The Green Road Project: Healing Wounded Warriors Through Nature

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1 The Green Road Project: Healing Wounded Warriors Through Nature

2 The Green Road Project: Healing Wounded Warriors Through Nature Master Gardeners University of Maryland (UMD) Extension Montgomery County, MD. September 6, 2018 Jack Sullivan, FASLA, Landscape Architect

Walter Reed National Military Medical Center Bethesda, MD Iraq and Afghanistan Wars since 2003: Traumatic Brain Injury and Post-Traumatic Stress Disorder in 30% of the

3 Walter Reed National Military Medical Center Bethesda, MD Iraq and Afghanistan Wars since 2003: Traumatic Brain Injury and Post-Traumatic Stress Disorder in 30% of the force 22 Military Veteran suicides each day: 18% of all U.S. suicides, yet military represents 9% of the population Drugs and surgery had proven relatively ineffective

Mikulski (D-Md.) Green Road dedication ceremony, September 26, 2016.

5 "The Green Road is a place to heal the body, strengthen the mind and reinvigorate the spirit. By connecting with nature, injured service members can reconnect to themselves, their families and the country they fought for. Sen. Barbara A. Mikulski (D-Md.) Green Road dedication ceremony, September 26, After five years of cooperative planning, design, permitting and construction, the Green Road was finally opened. Military personnel, their families and caregivers have ready access to nature on the fastgrowing and ever-urbanizing military hospital in suburban Washington, DC.

6 National Intrepid Center of Excellence (NICoE) Walter Reed National Military Medical Center New medicine = Holistic care Combine holistic and conventional care for TBI and PTSD Multibillion dollar national model

7 The NICoE building incorporated access to natural light, views to nature outdoors and in images, and an architectural interpretation of a "Central Park" with a labyrinth for meditation and movement.

8 Walter Reed Healing Arts Program Multimodal (visual arts, music, creative writing, etc.) Partners: Americans for the Arts, National Endowment for the Arts, and others Most Wounded Warriors are now making art Evidence for efficacy in brain disease The arts program was the most helpful part of my therapy

9 Mask-making: Using the visual arts to express the pain of trauma and the desire to heal

10 NSAB Campus 2010 Concept of the GREEN ROAD emerges as a way to preserve the wooded stream for alternative engagement with nature.

11 Green Road Partners: Bethesda Navy Base: Connecting ADA-compliant pathway Sponsoring nonprofit: The Institute for Integrative Health Lead donor: TKF Foundation, Annapolis (Tom and Kitty Stoner) Design and Construction: CDM Smith, Inc. (engineering) University of Maryland Landscape Architecture Program Research: 4 Institutions Uniformed Services University of the Health Sciences (lead) Consortium for Health & Military Performance National Institutes of Health, Clinical Center Pain & Palliative Care Services University of Arizona Arizona Center for Integrative Medicine Harvard Medical School / Mass. General Hospital Benson-Henry Institute for Mind-Body Medicine

12 The Green Road Team Funding, Research, Design and Construction

13 Holistic Care Healing buildings: Evidence-based design Family engagement (family living quarters on campus) Integration of care (Conventional and Holistic care) Conventional care = single-organ system Holistic care = whole-body therapies Basic wellness Nutrition Exercise Stress relief Alternative medicine Advanced wellness Art-Making Therapies Healing with Nature

The TKF Foundation Open Spaces Sacred Places Tom and Kitty Stoner believed: Urban green space could provide a place of sanctuary Places conceived and created by urban communities could also provide

14 The TKF Foundation Open Spaces Sacred Places Tom and Kitty Stoner believed: Urban green space could provide a place of sanctuary Places conceived and created by urban communities could also provide opportunities for reflection and rejuvenation Since 1996 more than 130 Open Spaces Sacred Places have been created in the Baltimore-Annapolis-Washington region with the Foundation s support. The people who use these spaces identify the transformational effect of being intimately connected with nature through their community journal entries. Powerful writings raised the question about scientific proof that mental and physical health could be improved as a result of developing a personal connection with nature, inspiring the creation of the Nature Sacred Awards.

