Printable Version 

Assessing Surroundings

For someone like Andrea, it will help to go into more detail about Surroundings as part of the Integrative Health Assessment; doing so can act a springboard into conversations about how to incorporate surroundings into the Personal Health Plan (PHP).

Mindful Awareness Moment

Assessing Your Own Surroundings

• How is your home environment? What one thing could you change, right now?
• How about your work environment?
• What sort of emotional surroundings do you experience each day?
• How much do your surroundings—physical and emotional—affect your well-being?
• How important are your surroundings to you, compared to the other seven areas of self-care within the Circle of Health.

The handout “Assessing Your Surroundings” offers additional questions.

You can ask Andrea to take stock of several possible areas, noted above. Note what arises that could receive more attention in her PHP:

• Home. Andrea lives alone. She rents an apartment that she does not like. The cost of living is high in the city where she lives, so she has to keep room temperatures cold in the winter. She lives in a neighborhood that has a lot of crime. Her home is cluttered, but she keeps it relatively clean. She is not a hoarder. Sometimes she sees roaches. She has a smoke detector. No air conditioning, but fans work to cool down her apartment. She drinks filtered water.
• Work. Andrea likes her job, but she is competing for a promotion, and that has created tension with her coworkers. When not working from home in her apartment, she works in a cubicle that is quite noisy. She has not taken the time to decorate it. She has had carpal tunnel symptoms lately from using her computer. She takes a total of 10 minutes of breaks a day, if that, and she works through her lunch time. Her office environment has some natural light and, unlike her apartment, is never too cold or hot.
• Toxins. Andrea does not know of having any current toxic exposures. She is never around people who smoke. No seasonal allergies, but she tries to avoid gluten. She thinks there is some asbestos in her building, but they have supposedly taken care of it. No exposures to radon or lead. She does report having an array of chemical sensitivities, especially to volatile organic compounds.
• Senses. Her living space is neither comfortable nor peaceful. Her sleep is poor because of noise and a lot of light coming through her bedroom curtains. Her apartment has radiators that do not work well, and she hates to pay for electricity for portable heaters. Andrea wishes she had more light. No plants; okay furniture. She does not have any art or photographs on the walls.
• Emotions. Andrea reports being happy once a week, usually after a she makes good progress at work, or if she has a date that goes well. No experiences of violence, including intimate partner violence, either at home or at work. She does not have any close friends or family who are local. She says she spends too much time online and he gets caught up following the news, even though it stresses her out. She works 60-70 hours a week, because she works from deadline to deadline. No vacations in the past year. Too tired at the end of the day for hobbies.

The next five sections explore various aspects of Surroundings in greater depth. Note that all the circles highlighted in Figure 1 are covered.

1. Home: Improving Living Conditions

---

He is happiest, be he kin or peasant, who finds peace in his home.

–Goethe

---

When you are helping a person create a PHP focused on Surroundings, it is helpful to start with a discussion of their living situation. Do they have a home? Who lives with them? What is it like to live there? How clean and organized is it? How comfortable is it? According to the National Center for Healthy Housing, a healthy home should be all of the following¹:

• Dry
• Clean (refer to “Clutter, collecting, hoarding, and squalor” later in this section)
• Pest-free
• Safe
• Contaminant-free (refer to “Section 3. Exposures and Toxins” below)
• Ventilated
• Maintained

Back to basics: Homelessness

Before people can focus on their home environment, they need to have a home in the first place. Always keep homelessness in mind as you are exploring Surroundings with someone. Here are some key facts on homelessness:

• Lifetime prevalence of homelessness in the United States has been estimated to be between 5% and 14%.²
• 73% of homeless people have unmet health needs.³ An estimated 40% of homeless people are dependent on alcohol, 25% are dependent on drugs, and mental illnesses are common as well, with a prevalence of 11% for depression, 23% for personality disorder, and 13% for major psychotic illness.
• Homeless veterans have four times the odds of seeking care at emergency departments (EDs) than non-homeless veterans. Homeless ED users were more likely to have a diagnosis of drug use disorder (odds ratio [OR] = 4.12), alcohol use disorder (OR = 3.67), or schizophrenia (OR = 3.44) in the past year.⁴
• Fortunately, the federal strategic plan to decrease homelessness in the United States has made a difference. For example, through the efforts of the VA, homelessness among Veterans declined by 50% between 2010 and 2017⁵.
• VA Homeless Veterans Aid Line
• 1-877-4AI-DVET
• 1-877-424-3838

Clutter, collecting, hoarding, and squalor

In her PHI, Andrea expressed concern about the level of clutter in her home. Some people simply need guidance or encouragement related to tidying up, but for others, the situation may be more complex. A home visit might help assess the severity of the problem, if appropriate.

Hoarding

An estimated 5% of people fit the criteria for being hoarders.⁶ Hoarding is included in the fifth Diagnostic and Statistics Manual (DSM-5) as a discrete diagnosis. Hoarders are not just collectors; they are not just dealing with clutter or challenges with being organized.⁷ Their living spaces are cramped, unsanitary, and potentially dangerous. The key characteristic of hoarding behavior is that it interferes with a person’s quality of life and normal functioning. In roughly half of hoarders’ homes, items such as the sink, tub, stove, or shower are not used because they are full of accumulated objects.⁸

Hoarding behavior seems to begin for many in the teen years after a traumatic or stressful event, and it typically worsens in middle age.⁸ It has been linked to genetics, neurocognitive functioning, avoidance tendencies, and personality traits⁹. Hoarding runs in families, and 75% percent of the time, it is associated with other mental health issues, such as depression, alcohol abuse, anxiety, or dementia. Hoarding behavior is viewed by many as being closely related to obsessive-compulsive disorder (OCD), and people who have OCD and are hoarders have worse outcomes than people with OCD who do not hoard. Hoarders seem to experience negative emotions more intensely and to have lower tolerance for them¹⁰.

