Virtual Nature as an Intervention for Reducing Stress and Improving Mood in People with Substance Use Disorder

Abstract

物质使用障碍（SUD）困扰着美国很大一部分人口，每年造成的负面影响超过4200亿美元。这些人在整个康复过程中经常会经历负面情绪，包括焦虑、抑郁、压力和负面影响。目前，SUD的循证治疗策略包括认知行为治疗、动机访谈、12步计划和正念治疗。在患有SUD的个体中，有一项尚未深入研究的干预措施是利用自然环境作为治疗手段。在其他患者群体中，大自然通过调节自主神经系统功能、减轻抑郁症状和改善情绪来减轻压力和焦虑。这项研究的目的是调查观看自然录像是否同样能减轻SUD患者的压力和改善情绪。一个交叉设计被用来比较观看自然场景和练习基于正念的活动，为患有SUD的妇女在一个住宅治疗设施。在四周多的时间里，参与者在他们每日计划的前10分钟里参与了这两项活动。在每10分钟治疗前后，立即测量心率，单位为每分钟心跳（BPM）；使用积极和消极影响量表（PANAS）测量情感；使用从“非常不愉快”到“愉快”的10分评定量表测量整体情绪。36名女性完成了研究。在观看自然场景和练习基于正念的活动时，平均负性情感得分在统计学上显著降低( )和心脏率（ ）。In addition, for participants in both conditions, overall mood improved significantly ( ）。从这项研究结果提供了初步证据表明，观看自然具有与SUD恢复过程带来的压力和负面情绪的治疗MBT类似的优点，并且可以与SUD个人额外的，具有成本效益的治疗策略。

1个。介绍

Substance use disorder (SUD) afflicts a large percentage of the population, with negative implications that cost the United States more than $400 billion annually [1个,2个]。与SUD个人可向在不同场合不同的医疗服务提供者的治疗，但只有1/10收取任何形式的专业治疗为他们的障碍。治疗SUD通常包括行为，社会和认知干预行动，解决心理和情绪的影响，除了药物干预[三]。谁参与治疗了较长时间，如在住院治疗计划的个体，更可能停止使用的物质，减少犯罪的参与，并提高自己的能力函数[4个]。虽然使用的物质和恢复弃权是可能的，过程到那里不是一件容易的一个[5个]。

According to the recent Surgeon General’s Report, more than 60% of those who receive treatment for addiction relapse within the first year indicate the complexities and challenges of the recovery process [6个]。在整个恢复过程中，与SUD的个体经常遇到消极情绪，包括焦虑[7个–10]，抑郁症[11,12]，应力[八,10,12]，以及负面影响[9个,11,12]。酗酒个人增加的负面影响，失望，和无价值感，降低正面影响事业的渴望用酒精为调节情绪[11]。那些SUD和情绪或焦虑症有一个显著上升渴求强度与物质使用的相关频率和复发的风险[7个]。了解情绪和生理上的变化，个人在自己的恢复过程经历，特别是当它混有其他精神疾病，强调需要采用循证治疗方法，以协助恢复过程的范围[7个]。

Currently, nonpharmacological evidence-based strategies to treat SUD include cognitive behavioral therapy (CBT) [13,14]，激励访谈[15,16]，12步计划[17,18]，以及基于正念的治疗[19,20]。在过去的几年里，各种形式的基于正念疗法（MBT）的已越来越多地在SUD恢复治疗方案中实现的21]。MBT策略具有改善情绪调节和心情，减小的应力，和的物质更大程度地降低滥用相关联时与教育计划，支持疗法，松弛，图像和艺术治疗[比较12,19,21–24]。Hofmann and Gómez [25] found the effects of MBT for anxiety and depression to be comparable to CBT. Studies show that mindfulness-based cognitive therapy (MBCT) contributes to non-pharmacologic treatment approaches, reduces dysregulation of affect and risk of relapse of major depressive symptoms, and significantly reduces substance use [26,27,28]。Like other MBT approaches, mindfulness-based relapse prevention (MBRP) has similar benefits of improving emotional affect, mood and stress. In addition, compared with usual treatment, MBRP is associated with greater reduction in frequency of use, cravings, and withdrawal symptoms, and significantly lower expectancies of drug use [20,29–32]。In one study, MBRP outperformed 12-step and psychoeducational treatment strategies in their ability to reduce substance use [33]。周围的治疗SUD的使用MBT的研究表明，它是一个有前途的非药物的方法来保健的各种方式。