15 The TKF Foundation Nature Sacred Award $4.5 Million Total Award 11 Planning Grants Awarded ($50,000 each) 5 Projects Awarded (Design, Implementation and Research) 2011 TKF Foundation Nature Sacred Planning Grant 2013 TKF Foundation Nature Sacred Design, Implementation and Research Grant ($1.1 Million to the Green Road)

Nature Sacred National Awards Projects The Green Road at Naval Support Activity, Bethesda, Maryland The Naval Cemetery Memorial Landscape, Brooklyn, New York Landscapes of Resilience:

16 Nature Sacred National Awards Projects The Green Road at Naval Support Activity, Bethesda, Maryland The Naval Cemetery Memorial Landscape, Brooklyn, New York Landscapes of Resilience: Joplin-Butterfly Garden and Overlook, Joplin, Missouri; Queens Community Gardens, New York A Nature Place, Legacy Emanuel Health Center, Portland, Oregon Mechanisms and Design Elements of Restorative Experiences

18 Challenges for the Green Road Design: Requests from Focus Groups and Researchers A PLACE TO CONNECT. The Green Road promotes the communal nature of military life. Wounded service members will gain strength and resilience from gathering with one another and their loved ones in this peaceful setting. A PLACE TO DE-STRESS. According to evidence-based studies, exposure to nature reduces levels of perceived stress, anxiety and depression, while boosting self-esteem and a sense of well-being. A PLACE TO HONOR THE FALLEN. Remembering lost comrades is an important part of healing for many warriors. The commemorative pavilion an element of the project expressly requested by service members will make this possible.

19 Challenges for the Green Road Design: Requests from the TKF Foundation DISTINCTIVE PHYSICAL BOUNDARY. The Stone Creek stream valley and steep wooded ravine clearly frame a distinct topographical space apart from the urban density of the hospital and residential areas. ASSESSIBLE PATHS. The paved pathways give access to the sights and sounds of the stream and the lower woodland, 30 below the urban campus. PORTALS TO MARK PASSAGES. At the lower arrival, a bridge crosses a small tributary and announces a transformation into the healing woodland garden. Above, the stone fountain welcomes visitors at the entrance to the Commemorative Structure. PLACES TO REST AND REFLECT. The Communal Structure (gathering) and Commemorative Structure (solitude) provide shelter, comfort and convenience. Two TKF Benches, each with Journals, offer rest and reflection.

20 The Healing Garden on the Green Road Images by Sarah Ashmun and Jack Sullivan Early studies for the Healing Garden, plant palette, and walk along the.

21 Communal Structure Commemorative Structure

22 Planting Plan Increasing plant variety for habitat diversity and human interest

23 Photos by Jared Green Fallen tree trunks remain throughout the grounds. They contribute to the ecological continuum and symbolize the fallen soldiers legacy in the ever vigilant struggle for freedom.

24 Photos by Jared Green Stream restoration heals the landscape and invites access to the water.

The bridge is a threshold and the pavilions

26 Photos by Robin Yarinov Paths guide the journey. Along the way, structures mark passages and destinations. The bridge is a threshold and the pavilions beckon visitors to pause, reflect and commune with nature and with each other. The structures frame the view; nature dominates.

27 Inspiration for the Commemorative Structure Lily Pool Lincoln Park, Chicago by Alfred Caldwell 1936 "A cool, refreshing, clear place of trees and stones and running water." - Alfred Caldwell, Landscape Architect Stone, Water, Wood

28 Exiting conditions at proposed site of the Commemorative Structure

29 Study for the Commemorative Structure in the context of the woodland

The Commemorative Structure: Invites participants

and reflect on their own lives in a place that

31 The Commemorative Structure: Invites participants to quietly contemplate nature, remember the fallen, and reflect on their own lives in a place that gives prospect and refuge with little separation from the landscape. Located at a high point on the site, it affords distant views into and across the ravine.

32 The Communal Structure: Encourages informal meetings with friends, gatherings of family members and caregivers, therapy sessions and chance encounters with other participants in the healing woodlands. Designed to dignify the user, respect the integrity of the landscape, provide convenience and comfort, and inspire a dialogue with nature, with each other and with one s self.

33 Jack Sullivan The Stone Council Ring: An informal place for gathering or quietly sitting alone. Opportunities for social exchange and therapeutic exercises. Programs are not prescribed, but they are accommodated and encouraged. Photo by Jared Green

34 The TKF Bench and Journal

35 The TKF Journal: Qualitative Evidence of the Healing Effects of Nature Journal entries are collected, transcribed, translated and interpreted.

