils the wonderful intent, and so I get it. But here are a few downsides to consider. It’s like a jungle sometimes, and this should make us wonder how to keep from going under.

Ticks. These blood-sucking little arachnids have spoiled much of the carefree enjoyment of the great outdoors, and are only getting more numerous and active as the planet heats up. In my practice I see Lyme disease frequently, but there are other infections like ehrlichiosis, babesiosis, anaplasmosis, Borellia miyamatoi disease, Rocky Mountain Spotted Fever, and tularemia that can be contracted from a tick bite. I have 2 patients who can no longer eat meat after a tick bite triggered a new and serious allergy to foods like pork, beef, rabbit, lamb, and milk (alpha-gal syndrome). Prudent tick bite prevention measures help. Do a good tick check when you’re done.

Mosquitoes. While mostly a nuisance, mosquito bites can also transmit West Nile virus. Although most infections are mild or asymptomatic, about 1 in 5 people develop a fever and other symptoms, and 1 out of 150 develop very serious illness. Uncommonly, mosquitoes in the US can also transmit encephalitis viruses, and even more rarely Zika (although the spike in cases in 2016 was over by 2017). In higher risk parts of the world there are malaria, dengue, and yellow fever to contend with, making forest/nature bathing a riskier proposition. We can reduce the risk of mosquito bites by using insect repellent and wearing long-sleeved shirts and long pants.

Poison ivy. One element of forest bathing is using the 5 senses including touch to immerse oneself. But not all plants like to be touched, and poison ivy in particular has evolved a highly effective way of discouraging human contact. Obligate forest bathers including deer, raccoons, muskrats and rabbits apparently eat poison ivy like a delicacy. Most things in the forest should not be tasted by us! And it never hurts (or itches) to review what poison ivy looks like:

Allergens, pollen, and mold spores. I’m struggling this spring with tree pollen. It’s been off the charts. In terms of pollution the air in forests is cleaner. Dust and particulates are naturally adsorbed by plant and leaf surfaces, and some gaseous pollutants get absorbed through a leaf’s pores. But natural pollen and spores are ubiquitous, and can trigger allergic symptoms. I like Xyzal as the best non-sedating antihistamine.

Rabid animals, bees, snakes, predators. These are low probability encounters, but I will say that in my years of walking through the woods I have encountered one porcupine, several raccoons, one black bear, one bobcat, and thousands of vicious chipmunks. None of them attacked me. For some perspective, in the U.S. bees kill an average of 60 people per year, snakes 6, cows 20, bears 1, dogs 28, and other random mammals combine for about 50.

Injuries. Challenging terrain should be considered, especially for older individuals for whom elevation gains, rocky paths, and tree roots could present injury risks. Ankle sprains would seem to be more likely in city slickers like me who are used to walking on flat concrete surfaces.

Talkative fellow hikers. Another risk of trying to escape humanity while reconnecting with nature is that other people might be around. Exchanging pleasantries with fellow human beings in nature can be really nice, and small social interactions are a major boost for people experiencing loneliness. But there is always a risk that a skilled conversationalist intercepts our attempts to find zen, in which case we might state that we are in the woods “looking for Shinrin-yoku.” But that kind soul might not understand, and instead offer to help us find what they presume is an elusive forest elf with a funky name.

A "Korrigan,” or small elf of Celtic forests. Not to be confused with shinrin-yoku.

Getting lost. For those of us with defective internal compasses or clocks, paying careful attention to our bearings is very important. I was once on a hike with two beautiful people in the woods, and the sun set faster than we anticipated. Before long we could only see a few feet in front of our faces. There was a nearby creek leading back to our cabin, so we followed the flowing water, stumbling into the freezing cold stream more than a few times. A healthy respect for the wild at night is as important as never turning your back on the ocean.

Benefits!

Although the above risks are stated with sincerity, I do list them somewhat tongue in cheek. Of course the benefits of clearing our minds to journey out and dwell in some beautiful patch of nature are numerous and significant!

