International Journal of
Environmental Research
and Public Health
Perspective
Expanding the Mind–Body–Environment Connection to
Enhance the Development of Cultural Humility
Isabelle Soulé 1, Chloé Littzen-Brown 1 , Amber L. Vermeesch 2,* and Layla Garrigues 1
1 School of Nursing & Health Innovations, University of Portland, Portland, OR 97203, USA
2 Department of Family and Community Nursing, School of Nursing, University of North Carolina Greensboro,
Greensboro, NC 27412, USA
* Correspondence: alvermeesch@uncg.edu
Citation: Soulé, I.; Littzen-Brown, C.;
Vermeesch, A.L.; Garrigues, L.
Expanding the
Mind–Body–Environment
Connection to Enhance the
Development of Cultural Humility.
Int. J. Environ. Res. Public Health 2022,
19, 13641. https://doi.org/10.3390/
ijerph192013641
Academic Editors: Paul
B. Tchounwou and Jon
Øyvind Odland
Received: 15 August 2022
Accepted: 19 October 2022
Published: 21 October 2022
Publisher’s Note: MDPI stays neutral
with regard to jurisdictional claims in
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iations.
Copyright: © 2022 by the authors.
Licensee MDPI, Basel, Switzerland.
This article is an open access article
distributed under the terms and
conditions of the Creative Commons
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
4.0/).
Abstract: The unique health care needs of diverse individuals and communities are complex. To
meet these needs, healthcare professionals are being called upon to alter traditional ways of thinking,
perceiving, and acting in order to create more inclusive environments. Research shows that using
mindsight, a process that increases both insight and empathy, can enhance an individual’s mind–
body-environment connection, increase self-awareness, and promote the development of cultural
humility. This paper will discuss the current perspectives on the mind/body/environment connection
from a Western lens that may impact the enactment of cultural humility for healthcare providers. Two
evidence-based approaches, yoga and forest therapy, are recommended as effective intervention tools
in fostering mindsight and cultural humility. Blending traditional cognitive learning with techniques
anchored in the physical body may hold promise in supporting the development of mindsight and
cultural humility in healthcare education and practice.
Keywords: cultural humility; mind–body; mindsight; yoga; nature-based intervention; forest therapy
1. Introduction
Interest in the development of cultural humility has risen in the past 25 years resulting
in an extensive body of literature to support understanding, planning, implementing,
evaluating, and refining care across diverse populations. Cultural humility, a paradigm
introduced in the late 1990’s as an alternative to the mainstream model of cultural compe-
tence, has three primary tenets (a) a lifelong commitment to self-reflection and self-critique,
(b) identifying and leveling power differentials, and (c) building mutually beneficial, high-
quality partnerships [1,2]. Cultural humility is based on the simultaneous process of
discernment of self and others, an awareness of the power dynamics that underlie inter-
actions and contexts, and an ability and willingness to attune to and learn from the lived
experience of diverse individuals and communities. While cultural humility includes a
mindset, this paper introduces the physicality, or physical nature of developing cultural
humility, and posits that techniques anchored in the body including yoga and nature-based
therapies, hold promise in enhancing the development of cultural humility in healthcare
education and practice.
Honoring individuals and communities as experts in their own experience requires
healthcare providers to be self-aware, open-minded, and open-hearted, blending the roles
of teacher and learner. Healthcare providers who practice cultural humility demonstrate
intellectual, attitudinal, and behavioral flexibility to interact in a non-judgmental way with
individuals who have widely different values, beliefs, worldviews, and healthcare practices
than their own [3] Western healthcare providers are often educated to think of themselves
as experts, which can lead to misinterpreting or dismissing teachings that offer an alternate
set of values or beliefs [1] Moreover, building partnerships where health professionals
value the expertise of the client and community in their own decisions often runs contrary
Int. J. Environ. Res. Public Health 2022, 19, 13641. https://doi.org/10.3390/ijerph192013641
https://www.mdpi.com/journal/ijerph
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to how professionalism is taught and role modeled in healthcare education and practice
today [1,4].
The unique health care needs of diverse individuals and communities are complex.
To meet these needs, healthcare professionals are being called upon to alter traditional
ways of thinking, perceiving, and acting in order to create more inclusive healthcare in-
teractions and environments. Incorporating integrated health and nature-based strategies
can support diverse groups in meeting their health and wellness goals, while also pro-
moting the development of cultural humility in healthcare providers and systems. The
following paper will discuss the current perspectives on health from a Western lens that
may impact the development of cultural humility and will conclude by recommending
evidence-based approaches to developing cultural humility by using innovative integrative
health interventions.