If a person mentions dealing with a lot of clutter, it is worth exploring whether or not he or she meets criteria for hoarding behavior. Unfortunately, diagnosing it is easier than effectively treating it. Selective serotonin reuptake inhibitors (SSRIs) are now thought to be more helpful than previously assumed,¹¹ and cognitive behavioral therapy is helps too.¹¹ A small study found venlafaxine to be helpful¹². Forcible cleaning and organizing by a family member or other concerned party does NOT improve the situation, primarily because most people who hoard do not view their behavior as problematic. Furthermore, they tend to refill a newly cleaned space with new hoarded items. One tragic outcome of hoarding behavior is that hoarders experience a high level of rejection by family members; it is on par with the rejection experienced by schizophrenics.⁸ For more on hoarding, check out the information available through the International OCD Foundation.

Squalor

In contrast to hoarding, where accumulated objects may lead to unsanitary conditions, squalor specifically involves the accumulation of refuse (garbage) in the home.¹³ In a review of over 1,100 cases of people living in squalor, half of them were elderly, and they commonly struggled with dementia, alcoholism, or schizophrenia as well.¹⁴ Questions from the “Environmental Cleanliness and Clutter Scale,”¹⁵ (ECCS) can help, assess for squalor. Scoring 12 or higher on the ECCS scale suggests a person lives in squalor.

Key questions the ECCS focuses on include:

• Accessibility.
  • How easy is it to move around the dwelling?
• Accumulation of garbage.
  • How much refuse is there in garbage cans, the kitchen sink, etc.?
• Collection of “items of little obvious value.”
  • Do they have huge numbers of plastic backs, old newspapers, pieces of thread, or other such items?
• Cleanliness of floors, carpets, furniture, bathrooms, and the kitchen.
  • Are things hygienic?
• Presence of odors.
  • Is there a foul smell?
• Presence of vermin.
  • Did you see anything scurrying around when you visited their home?

Living conditions: Other considerations

Pests

Whether someone is living in squalor or not, ask about pest control, if appropriate. The Centers for Disease Control and Prevention (CDC) has a number of resources on dealing with different pests. In the past several years, bed bugs, in particular, have made a comeback in many American homes.¹⁶ The CDC website has a patient information page on bed bugs. Good resources for health care professionals include the educational materials at the University of Kentucky Entomology website.

Accident prevention

In addition to reminding people about having smoke and carbon monoxide detectors, be sure to assess for fall risk, if possible.

Weapons

As you think about surroundings, be sure to ask people – particularly veterans¹⁷ – ALWAYS ask about suicide risk. When appropriate, pass along the number for the Suicide Crisis Line: 1-800-273-8255.

2. Work Conditions

Surroundings at work, both physical and emotional, also influence health. Employed Americans with children have workdays that are an average of 8.8 hours long.¹⁸ It is important, knowing that a significant proportion of many people’s lives are spent at work, to ensure that work surroundings are as healthy as possible. Having a job at all is good for one’s health, and factors like work safety, ergonomics, and relationships with coworkers matter as much as the physical attributes of a person’s workspace. If a person has a job that they find stimulating, and they have a lot of autonomy at work too, they will have a 34% decrease in their odds of dying¹⁹. Of course, dealing with the demands of work can lead to problems. For more information, refer to “Healthy Work Habits: Avoiding Workaholism.”

Back to basics: Unemployment¹⁸

Having an income, much like having shelter, is a fundamental need. Data for 20 million people indicates that not having a job markedly increases mortality; the hazard ratio is 1.63.²⁰ Unemployment also contributes significantly to chronic illness, including many mental health problems.²¹ The relative risk of suicide in those who have become unemployed in the past five years, as compared to those who are employed, is 2.50.²² Unemployment rates have substantially increased with the COVID-19 pandemic.

Ergonomics and repetitive use injuries

Keep ergonomics in mind as you think about surroundings. Ergonomics is, as the CDC puts it, “the scientific study of people at work.”²³ Its goal is to reduce problems related to repetitive use of muscles, muscle overuse, and poor posture. It also tailors tasks and tools to an employee’s capabilities and limitations. Ergonomics changes can support individual employee’s health and well-being and lead to a more sustainable workforce²⁴.

Mindful Awareness Moment

Notice your body position right now, as you are reading this material. How are you doing from an ergonomics standpoint?

• Are there any parts of your body that feel fatigued?
  • Your neck?
  • Your lower back?
  • How do your hands feel turning pages or using a mouse or a keyboard?
  • Are your eyes fatigued?
• How are the ergonomics of other places where you spend a large proportion of your time?
  • For workspaces, either at home or at work?
  • What about for where you sleep?

Think of one positive change you can make, and set a goal.

Study findings regarding the efficacy of ergonomic interventions are mixed, but they find moderate benefit for some conditions, such as work-related neck problems. Chair-based interventions seem to help reduce musculoskeletal symptoms²⁵. There is less data supporting ergonomic interventions for the upper limbs,²⁶ and it is not clear that ergonomic positioning or equipment help for carpal tunnel syndrome.²⁷ A 2015 review of 28 studies related to ergonomics and health care concluded that ergonomic interventions, in general, improve outcomes for health care workers²⁸ overall.

