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Building Back Differently: The Role of CLM in Public Health Promotion through Nature-based Solutions

“The future of humanity is undoubtedly urban,” warns the UN-Habitat in their World Cities Report (2022), urging public health policies to address the growing health risks associated with urban expansion. Urban environments — characterized by traffic, pollution, noise, and overcrowding — not only create fertile ground for physical health issues but also place a significant burden on the mental health of their citizens (Olszewska-Guizzo et al., 2023). Neuropsychiatric diseases now account for 19.5% of all disability-adjusted life years  (DALYs), while depression is responsible for 6.2% of DALYs (World Health Organization, n.d.). These mental health challenges deteriorate citizens’ quality of life and generate serious economic losses for the state.

Figure 1: Population living in urbanized areas in 1990, 2014, and 2050 by continent and worldwide, UN, 2018 (https://www.esa.un.org/ unpd/wup)

Governments are increasingly recognizing the urgent need for interdisciplinary, evidence-based solutions to address this mental health crisis (Gruebner et al., 2017). A growing body of research highlights the restorative effects that contact with nature has on human health (Olszewska-Guizzo, Sia, & Escoffier, 2023). These effects include reducing stress and fatigue, triggering positive emotions, and improving cognitive functions such as concentration, memory, and creative performance (WHO, 2021).

Nature-based Solutions (NBS) are emerging as effective and cost-efficient strategies for addressing the growing mental health challenges in urban environments. The IUCN defines NBSs as actions to protect, sustainably manage, and restore natural or human-modified ecosystems, offering benefits for both environmental preservation and human well-being. Adopting NBSs to confront human health challenges arising from unhealthy environments aligns with the One Health approach (WHO) — which recognizes the interdependence of animal, ecosystem, and human health — and the UN 2030 Agenda for Sustainable Development. NBSs have been well-documented to support people’s emotional, mental, and physical health by adopting a holistic approach to prevention, promotion, rehabilitation, and therapy.

Figure 2: "Envisaging the Future of Cities," World Cities Report 2022 (https://unhabitat.org/sites/default/files/2022/06/wcr_2022.pdf)

Not Just Green

Often there is limited space available in cities for green areas, so it is important to optimize the design and use of the available green spaces (Olszewska-Guizzo, Sia, Fogel, et al., 2022). Urban planners, landscape architects, and conservation experts need to understand which types and characteristics of urban green spaces (UGS) most effectively benefit citizens’ mental health. This challenge inspired the development of the Contemplative Landscape Model (CLM) in 2016. The CLM measures how different landscape scenes can positively influence mental health through passive exposure. It focuses on landscape components that, when combined, trigger low-frequency brain activity associated with decreased cognitive strain, increased relaxation, and positive affect, as well as positive effects on mood and anxiety disorders(Olszewska-Guizzo, Sia, Escoffier, 2023).

The CLM evaluates landscape scenes based on seven key-components, each of which is rated using a 1–6-point scale. The final CLM score, the average of the seven key-components, provides a comprehensive assessment of a landscape's potential to offer beneficial mental health outcomes. The CLM is increasingly being used by practitioners to bridge the gap between landscape design and evidence-based impacts on mental health. It is also helping policy-makers make informed decisions on how to effectively curate UGSs to improve the mental health of their communities.

Figure 3: Seven key-components of Contemplative Landscape Model (CLM).

The main advantages of using the CLM include:

  • Accessibility and Ease of Use: The tool can be easily learned following formal training and applied by urban design practitioners, landscape architects, and those with a keen eye for landscapes.
  • Accuracy: The final CLM score is an average from the seven key landscape components in a single view or at multiple sites across the area, which helps to eliminate human error.
  • Cost-effectiveness: The CLM requires minimal equipment. Evaluations can be conducted in a single site visit using tablets or just pen and paper.
  • Efficiency: CLM also works with digital representations of landscapes (photos or videos) to save time, making it ideal for practitioners needing to assess multiple sites.
  • Versatility: The CLM can be applied to a wide range of sites, including urban, suburban and rural spaces, making it a useful tool for diverse environments, and scales.
  • Dual-purpose: The CLM can be used as an evaluation/ audit tool for green spaces, but also as a set of design guidelines to develop new creative mentally-healthy environments.
Figure 4: CLM evaluations can be conducted using tablets.

