Wilderness Deprivation Disorder running head: Wilderness Deprivation Disorder

Wilderness Deprivation Disorder: A Case Study

presented to Dr. Youngkhill Lee

In partial fulfillment of the requirements of HPER R561 Advanced Therapeutic Recreation Processes

by Ray Woodcock March 29, 2006

Wilderness Deprivation Disorder Summary of Case Laura is an 85-year-old Caucasian who shares a room with her husband in a nursing home. The social services representative at her nursing home has agreed to allow me to work with her, with her informed consent, to explore the possibility that her presenting symptoms, detailed below, are consistent with the proposed diagnosis of Wilderness Deprivation Disorder (WDD). The wellness-oriented diagnosis of WDD concentrates primarily upon the addition of stimuli from nature, or the outdoors, to enhance the well-being of persons who may or may not display signs of pathology as defined by the DSM-IV-TR. In the interests of developing the WDD diagnosis, I have approached this clients situation as a case study for research, and have therefore invested a greater-than-normal amount of time in becoming familiar with its facts.

In this review, I have explored at length the problematic nature of Lauras circumstances. I have grappled, in particular, with the possibility that Laura might encounter the outdoors in either of two forms: as a place in which she would derive pleasure from mere contact with nature, or as something from which she might internalize certain perspectives or benefits by means of activities conducted in the outdoors. Because of the extremely constricting limits imposed by Lauras circumstances, I have concluded that one might best proceed along two tracks: (1) advocating and educating for change, so that nursing homes like this one facilitate more possibilities for outdoors-oriented contact and activities, and (2) in the meantime, treating Lauras situation as essentially that of a prisoner, and seeking to incorporate elements of nature in her nursing home room just as one might seek to incorporate them in a prisoners cell. My conclusion, given the full array of constraints, seems both realistic and bleak.

Wilderness Deprivation Disorder Background Laura grew up in farming territory. She and her husband bought a house in the country,

and lived in that house for virtually all of their adult lives. Thus, from birth to about age 80, with exceptions of perhaps two years in her youth, she always lived in the countryside. As such, she was perpetually active in gardening; worked in and with shrubbery, woods, fields, and animals; and was otherwise immersed in rural life. About five years ago, she and her husband decided they could no longer manage the country life, and decided to move into an apartment in a nearby town. In that apartment, their only regular contact with the outdoors was to take a walk, every day or two, to drop their trash bag into a dumpster located about a city block away. They tended to keep their shades drawn, primarily in fear of the potential for criminal acts by persons who occasionally walked or bicycled past their apartment. This past year, after repeatedly failing to mind their diets, medications, and other aspects of aging life, they were relocated to their present residence. Their room in a nursing home has a view of a back yard and a field. Due to senility, however, her husband is not allowed to leave the building unescorted, and Laura does not attempt to go outdoors without him. There is, in any case, not really any place where they could go: there are no sidewalks on the street; and while the exterior of the nursing home does have a smallish lawn, it has no walkway, picnic table, or other location where she and her barely mobile husband could sit down. Moreover, any activities on that lawn would be undertaken in full view from the windows of their fellow nursing home residents rooms. Laura, a shy person, shows no great inclination to be out on the lawn. Nursing home staff rarely escort residents outside the building; and when they do, the destination is invariably a restaurant in town or some other location in the built environment. There have been no guided individual or group forays to the lawn, to the nearby lakefront, or to any other outdoor locations.

Wilderness Deprivation Disorder Comorbidity Laura has met with the nursing homes social services representative, but it does not appear that she has ever undergone a thorough mental health assessment. There are also no

indications that any standardized instruments (e.g., Beck Depression Inventory, MCMI-III) have been employed to assess her condition. This may be appropriate; she displays no signs of severe pathology. Even if she did, for the record, her finances are essentially nonexistent, and the social services representative doubts that her health insurance would pay for any such assessment. In the event such assessment does become a possibility, I would suggest exploration of a few potential diagnoses. First, I noticed some instances of memory lapse consistent with a cognitive disorder typical of old age. From Lauras remarks about the nature of her married life, and from my observation of her interactions with her husband and others, one would ideally seek to rule out dysthymia or a another mood disorder, as well as PTSD or possibly complex PTSD (cf. Herman, 1997). Although it appears unlikely, one might also want to rule out social phobia and avoidant personality disorder after taking account, in all cases, of her current medications. Given funding realities, as well as Lauras strong sense of stigma associated with mental health treatment, the social services representative suggested that Laura meet with me, to see whether there may be some affordable intervention untainted by that stigma. In the interests of advancing the understanding of WDD as a potentially viable diagnosis, I agreed to meet with Laura for this purpose, and to explore her case extensively, without charging a fee. Symptoms It goes without saying that one might detect and interpret phenomena from Lauras past and present life experiences in an indefinite number of variant ways. My observations and reflections have focused particularly upon identifiable regards in which her relationships to