Various work-related interventions are safe to try, and they are worth discussing with people who have work-related problems. For people like Andrea, who work at a computer a significant amount, we know that ergonomics is worth offering²⁹. For more information, check out the “Improving Work Surroundings through Ergonomics” tool. It offers specific suggestions for common work-related problems.

3. Exposures and Toxins

We are exposed to thousands of toxins daily, including air pollutants, pharmaceuticals in our drinking water, heavy metals, and pesticides. In 2016, the World Health Organization (WHO) concluded that at least 12.6 million people die each year because of preventable environmental causes, almost a quarter of all yearly deaths³⁰ worldwide.

A 2011 systematic review found that in 2004, 4.9 million deaths (8.4% of the total number worldwide) and 86 million Disability-Adjusted Life Years (DALYs) were attributable to specific environmental exposures.³⁰ The biggest culprits were smoke from solid fuel use, second-hand smoke, occupational exposures, chemicals involved in acute poisonings, and air pollution. Indoor air pollution, specifically, has been linked to 3.5 million deaths each year³¹. The authors note, however, that many chemicals known to cause harm could not be included in their review due to lack of data; we simply do not study all the potentially harmful compounds we are already using.

When thinking about surroundings and health, it can be less overwhelming if one focuses on reducing total chemical burden; that is, focus on specific ways to reduce just one or a few exposures at a time. Exposures a person could minimize can include anything from cigarette smoke or wood smoke to chemicals used in farming and car exhaust. One can eat foods that are less likely to contain pesticide residues, avoid bisphenol A in beverage containers, or use more “green” household cleaning products, for example. For more information specifically about toxins in food, refer to the tool “Food Safety”. Chapter 6 of the Passport to Whole Health includes a clinical tool on “Detoxification” that discusses what we know about popular ways to “detox” the body. The diagram in Figure 3 conceptualizes the various types of exposures we might encounter in our day-to-day lives.³⁰ Again, working to reduce any one of these may be beneficial.

Figure 3. Environmental Health: Potential Sources of Toxic Exposures.

Reproduced with the permission of the publisher, from Environmental Health, Geneva, World Health Organization, 2011.³⁰

The number of potential environmental toxins is vast. Fortunately, there are a number of resources that can be helpful. The National Library of Medicine’s Medline website includes a well-done introduction to environmental health and links to key resources. Check out the “Related Health Topics” list on the right side of the screen. Topics include air pollution, drinking water, mold, noise, and water pollution.

Environmental Exposure Resources

Water quality

• United States Geological Survey: A Primer on Water Quality
• Centers for Disease Control and Prevention: Drinking Water

Moisture and mold

• National Library of Medicine: Molds
• Centers for Disease Control and Prevention: Mold
• World Health Organization Guidelines for Indoor Air Quality: Dampness and Mould

Electromagnetic fields (EMFs)

• World Health Organization: Questions and Answers, Electromagnetic Fields

Idiopathic Environmental Intolerances

Our patient, Andrea, notes that paint fumes and other chemical odors elicit various symptoms for her. She is likely one of 12-30% of people who have idiopathic environmental intolerance (IEI) to airborne chemicals.³²

IEIs have been given many names, ranging from sick building syndrome to multiple chemical sensitivity. Gulf War syndrome shares similar characteristics. Some key points to know about working with these challenging conditions include the following:^33,34

• Many organizations do not recognize IEI-related disorders as “official” diagnoses.
• Theories about the etiology of these problems abound. Some focus on biochemical pathways, while others emphasize the relationship between IEIs and mental health-related issues.
• IEIs are chronic, with reproducible symptoms that are often elicited with low levels of multiple, unrelated chemicals. Symptoms are reproducible and can involve any number of organ systems.
• These disorders have any number of triggers; common examples include off-gassing from appliances, ink, exhaust fumes, and chlorinated water.
• Many different symptoms are associated with IEIs, which makes treatment especially complex.
• The best ways to treat these disorders is avoidance, which can be quite challenging if a person is experiencing symptoms related to items in or near their homes. Biomolecular approaches (medications, supplements) do not seem to be particularly effective for IEIs, according to large-scale surveys of people with these conditions. Mindful awareness and mind-body practices, are generally viewed by patients as the most helpful approaches they have tried.
• These problems can resolve over time, but not for everyone.

For additional information that can be used for both patients and clinicians, refer to the Osher Center’s module: “An Integrative Approach to Environmental Intolerances: Multiple Chemical Sensitivity and Related Illness.”

4. Sensory Input and Health

When you think of a healing environment, what comes to mind? A spa? A Japanese garden? Perhaps a corner of your house? Few of us would immediately think of a clinic or hospital. But that view is beginning to change as health care organizations are becoming aware of the growing body of evidence that shows the benefits of a healing environment, and are incorporating ideas generated by such studies into new facilities.³⁵

Healthy food for the senses: simple approaches

We know that our sensory environments have a significant impact on health³⁶. Light levels affect mood and sleep quality.³⁷ Loud noises can influence blood pressure and heart rate for hours after a person hears them. Music can have a variety of effects, including providing a sense of calm, depending on the type of music and individual preferences³⁸. Choosing the right color can change the feel of a space; cool tones slow the autonomic nervous system, while warm tones activate it.³⁹ Displaying art—particularly art that features the natural world—improves patient outcomes.⁴⁰ A 2014 Cochrane review reported that additional studies are needed, but there is no harm in changing sensory surroundings to support health⁴¹. A 2014 systematic review concluded that the “built environment” of a hospital plays an important role in outcomes, particularly when it comes to audio and visual aspects of a space.⁴²