Global Examples: Singapore

The CLM has received increasing attention among professionals and researchers worldwide and is slowly finding its place in nature-based health promotion policies. The first country to adopt the CLM in its urban greening initiatives was Singapore. The National Parks Board (NParks) recognized the value of the evidence-based approach early, as part of their City in Nature initiative, which aims to ensure that the available green spaces are designed optimally to maximize the well-being of citizens across a diverse demographic, from the elderly and hospital patients to children with special needs.

The research conducted in Singapore, in collaboration with NParks and the National University of Singapore, found that therapeutic gardens with contemplative features contribute positively to a person's mental health and overall well-being. They also concluded that there were positive neuro-psychophysiological benefits from passive exposure to a therapeutic garden for the mental health of individuals with clinically concerning depressive disorders (Olszewska-Guizzo et al., 2022; Olszewska-Guizzo, Sia, Fogel, Escoffier, & Dan, 2022).

Figure 5: Neuroscience research studies conducted in Singapore between 2018 and 2021

 

Singapore established the network of 13 therapeutic gardens scattered across the city-state, with plans for an additional 7 to be completed by 2030. Each garden is designed according to the contemplative landscape guidelines to encourage visitors to enjoy everyday contact with the salutogenic nature of the premises.

NParks’ efforts go beyond transforming parks and are slowly moving into the wider urban environment.  There is a growing number of public officers and professionals trained in use of CLM for landscape assessment and design (an example of a recent workshop). Their continued research into Nature-based Solutions integrating CLM aligns with Singapore’s healthcare transformation plan, Healthier SG, to promote preventive health strategies for the whole population. Singapore’s efforts are setting a powerful and inspiring example of how states can benefit from embracing Nature-based Solutions to create healthier communities while prioritizing evidence-based design of their available green spaces.

Global Examples: Sweden

Sweden is the second country to incorporate the Contemplative Landscape Model (CLM) into its national health policy as part of its Nature-based Rehabilitation (NBR) program.  Alos known as the Skåne-model, or Naturunderstödd Rehabilitering (NUR), it launched in 2013, and is the first of its kind in the Nordic region. NUR is currently active in the southern region of Skåne County, with plans to expand throughout the rest of the country.

The program is founded on extensive research from the Alnarp Rehabilitation Garden, run by the Swedish University of Agricultural Sciences (SLU) (Grahn & Pálsdóttir, 2021). It emphasizes the role of nature in aiding patients to recover from stress-related mental illnesses, specifically exhaustion syndrome, mild to moderate depression, and anxiety (Grahn, Pálsdóttir, Ottosson, & Jonsdottir, 2017). The program takes eight weeks and is run at selected rural properties across Skåne Region (Wissler & Pálsdóttir, 2024).

Figure 6. One of the NBR providers' rural property.

The NBR program supports the rural development goals by employing trained coordinators to deliver the nature-based interventions and services of the program on their premises. These interventions are designed with the following core objectives in mind:

1) Rehabilitation Focus: Aims to support the standard of care to improve physical, mental, and social health through nature-supported activities.

2) Nature-Infused “Awake Rest:” Focuses on relaxation and recovery in a peaceful, undemanding natural environment that promotes mental rejuvenation.

3) Integration of Meaningful Activities: Encourages daily tasks in natural settings, offering participants purposeful engagements that align with the day-to-day operations of the NBR provider.

NBR requires from providers to maintain the quality standards set by the program. These include both the day activities to be offered to the patients and the quality and design of the property's natural environment. The CLM has been introduced to the program as a tool of evaluation for the property's landscape and to provide a systematic approach to develop quality standards comparable between the properties.

Figure 7: CLM on-site evaluations of NBR providers.

