PERSPECTIVE
published: 10 February 2022
doi: 10.3389/fpsyg.2022.766283
Unpacking Relational Dignity: In
Pursuit of an Ethic of Care for
Outdoor Therapies
Nevin J. Harper1* and Carina Ribe Fernee2,3
1 Faculty of Human and Social Development, University of Victoria, Victoria, BC, Canada, 2 Department of Child and
Adolescent Mental Health, Sørlandet Hospital HE, Kristiansand, Norway, 3 Faculty of Health and Sport Sciences, University
of Agder, Kristiansand, Norway
Edited by:
Tonia Gray,
Western Sydney University, Australia
Reviewed by:
Jamie Mcphie,
University of Cumbria,
United Kingdom
Ben Knowles,
University of Tasmania, Australia
*Correspondence:
Nevin J. Harper
njhaper@uvic.ca
Specialty section:
This article was submitted to
Psychology for Clinical Settings,
a section of the journal
Frontiers in Psychology
Received: 28 August 2021
Accepted: 07 January 2022
Published: 10 February 2022
Citation:
Harper NJ and Fernee CR (2022)
Unpacking Relational Dignity: In
Pursuit of an Ethic of Care
for Outdoor Therapies.
Front. Psychol. 13:766283.
doi: 10.3389/fpsyg.2022.766283
Dignity is a universal principle that requires us to treat every person as having worth
beyond who a particular person is or what they do. Dignity is a complex and sometimes
contested idea, that at times can be compromised in health care and allegedly
also within the practice of outdoor therapy. Outdoor therapies comprise a range of
therapeutic approaches including nature-based therapy, adventure therapy, animal-
assisted therapy, forest therapy, wilderness therapy, surf therapy, and more. Within
the literature of outdoor therapies there has been limited research on ethics related
to common understandings of care concepts such as relational dignity and human
rights. The aim of this paper is therefore to unravel briefly whether dignity in general,
and relational qualities of dignified care more particularly, might be a useful concept to
apply in order to support an ethical practice in outdoor therapies.
Keywords: outdoor therapy, relational dignity, ethic of care, ecological dignity, wilderness therapy, dignity
INTRODUCTION
“The unconditional and non-descriptive character of dignity as a principle is both its force and its
weakness; it appeals to many and nobody could be against it, but it refers to different values in particular
situations. Tensions in practice emerge when there are differences in how to understand a respectful
approach, or how to best interpret dignity” (Pols et al., 2018, p. 91).
Dignity is a foundational principle, referring to a human right for all people. The ethical principle
is that all humans have dignity, simply because they are human (Pols et al., 2018). Protecting this
intrinsic (Leget, 2013) or inherent (Nordenfelt, 2004) dignity would mean to protect humans and
humanity itself. According to Pols et al. (2018), this requires us to treat every person as having a
dignity or worth beyond the worth of who a particular person is or what they do. When dignity is
seen as inherent worth, it is something that cannot be acquired, but can be violated, and so-called
indignities are affronts to human dignity. However, to describe situations where this happens, the
understanding of the somewhat abstract principle needs to be made concrete, beyond an appeal for
care that is worthy or humane.
Dignity remains a complex and sometimes contested concept, and when loss of dignity is
reported within our field of practice, it is our ethical obligation as practitioners and researchers, to
respond and to ensure that we protect and restore dignity as best we can. Successful therapy relies
on the quality of relationship between therapist and client (alliance) and is one of the strongest
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in-treatment factors influencing positive outcomes (Elvins
and Green, 2008; Wampold, 2021). Relational dignity carries
significant implications beyond ethical therapeutic practice;
dignity has been described as the concept that ties health and
human rights together (Jacobson, 2009). Within the literature of
outdoor therapies there has been a lack of dialog and research on
ethics related to common understandings of care concepts such
as relational dignity and human rights (Mitten, 1994; Becker,
2010; Harper, 2017). Recent research brings to light a dire
need for further empirical and philosophical development of
outdoor therapy ethics (Dobud, 2021; Harper et al., 2021). These
recent publications provide the impetus for this article, but the
desirability of relational dignity as an explicit value in the practice
of outdoor therapy and healthcare has been recognized and
recently called for (see Fernee and Gabrielsen, 2020). While we
identify the scarcity of literature on this topic, we do acknowledge
that practitioners and researchers constantly strive to improve
practice and that critical discussions and dialog are present at
conferences, within professional associations and trainings.