In discussing sensory input with people, take a moment to ask them to describe their living and work spaces in more detail. Explore the following topics:

• Light (light levels during the day and during the night)
• Noise (traffic, sirens, neighbors)
• Color
• Temperature (sufficient heating and air conditioning)
• Presence of nature (plants, aquariums, views outside)
• Smells

People often have a number of great ideas about improving their sensory surroundings, if they are simply given a bit of encouragement. Examples include the following:

• Buying light-opaque curtains or a sleep mask
• Wearing earplugs to bed
• Painting a room or adding more art to the walls
• Buying an electric heater or fan
• Buying a plant or fresh flowers
• Walking in a local park
• Opening windows
• Having smokers cut back and/or smoke outdoors
• Cleaning with less noxious household products
• Changing humidity levels to decrease mold growth

Sensory inputs and beyond in health care settings

Environmental design draws from evidence-based findings regarding what aspects of a health care environment can enhance health, above and beyond what is “done to” patients in terms of tests and procedures. It factors in the following areas, among others, as fundamental aspects of OHEs⁴³:

• Patient choice and control
• Enhancing human connection
• Reducing negative sensory inputs
• Ensuring patients can find their way around a given site
• The presence of art and subject matter that is most likely to be healing
• The role of color in healing environments
• The importance of light and sound levels for healing
• Music and healing
• Drawing nature into health care settings

For more detailed information about each of these, along with a synopsis of research findings and specific guidelines for how you, as a clinician, can use environmental design in your own practice refer to, “Healing Spaces and Environmental Design” in Chapter 6 of the Passport to Whole Health. There is also “Informing Healing Spaces through Environmental Design: Thirteen Tips,” a tool that goes into more detail regarding research findings.

The power of nature⁴⁴

Whenever you create a health plan with someone, consider whether or not spending more time in nature—time in green spaces—would be helpful. There is good support in the medical literature for spending time in parks, gardens, and other areas of natural beauty. Here are some examples of some relevant studies:

• An analysis of data from the US Nurses’ Health Study found that those with the highest quintile of “cumulative average greenness” near their home had a 12% lower rate of all-cause nonaccidental mortality than nurses in the lowest quintile⁴⁵. A review of 12 studies that involved millions of people around the world found a correlation with “higher residential greenness” and mortality from cardiovascular disease, but it noted more data were needed to determine if there was a reduction in all-cause mortality⁴⁶.
• Prevalence of 15 out of 24 different “diseases clusters” was lower for people living within a 1 kilometer of green spaces, in a study that included data for over 345,000 people in the Netherlands⁴⁷. Depression and anxiety were affected more favorably than other disorders, and there were also benefits for neck and back complaints, asthma, migraines and vertigo, diabetes, and medically unexplained physical symptoms, as well as other health issues. The benefit was strongest for people with low socioeconomic status and children.
• Urban green spaces have favorable impacts on physical activity, mental health and wellbeing, and social contact, in addition to all the ecological benefits they confer⁴⁸. Mental well-being is associated with both number of green spaces and acreage of green spaces, in a way that supports a dose-response relationship⁴⁹.
• Time in outdoor environments reduces stress, according to a 2018 review that looked at heart rate changes, blood pressure changes, and self-report measures³⁶.
• A 2016 review concluded that, while studies were limited, there was a suggestion of an association between exposure to nature and healthier childhood cognitive development and adult cognitive function⁵⁰. People with dementia who are in care facilities seem to have less agitation if they spend time in a garden⁵¹.
• Green exercise, which is activity in a natural setting, increases self-esteem and mood, particularly for people with mental illness. Any sort of green environment has benefit, but the presence of water leads to even greater effects⁵². In a review of 13 trials, 9 of them showed that green exercise had more benefits than indoor exercise when it came to increases in energy and revitalization and decreases in depression, tension, confusion, and anger⁵³.
• Nature Deficit Disorder, a term coined by Richard Louv, was described based on a concern that limited exposure to the natural world has a profound negative impact on children (and people in general⁵⁴).

5. Emotional Surroundings

---

It was only from an inner calm that man was able to discover and shape calm surroundings.

—Stephen Gardiner

---

Many aspects of physical surroundings influence Whole Health. The same is true for emotional surroundings. As you talk with people about their emotional well-being, take time to explore what in their surroundings brings them happiness. It will vary from person to person. It may be a particular attribute of a place, or the memories associated with it. Introverts may be more comfortable in surroundings where they have more solitude⁵⁵; extroverts may feel better in groups of people. An activity like climbing might be a joyful experience for one person and a terrifying one for someone else. Mindful awareness can be useful, because we need to know what ours emotional states are and why before we can begin to set emotional surroundings-related goals.

Surroundings influence emotions, but the reverse is also true. Data from thousands of people, compiled by groups like the National Opinion Research Center at the University of Chicago, suggests for most people, happiness does not depend significantly on external circumstances. Wealth, in particular, is a poor predictor.⁵⁶ More optimistic, altruistic, and generally happy people are less likely to be affected by challenging external circumstances; their emotional health allows them to handle their surroundings and stay healthy.^57-60

Mindful Awareness Moment

Noting Emotional Surroundings

Part One. Pause for a moment and assess your current internal emotional state.

• What emotions are you experiencing in this moment?
• Where do you feel those emotions in your body?
• If you had to assign those emotions a color, sound, or texture, how would you describe it?

Part Two. Now, take a moment to assess your emotional surroundings.