类似于MBT的好处,一般population, there is a large body of research on exposure to nature as an intervention for reducing stress, anxiety, agitation, and depression, as well as for improving mood [34–37]。这项研究是植根于减压理论，该理论认为，置身于大自然通过副交感神经系统，这是人类的先天和进化偏爱自然的环境[有利于激活减轻压力38]。Improvement in mood and reduction in stress have been found with both exposure to actual nature and to images of nature (e.g., pictures, slideshows, videos, and virtual reality). In some studies, individuals are exposed to a cognitive/emotional stressor, and after exposure to actual or images of nature, stress is reduced as indicated by reductions in heart rate and blood pressure and by parasympathetic response, which is measured by heart rate variability [4个,34,39–41]。情绪的变化与各种标准化规模和库存，如科恩 - 曼斯菲尔德激越问卷，状态 - 特质焦虑量表，并积极和消极情感量表（PANAS）测量。在普通人群中的情绪的改善也看到痴呆个人之间。大多数人患有痴呆症的经验负面情绪/影响如伴有行为很难照顾的人员来管理，并且搅拌和/或焦虑的人遇到情感[产生压力42,44]。与一般人群，直接置身于大自然已经证明，以减少负面情绪/影响与痴呆有关[34,39]。For example, studies have demonstrated that agitation is significantly reduced relative to time spent in outdoor gardens [44,45]。In several studies, reduced stress and improved mood were achieved in as little as 10 minutes of viewing nature [35,39,40]。

迄今为止，对自然的心理健康益处的研究已经在普通人群和个人与老年痴呆症之间进行。与SUD个体常常感到压力和负面情绪的恢复过程的一部分;然而，出现在使用性质的，与该人群的治疗研究仅限于基于荒野-SUD方案[46–49]。在自然的环境中进行一个定性研究，个人20-50岁报导享受和平，宁静，清新的大自然中，而不是将其视为混乱和激烈的典型处理环境的空气。在另一项研究，与会者报告享受与野生动物互动[50]。In these studies, treatment has focused on activities completed in nature rather than on the direct benefits of nature itself.

Given the stress and negative emotions experienced by individuals recovering from SUD and the large body of research supporting the mental health benefits of nature, it is important to examine whether these benefits could also be experienced among this population. Therefore, the purpose of this study was to investigate whether viewing a nature video could reduce stress and negative emotions among women in a residential SUD treatment program, after 10 minutes of exposure, as has been demonstrated with other populations.

2个。Methods

采用交叉设计，比较使用MBT策略典型的编程虚拟的自然条件。控制条件不能使用，因为服务不能从个人住宅的治疗方案扣缴。批准从北亚利桑那大学的机构审查委员会办公室收到开展此项研究。

2个。1个。Setting

这项研究是在一个住宅SUD处理设施，位于凤凰谷，仅用女性年满18周岁，并进行以上（60％为18岁至35岁），并提供治疗的三个阶段。第一阶段是高度结构化的和密集的程序，其包括对等辅导，教育节目，12步会议，SMART恢复组，和咨询。第二阶段包括类似的编程为第一阶段，但更侧重于重返社会，就业服务，以及更高层次的生活技能。第三阶段是在门诊的程序，进一步发展了以前学到的技能，继续走向复苏和健康的工作。在治疗第一阶段的所有参与者都被邀请参加这项研究由于时间在该设施的平均长度，在第一阶段出现复发的可能性，以及结构化相的性质。

2.2。人口

这项研究包括了妇女谁是18岁以上，并参加了SUD治疗方案的第一阶段。排除标准的18谁见了这些入选标准提供所描述的研究为目的的同意书所有感兴趣的居民岁以下的女性。基于通过一项类似的研究[51], using a power of 0.90, a sample size was determined to be 40 participants, each with 16 data collection times in a two-treatment crossover design. Forty-five women provided consent, and five withdrew from the recovery program before the study began. Among the 40 women who provided consent, 36 participated throughout the study period. The reasons for attrition included leaving the residential treatment facility, not being at the facility during the entire length of the study or transitioning to the second treatment phase.