Background
Much of the research and literature promoting care of diverse individuals in the
healthcare environment has emerged from the United States, and has been conceptualized,
carried out, and evaluated predominantly by Western-educated, biomedical practition-
ers. These influential cultures share a focus on individualism, a belief system based on
the separation and autonomy of individuals [1]. An individualistic perspective may not
recognize how individualism undermines the social fabric of a community, the interde-
pendence of individuals with each other, and the natural environment in which they live
and interact [1]. In contrast, individuals and populations that come from a collectivist
perspective perceive themselves as intrinsically part of a group and emphasize interdepen-
dence over independence, affiliation over confrontation, and cooperation over competition
Collectivism recognizes the group, and not the individual, as the basic unit of survival.
Both individualism and collectivism have equal, albeit different, merits. However, of
pivotal importance is the understanding that each of these perspectives relies on different
mechanisms and values in decision-making [1]. These differences manifest themselves
in matters such as gender roles, positions of authority, sense of self and personal space,
communication, relationship to time, relationship to others, learning styles, and spiritual
practice. Within the healthcare system, these differences manifest in how health and illness
are perceived and manifested; what is thought of as cause; how, when and where communi-
cation occurs; the roles of the health professional, client, family, and community; and how
treatment is negotiated, implemented, and evaluated. Because cultural humility relies on
the accurate, simultaneous discernment of self and others, healthcare providers must learn
to hold individualism alongside collectivism with an ability to skillfully move between
these two distinct standpoints in order to better support the needs of diverse individuals
and communities.
The separation of the mind from the body in modern Western thought, in favor of
the mind over affective and perceptive knowing, is woven throughout biomedicine and
healthcare education [5,6]. Rooted in the philosophy of the mind, the separation of the
mind and body is commonly referred to as Cartesian dualism as originally proposed by
Rene Descartes [7]. This perspective perceives the body largely as a transporter of the mind,
and the methods of teaching, learning, and healthcare provision as fundamentally a disem-
bodied process [8]. When a primary effort of healthcare education and professional practice
is cognitive knowing, the physical body, with its sensations, emotions, affective processes,
and visceral responses, is excluded as another important way of knowing [9,10]. Physical
bodies, however, are central elements in communicating and interpreting cultural norms
through movements, gestures, posture, voice, scent, sound, visual cues, and proximity to
one another [11]. Moreover, relational aspects of care such as compassion and empathy are
far more related to affect than to cognition.
Bennett and Castiglioni (2004) [5] argue that the exclusion of the physical body leads
to cognitive-based observation of an experience rather than to the embodied experience
itself. These cognitive-based observations are limited in that they are separate from bodily
Int. J. Environ. Res. Public Health 2022, 19, 13641
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perceptions, feelings, emotions, or personal and interpersonal interactions. When a primary
focus of healthcare provision is cognitive-based observation, including analytical processing
and reasoning, it limits the ability to accurately perceive the whole and interconnecting
parts [5]. This limited viewpoint affects a healthcare providers ability to perceive themselves
accurately, discern power dynamics present; therefore, preventing them from leveling those
power differentials. Furthermore, without an embodied, physical awareness of themselves
and of others, providers will be limited in their ability to build mutually beneficial, high-
quality partnerships, another key tenet in the development of cultural humility.
Many scholars have argued that to successfully engage with others, knowledge alone
is insufficient; one must develop a sensitivity for appropriate responses and the feeling
of appropriateness (multisensory awareness) which allows for accurate discernment of
the context, emotions, and meaning-making of interactions that accompanies cognitive
knowledge [1]. This ability to physically experience one’s own and another’s experience
is termed embodiment, including the integration of the cognitive, relational, emotional,
aesthetic and spiritual aspects of human experience, and revealed through empathy for, and
connectivity with diverse others. The extent of one’s ability to be aware of another person’s
state of mind and emotions depends on one’s own self-awareness, and research has demon-
strated that people who are more aware of their physical bodies are more empathic [10]. In
addition, when individuals can sense their own internal state, the pathways for resonating
with others are also open [10]. Bennett and Castiglioni (2004) [5] addressed “embodied
ethnocentrism,” meaning things feel familiar and comfortable in one’s own culture. This
experience can be considered the physical manifestation of ethnocentrism—the perception
that one’s culture is central to reality. When steeped in embodied ethnocentrism there is a
feeling of discomfort when in the presence of unfamiliar others, situations, or surroundings.
