|Posted on November 8, 2020 at 1:20 PM|
The Role of Soundscape in Nature-Based Rehabilitation: A Patient Perspective
Gunnar Cerwén, Eja Pedersen, and Anna María Pálsdóttir
Additional article information
Nature-based rehabilitation (NBR) has convincing support in research, yet the underlying mechanisms are not fully understood. The present study sought to increase understanding of the role of soundscapes in NBR, an aspect paid little attention thus far. Transcribed interviews with 59 patients suffering from stress-related mental disorders and undergoing a 12-week therapy programme in the rehabilitation garden in Alnarp, Sweden, were analysed using Interpretative Phenomenology Analysis (IPA). Described sounds were categorised as natural, technological or human. The results showed that patients frequently referred to natural sounds as being part of a pleasant and “quiet” experience that supported recovery and induced “soft fascination”. Technological sounds were experienced as disturbing, while perception of human sounds varied depending on loudness and the social context. The study further uncovered how sound influenced patients’ behaviour and experiences in the garden, through examination of three cross-theme dimensions that materialised in the study; sound in relation to overall perception, sound in relation to garden usage, and increased susceptibility to sound. The findings are discussed in relation to NBR; the need for a more nuanced understanding of susceptibility to sound among people suffering from mental fatigue was identified and design considerations for future rehabilitation gardens were formulated.
Keywords: garden therapy, soundscape, design, health, mental restoration, nature-based rehabilitation, soft fascination, horticulture therapy, therapeutic landscape
1.1. Soundscape Research
Research on soundscapes—as in the study of the experience of the acoustic environment [1,2]—was first initiated in the late 1960s [3,4]. In recent years, there have been substantial developments in the field [5,6]. There is now an increased understanding of the contextual experience of sound, and also of how the sonic environment can be influenced in a strategic manner to improve the overall soundscape. Previously, such environmental considerations had been limited to a “defensive” approach [7,8]. In a defensive strategy, the main intention is to protect human beings from unwanted sounds (noise). However, while the defensive strategy has been a dominant and useful approach in environmental planning for many years, it has failed to pay attention to the actual experience of sound. In the opposite and more positive approach to sound, sometimes referred to as “offensive”, the focus shifts from noise to consideration of what people want to hear. These approaches, together with a third (“creative” approach), may be used interchangeably in order to improve the sonic environment . In such a holistic soundscape approach, consideration of unwanted sounds (noise abatement) is combined with consideration of wanted sounds for improved experience and/or masking effects . For instance, soundscapes can be influenced through noise screening , localisation of functions , creation of biotopes for birds , consideration of walking material , introduction of water features [15,16], rustling vegetation  or sound art [8,18].
The relationship between sound and mental health has mainly been studied from the perspective of the adverse effects of noise on humans, either directly or through stress reactions induced by negative associations [19,20,21]. There are clear indications of an enhanced risk of impaired mental health after long-term noise exposure. It has been suggested that greenery could mitigate the negative impact, so that the sound is perceived as less annoying if green urban areas are provided. Several studies have found that this is the case sometimes, but not always [22,23]. The provision of sound in green environments intended for psycho-physiological restoration purposes and whether this has an impact on the link between the physical environment and possible curative effects is less well studied, but an increasing number of recent studies point to such connections. In an investigation in which subjects were exposed to a psychological stressor , it was shown that stress recovery was faster during exposure to nature sounds at 50 dBA rather than to three different types of noises (40–80 dBA). Similar findings were reported in a study  where subjects exposed to virtual reality nature (including sound) recovered faster after stress than subjects exposed to virtual reality without sound. It has also been shown that sounds perceived as pleasant (most typically birdsong, music and ocean sounds) can reduce skin conductance level for subjects at rest . In healthcare, studies have shown that sounds of nature from speakers can have positive effects during difficult procedures, reducing stress and anxiety [27,28] as well as experienced pain .
In order to understand the experiential dimension of sound, it is necessary to go beyond measurements of sound pressure levels . Soundscape research provides a platform for discussing perception of sound in terms other than annoyance, as well as opening up new possibilities for design and management of sounds. A soundscape includes all types of sounds in an environment, with emphasis on how they are experienced in a context [1,5,6].
1.2. Nature-Based Rehabilitation and Stress
Problems relating to mental health are estimated to be among major reasons for work disabilities globally [30,31], and can have severe negative effects on everyday lifestyle  and in the long run lead to physical and mental depletion . There have been reports that nature and nature-like environments can assist in mental recovery . It has also been shown that by spending time in natural environments, concentration ability and directed attention can be improved [35,36], and perceived stress relieved .
In nature-based rehabilitation (NBR), it has been found that sensory stimuli of outdoor nature experiences can play an important role in treatment of stress-related mental conditions such as exhaustion disorder [35,38,39,40]. Caregivers in NBR claim that the connection to nature through sensory impressions can help patients “open up” to treatment . The role of sensory experience in NBR could possibly also be related to the notion of ‘soft fascination’ in attention restoration theory (ART) , an important form of experience that is useful for mental recovery. According to ART, soft fascination occurs when people experience things without a focus or specific demands. This recovery allegedly occurs in nature or nature-like environments, where the subject is free and able to discover, recover and relax.
A less well studied sensory input in the NBR context is sound, although this was indicated to be a potentially important aspect in a semi-structured interview study conducted previously with 59 former participants at Alnarp Rehabilitation Garden, where the role of nature as a supportive environment was explored . A new aspect of NBR for individuals recovering from stress-related mental disorders was identified, i.e., social quietness, referring to the need for solitary encounters with nature without disturbance by others. Perception of sound in the rehabilitation garden was not a specific topic in that study, but the participants mentioned sound as an important hindering or supportive factor in a therapeutic environment. This finding suggested the need for a follow up analysis, in which sound was given more thorough attention.
The aim of the present study, consequently, is to examine the role of sound in NBR for individuals with stress-related mental disorders and to identify essential aspects for the future design of restorative spaces for mental recovery. .... https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5201370/
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