Wilderness Deprivation Disorder nature, and to other activities linked to nature (e.g., nature-related socializing), differ markedly from what appears to have been her experience during her years in the countryside, as follows: Deprivation of physical challenge. Both Laura and the social services representative confirm that Laura is seeking opportunities to be of use, around the nursing home, and particularly in a physical capacity. She was briefly helping to roll wheelchair-bound fellow residents from the dining hall to their rooms, until it was decided that this wellmeaning effort deprived residents of their own needed exercise. The nursing home does not offer an exercise room or exercise classes. It is not clear, in any event, that such facility would appeal to her: during her four years in the apartment prior to entering the nursing home, she had an exercise bike that she never got around to using. She does not appear to suffer from any conditions that would prevent her from being more physically

active. One reason for her uninvolvement in some physical challenges appears to be that she feels her husband relies increasingly upon her for guidance and cues in everyday living, and she appears reluctant to relinquish that role or uncertain that she can do so safely. Lack of contentment with available diversions. Unlike her husband, Laura does not appear content to spend the afternoon watching TV. It is, for her, a nighttime diversion; the daytime is a time to be active. Her inordinate shyness prevents her from becoming deeply involved with the nursing homes slate of activities, which in any event is quite sparse. She is not able to name anyone toward whom she feels exceptionally close or with whom she feels she can comfortably share secrets about herself. While she and her husband report being on cordial terms with a number of their fellow residents, there is no one with whom she engages in private conversation, other than her husband. She reads,

Wilderness Deprivation Disorder but does not find it a pastime sufficient to absorb large numbers of hours. The point is

not that she needs to find a way to become more socially involved than she seems to have been at any other time in her adult life; it is, rather, that working from where the client actually is she seems to perpetuate the activity-oriented sense of priorities that guided her decades in the country, where there was work to be done and where she learned to view social life as secondary. Loss of purpose. Despite stories of persons who have thrived in the protective environment of a nursing home, Lauras ingrained sense of life there is that one has become forgotten, irrelevant, and unwanted, and is essentially just waiting to die. This message appears to be underscored by the very low morale evident in the affect of numerous residents. Laura did not merely have a purpose for others during her childrearing years; she evidently retained a sense of purpose during the two ensuing decades during which the children were gone and she was tending an empty nest. In her worldview, it seems, purpose derives in part from the simple activities of struggling against the elements to make a life to keep the house and property in good shape, to tend the flowers, and otherwise to defend ones existential outpost. Ironically, the nursing home environment, with its regular feeding, tracking of ones medications, and otherwise helpful ambiance, appears thereby to rob Laura of the necessity to fend for herself and, with it, of a part of her sense of purpose. Loss of place. There could scarcely be a more profound contrast, within Lauras lifetime experience, than the contrast between her bed in a highly institutional nursing home room, which appears to remind her of an extended stay in a cheap motel, and the home she had in a rich rural setting for a period of more than half a century. During those

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decades, her hands and eyes had probably covered every inch of that house and most of the three acres on which she lived, for that matter, as she worked on hands and knees to plant flowers and grass, pull weeds, grow grapes, apply sawdust to the roots of seedlings, pick her husbands freshly clipped boughs off the ground, and so forth. In the old setting, everything was special, had been in some sense personally incorporated into her existence. Here, nothing is special; nothing holds the memory of a child or the echo of a holiday; everything in this cinderblock and linoleum structure will endure just fine without her when she is gone. Indicia of outdoor orientation. I took Laura and her husband for a ride in the car. When we stepped out of the nursing home, I noticed immediately that her eyes were sparkling and she was smiling in sharp contrast to her husband, who despite his years of life in the country, now seemed reluctant to stray from the safety of his home in the facility. I also noticed, during the drive, that while she spoke of social relationships among farmers in the countryside where she had spent her life, she also made numerous comments about the cows and sheep, woods and fields, rainfall, storms, and other aspects of the outdoors. Loss of outdoor-oriented social opportunities. Activities in the outdoors cutting wood for heat, growing food in the garden, taking care of trees grown to sell, and other similar undertakings comprised a significant part of the time that Laura and her husband spent together during their decades in the country. Without those activities, the couple appears to have fewer things to talk about. Also, they do not seem to be spending time together in the same sense: instead of being jointly occupied with a given task (e.g., helping one another to tie up a trees branches), they appear to be largely silently as they sit in separate chairs and watch TV. As just noted, Laura was also aware of neighbors social