In the summer of 2024, six of the eight current NBR providers’ properties in the Skåne region were evaluated by independent experts using the Contemplative Landscape Model (CLM). This was the first time the CLM was conducted on rural properties. Previously, the CLM was used almost exclusively on urban environments. For this evaluation, an average of 12 to 23 landscape views per rural property was scored based on site maps, and the average score was computed for each location. This evaluation was carried out in preparation for the fourth procurement phase of the NUR program. The satisfactory performance of the CLM in this new context demonstrates its versatility and reliability, further supporting Sweden's ongoing commitment to integrating Nature-Based Solutions into public health policy. Sweden is the first country in Europe to adopt the Contemplative Landscape Model (CLM) as part of its national health policy.  The adoption reflects their commitment to innovative approaches, including evidence-based initiatives such as the Alnarp Rehabilitation Garden and therapeutic gardens for dementia patients(Pálsdóttir, Wissler, & Thorpert, 2024; Pálsdóttir, O'Brien, Poulsen, & Dolling, 2021), and highlights the country's leadership in promoting preventive health strategies through nature. Sweden's efforts are setting a model example for other European nations to follow in creating healthier, more resilient communities.

Final Thoughts

The path to sustainable (positive) urban futures requires “collaborative, well-coordinated and effective multilateral interventions” by cities and sub-national governments. The health and well-being of citizens are classified as a top priority by the WHO to build resilient cities.  Cities must understand that it is no longer enough to “[build] back better” to meet the 2030 Agenda for Sustainable Development the New Urban Agenda. It is time to “[build] back differently.

Improving citizens’ access to mental health programs and developing holistic strategies to address mental illness remains a key concern worldwide. Without transformative action, mental health problems will “contribute to human suffering, premature mortality, and social breakdown, and will slow down economic recovery.” Improving the mental health of communities is essential not only for enhancing the quality of life of individuals but also for the continued economic and social development of states.

Recognizing the health-promoting value of landscapes, by integration of the Contemplative Landscape Model (CLM) by countries like Singapore and Sweden highlights its potential as a vital tool in integrating Nature-Based Solutions into national public health policies. It is, therefore, crucial to continue educating governments and decision-makers across the globe on the impact of evidence-based landscape design on public health. Through continued collaboration, research, and innovation, the CLM can become a foundational tool for preventive health strategies, helping to promote healthier, happier, and more resilient communities across the globe.

Reference List

Grahn, P., & Pálsdóttir, A.-M. (2021). Does more time in a therapeutic garden lead to a faster return to work? A prospective cohort study of nature-based therapy, exploring the relationship between dose and response in the rehabilitation of long-term patients suffering from stress-related mental illness. International Journal of Physical Medicine & Rehabilitation, 9, 1000614. https://doi.org/10.4172/2329-9096.1000614

Grahn, P., Pálsdóttir, A.-M., Ottosson, J., & Jonsdottir, I. (2017). Longer nature-based rehabilitation may contribute to a faster return to work in patients with reactions to severe stress and/or depression. International Journal of Environmental Research and Public Health, 14(11), 1310. https://doi.org/10.3390/ijerph14111310

International Union for Conservation of Nature. (n.d.). Nature-based solutions. https://iucn.org/our-work/nature-based-solutions

National Parks Board. (n.d.). City in nature. https://www.nparks.gov.sg/about-us/city-in-nature

Olszewska-Guizzo, A., Fogel, A., Escoffier, N., Sia, A., Nakazawa, K., Kumagai, A., Dan, I., & Ho, R. (2022). Therapeutic garden with contemplative features induces desirable changes in mood and brain activity in depressed adults. Frontiers in Psychiatry, 13. https://doi.org/10.3389/fpsyt.2022.757056

Olszewska-Guizzo, A., Russo, A., Roberts, A. C., Kühn, S., Marques, B., Tawil, N., & Ho, R. C. (2023). Editorial: Cities and mental health. Frontiers in Psychiatry, 14, 1263305. https://doi.org/10.3389/fpsyt.2023.1263305

Olszewska-Guizzo, A., Sia, A., Fogel, A., Escoffier, N., & Dan, I. (2022). Features of urban green spaces associated with positive emotions, mindfulness, and relaxation. Scientific Reports, 12, 20695. https://doi.org/10.1038/s41598-022-24637-0

Olszewska-Guizzo, A., Sia, A., & Escoffier, N. (2023). Revised contemplative landscape model (CLM): A reliable and valid evaluation tool for mental health-promoting urban green spaces. Urban Forestry & Urban Greening, 86, 128016. https://doi.org/10.1016/j.ufug.2023.128016

Pálsdóttir, A.-M., O'Brien, L., Poulsen, D., & Dolling, A. (2021). Exploring migrants’ sense of belonging through participation in an urban agricultural vocational training program in Sweden. Journal of Therapeutic Horticulture, 31(1), 11.