Furthermore, without a similar sense or feeling for another’s context, there are limitations
in one’s depth of understanding, and ability to adapt, demonstrate empathy, and ultimately
build high-quality interpersonal relationships.
Recent developments in interpersonal neurobiology reveal the interconnection and
interdependence of mind and body. Specifically, mindful awareness, a state that includes
awareness of the inner workings of the mind, sensory systems, and visceral responses, can
help regulate emotional responses by promoting empathy and openness to diverse values,
beliefs, and worldviews [11]. This flexibility allows an individual to lean in to or approach
an unfamiliar or challenging circumstance rather than withdrawing from it [11].
In Philosophy in the Flesh, Lakoff and Johnson (1999) [1] addressed the physical
aspects of interrelatedness in this way:
There exists no . . . person . . . for whom thought has been extruded from the
body. That is, there is no real person whose embodiment plays no role in meaning,
whose meaning is purely objective and defined by the external world, and whose
language can fit the external world with no significant role played by mind, brain,
or body. Because our conceptual systems grow out of our bodies, meaning is
grounded in and through our bodies (p. 6).
Given the innate link between mind and body, what is interpreted in the mind is
also felt in the physical body. Therefore, fear, anxiety and uncertainly are consistently
accompanied by physical tension, narrowed thinking, and skewed perceptions. These
constrictions, when chronically held in the body, can limit one’s ability to perceive oneself,
the world, and others accurately [1]. A recent example of substantial importance is the
COVID-19 pandemic; and in particular, the experience of healthcare providers who have
worked throughout the pandemic. With an unprecedented degree of uncertainty and
continuously changing environments, healthcare providers have reported a significant
increase in chronic anxiety, fear, and moral distress which compromises their ability to
build high quality partnerships [12,13].
Developing the skills to work effectively across diverse populations requires physical
and multisensory awareness, and adaptation to intellectual, attitudinal, and behavioral
differences. The bodily experience of feeling comfortable across diverse cultures includes
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an embodied awareness that is mediated through bodily sensory experiences involving
the skin, muscular, tactile, visual, auditory, olfactory, and gustatory pathways [14]. It also
involves the energetic field around us that brings a sense of resonance or dissonance when
in the physical proximity of diverse others. This sensibility also extends to our relationship
to the built environment and sensing our connectivity to the natural world around us. [5,15].
Working in parallel with traditional cognitive learning, techniques anchored in the physical
body may hold promise in adding support to the development of cultural humility in
healthcare education and practice.
2. Embodied Understanding: Mindsight
A new field of study, interpersonal neurobiology, integrates a variety of sciences with
alternate ways of knowing that has helped illuminate the subjective world of the mind.
Based on research investigations of affective neuroscience, an illustrative process has been
developed to enhance an individual’s ability to open a more adaptive and flexible way
of being [11]. Daniel Siegel’s (2010) [10] theory of “mindsight” is a process that has been
found to increase both insight and empathy and is at the foundation of both social and
emotional intelligence. Mindsight, based on ancient wisdom traditions of mindfulness and
contemporary interdisciplinary discovery and brain research, can be cultivated through
practical steps, can change the physical structure of the brain, and activates the circuits that
create resilience and well-being, as well as those that underlie empathy and compassion [10].
Mindsight is best thought of as a kind of focused attention that allows observation of the
internal workings of one’s own mind and helps to perceive mental processes that may be
typically outside conscious awareness. This practiced observation helps us to understand
ourselves as unique cultural beings, including our distinctive blend of beliefs, values, and
worldviews, and the larger context in which they have developed [1]. Mindsight shifts us
from automatic processing to illuminate ingrained behaviors that may not be well suited to
building rapport with people of diverse backgrounds. The ability to understand one’s own
mind as a parallel process to accurately discerning the inner world and contexts of others is
essential in building rapport and working effectively across diverse worldviews. If one is
unable or unwilling to make these shifts, then entrenchment, judgment, dividedness, and
exclusion ensue. Becoming conscious of one’s patterns of the mind, that are enacted through
the physical body, stimulates intrapersonal growth which also facilitates interpersonal
growth in an iterative cycle [1].