Meditative mindfulness. Forest bathing is like meditating. For me the goal of meditation is to practice acknowledging internal and external stimuli. I try not to fight or suppress any discomfort or anxiety these stimuli can bring, but instead shift focus back to breathing and acceptance. Resting our consciousness in stillness, floating above the adrenaline, cortisol, noise, and pain takes time. There is stubborn grace in embracing life in this chaotic, indifferent world. That’s my goal.

The forest superorganism hums along, and we can tune in to it, thereby tuning out the stressful notes within ourselves for a long moment.

I love meditation. I need to do it more than I just talk about it. And meditating while in the woods would be the bee’s knees.

Parasympathetic tone. Deep breaths. Vasodilation. Skeletal muscle relaxation. Healthy peristalsis. Easing of heart rate. Lowering of blood pressure. Rest and digest. Shinrin-yoku has been shown to increase parasympathetic nervous system activity, and therein lies most of the benefit for our health.

Beauty and a sense of awe. Appreciating forces larger than ourselves, time scales broader than our mayfly lives, and the wonders of the natural world can lead to a sense of awe. Cultivating and seeking out this sense has been shown to be beneficial, particularly for mental health. One psychologist summed this up nicely: Awe is the feeling of being in the presence of something vast that transcends your understanding of the world. Lying on our backs on a warm earth, looking up into a canopy of swaying trees, marveling at the complexity of a bird’s song beneath a blue sky on a hospitable planet - that’s awesome.

The color green has been shown independently to have calming effects on the mind, and can promote creativity. The last I checked there was still plenty of green in the natural world, if we can preserve it.

Walking as exercise. Exercise is good for a lot of reasons, and a mindful walk in the woods is extra good. I think this statement can stand on its own without references.

Good for the immune system. As Dr. Quave previously noted, research has validated forest bathing as beneficial for immunity. For example, studies have shown “increased human natural killer (NK) activity, number of NK cells, and intracellular levels of anti-cancer proteins, suggesting a cancer preventive effect” with taking in the forest atmosphere. Stress hormones are reduced, which otherwise contribute to immune dysregulation.

Better sleep. What we do in our daytime lives also impacts our nights. Finding peace and quiet during the day, even in small moments, can turn down hyper-alert impulses and rumination at bedtime.

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Alternatives

Not everyone has easy access to pristine forests or natural spaces. I live in center city Philadelphia. Fortunately William Penn thought public parks were important, and drew up plans for major public squares to be devoted to green space. 4 of these are still thriving. We also have Fairmount Park and other green acres. Walking through Washington Square is not an immersive experience of primal nature, but spreading a blanket on the soft grass beneath 200 year old sycamore trees can still be transporting.

I work in Jersey, and behind our office complex there is an old church. On the grounds there is a dilapidated wooden picnic table. It’s beneath a massive oak tree, and on rare occasions when I have time for a lunch break I’ll go out there and sit with my lunch. Even in the burbs nature folds you into its calming embrace, as starlings bring food to their chirping babies in the nests under the church eaves. Squirrels run around, butterflies flit between wildflowers, and little ants explore and patrol. I’ve seen frogs, ducks, hawks, groundhogs, rabbits, and many bird species as I take some deep breaths before heading back in to the windowless office. This is what it looked and sounded like on Wednesday:

In some ways, practicing mindfulness and appreciating nature amid the structure and noise of civilization is an even more important skill than narrowly trying to find time to make it to the forest.

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Final prescription. Do you think that recommending forest bathing could ever have a place in allopathic medicine? Yes. Yes I absolutely do. And thanks for reminding me to throw this into my tool box of recommendations for stress, anxiety, depression, hypertension, and better health maintenance in general. Being aware of the small risks inherent with spending time in nature might help us get back out of the forest truly refreshed, renewed, and with a sense of calm that transcendent moments can lend us.

Would you accept a prescription?