Outdoor therapies include a range of therapeutic approaches
identified as nature-based therapy, adventure therapy, wilderness
therapy, animal-assisted therapy, forest therapy, surf therapy
and more (Harper and Dobud, 2020; Harper et al., 2021). The
umbrella term of outdoor therapies captures practices sharing
three common factors: (1) place-based (generally outdoors), (2)
active bodily-engaged practices, and (3) place client, therapist,
and nature in a relational triad thereby removing a human-
nature dichotomy (Harper and Doherty, 2020). We acknowledge
that “nature,” “wilderness” and other terms are contested (as
colonial, romantic, reductionist) concepts and point readers to
critical perspectives on outdoor therapies published elsewhere
(Harper et al., 2017; Mitten, 2020). Most outdoor therapies
have been found, in repeated systematic reviews, to have
positive health and wellbeing benefits (see Cooley et al.,
2020; Stier-Jarmer et al., 2021). Wilderness therapy is one
internationally practiced form of outdoor therapy in which
contextual realities of increased intensity, duration, challenge
and other significant factors are present while intact groups
travel in less-inhabited and more remote “wilderness” areas
for multiple days to weeks (Fernee et al., 2019). These factors
complicate and heighten the need for relational dignity (e.g.,
concerns about power differentials, reliance on the skilled
leader, sense of physical and emotional safety), hence requiring
careful attentiveness from the practitioners, and arguably further
research, dialog and philosophical practice development (Mitten,
1994; Harper et al., 2019).
As authors, we believe it to be obvious that all clients deserve to
be treated with a respect that acknowledges their personal dignity
and hope for this to become an internalized norm across all forms
of outdoor therapies. In this paper, we begin a conceptual and
practical exploration of what relational dignity means and how it
may translate into an ethic of care for psychological interventions
in the outdoors. As such, the aim of this paper is to unravel briefly
how dignity in general, and relational qualities of dignified care
more particularly, might be understood in the literature, again as
a means to consider the potential of relational dignity as a useful
concept to excel and improve practice in outdoor therapies.
UNPACKING RELATIONAL DIGNITY
Dignity refers to the intrinsic value of each human life and has
been described as nothing less than a central feature of our
humanity. The United Nation’s Universal Declaration of Human
Rights recognizes the inherent dignity and equal rights of all
members of the human family as the very foundation of freedom,
justice and peace in the world (Miller, 2017). These essential
facets of dignity should not only be understood and ideally
agreed upon, but most importantly acted on, by all healthcare
practitioners and indeed, everyone. In the context of healthcare,
dignity appeals to fundamental values of what good care entails
(Pols et al., 2018).
However, it is often easier to conceptualize dignity in negative
terms – for instance by recognizing undignified or disrespectful
treatment – rather than in the positive. Second, dignity has
intrinsic, relational, and distributional dimensions, that all have
implications primarily for an individual’s sense of self-worth and
well-being, and secondarily for a proposed ethics of care (Pringle
et al., 2021). We shall return to all of these aspects of dignity after
first having considered the most commonly expressed concerns
regarding the concept.
Complaints Against the Concept of
Dignity
While dignity overall is a sustained and even reemerging concept
across a number of disciplines, there are wide-ranging complaints
against the concept that covers everything from its supposedly
general uselessness to its exclusionary nature (Miller, 2017).
We feel obliged to consider some of these complaints, before
still choosing to operationalize dignity, and propose it as a
fundamental value in care ethics for outdoor therapies.
Macklin (2003) claims that dignity is a vague reworking of
other values that she finds more useful and precise, such as
respect for autonomy. Another complaint along the same lines
is the charge that dignity is an ineffectual concept. Miller (2017)
refers to Fanon (2008) assertions that respect for human dignity
alone cannot alter reality. In the context of oppression, for
instance, there may not be any other option than to fight and
resist, thus rendering the idea of dignity an impotent notion
against systemic powers and interests. These two concerns relate
to a third criticism, expressed by theorists interested in issues
such as race, class, gender, and disability. These scholars rightfully
direct awareness toward who the concept of dignity has tended
to include and benefit, and on the other hand, who are then
excluded from its circle? As such, voicing the concern that dignity
might so happen to be an overwhelming white, Western, male,
and able-bodied notion (Miller, 2017).