2.3。程序

妇女在恢复程序的每一天开始在预先指定的组中与同龄人有三个大房间和至少一名工作人员之一。每天早晨，在节目开始时，参与者无论是观看性质的视频或从事的MBT活动第10分钟他们的日常节目。MBT活动对恢复程序典型的编程。在为期四周的研究中，参与者被曝光每周2天至性质的视频与自然的声音和一个星期的MBT 2天。这些暴露每周改变对于每个三组参与者的顺序（表1个）。

该MBT条件包括10分钟的活动，比如静静坐着冥想，或听的引导冥想，或从工作人员阅读。这些活动向变根据该工作人员的计划;然而，每一个会议是与标准的MBT技术一致。在自然界中视频条件，参与者观看的高清晰度，固定角性质视频与天然存在的声音。相同的视频显示了整个研究。视频显示俯瞰太平洋，并在前台自然发生的声音从现场树木，瀑布度过了一个悬崖，海鸟新兴进出来看，和悬崖顶视图（图1个）。参与者只需指示始终保持了十几分钟安静和视频的直接视野内坐。

Prior to and immediately after 10 minutes of viewing the nature video and participating in the MBT activities, the participants’ heart rate was taken using a pulse-oximeter and mood was assessed using the 10-item self-report PANAS [52]和自我报告从非常不愉快（1）在10分制评定整体情绪的非常愉快（10）。这10项措施PANAS积极的兴趣，兴奋，强壮，热情，骄傲，警觉，鼓舞，决心，专注，积极的影响。负面影响是为心疼，难过，内疚，恐惧，敌对，易怒，惭愧，紧张，战战兢兢，不敢测量。

研究人员训练的人员来监视参与者的有效性，同时和记录心脏速率，评估和评级整体情绪，在每次条件后。在研究开始时，研究人员和研究助理出席了10分钟的时间内，以支持员工，并帮助确保数据收集的完整性的开始和结束。由研究人员和研究助理的监督也逐渐消失一段时间工作人员协助参与完成研究方案论证能力。

2.4条。数据分析

概要描述性统计计算为装置（标准偏差）和计数（百分比）。基于模型的统计计算为装置（平均值的标准误差）。广义估计方程方法是用来评价在每次条件后以及条件之间分摊在心脏速率，负和正影响，和整体情绪差异。预VS后置条件的测量和条件类型（性质VS MBT）之间的相互作用是主要感兴趣的;然而，主要的影响也是感兴趣的。的0.05（双尾）α被用作准则统计学意义。SPSS版本。25是用于分析。

三。Results

Thirty-six participants completed the study, with 30 reporting their age, which ranged from 18–61 years (36.2 ± 12.7). All participants were in the first phase of treatment and had a diagnosis of SUD. As requested by the recovery program, additional sociodemographic data were not collected to respect the women’s anonymity. Due to inconsistency in attendance by the participants in the research study, complete data could only be obtained for 9 conditions out of the 16 projected at the beginning of the study. Participants missed days when data were collected due to not entering the treatment facility until after the study began, attending an appointment that required them to miss the first part the group and/or leaving the treatment facility prior to the conclusion of the study. There was not a single participant who participated in all 16 days of the research study. The days missed ranged from two to nine (mode = 4 days missed, mean = 5.89 days missed).

As a result, analysis was performed using data from 9 conditions for the 36 participants. Considering the truncated number of conditions that could be evaluated, the adequacy of our sample size was reconsidered. Given the crossover design and nine repeated measurements available, 36 participants would yield .90 power to detect an effect size (f) of .16, alpha = 0.05, assuming an average correlation of右 = 0.60 across contiguous measurements. This effect size is analogous to Cohen’s丁 = 0.32, classified as “medium” [53]。

概要描述性统计计算为装置（标准偏差）和计数（百分比）。基于模型的统计计算为装置（平均值的标准误差）。A generalized estimating equations approach was used to evaluate differences in heart rate, negative and positive affect, and overall mood assessed before and after each condition as well as between conditions. Specifically, the change scores from pre- to postsession were calculated for each participant, and then these values were modeled by group over time. The average change scores for each session, by group, are provided (Figures2个–4个）。预VS后置条件的测量和条件类型（性质VS MBT）之间的相互作用是主要感兴趣的;然而，主要的影响也是感兴趣的。的0.05（双尾）α被用作准则统计学意义。SPSS版本。25是用于分析。

After 10 minutes of participation, mean heart rate decreased 3.76 BPM in the MBT condition and 5.61 BPM in the nature video condition from pre- to postmeasurement ( ）。这种变化没碰到过条件不同（图2个）。情绪的分析表明，在平均PANAS负统计学显著减少影响分数（ )在这两种性质视频（-0.9074）和MBT为（-1.7394）条件下预至postmeasurement，尽管在变化没有差异跨越条件指出（ ;数字三）。PANAS积极影响分数没有观看性质的视频（平均变化-0.4155显著变化; )or participating in the MBT activities (mean change −0.0049; ）;没有被跨越的条件观察到显著差异（ ）。整体情绪（愉悦感）明显改善( )对于这两种情况，平均变化得分的0.2369观看性质和0.2938为MBT（图4个）。