Wilderness Deprivation Disorder

interactions, with herself and with others, and she seems to have conceptualized many of those interactions in terms arising from the rural life. For instance, she might cite a farmers ownership of sheep, rather than cattle, to demonstrate that he and his neighbors did not always see eye-to-eye. Previously, visiting a neighbor (or even being in the company of others, as in church or when going shopping) always included an element an outdoor activity even if the actual socializing occurred indoors, which was not always the case insofar as it was necessary to travel across the countryside in order to get to that neighbors residence. Finally, many of Lauras social opportunities (e.g., working with other women to decorate the church, or to prepare food for a monthly lunch for the children in the nearby parochial schoolhouse) entailed an outdoor component (e.g., getting flowers from a nearby patch, or vegetables from the garden). It appears that, in an apartment or nursing home residence in town, where she has lacked such obligations and resources, she has concomitantly lacked the basis or justification for such social interactions. Review of Symptoms The outdoors varies enormously in its physical features: it includes prairie and mountains, wilderness and farmland. It would be impossible to approach Lauras case from a global perspective that sought to catalog the differential effects, upon her, of exposure to myriad varieties of nature. Nor would such an approach necessarily be on the mark. In listing her symptoms, above, the focus was upon the difference between her life now and the life she experienced in the domesticated rurality of her former years. Perhaps she, and many before her, would have benefited from exposure to various aspects of raw wilderness including aspects with which they may have had no appreciable contact for millenia, since mankind first began to

Wilderness Deprivation Disorder move away from an outdoor existence. But for purposes of a relatively immediate, clinical intervention, the focus here is upon the effects of incremental denial of wilderness exposure within the scope of Lauras life experience. How, in other words, can one hope to restore some missing elements of Lauras previously intensive outdoor exposure, short of the infeasible option of relocating her and her husband back to the country house they vacated? One can imagine extension of that question to

children who experience profound homesickness when they leave home to go away to college; to persons who are separated by divorce from the familial roots they have planted; to workers who must relocate for their jobs; and so forth. Here, however, the focus is solely upon Laura. One could seek to provide symptomatic relief, responding discretely to each of the ills sketched above. There is a chance, however, that that list of symptoms neglects or misrepresents something important, or that a single underlying mechanism is responsible for generating several such effects and, perhaps, that treating the effects will leave the underlying cause untouched. Hence, rather than address those symptoms in isolation, the approach taken here will be to outline theories that may provide more global insight into the case. This is not to say that the specified symptoms cannot provide guidance or serve in any sense as limiting criteria; it is merely that a point-by-point analysis of symptoms might miss the forest for the trees. For reasons just described, it would appear relatively unhelpful to base this inquiry upon an innate evolutionary preference, postulated by some writers, for savannah-like terrain (see Riley, 1992). Most portions of the land surrounding Lauras country home were either naked farmland or dense woodland. It was not a particularly savannah-like place. Nor is it clear that the arrangement of the surrounding landscape would be crucial to this inquiry in any event. The symptoms described above would seem to lie within the experience of numerous persons from a

Wilderness Deprivation Disorder variety of backgrounds. Surely they are not all longing, in any immediate sense, to return to a savannah-like existence that they, personally, have probably never experienced that may, indeed, seem less appealing to them than does their old home, wherever it may have been.

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In part, this inquiry will disregard the last of the symptoms listed above, pertaining to the loss of outdoor-oriented social opportunities. That decision is perhaps less significant than might appear at first glance. Some of the richness of Lauras life in the country arose from its web of irreplaceable social links. The formative, old-fashioned, barn-raising rural social network of her childhood may have lived on, inside her, for as long as she could experience actual and remembered contacts with her brother, who inherited the farmhouse in which she was born, a scant two miles from her marital home. That farmhouse, that memory of an older culture, may live on inside her still; it may be a fount of inchoate recollection from which, even now, a suitable intervention could draw. But for purposes of this inquiry, it will be assumed that the culture of outdoor-oriented social opportunities has been dying since she was born has been drying up, in any case, for some 40 years now, since the advent of highly mechanized agriculture and the closing of the adjacent one-room schoolhouse that served as her social focal point during her childrens early years. There is some evidence that, over the decades, Laura slowly adapted herself to what was becoming, for her, a social desert that, in other words, it may not be a question of seeking to return her to a rich life she left behind, but rather of recognizing that, by the time she left, there was not much left to leave. The list of symptoms, thus annotated, suggests two general spheres of inquiry, pertaining to place and to activity within it. Regarding place, it appears that Laura now occupies a setting that is alien to her, one that will not easily come to feel like a home. Regarding activity, Laura seems to need to use her time and abilities in ways that provide exercise and challenge, absorb