Let us apply the latter concern to the context of outdoor
therapies. Some wilderness therapy organizations in the
American for-profit sector, for example, are often inaccessible
due to high costs. Additionally, forced transport is employed in
some wilderness therapy programs, which includes youth being
taken from their family homes against their will (Dobud, 2021).
Are some parts of outdoor therapy practices undermining the
autonomy and respect for its participants? Are for instance, teens
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who are identified as struggling and considered in need of out-
of-home treatment not deserving of being treated with dignity at
all times? Forced transport and resultant involuntary treatment
strips autonomy and choice from youth and compromises
their inalienable rights while also compromising practictioners’
adherence to their professional codes of ethics allowing
potentially indignified scenarios to occur.
Another concern particularly relevant for outdoor therapy
approaches is that dignity as a concept has historically excluded
the more-than-human nature (e.g., forests, rivers, animals,
etc.) although the animal-assisted therapies have long-provided
direction on this with care and dignity afforded to therapy
animals (horses, dogs, etc.). Thus in our proposed ethics of care
for outdoor therapies, we include all of nature – human and non-
human – as vital parts of an ecosystem in dire need of dignified
care; or, ecological dignity.
A final common complaint is that although dignity might be
a vitally important concept, its ground or normative foundation
often remains uncertain and inadequately delineated (Miller,
2017). Badcott and Leget (2013), on the other hand, note that
the general public seems to possess a somewhat immediate and
relatively clear intuitive understanding of what might infringe
upon the respect for human dignity. If intuition is all that is
required, awareness of theoretical aspects of dignity and their
underlying principles might not be necessary after all? However,
in light of the recent attention directed toward the threat of
human dignity in outdoor therapy practices, an unpacking
of fundamental moral attitudes and values seem warranted.
This text is therefore geared toward assisting outdoor therapy
professionals and administrators alike to fully appreciate the
nature and relevance of human dignity for their practice, which
again is offered herein to spark an introspective look at our own
practices and to identify situations where failure to treat people,
and the environment for that matter, in dignified ways might
arise. It is time for change, and to create new, more dignifying and
caring, stories, we propose, where one path forward is to adopt an
integrative and interconnected understanding of dignity driven
by a relational ontology.
An Integrative Understanding of Dignity
While there are various ways of understanding dignity, an
integrative approach (Leget, 2013) combines three aspects: (a)
an intrinsic dignity, which refers to the unconditional worth
of every human being; (b) a subjective dignity, which is each
person’s unique experience of dignity; and (c) social or relational
dignity, which understands dignity as an intersubjective category
that is constantly constituted and negotiated by people and
circumstances. Subjective dignity is often co-determined by one’s
environment, where the idea is that the more the experience of
one’s dignity is undermined by one’s circumstances, the harder it
is to sustain a notion of dignity. While intrinsic dignity in essence
is independent from empirical reality, subjective feelings of self-
worth are frequently enhanced or undermined in any given
situation. An integrative view of dignity acknowledges a mutual
interdependence of these three aspects; however, according to
Leget (2013) relational dignity is of most relevance to ethics of
care because of its sensitivity to particular situations, contexts
and complex webs of relations. When extending this web to
include environments and other species, we come closer to the
interconnectedness that is relevant for outdoor therapies.
Relational reciprocity is important in the context of
healthcare, in the sense that providing care that is not dignified,
also jeopardizes the dignity of practitioners (Pols et al., 2018).
Dignity signifies an ethical relationship between selves and
others, and because of this reciprocity, dignity is not reducible
to the judgment of one person alone. According to Pols et al.
(2018), dignity emerges in social contexts where creating
and maintaining ethical relations take place in processes of
engagement, mirroring, and constant negotiations of values and
attitudes. In future investigations of dignity and care in outdoor
therapies, we may find that caregivers do not merely follow rules
that prioritize some values over others, but rather co-labor with
rules if they believe dignity is at stake.