4个。讨论

To our knowledge, this is the first study to be reported on the effects of virtual nature on measures of stress and mood. The results indicate potential that viewing and listening to nature videos (virtual nature) could be beneficial as an adjunctive therapy in SUD treatment programs. Key findings are statistically significant decreases in heart rate (a measure of stress reduction) and negative affect and improvement in overall mood among participants in both conditions in only a 10 minute timeframe. These results are consistent with prior research on the benefits of viewing nature for reducing stress and improving mood [34,39,54,55]，有10分钟的时间范围内[35,56,57]。这项研究的结果也表明，观察大自然似乎是基于正念的策略同样是有益的。虽然SUD恢复方案正在越来越多地使用MBT策略[12,20,21,24]，从这项研究结果提供了初步证据表明，观看自然可以作为额外的编程策略，与基于正念的策略类似的好处。

While the results of this study show a reduction in stress, as measured by heart rate, and negative affect, and an improvement in overall mood, interestingly positive affect did not improve in either condition. Perhaps the lack of improvement in positive mood may be explained by data collection occurring in the morning at the start programming when participants may have a higher level of positive mood and therefore less change is available to be measured. In future studies, it may be beneficial to examine the effect of conditions offered at various times of the day, to assess if a similarity or difference among conditions exists. Given the constraints of conducting the study within an existing program, measurement of mood took place in a group environment with as many as 18 other participants, with people coming into the group at varying times during pretesting and with talking among participants. This context may have influenced the mood and possibly self-reporting of mood. While previous studies have used heart rate as a measure of stress reduction [37,38,39,41]这项研究的局限性在于它是唯一使用的生理测量方法。在未来的研究中，诸如血压和/或心率变异性的额外测量可以加强结果测量。这项研究的一个关键限制是不能使用对照条件，因为不能拒绝参与者接受治疗。缺乏控制条件可以解释自然视频和MBT条件下情绪和心率的相似结果，并反映类似的放松条件。虽然功率分析确定需要16次暴露，但仅获得9次暴露，因为参与者错过了非现场预约的研究日，在研究开始后进入康复计划，或在研究结束前停止参与治疗计划。

5。结论

Despite the limitations of this study, the results with only 9 conditions demonstrate great potential for virtual nature being used as an additional nonpharmacologic treatment strategy in in SUD programs, especially those in urban settings. Given that only 1 in 10 individuals receive specialty treatment for SUD [三], use of virtual nature has a practical application as a cost-effective treatment strategy that can be readily implemented to provide an acute effect for stress reduction and improvement in mood. This treatment approach is cost-effective because it requires only a large screen high-definition television and nature videos of landscape images that have elements shown to be therapeutic. In addition, very little staff training is needed to implement virtual nature treatment, thereby maintaining its low cost. While virtual nature could be used as a treatment strategy during organized programming, it has the added benefit of being used by members of SUD programs on an as-needed basis, when struggling with some of the negative emotions that occur with the recovery process. Having a room or area set up as a “virtual nature space” would allow members of SUD programs to self-manage emotions by utilizing the space on an as-needed basis. Virtual nature used in this way could therefore become part of a host of strategies that are routinized for self-management of the recovery process. While actual nature would be preferential, virtual nature is a cost-effective option for treatment facilities, who would not be able to afford the higher costs of creating an outdoor therapeutic garden. In addition, virtual nature may benefit treatment facilities located in urban areas, where land is at premium, and access to an outdoor space—for example, to create a therapeutic garden—is not available.

创建虚拟性质的空间，用作独立的，自选择的治疗策略或集成到编程，提供SUD恢复程序参与者提供常规化疗法的工具，可用于维持应力降低和放电之后以及在其整个恢复改善情绪.可通过各种在线媒体来源性质的流行视频使这是一个可行的选择。随着好处自然知识，个人的恢复可以结合通过走访当地的公园，以帮助维持复苏观看虚拟性与大自然直接接触;两者的经验有证据支持他们的心理健康益处。

数据可用性

用于支持该研究的数据可以提供，请通讯作者。

Conflicts of Interest

作者宣称，他们没有利益冲突。

Acknowledgments

作者想感谢参与人员和工作人员谁帮助完成了这个研究项目。此外，还特别感谢北亚利桑那大学西南健康公平研究合作组织（NIH/NIMHD RCMI U54MD012388；Baldwin/Stearns MPI）在编写本手稿时使用了他们的服务。

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