Wilderness Deprivation Disorder her attention, and yield some social contact. Phrased thus, these are, again, not unique to old folks; one can readily imagine similar experiences for the high school graduate who goes away to college in a strange place, or for the worker whose relocation denies the possibility of continuing in his/her accustomed ways of relating to place and activity. And again, while the list of symptoms itself may neglect something important, the

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possibility of such neglect seems less worrisome when one focuses on these two general spheres (i.e., place and activity) rather than upon multiple specific symptoms. In respect to both such spheres, there may be elements that she could indeed, must satisfy without recourse to the outdoors. But the question here is whether access to nature can provide an efficient response to multiple relevant concerns, so as to fuel ones belief in the plausibility of WDD as a useful diagnostic interpretation. Theory The theory at hand, baldly stated, using Lauras case as an example, is that gradual or rapid changes in life circumstances may deprive people of exposure to aspects of wilderness experience that, if experienced, would enhance wellness or quality of life. This is not the same as saying that Laura would immediately be better off if she were plunked down in the middle of nowhere. Given her genes and rearing, her strengths and weaknesses, she may be at her best in an environment that offers a decidedly diluted version of the primeval home just so the attenuation of environmental experience is less extreme than that which obtains in the residence she now occupies. Several different perspectives suggest that there is a pervasive human need or tendency to be oriented toward nature. For example, Clayton and Opotow (2003) describe a controversy surrounding the definition of nature itself which, in some views, includes (or should be

Wilderness Deprivation Disorder considered as properly including) humans. Thus, they cite the ecopsychology movement as

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holding that humans need to rediscover their ties to the natural world in order to experience full mental health (p. 7). Taking a different approach, White and Heerwagen (1998) cite the biophilia hypothesis, by which there is said to be an innate tendency to focus on life and lifelike processes (Wilson, 1984, p. 1). Reaching a somewhat similar outcome, White and Heerwagen suggest that positive responses to natural stimuli may be introduced into mental health interventions in relaxation therapy, in wilderness challenge programs, and in the design of clinical environments. Because of irremediable changes in Lauras life and society, the proposed solution path is not to seek resurrection of a former lifestyle that, by now, may be lying stiff in its tomb. Instead, it is suggested that, to some extent, the best aspects of the life formerly experienced by someone like Laura may, themselves, have been mere shorthand for even better encounters with nature by her ancestors, and that those ancestors adaptations may likewise have entailed, in turn, some loss of wilderness exposure experienced by their ancestors, and so on, back up the tree of heredity. In that conceptualization, an attempt to recreate Lauras personal past would appear misdirected, when compared to the project of introducing superior elements of wilderness, as experienced by humans in somewhat more remote antiquity. There would be, one presumes, some point at which the research would have gone too far back, where the relatively pure wilderness experience would lie beyond Lauras capacity to adapt and enjoy. Rather than install her in yet another alien world, the trick would be to arrive at a purer, but not extreme, array of circumstances that would not be vastly less diluted than those which she treasured in her old life.

Wilderness Deprivation Disorder Place

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There are, logically, those places to which one is emotionally attached, and then there are those places to which one is effectively not. It is not just that people tend to prefer certain kinds of landscapes or views over others (Kaplan & Kaplan, 1989). Arefi (1999) suggests that place and non-place do not integrate that a person who finds him/herself living in a non-place (e.g., a nondescript, anonymous, industrial area) may experience something like a crisis of identity and, from it, may experience physical as well as mental health impacts. For example, research in environmental psychology has demonstrated beneficial effects of exposure to views of the outdoors through a window and even in mere photographs and murals depicting nature, when compared to more nondescript locations (Morris, 2003). To illustrate the possibilities, in their volume on place attachment, editors Altman and Low (1992) offer a half-dozen chapters that speak directly to aspects of Lauras situation. These include chapters on attachment to the ordinary landscape; to possessions (which, in Lauras case, are especially poignant due to the decision by her sister to empty the contents of Lauras former apartment during the hospital stay that preceded her transition to a nursing home, thereby robbing Laura and her husband of even some basic elements of a dignified existence); to special places from childhood and in the life courses of the elderly; to the home as a workplace in womens lives; and to ones local community; as well as a chapter on involuntary relocation and other disruptions. Space will not permit an exploration of so many aspects of place attachment. To introduce elements of the concept that do seem to address at least a part of Lauras situation, however, the last chapter just mentioned offers this definition:

Wilderness Deprivation Disorder Place attachment involves positively experienced bonds, sometimes occurring without awareness, that are developed over time from the behavioral, affective, and cognitive ties between individuals and/or groups and their sociophysical environment. These bonds provide a framework for both individual and communal aspects of identity and have both stabilizing and dynamic features. The environments may include homes or communities, places that are important and directly experienced but which may not have easily specified boundaries. Transformations in place attachment occur whenever the people, places, or psychological processes change over time. Disruptions of place attachment are noticeable transformations in place attachment due to noticeable changes in the people, processes, or places. (Brown & Perkins, 1992, p. 284).

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The theme of lost identity has other potential place-related dimensions as well. There is, for example, the very real possibility that the surrender of a house for an apartment, and then of an apartment for a room in a nursing home, implies a palpable loss of pride, of standing in the community as if to show the world that she is a person in decline, lacking significance. This is very far from Laura at her apogee, when she occupied a large house on three beautiful acres, with five children, and was heavily involved as well in the neighboring church and schoolhouse. Yet place attachment, broadly defined, may digress profoundly from the topic of wilderness exposure. Attachments to houses, children, and possessions however important such attachments may be, or may have been, to Lauras sense of identity is quite distinct from a need for contact with the outdoors. The key point would seem to be, not wilderness, but rather attachment to something, anything, that will provide stability, self-respect, or other mooring in the storm. The reply is that Laura no longer has many options in that regard. Her children are

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physically distant. She will most likely not again reside in a house, and certainly will not return to her high point. Exposure to nature is offered, not as a panacea, but as a single focus for the attachment need. If she could also find attachment and identity elsewhere, so much the better; but if nothing else comes through for her, there is at least the possibility that she will always have access to nature in some direct or vicarious way, and through that access may be able to derive some therapeutic benefit. How great is that possibility? Under other circumstances, it might have been feasible to mitigate the loss. Upon entering the nursing home, Laura was still able to drive. It might have been possible for her to drive herself and her husband out to their countryside neighborhood to, particularly, Sunday services at the church they attended for about 40 years. Unfortunately, the nursing home would not allow her to keep her car, and her sister has sold it. Moreover, her husbands animosity toward some members of that congregation would probably eliminate that possibility from consideration. Although the nursing home has a van for transporting its residents to the occasional restaurant, it is unlikely to use that van to transport Laura or anyone else on a random drive through the countryside. Experiences of that sort are likely to be reserved for those rare instances when one of her children visits and takes her and her husband on a local tour. There is, however, no specific place in the countryside where she appears comfortable with getting out and walking around not that her husbands mobility would permit much of that in any case so for practical purposes she is marooned at the nursing home. Indeed, it is possible that a return to the old haunts particularly, with the new owners permission, to the sold country home, and also to the neighboring church and now-vacant schoolhouse would merely remind Laura of how much she has lost. Brown and Perkins (1992)

Wilderness Deprivation Disorder offer a case study demonstrating that persons subjected to a natural disaster, wiping out their

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homes and communities, struggled to come to terms with their losses and to re-create a sense of stability and a positive identity, and eventually resolved the conflict between allegiance to past and present by incorporating valuable elements from the past into new present-tense commitments (p. 294). They also note, however, that it may be difficult to recreate place attachments when the new setting is unfamiliar. Not only the inside, but also the outside, has changed for Laura. At the nursing home, there is no garden; there is no sidewalk across the lawn. There are few trees. There is no place for solitude in the outdoors; there is not even a place to sit in it. And instead of a country road, there is a city street. The possibilities for discovering or rediscovering any link with the outdoors are severely circumscribed. Under such circumstances, it is not immediately obvious that Laura has any realistic options for deriving any significant therapeutic benefit from explorations of the link between personal identity and place attachment. Whether her circumstances are actually harmful to her mental health is not resolved here; the present observation is merely that such circumstances do not seem calculated to enhance her mental wellness. In summary, it did not appear, from my observation, that Laura drew great solace from the view out of her window, across a field and past a few trees to a railroad track perhaps a quarter-mile away. The view may have had some incidental therapeutic benefit, but did not seem equal to the task of counterbalancing symptoms like those described above. There also appeared to be few other aspects of place, experienced in itself, in which her new home would come to rival the old one in therapeutic power. This, and her apparent acquiescence in it, raises the question of whether, indeed, it had never been, for her, a matter of merely enjoying the place whether, that is, her home had become a home because of what she had done with her time in

