Therapeutic Gardens — Horticulture and Healing
By Tracy Greene Mintz, MA, MSW, ACSW
For The Record
Vol. 5 No. 5 P. 19

Can therapeutic gardens help your clients on the road to recovery?

Social workers accompany clients on a path toward healing. Imagine that often painful journey winding through a horticultural haven enriched by lush greenery designed to comfort fragile minds, bodies, and spirits.

Turning that image into reality was the topic at the Acer Institute’s first annual symposium on therapeutic and restorative gardens. The Acer Institute is a new enterprise with a mission to heighten the level of awareness and advocacy for building therapeutic, or healing, gardens in facilities that serve various populations. The focus this year was healing gardens in settings for individuals with dementia and others needing long-term care. Symposium participants from across the country represented such diverse fields as horticulture, architecture, landscape design, medicine, recreational therapy, law, psychology, facility development, and social work. The immediate goal of the symposium was to build a multidisciplinary “knowledge community” that will eventually publish research and develop standards of practice for therapeutic gardens.

What Does This Have to Do With Social Work?
Next to landscape architects, social workers were the largest discipline represented. The Acer Institute’s founder and director, P. Annie Kirk, BSW, MLA, ASLA, insists on including a sound social work perspective in her interdisciplinary approach to therapeutic garden planning and design.

While working with clients with chronic mental illness in community mental health settings, Kirk found that one of the more successful measures in treatment and compliance was referring clients to a landscaping crew. This intervention offered vocational rehabilitation and socialization skills, both of which were thought to increase program members’ ability to remain functioning in the community and thus avoid rehospitalization. Her clients’ health records indicated that during long inpatient stays, they had no access to exercise or the outdoors and as result had experienced significant functional declines.

“Staff and administration noted significant improvements in socialization, cognition, mood, and general function [eg, medication compliance], as well as reduction of inappropriate or violent outbursts, and satisfaction for those clients on the landscaping crew. When looking for a graduate degree program, I recalled the positive effect that this referral had on my clients. These memories struck me as an ‘ah-ha’ with regard to the benefits of health and well-being while working in nature,” says Kirk.

Kirk hopes her current project will provide much-needed advocacy and valuable intellectual property for restorative and therapeutic outdoor environments. With this emphasis on advocacy, Kirk has figured out how to take one of the guiding principles of social work, pair it with similar principles in allied disciplines, and put together a dynamic team to advance the institute’s mission. This particular program offers some unusual opportunities for social workers to get involved in a related but separate field where our input may not normally be sought, thus expanding our knowledge base and our sphere of influence.

Horticultural therapy as an intervention has grown from a seemingly simplistic, unscientific, fun client activity into a clinical intervention that demands to be taken seriously. Consequently, therapeutic gardens are demanding their rightful place as a crucial element in the design and planning phases of direct care facilities for all ages. The symbiotic relationship between social work and horticultural therapy is easy to grasp. In social work terms, the person-in-environment concept is appropriate from a social ecology construct, as the interaction between humans and our natural environment is enduring (Germain & Bloom, 1999). The growth and renewal metaphors are equally fitting as expressions of change and healing. Whatever the spin on it, therapeutic gardens celebrate creative interventions with a client-centered purpose.

In a healthcare setting, therapeutic gardens humanize patients. “One of the reasons I asked so many social workers to participate in the inaugural symposium,” says Kirk, “is that social workers understand the connection and level of comfort with the outdoors. For example, the maple tree (Acer is the Latin word for maple tree) is abundant and well known in our national landscape; it is familiar.” The familiar, especially for older adults and persons with dementia, has a therapeutic effect of stimulating memory and inspiring a meaningful connection between the past and the present (O’Donnell & Safford, 1997). When clients feel connected and comfortable, our work with them has a greater chance of being effective.

We Want the Best for Our Clients
According to Marie Valleroy, MD, a phychiatrist at Rehabilitation Medicine Associates in Portland, OR, prevention is the only way to combat the climbing cost of healthcare. Preventive medicine, or preventive health maintenance, is a strength of Western medicine, yet our current practice model is illness care rather than healthcare. Medical social workers, as well as those who practice in community mental health, experience this disparity daily. Valleroy and Jane Gordon, PhD, a public health researcher and analyst, are currently studying the benefits of a healing garden that had been erected just last year where an undeveloped patio stood at the Oregon Burn Center. “I don’t know how many of you have ever worked in or visited a burn unit,” says Valleroy, “but it is one of the toughest kinds of work to do. It’s hard for staff to work around this intense pain. Because burn patients are so susceptible to infection, they must remain indoors for days, weeks, even months at a time.” Because of the difficult nature of this type of work, staff turnover is high. So the garden was designed with the care and healing of caregivers, staff, and family in mind as a place where they could go to get a break. Preliminary research findings suggest that a majority of staff found the greatest benefit of the garden was to refresh and revitalize during their shift.

Vi Hansen, MSW, LCSW, a medical social worker, has advocated for 14 years to include healing gardens in hospital settings. Hansen recalls a stirring account of hope and healing where the garden was the most effective intervention for a man with a devastating cancer diagnosis. He was from a semirural area, came to the city for treatment, and had become very depressed during his long hospitalization. He was bedridden and connected to monitors and IVs that restricted his mobility.