Pálsdóttir, A. M., Wissler, S. K., & Thorpert, P. (2024). An innovative approach in research and development of clinical nature-based rehabilitation in health care and vocational training: The living laboratory, Alnarp rehabilitation garden. Landscape Architecture, 31(5), 116-123. https://doi.org/10.3724/j.fjyl.202404020196

Region Skåne. (n.d.). Naturunderstödd rehabilitering. https://vardgivare.skane.se/vardriktlinjer/forsakringsmedicin/naturunderstodd-rehabilitering/

UN-Habitat. (2022). World cities report 2022: Envisaging the future of cities. United Nations Human Settlements Programme (UN-Habitat). https://unhabitat.org/sites/default/files/2022/06/wcr_2022.pdf

United Nations. (n.d.). The 2030 agenda for sustainable development. https://sdgs.un.org/2030agenda

Wissler, S. K., & Pálsdóttir, A. M. (2024). A quality assurance framework for outdoor environments, facilities, and program standards in nature-based rehabilitation. Landscape Architecture, 31(5), 91-102. https://doi.org/10.3724/j.fjyl.202312140567

World Health Organization. (2021). Mental health promotion and mental disorders prevention: Framework for a comprehensive mental health strategy in Europe. WHO Regional Office for Europe. https://www.who.int/europe/publications/i/item/9789289055666

World Health Organization. (n.d.). Global health estimates: Leading causes of DALYs. https://www.who.int/data/gho/data/themes/mortality-and-global-health-estimates/global-health-estimates-leading-causes-of-dalys

World Health Organization. (n.d.). One Health. https://www.who.int/health-topics/one-health#tab=tab_1

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CLM field session in Singapore – How to recognize Contemplative Landscape features in the park

On 6.10.2023 upon the National Parks Board (NParks Singapore) request, Dr Agnieszka Olszewska-Guizzo conducted the onsite consultation and training for the NParks designers and officers regarding the use of the Contemplative Landscape Model (CLM). NParks is currently rolling out the CLM in their parks and actively using this evidence-based tool [read more here].

We’re hoping to mainstream this research and apply it to a lot more sites outside of our parks and gardens… So far, we’re still in the early stage of hand-holding, but we hope it becomes adopted and grows in the wider industry”, says Jason Wright, Director of Design at NParks.

During the session Dr Guizzo shared the practical considerations of the use of the tool in the evaluation of the newly implemented"Wellness Garden"  - a part of East Coast Park in Singapore.  Additionally, she has answered the doubts and addressed the considerations of NParks landscape architects team about the active use of the CLM.

This was a very fruitful exchange session where all issues could be discussed in confrontation with the actual site!

DALL·E 2022-10-10 19.18.56

What A.I. says about Contemplative Landscape Model?

It is fascinating how artificial intelligence can provide us with a third-person's view of our field of expertise. It is like having another expert summarising our work from an objective standpoint, making it more approachable for anybody. We recently asked ChatGPT about the Contemplative Landscape Model and its usability for professionals and how its benefits can be leveraged. Here is the Q&A with the A.I.!

What can the Contemplative Landscape Model do?

The Contemplative Landscape Model, developed by Dr. Olszewska-Guizzo, is a research-based framework that aims to identify the landscape scenes that have the highest potential to induce positive mental health outcomes from passive exposure to them. The model does not focus on identifying mental health benefits from nature exposure per se, but instead, it identifies design elements that can enhance the quality of the outdoor environment and promote human well-being.

The model's primary focus is on identifying specific design elements in the landscape that can create contemplative experiences and promote positive mental health outcomes. These elements include features such as water, vegetation, and other natural elements that can elicit a sense of calm and tranquility in the viewer. The model proposes that by incorporating these elements into the design of public spaces, designers can create environments that promote positive mental health outcomes and enhance the quality of life of users.