• If there are people around you, do you have a sense (through their spoken language or body language, or even based on your intuition) what they are feeling?
• Does your current location allow you to feel at ease, or do you feel tense or as though you have to be on your guard? Why?
• How does this location influence how you feel? Is there anything about this place that influenced the emotional state you identified in part one of this exercise?

What is one thing you could do to make your current location more supportive of positive emotions?

It can be helpful to have a patient take a minute or two to list what makes them happiest. Then, have them list a few sources of unhappiness. Bringing awareness in this simple way can inform how they write their Personal Health Plan. How might a person bring in more joy, and how might they decrease sources of sadness, fear, and anger? Perhaps more importantly, can they learn to work constructively with their emotional responses to the outside world, whatever those responses might be? That is the focus of many meditation practices.

Here are a few simple suggestions for improving emotional surroundings.

Incorporate more humor

Humor can be an important aspect of healthy emotional surroundings. Even before Norman Cousins described how he used humor for his own healing in 1975, humor was noted for having healing benefits.⁶¹ For example, laughter leads to increases in heart and breathing rates and oxygen consumption, reduced muscle tension, decreased cortisol, and improved immune function.^62,63 “Laughter Heals,” has more information.

Bring pets into the picture

One potential contributor to emotional surroundings is the presence of pets and other animals. Animal-assisted therapy (AAT) is known to decrease heart rate, pain, anxiety, and depression, and pet ownership is known to have a number of health benefits.^64,65 For more information, check out the “Animal-Assisted Therapies” tool.

Note the influence of media and technology and information overload

We live in an era of information overload (also known as infobesity, infoxication, information glut, data smog…yikes, information overload is happening in this very sentence!). Information overload is linked to poorer memory.⁶⁶ In prehistoric times, it served people well to seek and pay close attention to new information; this is not so helpful when we have almost unlimited access to billions of webpages, tweets, texts, and emails.

In the media, the estimated ratio of negative to positive content has been estimated to be roughly 17:1. That is, there are 17 times more negative stories than positive ones in the news.⁶⁷ People in the media know they sell more newspapers and have higher ratings if they focus on the negative. As they say, “If it bleeds, it reads.”

The bottom line is when you ask people about their surroundings, remember to ask about their virtual surroundings, which can have a significant effect on stress, mood, and overall perceptions of the environment. Many people find it helpful to periodically do a media/information fast.” Simply unplug for a period of time. There is more information in the tool, “Too Much Bad News: a Media/Information Fast”.

Assess if person is a highly sensitive person (HSP), and support them accordingly

It has been argued that 10% or so people meet the criteria for being a “Highly Sensitive People” (HSP). Psychologist Elaine Aron described what it means to be a “highly sensitive person” in her 1996 book of that title.⁶⁸ HSPs:

• Are easily overwhelmed by intense sensory experiences
• Have trouble with being rushed or needing to make deadlines
• Work to avoid upsetting or overwhelming situations
• Tend to have a heightened esthetic sense
• Like to withdraw after intense times, such as a busy day at work
• Tend to avoid violence, including in movies and TV

More information on highly sensitive people is available at The Highly Sensitive Person website.⁶⁹

When dealing with HSPs, it can be helpful for clinicians to keep the following in mind:

• They are highly attuned to whether or not clinicians are hurried or stressed, and they may limit what they disclose in a visit accordingly.
• Many of them tend to respond to very low doses of medications—both in terms of therapeutic benefits and adverse effects.
• It may help to encourage them to show up 10-15 minutes before they are supposed to see their clinician, if they have a tendency to be late.
• They may be affected strongly by the lighting in offices and examination rooms. Some will ask that you use scent-free hand cleaners.
• They often do well with visualization exercises and guided imagery. It can be helpful to have them envision themselves in a protective “bubble” or “shield” that helps them filter out some of the stimuli feel overwhelming to them.
• HSPs often benefit from encouragement to honor their introvert natures and take a set amount of time as alone time or time just for them each day.

As with all aspects of Surroundings in Whole Health, be creative, and encourage people to ask, at a deep level, what they want and need. For many of them, tapping into their emotional health will not be easy. It might help to look outward at emotional surroundings before looking inward at how traumatic experiences and other factors have had emotional health effects.

Back to Andrea

As Andrea discussed her Personal Health Inventory (PHI) and her surroundings with her primary provider, she gained insights into what she wanted to put into her PHP. The following are some of the goals she set, with the help of her entire care team. Note multiple goals are mentioned here, for the purposes of teaching, but in a typical visit, it is more likely that a person would only choose one of the following as an initial goal and then circle back after they are successful to set additional goals:

• Andrea struggles a great deal with clutter, but she does not meet criteria for hoarding behavior. She will explore how to declutter and save enough money to hire a professional organizer or housekeeper to help her, at least for a short period of time.
• Andrea’s clinician reviewed information about idiopathic environmental intolerance (Environmental Intolerances/Multiple Chemical Sensitivity) with her, and they will address her intolerance of strong scents using various mind-body approaches, including hypnosis.
• She is encouraged to take more breaks while she works, and to pause to eat lunch. She will see if he can get a standing workstation for his cubicle. She will change positions at least every half hour while she is working.
• Her overall toxin exposure seems to be minimal (recognizing her sensitivities are also an issue and are addressed separately). Her apartment has relatively clean water and air, and she is not exposed to hazardous chemicals at work, so far as she knows. She is very interested in learning more about low- and high- pesticide foods, and received more information on the Dirty Dozen and Clean Fifteen, which are featured in the “Nutrition” module.
• Andrea agrees there are some simple things she can do to improve her sensory environment at home. She plans to start wearing an eye mask to sleep, and she will consider playing music more often, particularly classical guitar, which she hopes to learn herself someday. She will clean with fragrance-free household products and avoid air fresheners in her house and car, since they give her headaches.
• She will experiment with adding more lighting to her apartment, since she thinks low lighting negatively affects her mood. She was given more information on Bright Light Therapy.
• In addition to going to the YMCA, she will go to a nearby park and run twice a week, as the weather allows, so that she has more time outdoors.
• On further discussion, Andrea does seem to be a “highly sensitive person.” She is very sensitive to her environment, is quite musically inclined, and though she has learned to hide it, is quite shy. She is given names of some potential books and websites she can use to learn more about this. She will give a media fast a try and was given the handout on “Too Much Bad News: How to Do an Information Fast.”
• Andrea will follow up with her clinical team in a week to let them know how it is going with following her plan. She will see her primary in 1-2 months. She was given links to several other handouts to review as well, including “An Introduction to Surroundings for Integrative Health,” “Healthy Work Habits: Avoiding Workaholism” and “Ergonomics: Positioning Your Body for Integrative Health.”
• On further discussion, Andrea agrees she is lonely, and at a future visit, she will explore Family, Friends, and Coworkers as it relates to her self-care.

---

Why should we think upon things that are lovely? Because thinking determines life. It is a common habit to blame life upon the environment. Environment modifies life but does not govern life. The soul is stronger than its surroundings.

—William James

---

Integrative Health Tools

• Informing Healing Spaces Through Environmental Design: Thirteen Tips
• Improving Work Surroundings Through Ergonomics
• Too Much Bad News: A Media/Information Fast
• Healthy Work Habits: Avoiding Workaholism

What we know about integrative health care has come to us thanks to the efforts, experiences, and collective wisdom of people from many cultures and backgrounds. We wish to acknowledge all the healers, researchers, patients, and peoples who have informed the content of this tool.

Author(s)

This overview was adapted for the Osher Center for Integrative Health at the University of Wisconsin-Madison from the original by J. Adam Rindfleisch, MPhil, MD.