Wilderness Deprivation Disorder it. She had never been one to sit and gaze out of a window, or to spend time merely contemplating in the outdoors. My conclusion was that I should hope the poverty of her new home, in terms of natural

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beauty and even sheer visibility, would somehow prove to be of slight significance in her overall health picture that, ultimately, although she came from a long line of farmers, her social and aesthetic insticts were not terribly different from those of a city girl, and that it would be activity, not mere place, that would matter most to her. It is also possible, though unexplored here, that there are further permutations within the possibilities of experience of place, and that she may be enjoying some such permutations on a non-obvious level. For example, one might use the analysis of Borrie and Birzell (2001), which seeks to measure the quality of wilderness experience, to examine Lauras own present outdoor exposure in terms of satisfaction, benefits, cognitive states, and socially constructed meanings applied to the experience. Activity In the Review of Symptoms, above, it appeared that Laura needs to use her time and abilities in ways that, among other things, will provide exercise and challenge, absorb her attention, and yield some social contact. In the examination of Place, just completed, it seemed that Laura might find it difficult to achieve a point of enjoying nature through purely passive experience in, or exposure to, natural settings in her new residence. Yet, going back to the summary of Theory, above, it was implied that she may nevertheless achieve experiences of nature that distill, in a microcosm, some of the best aspects of wilderness exposure that, in those regards, could actually supersede in quality (or, let us say, in intensity or therapeutic effect) the experiences that she (or her parents, for that matter) may have had. The remaining option is to look for such possibilities within the sphere of Activity to suggest, in essence, that the list of

Wilderness Deprivation Disorder symptoms did indeed misrepresent what was most important for Laura, in terms of therapeutic effects of exposure to the outdoors, insofar as that list substituted this researchers eye for her own: the list of symptoms asked how she could possibly thrive after losing the lovely views

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available during the rural segment of her life, when there are signs that her mere view of nature, or presence within it, has not been an overwhelming concern for her. Jones, Patterson, and Hammitt (2000) pose the possibility that people form affective bonds with landscapes through the experience of significant activities within them. They describe the difference between the view of the detached outsider, whom Laura is in the nursing home, and that of the long-term resident, who experiences a sense of belonging. The difference between this and place attachment is subtle, they say; it is that attachment refers to a specific location to Lauras country home, in this case, or to aspects thereof whereas affective bonding, or a sense of belonging, is possible within any location that bears some identifiable similarity. For present purposes, however, a better presentation of the concept may be that one can simply distinguish between the unique attachment or bond to a specific place and the general sense of belonging or familiarity that arises in any location in which one is reminded, consciously or otherwise, of some aspect of the original location. The factor deserving greater scrutiny, here, is the role that activity may play in forming those senses of bonding or familiarity. Thus, Ohta (2001) appears to suggest that interpretations of nature scenes vary according to peoples experiences that the scene, even when viewed in a mere photograph, may be a real environment for the viewer to the extent that s/he has experiences that come to mind or, perhaps, that subconsciously cause his/her reactions to vary from those of people who have no such experiences with that particular form of landscape. This possibility, in itself, could be taken to suggest merely that Laura should attempt to have good experiences within the nursing home, so

Wilderness Deprivation Disorder that it, too, could eventually come to feel like home to her. The premise of this inquiry, however, is that nature offers unique benefits that the experiences sought are specifically experiences having to do with nature, rather than with e.g., the interior of the nursing home. As one ponders the experiences that Laura has had and may yet have with nature, it

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begins to seem possible that the preceding discussion was superficial, in its impression that she engaged in an extensively outdoor-oriented life during her years in the countryside. She did, plainly, do exactly that. Yet in another sense, she did not. It may be that city people seek refreshment in the countryside; and perhaps this researcher, overly exposed to habitation, is imposing his impressions upon the subject because while some city people are outbound, some country people are inbound. During her country years, Laura did not avail herself of every opportunity to be outdoors. She did not often go on picnics; she did not prefer to sit and read outdoors. The world of nature was frequently not as appealing, to her and her family, as the world shown on TV. Nature was not broadly seen as an adversary, but neither was it the ultimate home. She would go out of the house to work in the garden, and no doubt this was good for her in many ways; but then she would go back into the house, the schoolhouse, or other buildings, to handle many other chores, and also to engage in most of the activities that constituted her leisure. Indeed, in some important ways, Lauras domestic life in the countryside may have been isolating and entrapping for her (see Ahrentzen, 1992; Herman, 1997). It should not be surprising if this inquiry has thus misconstrued the meaning of the country life to Laura. Others (e.g., Ryan, 2005) have likewise treated the outdoors as an instrumentality, misconstruing its actual significance to client or customer. Stokowski (2002) suggests that the sense of place is a social, not individual, construction. Stedman (2003) cautions that social interactions are not the only influences upon this