The Contemplative Landscape Model has practical applications in a variety of settings, from healthcare and educational facilities to urban parks and residential neighborhoods. By using the model to guide their design choices, landscape architects and urban designers can create environments that are not only visually appealing but also promote positive mental health outcomes.

Overall, the Contemplative Landscape Model offers a valuable tool for landscape architects and urban designers to create outdoor environments that promote human well-being and foster contemplative experiences.

What are the seven key elements of the Contemplative Landscape Model?

The seven key elements of the Contemplative Landscape Model are as follows:

  1. Layers of the Landscape: This refers to the different layers of the landscape, from the ground level to the sky, and how they interact to create a sense of depth and connection to the environment.
  2. Landform: The contours and shape of the land are used to create a sense of enclosure and openness, as well as to guide the flow of movement and energy.
  3. Biodiversity: Incorporating a diverse range of plant and animal life can help to create a sense of connection to nature and promote ecological health.
  4. Color and Light: The use of color and light can help to create a specific mood or atmosphere within the space, such as calmness or energy.
  5. Compatibility: The design should be compatible with the surrounding context, including the architectural style and cultural context.
  6. Archetypal Elements: The archetypal elements in the Contemplative Landscape Model are typically considered to be water, earth, air, and vegetation (e.g. forest, meadow, etc.). These elements are often used to create a connection to the natural world and evoke a sense of archetypal meaning and symbolism within the space.
  7. Character of Peace and Silence: The overall design should promote a sense of peace and silence, allowing visitors to relax and reflect.

What is the most important contemplative landscape element?

It is difficult to say that any one element of the Contemplative Landscape Model is the most important, as they all work together to create a space that promotes relaxation, reduces stress, and promotes positive mental health outcomes. However, some researchers have suggested that the use of natural elements such as water and vegetation may be particularly important in creating a restorative environment.

Research has shown that exposure to natural environments with these elements can help to reduce stress, improve cognitive function, and promote positive mood states. Additionally, the use of natural elements can create a sense of connection to the natural world, which can also promote well-being.

That being said, each of the seven elements in the Contemplative Landscape Model - Layers of the Landscape, Landform, Biodiversity, Color and light, Compatibility, Archetypal Elements and Character of Peace and Silence - plays an important role in creating a space that is restorative and promotes positive mental health outcomes.

...but the desert does not have any vegetation and is contemplative...

You are correct that a desert landscape may not have traditional forms of vegetation, but it can still be contemplative and have elements that promote positive mental health outcomes.

For example, a desert landscape may have unique landforms and patterns in the sand that can create a sense of awe and wonder. The play of light and shadow in the desert can also be captivating and calming, especially during sunrise or sunset. The stillness and quiet of a desert environment can also create a sense of peace and serenity.

The Contemplative Landscape Model recognizes that each landscape is unique and that different elements may be important in different contexts. While natural elements such as vegetation are often important in creating restorative environments, other elements such as landforms, light, and silence can also play an important role.

...moreover, the desert is a powerful archetype. The experience of being alone in the desert's harsh landscape is considered an existential experience.

You are correct that the desert can be a powerful archetype and evoke a variety of existential experiences.

The archetype of the desert can represent both harshness and isolation, as well as the potential for renewal and transformation. The vast and barren landscape can evoke feelings of solitude, self-reflection, and introspection, while also representing the potential for spiritual growth and renewal.

As such, the contemplative experience of being alone in the desert's harsh landscape can be considered an existential experience. The vastness of the landscape can make one feel small and insignificant but also connected to something greater than oneself. This sense of awe and wonder can promote a sense of mindfulness and presence, which can in turn promote positive mental health outcomes.

Where in the world Contemplative Landscape Model can be the most useful?

The Contemplative Landscape Model can be useful in many different parts of the world where there is a need to create outdoor environments that promote human well-being and foster contemplative experiences.

In particular, the model can be most useful in urban areas where people may have limited access to natural environments. Studies have shown that exposure to nature can have a positive impact on mental health and well-being, but many urban environments lack access to green spaces or natural scenery. By incorporating elements of the natural environment into urban design, such as green roofs, public parks, or street trees, the Contemplative Landscape Model can help to enhance the quality of the built environment and promote positive mental health outcomes.