The views expressed are those of the presenter and do not reflect the official position of the

37 Green Road Research Team Patricia Deuster, PhD, MPH Marni Silverman, PhD* Preetha Abraham, MA Clinical Center Pain & Palliative Care Service Ann Berger, MD, MSN Esther Sternberg, MD *Disclaimer/Disclosure: The views expressed are those of the presenter and do not reflect the official position of the Uniformed Services University or the United States Department of Defense. No conflicts of interest to disclose.

38 Study Population Wounded, Ill, and Injured Warriors, non-wounded service members, family members, and caregivers on the Naval Support Activity Bethesda (NSAB) campus Challenges: Limb amputation TBI, PTSD, depression, anxiety, aggression, alcohol and substance abuse, marital and social instability Loss of loved ones (deployment, death) Reintegration into family and civilian society Caring for Wounded Warriors

39 Long-term Objective Our hope is that objective evidence for the therapeutic power of nature will inspire health care and policy leaders and spark the development of more green spaces. As a complement to the world-class medical care service members (and their families) receive on the military base, the Green Road is a model for the future of whole-body wellness. Brian Berman, MD, President

40 Definition of Healing Quality of life literature: Unification of mind, body, and spiritual wellness that can result in life-transforming change and ultimately inner peace, irrespective of disease (or injury) outcome. Relational process involving the experience of integrity and wholeness and absence of wounding and suffering. Sloan DH et al. Patient Related Outcome Measures Ingram A. J Pain Symptom Manage Mount B. J Palliat Care

41 Health Benefits of Nature Psychological Social Spiritual Physical Physiological Autonomic nervous system Neuroendocrine / stress response system Immune system

42 Military Population Gaps Nature exposure - group outdoor recreational experiences: Improves psychosocial and functional well-being in veterans with PTSD and/or other mental health issues Gaps in literature: No comparison group (just looked at pre- vs. post- nature measures in same group) No appropriate measure of physical activity No objective biomarkers of stress, health, or well-being

43 Study Objective Assess acute healing effects of walking through the Green Road vs. Urban Road (minimally green area on NSAB campus). Compare measures before and after each Walk, as well as between the two Walks.

How do we measure the healing power of nature? Holistic metrics: Measure wholebody changes from illness to wellness using a mixed-methods approach.

44 How do we measure the healing power of nature? Holistic metrics: Measure wholebody changes from illness to wellness using a mixed-methods approach. Psycho-social-spiritual metrics: Subjective Self-report quantitative questionnaires Qualitative verbal interviews (language / content analysis) Stress biomarker profiles: Objective, non-invasive HPA Axis Immune System Autonomic Nervous System

Real-time, continuous data Correlate with GPS / location data Biochemical

45 Biomarker Measures Physiologic Metrics Heart rate / heart rate variability: Autonomic nervous system Actigraphy: physical activity Real-time, continuous data Correlate with GPS / location data Biochemical Metrics Saliva measures: HPA axis Cortisol, DHEA Sweat measures: neuroimmune In development

46 Study Design 1 x Baseline Measures Put on GPS, HRV monitor, & sweat patches Pre-Walk Measures WALK Post-Walk Measures Remove sweat patches, HRV monitor, & GPS Equipment check Briefing of Walk Quantitative Questionnaires: - Demographics, medical Hx, military Hx, lifestyle behaviors, attitude toward nature - Functional health survey - Psycho-social-spiritual Qs Biological measures: - HR/BP, Saliva sample Scales/questionnaires: - Stress - Pain - Mood Qualitative Interview: - Physical - Psych - Social - Spiritual Walk = Green Road or Urban Road (different days within the same week; randomized which walk first)

47 Other Measures Written Journal Entries: Qualitative language analysis Human-based content analysis of prominent themes Machine-based natural language processing (to be done with later funding) Stress Genomics: Gene expression changes in blood immune cells (to be done with later funding) Herbert Benson, MD (The Benson-Henry Institute for Mind-Body Medicine at Mass. General Hospital)

Reverse the psycho-social-spiritual and biological profiles associated with

48 Hypothesis By offering a sacred place to reflect, relax, socialize, and restore, the transformative healing power of the Green Road will help: Reverse the psycho-social-spiritual and biological profiles associated with chronic stress-related illness/injury Promote increased health, resilience, and well-being

The Evolution of Nature in Cities: Sanitary to Sustainable (to Sacred)

The Evolution of Nature in Cities: Sanitary to Sustainable (to Sacred) Kathleen Wolf, Ph.D. Research Social Scientist University of Washington (Seattle) School of Environmental and Forest Sciences USFS