Andorno (2013) reminds us that promotion of patients’
dignity is a crucial element of the medical profession and
perhaps has become especially urgent in the often time-pressured
context of modern healthcare. Critically, it is in the delivery of
healthcare that respect for dignity is often noticeably threatened
or compromised (Badcott and Leget, 2013). All clients are
to a greater or lesser extent vulnerable. For instance, in the
case of mental health care for children and adolescents, they
are potentially vulnerable first to their young age and next
due to the mental ill-health from which they are suffering. In
addition, they may be vulnerable due to distress for instance in
relation to receiving care at a clinic or the asymmetric power
relationship with their assigned carer(s). If a youth chooses
to take part in an outdoor therapy treatment, or happens to
be forced, additional vulnerabilities can arise. Another example
from the context of nature-based therapy is for instance the
concern for confidentiality when client and therapist in a local
park setting (as opposed to an indoor office setting) may come
across someone the client knows. Predicting this possibility is
a necessary responsibility of the therapist to negotiate with
the client to ensure dignity in the moment it happens. These
different contexts of outdoor therapies all represent demanding
terrain to navigate an ethic of care in situations where dignity
issues are at stake.
IN PURSUIT OF AN ETHIC OF CARE FOR
OUTDOOR THERAPIES
Ethics of care originated in feminist writing of the 1980s (e.g.,
Gilligan, 1989) and has since evolved into a “mosaic of insights
with critical potential and a great sensitivity to contextual
nuance” (Leget, 2013, p. 950). Ethics of care should be sensitive
to the particularity of situations rather than the generalizable
features; to the subtle ways in which people may be excluded,
marginalized, disrespected, or devalued. Care needs to be attuned
to the complex webs of personal relations and in particular
our emotional attachments and vulnerabilities. This includes
human and ecological awareness and sensitivity as discussed
above. A genuine interest in people’s lived experience requires
an open-minded approach in which one abstains from, or
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minimizes, using predefined categories, pathologies and labels,
and instead, adopts a resource-focused, person-centered and
ecological approach. As such, care can include everything that we
do to maintain, continue and repair our collective life worlds so
that we can live in it as well as possible (Leget, 2013).
Moving Forward: Proposed Steps
Toward Relational-Dignified Care
“But dignity cannot only be violated. It can (and must) also be
positively promoted” (Andorno, 2013, p. 972, italics in original).
Care ethics is a theoretical framework particularly well-
suited to explore how remaking and advancing dignity in a
less individualistic and more relational fashion might improve
practice. A synergistic relationship between relational dignity
and care ethics maps the interaction between ethics as caring,
and ethics as dignity (Gilligan, 1989; Miller, 2017). As such,
we are interested in the web of relations that helps to make
meaningful the world in which our clients live (e.g., their homes,
communities, local ecosystems, and other socio-economic,
cultural and political realites).
We must reiterate two aspects with regards to this focus on
care-in-practice. First, it does not render the one on the receiving
end passive and it is not in any way meant to circumscribe the
agency of those receiving care. Second, our actions as carers
correspond with and display our attitudes, where respect is
most often the attitude discussed in conjunction with dignity.
According to Miller (2017), care can function in a similar manner,
in the sense that care also embodies our attitudes. Care and
respect as an attitude differs, though, and we shall dwell on this
for a moment. Respect is an attitudinal recognition of another’s
dignity that, in terms of action, keeps us from interfering with
their lives directly. Care, in contrast, entails the attitudinal
recognition of another’s dignity, but encourages the action of the
carer stepping in to support the life situation of the one for whom
they are caring.
By now we are well aware that not all care is good care.
Good care affirms the inherent dignity of the person cared
for, ideally while also supporting those in need in their agency
and flourishing. Care that is insufficient or bad is most often
understood as care that fails to meet the expressed or implicit
needs of the care receiver. According to Miller (2017), the attitude
of care is as vital to the interaction as the action itself. So what
does bad care that is expressed in terms of attitude look like?
A person can have their needs met, but have them met in a
way that compromises their dignity, which leads Miller (2017)
to emphasize that how we meet others’ needs is just as morally
significant as that we meet them, thus emphasizing the relational
qualities of care.