Originally Created: 2014, Updated: 2018

Modified for UW Integrative Health: 2020

References

1. Healthy Homes Principles. Accessed September 6, 2019, Http://www.nchh.org/WhatWeDo/HealthyHomesPrinciples.aspx
2. Toro PA, Tompsett CJ, Lombardo S, et al. Homelessness in Europe and the United States: A comparison of prevalence and public opinion. Journal of Social Issues. 2007;63(3):505-524.
3. Baggett TP, O'Connell JJ, Singer DE, Rigotti NA. The unmet health care needs of homeless adults: a national study. Am J Public Health. Jul 2010;100(7):1326-33. doi:10.2105/ajph.2009.180109
4. Tsai J, Doran KM, Rosenheck RA. When Health Insurance Is Not a Factor: National Comparison of Homeless and Nonhomeless US Veterans Who Use Veterans Affairs Emergency Departments. American journal of public health. 2013;103(S2):S225-S231.
5. US Department of Veteran Affairs. Point-in-Time (PIT Count). Updated February 19, 2019. Accessed September 6, 2019, https://www.va.gov/HOMELESS/pit_count.asp
6. Samuels JF, Bienvenu OJ, Grados MA, et al. Prevalence and correlates of hoarding behavior in a community-based sample. Behaviour research and therapy. Jul 2008;46(7):836-44. doi:10.1016/j.brat.2008.04.004
7. Frost RO, Gross RC. The hoarding of possessions. Behav Res Ther. 1993;31(4):367-381.
8. Chater C, Shaw J, McKay SM. Hoarding in the home: a toolkit for the home healthcare provider. Home healthcare nurse. Mar 2013;31(3):144-54. doi:10.1097/NHH.0b013e3182838847
9. Dozier ME, Ayers CR. The etiology of hoarding disorder: a review. Psychopathology. 2017;50(5):291-296. doi:10.1159/000479235
10. Timpano KR, Shaw AM, Cougle JR, Fitch KE. A multifaceted assessment of emotional tolerance and intensity in hoarding. Behav Ther. Sep 2014;45(5):690-9. doi:10.1016/j.beth.2014.04.002
11. Saxena S. Pharmacotherapy of compulsive hoarding. J Clin Psychol. May 2011;67(5):477-84. doi:10.1002/jclp.20792
12. Saxena S, Sumner J. Venlafaxine extended-release treatment of hoarding disorder. International clinical psychopharmacology. Sep 2014;29(5):266-73. doi:10.1097/yic.0000000000000036
13. Snowdon J, Halliday G, Hunt GE. Two types of squalor: findings from a factor analysis of the Environmental Cleanliness and Clutter Scale (ECCS). International psychogeriatrics / IPA. Jul 2013;25(7):1191-8. doi:10.1017/s104161021300032x
14. Snowdon J, Shah A, Halliday G. Severe domestic squalor: a review. International psychogeriatrics / IPA. Feb 2007;19(1):37-51. doi:10.1017/s1041610206004236
15. Halliday G, Snowdon J. The Environmental Cleanliness and Clutter Scale (ECCS). International psychogeriatrics / IPA. Dec 2009;21(6):1041-50. doi:10.1017/s1041610209990135
16. Bernardeschi C, Le Cleach L, Delaunay P, Chosidow O. Bed bug infestation. BMJ. 2013;346:f138. doi:10.1136/bmj.f138
17. Hoffmire CA, Bossarte RM. A reconsideration of the correlation between veteran status and firearm suicide in the general population. Injury prevention : journal of the International Society for Child and Adolescent Injury Prevention. Mar 26 2014;doi:10.1136/injuryprev-2013-041029
18. United States Department of Labor, Statistics BoL. Economic News Release: Employment Situation of Veterans Summary. Accessed May 30, 2014, http://www.bls.gov/news.release/vet.nr0.htm.
19. Gonzalez-Mulé E, Cockburn B. Worked to death: the relationships of job demands and job control with mortality. Personnel Psychology. 2017;70(1):73-112. doi:10.1111/peps.12206
20. Roelfs DJ, Shor E, Davidson KW, Schwartz JE. Losing life and livelihood: a systematic review and meta-analysis of unemployment and all-cause mortality. Social science & medicine (1982). Mar 2011;72(6):840-54. doi:10.1016/j.socscimed.2011.01.005
21. Herbig B, Dragano N, Angerer P. Health in the long-term unemployed. Deutsches Arzteblatt International. Jun 2013;110(23-24):413-9. doi:10.3238/arztebl.2013.0413
22. Milner A, Page A, LaMontagne AD. Long-term unemployment and suicide: a systematic review and meta-analysis. PLoS One. 2013;8(1):e51333. doi:10.1371/journal.pone.0051333
23. Centers for Disease Control and Prevention. Workplace Safety and Health Topics: Ergonomics and Musculoskeletal Disorders. Accessed May 30, 2014, http://www.cdc.gov/niosh/topics/ergonomics/
24. Meyer F, Eweje G, Tappin D. Ergonomics as a tool to improve the sustainability of the workforce. Work (Reading, Mass). 2017;57(3):339-350. doi:10.3233/wor-172563
25. van Niekerk SM, Louw QA, Hillier S. The effectiveness of a chair intervention in the workplace to reduce musculoskeletal symptoms. A systematic review. BMC musculoskeletal disorders. 2012;13:145. doi:10.1186/1471-2474-13-145
26. Hoe VC, Urquhart DM, Kelsall HL, Sim MR. Ergonomic design and training for preventing work-related musculoskeletal disorders of the upper limb and neck in adults. The Cochrane database of systematic reviews. 2012;8:Cd008570. doi:10.1002/14651858.CD008570.pub2
27. O'Connor D, Page MJ, Marshall SC, Massy-Westropp N. Ergonomic positioning or equipment for treating carpal tunnel syndrome. The Cochrane database of systematic reviews. 2012;1:Cd009600. doi:10.1002/14651858.cd009600
28. Mao X, Jia P, Zhang L, Zhao P, Chen Y, Zhang M. An evaluation of the effects of human factors and ergonomics on health care and patient safety practices: a systematic review. PLoS One. 2015;10(6):e0129948. doi:10.1371/journal.pone.0129948
29. Mani K, Provident I, Eckel E. Evidence-based ergonomics education: promoting risk factor awareness among office computer workers. Work (Reading, Mass). 2016;55(4):913-922. doi:10.3233/wor-162457
30. Prüss-Ustün A, Vickers C, Haefliger P, Bertollini R. Knowns and unknowns on burden of disease due to chemicals: a systematic review. Environmental Health: A Global Access Science Source. 2011;10:9. doi:10.1186/1476-069x-10-9
31. World Health Organization. Burning opportunity: clean household energy for health, sustainable development, and wellbeing of women and children. 2016;
32. Caress SM, Steinemann AC. A national population studey of the prevalence of multiple chemical sensitivity. Archives of Environmental Health. June 2004;59(6):300-5.
33. Joffres MR, Sampalli T, Fox RA. Physiologic and symptomatic responses to low-level substances in individuals with and without chemical sensitivities: a randomized controlled blinded pilot booth study. Environ Health Perspect. Sep 2005;113(9):1178-83.
34. Caress SM, Steinemann AC. A review of a two-phase population study of multiple chemical sensitivities. Environ Health Perspect. Sep 2003;111(12):1490-7.