Neuroplasticity is the capacity for creating and growing new neurons and neural
connections in response to experiences [16]. This lifelong process is relevant in the develop-
ment of cultural humility because it is foundationally about being able to understand one’s
own reality and having genuine empathy for the experience of another, albeit significantly
different from one’s own. The physical sense of empathy includes not only an intellectual
connection but an attunement through facial expressions, tones of voice, gestures, and
postures—some so imperceptible that they can only be seen on a slowed-down recording. It
can be a palpable sense of connection and aliveness; for example, one client referred to it as
“feeling felt,” [10], (p. 10). This skill to monitor and modify one’s internal world is termed
mindsight [10] and can be conceived as the embodied and relational process that leads a
healthcare provider toward self-awareness, a sensibility of the power dynamics at play in
any given context or interaction, and an ability to build mutually beneficial partnerships
with diverse patients, families, and communities. Embodied practices such as mindsight
can be a powerful way to integrate consciousness and offers hope for evidence-based
processes that promote open-mindedness, open-heartedness, attunement, and a felt sense
of empathy, understanding and connectivity with others [10].
2.1. Yoga as a Tool to Develop Mindsight and Cultural Humility
An example of a mindful practice that shows promise in enhancing the development of
mindsight and cultural humility, is yoga. Yoga, an ancient wisdom tradition, can be traced
back to the third century BCE and is rooted in Indian philosophy [17,18]. In traditional
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yogic texts, yoga is defined as the union of the individual with the Absolute (e.g., a higher
power); a pathway that allows for such a union, and an unruffled state of mind under
all conditions [19]. In contrast, in western society, yoga is most often thought of as a
physical practice focused on yoga postures (asana), with or without breathing exercises
(pranayama), or meditation (dhyana). Yoga practice from either of these perspectives
slows down physical movement, brings focused attention to the physical body, and its
corresponding feelings and sensations, raising conscious awareness of the mind–body–
environment interaction. Learning to be fully present in the here and now can be used
to support the connection between mind/body/environment, therefore enhancing the
development of self-awareness, an essential component in the lifelong development of
cultural humility.
As a mind–body intervention, yoga has shown promising results for a variety of
human concerns, including: healthy eating habits [20]; asthma [21]; cancer symptom
management [22]; cardiovascular disease [23]; menopause [24]; multiple sclerosis [25];
pain [26,27]; and mental health conditions [17] such as anxiety [28], depression [29], and
post-traumatic stress disorders [30]. Scientists have postulated how participating in yoga
as an intervention can have such positive impacts across the human condition, albeit
with limitations. By means of polyvagal theory [31], yoga has been claimed to facilitate
eudemonic well-being and physical, mental, and behavioral health benefits for diverse
populations through enhanced self-regulation and resilience cultivation [32]. Similarly,
yoga has been proposed to optimize the human hypothalamic-pituitary-adrenocortical axis
by regulating cortisol levels, increasing blood flow in the brain, and promoting neurogenesis
and synaptogenesis, ultimately increasing neuroplasticity [33].
Yoga is posited as a tool to help promote mindsight and cultural humility, and is
of particular importance at this time in history, as healthcare providers have reported
suboptimal well-being at work due to the numerous implications from the COVID-19
pandemic. Developing a mind–body–environment connection is increasingly important to
protect and enhance well-being, especially during times of separation, stress, and sickness,
hallmarks of working through the COVID-19 pandemic. Recent research supports that
suboptimal well-being at work is a significant correlate for several negative organizational
(e.g., patient medication errors) and personal outcomes (e.g., well-being) [13,34]. These
suboptimal states of duress can limit nurse’s ability to develop self-awareness, which then
limits their ability to effectively build high-quality partnerships across differences. While
more research is needed, yoga shows promise in promoting the mind–body–environment
consciousness necessary for developing mindsight and cultural humility and improving
both individual well-being and interpersonal relationships.
2.2. Forest Therapy as a Tool to Develop Mindsight and Cultural Humility
Another example of a mindful practice that can be used in developing mindsight
and cultural humility, is the nature-based intervention of forest therapy, also referred to
as forest bathing or shinrin-yoku. Forest therapy is a way to connect oneself with the
natural world in order to increase the mind–body-environment connection [11]. There are
various definitions for nature depending upon the context and culture of individuals and
populations; however, for this paper, nature is defined as an environment, either urban
or rural, that has naturally grown plants or plants grown by humans [35]. Forest therapy
includes both active and/or passive participation including being in the presence of and
viewing nature or direct, active engagement with nature. According to the Association of
Nature and Forest Therapy, forest therapy is a “relational practice that brings people into
deeper intimacy with natural places,” [36], (para. 1). Additional considerations for forest
therapy include the idea that one’s own physical body is a natural place [37]. Therefore,
engaging in forest therapy aids in strengthening the mind–body–environment connection.