Wilderness Deprivation Disorder construction that features of the landscape itself do contribute to it. Nonetheless, within a given set of circumstances, such as those confronting Laura in the nursing home, one might

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theorize that the task is to adapt to, join in, and co-opt to her own ends any possibilities for placecreating activity. Injecting elements of exposure to the outdoors may thus be construed as a partial response a powerful one, perhaps, but nevertheless only part of the larger picture of seeking out activities that will help to build a sense of belonging, of home, and of physical and emotional safety. In their classic work in environmental psychology, Rachel and Stephen Kaplan (1989) identified four key components in restorative experience which, as Scopelliti and Giuliani (2004) emphasize, is distinct from the conception of natural environments as having some innate restorative potential. Those key components are being away (i.e., getting away from the usual situation, task, or mental preoccupation); extent (i.e., connectedness of the immediate experience with the larger world, and particularly with a whole other world, as where one senses that the wilderness extends far beyond the part of it that one sees immediately); fascination (i.e., the restorative experience draws peoples attention without requiring them to make any exertion to focus their attention on it); and compatibility (i.e., there must be mutual support among patterns within the immediate environment, actions required by the environment, and the individuals own inclinations so that, again, the individuals attention tends to move, without effort, in the direction suggested by the environment) (Kaplan & Kaplan, pp. 182-186). In a more exhaustive review, which this paper cannot provide, it would be worth exploring the varying extents to which Scopelliti and Giuliani, and others, find that older people require these four key components. The state of knowledge presented in this paper, with respect to these key components, is simply that Laura may find different activities beneficial in different ways, due to

Wilderness Deprivation Disorder their differential employment of such components and that, in any case, there may be good reason to focus upon activity rather than place in this analysis. To underscore that restorative experience may consist of fragmentary exposure to distractive phenomena, Kaplan (2001) explores the micro-restorative experience (p. 508) of glancing out of a window in ones home which, she says, can briefly take ones thoughts to

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other places, many times each day, with potentially powerful recreational and therapeutic effects. This argument suggests that the view out of Lauras window may be significant, not because of its function as a conscious reminder of her decades of country living, but rather because of its potential for momentary, unconscious, but nevertheless therapeutic distraction where the distraction is congruent with Lauras mindset because it does, after all, expose her to the outside with which she is so familiar. If it is possible for Laura to obtain therapeutic benefit from tiny snatches of positive experience in that regard, it may also be possible to seek out other activities through which she may obtain micro-restorative exposure to traces of wilderness. Glancing out of the window is a rather extreme example of activity; the effort involved is so infinitesimal as to render it nearly coextensive with ones mere existence in the room. But as just explained, it is indeed the action, the glance, that opens up the possibility of beneficial distraction from the here-and-now and provides a reassurance that the great big outdoors is still there. On a less extreme level, there may be actions, however slight, that in the aggregate may keep Laura in touch with good aspects of the outdoors. The next section of this analysis explores interventions that may facilitate the possibility of therapeutic activity.

Wilderness Deprivation Disorder Avenues of Recourse According to Shank and Coyle (2002), Quite often, environments that are intended to give quality care are overly medicalized and impersonal, or they are stark, institutional, and

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uninviting (p. 176). Lauras nursing home embodies some elements of both of those nadirs. To be sure, the staff seems generally congenial, and Laura and her husband have admittedly had the opportunity to bring personal effects into their room (although, again, her sister has commandeered most such effects and presently refuses to surrender them). Despite these touches, however, the place fails to provide the sorts of interventions Shank and Coyle describe. There is no program of pet-assisted therapy, nor much contact at all with animals. As mentioned earlier, there is little to do outdoors, and no program through which to do it. There is no greenhouse, no horticultural therapy program, not much greenery, no portable gardening cart, no potted plants in the room. There are no birdfeeders, birdbaths, or caged birds, no gardens, no aquariums. To compound the situation, Laura herself does not appear overly motivated to seize opportunities for outdoor-related undertakings. She is not agitating for activities like those just listed. That, however, may be a function of disempowerment. In the apartment they occupied before moving to the nursing home, Lauras husband did have a bird feeder, and filling it was an activity he looked forward to each day. Laura seems to have considered it her duty in life to make her husband happy, including whatever activities have been important to him. Thus, in their previous apartment, she would comment upon the trains passing by on the nearby railroad track (he spent his career working on the railroad), on the birds feeding at his feeder, and on other outdoor topics of interest to him. It seems likely that a birdfeeder outside their window would once again serve as a beneficial activity for both of them. Moreover, one might note that the example of the birdfeeder suggests that it might be more appropriate to adopt a systems