35. Zborowsky T, Kreitzer MJ. Creating optimal healing environments in a health care setting. Minnesota medicine. Mar 2008;91(3):35-8.
36. Kondo MC, Jacoby SF, South EC. Does spending time outdoors reduce stress? A review of real-time stress response to outdoor environments. Health & place. May 2018;51:136-150. doi:10.1016/j.healthplace.2018.03.001
37. Shochat T, Martin J, Marler M, Ancoli-Israel S. Illumination levels in nursing home patients: effects on sleep and activity rhythms. J Sleep Res. Dec 2000;9(4):373-9.
38. Bradt J, Dileo C, Grocke D, Magill L. Music interventions for improving psychological and physical outcomes in cancer patients. The Cochrane database of systematic reviews. 2011;(8):Cd006911. doi:10.1002/14651858.CD006911.pub2
39. Baughan-Young K. Healing power of color as cheap as coat of paint. Managed care (Langhorne, Pa). Nov 2001;10(11):40-1.
40. Lankston L, Cusack P, Fremantle C, Isles C. Visual art in hospitals: case studies and review of the evidence. Journal of the Royal Society of Medicine. Dec 2010;103(12):490-9. doi:10.1258/jrsm.2010.100256
41. Drahota A, Ward D, Mackenzie H, et al. Sensory environment on health-related outcomes of hospital patients. The Cochrane database of systematic reviews. 2012;3:Cd005315. doi:10.1002/14651858.CD005315.pub2
42. Laursen J, Danielsen A, Rosenberg J. Effects of environmental design on patient outcome: a systematic review. Herd. Summer 2014;7(4):108-19.
43. Daykin N, Byrne E, Soteriou T, O'Connor S. The impact of art, design and environment in mental healthcare: a systematic review of the literature. The journal of the Royal Society for the Promotion of Health. Mar 2008;128(2):85-94.
44. Louv R. Last Child in the Woods: Saving Our Children From Nature-Deficit Disorder. Algonquin Books in Chapel Hill, NC; 2008.
45. James P, Hart JE, Banay RF, Laden F. Exposure to greenness and mortality in a nationwide prospective cohort study of women. Environmental health perspectives. Sep 2016;124(9):1344-1352. doi:10.1289/ehp.1510363
46. Gascon M, Triguero-Mas M, Martinez D, et al. Residential green spaces and mortality: a systematic review. Environment international. Jan 2016;86:60-7. doi:10.1016/j.envint.2015.10.013
47. Maas J, Verheij RA, de Vries S, Spreeuwenberg P, Schellevis FG, Groenewegen PP. Morbidity is related to a green living environment. Journal of epidemiology and community health. Dec 2009;63(12):967-73. doi:10.1136/jech.2008.079038
48. Lee AC, Jordan HC, Horsley J. Value of urban green spaces in promoting healthy living and wellbeing: prospects for planning. Risk management and healthcare policy. 2015;8:131-7. doi:10.2147/rmhp.S61654
49. Wood L, Hooper P, Foster S, Bull F. Public green spaces and positive mental health - investigating the relationship between access, quantity and types of parks and mental wellbeing. Health Place. Nov 2017;48:63-71. doi:10.1016/j.healthplace.2017.09.002
50. de Keijzer C, Gascon M, Nieuwenhuijsen MJ, Dadvand P. Long-term green space exposure and cognition across the life course: a systematic review. Current environmental health reports. Dec 2016;3(4):468-477. doi:10.1007/s40572-016-0116-x
51. Whear R, Coon JT, Bethel A, Abbott R, Stein K, Garside R. What is the impact of using outdoor spaces such as gardens on the physical and mental well-being of those with dementia? A systematic review of quantitative and qualitative evidence. Journal of the American Medical Directors Association. Oct 2014;15(10):697-705. doi:10.1016/j.jamda.2014.05.013
52. Barton J, Pretty J. What is the best dose of nature and green exercise for improving mental health? A multi-study analysis. Environmental science & technology. May 15 2010;44(10):3947-55. doi:10.1021/es903183r
53. Thompson Coon J, Boddy K, Stein K, Whear R, Barton J, Depledge MH. Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental wellbeing than physical activity indoors? A systematic review. Environmental science & technology. Mar 1 2011;45(5):1761-72. doi:10.1021/es102947t
54. Moss S. Natural Childhood: A report by the National Trust on ‘nature deficit disorder’. Accessed September 6, 2019, https://bobbloomfield.files.wordpress.com/2013/02/natural-childhood-report.pdf
55. Cain S. Quiet: The Power of Introverts in a World That Won’t Stop Talking. Crown Publishers, New York; 2012.
56. Myers DG, Diener E. The pursuit of happiness. Scientific American. May 1996;274(5):70-2.
57. Rasmussen HN, Scheier MF, Greenhouse JB. Optimism and physical health: a meta-analytic review. Annuals of behavioral medicine : a publication of the Society of Behavioral Medicine. Jun 2009;37(3):239-56. doi:10.1007/s12160-009-9111-x
58. Post SG. Altuism, happiness, and health: it's good to be good. International Journal of Behavioral Medicine. 2005;12(2):66-77. doi:10.1207/s15327558ijbm1202_4
59. Steinert Y. On prescribing happiness. Family medicine. Oct 2005;37(9):663-4.
60. Southwick SM, Charney DS. Resilience: The science of mastering life's greatest challenges. Cambridge University Press; 2012.
61. Cousins N. Anatomy of an illness (as perceived by the patient). The New England journal of medicine. Dec 23 1976;295(26):1458-63. doi:10.1056/nejm197612232952605
62. Bennett MP, Lengacher C. Humor and laughter may influence health: III. Laughter and health outcomes. Evid Based Complement Alternat Med. Mar 2008;5(1):37-40. doi:10.1093/ecam/nem041
63. Bennett MP, Lengacher C. Humor and laughter may influence health IV. Humor and immune function. Evid Based Complement Alternat Med. Jun 2009;6(2):159-64. doi:10.1093/ecam/nem149
64. Nepps P, Stewart CN, Bruckno SR. Animal-Assisted Activity: Effects of a Complementary Intervention Program on Psychological and Physiological Variables. Journal of evidence-based complementary & alternative medicine. May 1 2014;19(3):211-215. doi:10.1177/2156587214533570
65. Barker SB, Wolen AR. The benefits of human-companion animal interaction: a review. Journal of veterinary medical education. Winter 2008;35(4):487-95. doi:10.3138/jvme.35.4.487
66. Klingberg T. The Overflowing Brain: Information Overload and the Limits of Working Memory: Information Overload and the Limits of Working Memory. Oxford University Press; 2008.
67. Williams R. Why We Seem to Prefer Bad News Over Good News. Medium. Accessed April 4, 2025. https://raybwilliams.medium.com/why-we-seem-to-prefer-bad-news-over-good-news-395968a3af4e
68. Aaron EN. The highly sensitive person: How to thrive when the world overwhelms you. Element, London. 1996;
69. The Lung Association. Accessed August 26, 2014, http://www.lung.ca