Strong scientific and objective evidence exists for ways in which forest therapy supports
multiple aspects of well-being, including reduced stress levels, increased immune response
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and function, improved cardiovascular and respiratory health, attention restoration and a
reduction in depression symptoms [38,39].
Forest therapy has been found to produce positive benefits for individuals engaging in
the natural environment including positive health, increased energy, increased sense of pur-
pose, and a decreased sense of stress [40–44]. In addition, there have been numerous studies
investigating stress reduction through cognitive behavioral therapy and mindfulness ap-
plied in a forest environment. For example, response rate for stress reduction interventions
includes baseline cognitive behavioral therapy and mindfulness in natural settings out-
doors or indoors with plants with stress reduction in six weeks [45]. Kim et al. (2009) [39]
investigated the application of a four-week forest-walking based cognitive-behavioral ther-
apy program for treating clinical depression. The results showed a significant decrease in
depression after the nature intervention. Morita et al. (2011) [46] investigated two-hour
forest-walking sessions conducted on eight different weekend days, which provided reduc-
tions in feelings of depression, anxiety, and stress. Immersive experiences in nature have
been found to improve mindfulness, rejuvenate one’s body, mind and energy, and reduce
physical, emotional, and cognitive stress [44] while deepening respect toward the natural
environment. These improvements allow for productive changes in attitudinal, intellectual,
behavioral flexibility, and bring internal clarity and calmness, which are foundational tools
for successful engagement with self, others, and the natural environment [47].
Two theoretical frameworks, stress reduction theory and attention restoration theory
further demonstrate the connection between forest therapy and the development of mind-
sight and cultural humility. Stress reduction theory, originally proposed by Ulrich [48]
postulates that in the presence of nature, there is a negative association with stress, meaning
that when in a natural environment, perceived stress decreases. Furthermore, as individ-
uals experience a reduction in stress through nature exposure (i.e., forest therapy), their
capacity for mindsight increases, which in turn opens the channels for self-awareness and
the development of cultural humility. Similarly, attention restoration theory as originally
proposed by Kaplan and Kaplan postulates that with nature exposure there is a positive
association with attention, meaning that in the presence of nature, attention increases [35].
It can then be postulated that with a reduction in stress and an increase in attention, the
context is fitting for the development of mindsight and cultural humility.
3. Conclusions
The development of mindsight and cultural humility are a vital set of skills necessary
for healthcare providers in contemporary professional practice, requiring a lifelong com-
mitment to deepening self-awareness, leveling power differentials, and building mutually
beneficial high-quality partnerships with diverse others. Current Western perceptions of
individualism in addition to the COVID-19 pandemic have generated a mind–body dis-
connection for healthcare providers, and interventions such as yoga and/or forest therapy
show promise in helping to reconnect with oneself, develop high-quality interpersonal
relationships, as well as a deeper connection with the natural world.
Because the mind and the body work in synchrony to receive and interpret sensory in-
formation, blending cognitive and embodied abilities can enable perception with increased
depth, clarity, and accuracy. Yoga and forest therapy are recommended as established ways
to improve interconnection between body, mind, and the natural environment in addition
to reducing stress and anxiety, increasing focused attention, and improving self-awareness.
Noting the physical nature of the development of cultural humility, further research is
needed to understand the context in which self-awareness is best developed; strategies to
promote self-awareness; examination of the varying capacity, propensity, and/or desire of
individuals to develop self-awareness, and reliable and valid measures for studying the
application of self-awareness on the development of cultural humility as it is manifested in
an educational setting, clinical encounter, or in a healthcare system.
Author Contributions: Conceptualization, I.S., L.G.; Design, I.S., L.G., C.L.-B., A.L.V.; Funding
acquisition, I.S., L.G., C.L.-B.; Support: A.L.V.; Writing—original draft, I.S., L.G., C.L.-B., A.L.V.;
Int. J. Environ. Res. Public Health 2022, 19, 13641
7 of 8
Writing—review and editing, I.S., L.G., C.L.-B., A.L.V. All authors have read and agreed to the
published version of the manuscript.
Funding: This research was funded and made possible by the University of Portland School of
Nursing and Health Innovations.
Institutional Review Board Statement: Not applicable.
Informed Consent Statement: Not applicable.
Data Availability Statement: Not applicable.
Acknowledgments: We also would like to acknowledge Kate Priddy for their editorial support.
Conflicts of Interest: The authors declare no conflict of interest.
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