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perspective to this case to consider the couple to be the true client, of which Laura is merely a part, and for which she is a spokesperson (see e.g., Vetere, 2001). Several ambiguities regarding Lauras views toward the outdoors might fade in that case, given her husbands unambiguously enthusiastic orientation toward nature. Even without flinging her husband fully into the mix, the mere awareness of his presence and priorities might work to Lauras benefit, insofar as the provision of distractions for him might help to reduce a sense that she is not succeeding in keeping him happily occupied. In several relevant ways, Laura and her husband are probably not unique. The institutional rooms and dining hall of the nursing home are filled with people who seem to be, as one resident put it, waiting to die. There is a palpable sense that the residents do not call the shots, but are rather the sheep whom the staff members herd and direct. In other words, if this nursing home can so dramatically fail to provide the therapeutic environment urged by Shank and Coyle (2002), then so can others. The single most efficacious intervention might therefore be, not to fix Lauras situation by itself, but rather to proceed on the macro level to advocate for legislation, regulation, litigation, and/or education, on a local, statewide, or national level (see e.g., Galambos, 1998), so that nursing home operators and/or therapeutic staffers might become obligated or encouraged to facilitate extensive contacts with nature. Less ambitiously, one might at least seek to engage the relevant personnel at this nursing home in dialogue regarding the possibilities for therapeutic, Green engagement. Yet these suggestions, however good they may be, seem to dodge the question of whether one can prevail despite such adversity whether, that is, there is some way to sneak in some micro-restorative activities with an outdoor flavor, under present circumstances, regardless of whether the nursing home continues to resist measures like those mentioned in the previous

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paragraph. In this regard, Laura made a comment that may provide a foothold. She said, at one point, I dont intend to die here. Her husband, in his state of advancing senility, will probably never be allowed to leave. Given the unlikelihood that she would leave him there, it therefore appears she meant that she would stay until he died, and would then move out. That comment suggested that Laura essentially considers herself to be in prison, although for less than a life term. The foothold, then, is to look at the literature of captivity to see how people have coped with being prisoners of war (e.g., McCain, 1999), refugees (e.g., Russell, 1996), political prisoners (e.g., Mandela, 2006), or with other environments that have deprived them of basic elements of a decent existence. This is, in essence, a search for means to smuggle traces of wilderness into an interior space whose only connection with the outdoors is its unopenable window. Phrased thus, the search may embrace computer programmers, urban dwellers, and others whose circumstances put much of nature beyond their reach. It is not practicable to conduct that search at any great length in this paper. This is, in that sense, a negative report, along the lines of research in which a certain hypothesis is found to provide no explanation. It would have been easy enough to recommend, say, pet-assisted therapy, and to cite quantitative or qualitative research (e.g., Ebenstein & Wortham, 2001) testifying to its effectiveness all the while leaving unstated the reality that Lauras nursing home does not have a functioning pet therapy relationship arrangement. Such pretenses aside, the realities are that Laura and, it seems, others in her nursing home face a bleak existence in which, among other things, they are highly shielded from contact with nature, on multiple levels. Even if it should prove possible to make some initial breakthroughs like those which some prisoners may make to bring in a few small plants, for example, and to install photos of outdoor scenes on the wall of her room there is the problem

Wilderness Deprivation Disorder that Laura and her husband are tired. They no longer want complications; they do not seem to

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want to do anything other than what the nursing home administrators recommend and encourage. They appear, in other words, to have retreated into a helplessness, facilitated by the nursing home itself, featuring extreme docility and amotivation. When the pictures fall down or the plants die assuming Laura is even willing to have plants in her room, which may or may not be her final decision inertia will likely leave things as they lie. Sadly, in my role as one-time visitor and researcher from another location, several hours away, I will not have the time and resources to perpetually revisit the premises, so as to insure that any hard-won gains in outdoor experience have not been meanwhile rolled back in the name of cost-cutting and administrative convenience. It would therefore not be feasible for me, personally, to implement, maintain, and evaluate an outdoor-oriented program of therapy, even if circumstances appeared conducive to such a program. This summary does not necessarily end my involvement in the case, but it does capture the state of affairs as of a certain moment in time.

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