Navigating Difficult Ethical Terrain:
Positive Engagement and a Moral
Compass
Engagement emerges as crucial for dignified care, particularly
in situations where there are conflicts about the preferable
approach, when there is no consensus, choice or compromise.
The attentive engagement we are after is not achieved by
enforcing rules, as this would limit the possibilities of co-laboring
with our clients to find the better solution in a difficult situation,
in addition to excluding the affective and introspective process
that might be required. Aided by such positive engagement and
use of what Pols et al. (2018) call a moral compass, we believe
that outdoor therapy practitioners are better equipped to navigate
potentially difficult terrain and provide relational and dignified
care (e.g., consider the involuntary client scenario above). Such
an engaging and relational stance will not guarantee perfect
outcomes, nor is engagement in itself sufficient. Professional skills
and supportive conditions are also needed. As such, building
supportive infrastructure for personal engagement (i.e., from
leadership and administration in organizations) may guarantee
a general commitment to good care in frontline situations where
concrete values are in tension.
Ecological Dignity: Dignity Makers, the
Pursuit of Goodness, and Care for All
Given the increased interest in relational dignity but the present
lack of clarity regarding its translation into practice, it could be
useful to investigate further how the concept is understood by
those who have participated in outdoor therapies (e.g., Dobud,
2021). Dupré (2013) refers to the role of those whose dignity
has been lost or compromised as dignity makers. Insights from
dignity makers, or former participants, can help us elicit what an
outdoor therapy practice that safeguards dignity should entail.
Furthermore, ideals such as relational-dignified care in
outdoor therapy take their shape in practices amidst different
notions of what is good to do. All participants, and the outdoor
environment, play their part. By analyzing the alignments or
tensions in the interaction between participants, the context, and
the goods they pursue or embed, we might understand better
how situations unfold in which dignity is a concern. While
acknowledging that goodness is a loose or sensitizing concept,
according to Pols et al. (2018), it is possible to study forms of
good, as well as forms of doing good, as this is preferably part
of both our socio-material world, our thinking, and our future,
and could serve as pointers to identify examples of dignified care
within outdoor therapies in our overall pursuit of goodness.
Finally, a field of practice guided by ecological dignity
promotes care for all; clients, their families, communities, our
colleagues in practice, and nature herself. Integrative systems
thinking is necessary to envelope the broad range of actors in
relationship during outdoor therapy. Good practice will then
be comprised of multiple informants and feedback systems
including our dignity makers, those who work alongside us, and
the environments in which our programs and services are offered.
To illustrate this concept, imagine taking a client group into
their favorite forested area (relational dignity shown to clients),
noticing degradation of the ecosystem from overuse of that site
(an indignity needing to be addressed), and allowing the place
time for restoration (showing care and relational dignity). We
would suggest these practice behaviors be openly discussed with
clients to reinforce the concepts and have a live experience of the
care ethics proposed herein.
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CONCLUDING REMARKS
Considering the brevity of this paper, we concentrated on a
relational view of dignity and the performative functions of care.
“When we care well for others, we acknowledge and highlight
their inherent worth and dignity. We recognize, represent, and
reflect their value back to them, to ourselves, and to others who
stand in social relation with them. Care that is dignifying in
this way does not originate dignity in others. Dignity is inherent
worth and value is already present in those cared for. Thus, good
care acknowledges and preserves something that is already there”
(Miller, 2017, p. 113).
In other words, relational-dignified care is not something that
is earned, or to a greater or lesser extent deserved, it is something
that everyone in need of care could receive – a bit of goodness in
their lives – where good care can magnify, nurture, and promote
the dignity of others.
AUTHOR CONTRIBUTIONS
Both authors contributed toward generating ideas and revised the
final manuscript.
ACKNOWLEDGMENTS
The authors would like to acknowledge our dear colleague Leiv
Einar Gabrielsen (1968–2021) with whom we engaged these ideas
in conversation and who continues to provide inspiration for
making outdoor therapies better.
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Conflict of Interest: The authors declare that the research was conducted in the
absence of any commercial or financial relationships that could be construed as a
potential conflict of interest.
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