The model may also be particularly useful in areas with high levels of stress or trauma, such as healthcare facilities or areas affected by natural disasters. By creating outdoor spaces that are designed to promote contemplative experiences and enhance the sense of calm, the Contemplative Landscape Model can help to improve the mental health and well-being of people in these high-stress environments.

Overall, the Contemplative Landscape Model can be useful in many different parts of the world, especially in urban environments and high-stress environments where there is a need to promote positive mental health outcomes and enhance the quality of life of users.

Can the Contemplative Landscape Model be used in developing countries?

Yes, the Contemplative Landscape Model can be used in developing countries. In fact, it may be especially relevant in these countries, where urbanization and rapid development are often accompanied by a loss of natural landscapes and green spaces.

In many developing countries, the lack of access to green spaces and exposure to nature can contribute to poor mental health outcomes. By incorporating elements of nature into urban design, the Contemplative Landscape Model can help to create environments that promote positive mental health outcomes, even in highly urbanized areas.

Furthermore, the Contemplative Landscape Model is designed to be adaptable to different cultural contexts and geographic regions. It is based on a universal understanding of human responses to different types of landscapes, rather than on specific cultural or regional factors. This means that the model can be applied in many different countries and contexts, including developing countries.

Overall, the Contemplative Landscape Model can be a valuable tool in promoting positive mental health outcomes and enhancing the quality of life in developing countries. By incorporating elements of nature into urban design, the model can help to create healthier, more sustainable, and more livable cities in these countries.

Which social and economic groups can benefit the most from contemplative landscapes?

Contemplative landscapes can provide numerous benefits to a wide range of social and economic groups. However, certain groups may benefit more than others.

One group that may benefit greatly from contemplative landscapes is those living in urban areas, especially those who lack access to green spaces and natural environments. This can include low-income communities, as they often have less access to parks and other outdoor recreational spaces. Contemplative landscapes can provide these communities with a way to connect with nature, reduce stress, and improve overall mental health and well-being.

Additionally, contemplative landscapes can be beneficial for individuals who experience high levels of stress, such as healthcare workers, caregivers, and those in high-pressure jobs. These individuals may benefit from access to outdoor spaces that are designed to promote relaxation and contemplation, which can help to reduce stress and improve mental health.

Finally, contemplative landscapes can be beneficial for individuals who are recovering from trauma or experiencing mental health issues. Exposure to nature has been shown to have a positive impact on mental health and well-being, and contemplative landscapes can provide a space for individuals to relax, reflect, and heal.

Overall, while contemplative landscapes can benefit many different social and economic groups, those who may benefit the most include those living in urban areas with limited access to green spaces, individuals experiencing high levels of stress, and those recovering from trauma or experiencing mental health issues.

How costly it is to implement contemplative landscapes in the city or a neighborhood?

The cost of implementing contemplative landscapes into a city or neighborhood can vary depending on a range of factors, such as the size of the area, the existing infrastructure, the desired design elements, and the level of community involvement. However, in general, incorporating contemplative landscapes into urban design does not necessarily have to be an expensive undertaking.

One simple way to create contemplative landscapes is by opening up views to distant natural scenes. Another key-principles of contemplative landscape design is the use of natural materials and low-impact design elements, which can help to keep costs down. For example, incorporating existing vegetation, such as trees and shrubs, can provide numerous benefits without the need for costly landscaping. Additionally, incorporating low-cost design elements, such as benches, walkways, and water features, can help to create a contemplative atmosphere without breaking the bank.

Furthermore, community involvement can be a crucial factor in keeping costs down. By involving community members in the design process and encouraging volunteerism in the construction and maintenance of the space, costs can be significantly reduced. This can also help to build a sense of community ownership and investment in the space, leading to long-term sustainability.

Overall, while there may be some costs associated with implementing contemplative landscapes into a city or neighborhood, the use of natural materials and low-impact design elements, as well as community involvement, can help to keep costs down and make the project more feasible for a wider range of communities.