Finally, his wife and his social worker advocated for him to spend a little time in the garden as a last resort to improve his mood. The care team was convened. “Clinical staff buy-in is critical,” Hansen pointed out, and one by one he was unhooked from everything except one portable IV pole. He and his wife spent the afternoon on a shaded bench, his head in her lap. Not too long after, he was allowed to leave the hospital and return home. “Hospitals are so dehumanizing,” she says. “Nature is so rehumanizing.”

We Conduct Research
Although research supporting the idea of gardens as therapeutic environments, as opposed to just pretty places to sit, has been available since the 1970s, current crises and shifts in healthcare, from service delivery to at-risk populations to spiraling costs, may prove advantageous timing for proponents of healing gardens (Hatty, 2005).

For social workers engaged in research, the promotion of therapeutic gardens offers many exciting opportunities. “We want to link a planned garden to a likely outcome,” says Marni Barnes, LCSW, ASLA, a writer-researcher on emotional health and outdoor environments. In addition to studying specific interventions, even including the plants chosen, studies are needed to address the utilization and effectiveness of the design, implementation, and cost-effectiveness of gardens so funding sources can make informed choices when reviewing grants to agencies and facilities.

Too often, the garden at any facility or community setting is an afterthought when funds are scarce. Healing gardens are therapeutic interventions that need to be preplanned, funded, built, utilized, and legitimized by organizations such as the National Institutes of Health and Joint Commission on Accreditation of Healthcare Organizations. Jerry Smith, ASLA, a veteran landscape architect for a firm that designs healthcare facilities, counsels groups like the Acer Institute about “value engineering,” a euphemism for cutting some design element out of an architectural plan as a result of budgetary overages—and there are always overages. Smith says that if the healing garden is part of the project’s guiding principles, it is more likely to stay. He is a member of The Center for Health Design, based in Concord, CA, one organization trying to work with architects and landscape architects to raise the bar for inclusion and legitimacy for healing gardens. (Visit www.healthdesign.org for more information.)

We Are Activists in Our Communities
The Portland Memory Garden was designed for people with dementia. It took four years to complete with the help of fundraisers, the Alzheimer’s Association, the City of Portland, and volunteers. It features a well-lit, fenced area, benches to stop and rest, private places for families to visit, and dozens of species of plants and trees that are not only beautiful to look at, but are also safe to touch and not harmful if ingested. Some species of plants, such as lilac, were specifically chosen for their old-fashioned, familiar quality—like the maple tree—stimulating the long-term memory of individuals with dementia. The garden is designed to involve all the senses because of the prevalence of sensory loss in older adults. The garden is a practical intervention—it also has a restroom, two canopied areas for shelter, and a table with chairs. Symposium participants helped garden organizers by filling out a usability study, giving impressions of the space. Developing evaluation tools will be a critical element in creating and measuring standards of care for therapeutic gardens, another area where social work researchers can get involved.

In the gardens at Legacy Good Samaritan Hospital in northwest Portland, physical therapists take patients outside to do their work. I observed two patients in wheelchairs, one older adult and one young adult. The older woman wheeled her chair right up to the edge of the planter and began fingering leaves and flowers. The younger woman sped up and down the smooth garden paths. Both were visibly happy to be outdoors as the therapist asked them to demonstrate physical tasks.

After observing the session, I participated in an experiment. I was asked to experience the garden using a wheelchair, a walker, a cane, and carrying an IV pole. The differences were astounding because the garden has something to offer according to one’s changing eye level and functional ability to get close to nature. I was unable to speed down the garden paths, so a rest under a shade tree was plenty for the wheelchair trial. With the IV pole, I was upright and could see more of the layout of the garden, which made me imagine the freedom of open space after sleeping in a hospital room. Further, I was able to imagine living in the community with an assistive device, adapting to the world with altered physical functioning. It was a moving demonstration of some of the changes we ask our clients to endure.

We Promote Change
Care facilities and agencies are systems, and social work is all about systems. The multidisciplinary team at the Acer Institute means multiple systems working together toward a common goal. Social workers can help promote therapeutic gardens by leveraging everything we already know about these interventions and sharing that knowledge within the service delivery systems that employ us. Social workers can assist with studies, include outdoor work in treatment plans, and document interventions and outcomes as evidence-based research.

We can also help jump-start the business of it by understanding the cost-effectiveness of the interventions, (for example, could 30 minutes in the garden reduce the number of antianxiety medications a person takes per day?) If you are passionate about therapeutic gardens, get to know your funding source. What kind of return on investment are they seeking? Is it staff retention, fewer readmissions, reduced depression among hospitalized patients? Where older adults are concerned, if Medicare learned that facilities with a planned therapeutic garden also had earlier discharges and reduced drug costs, that could influence decision makers at all levels of facility planning and funding to look seriously at requiring a restorative space to qualify for funding. Indoor gardens could be considered for places where harsh seasons make outdoor gardens untenable. According to the American Association of Retired Persons, gardening and outdoor activities top the list of leisure activities for American adults. Some of these gardeners are surely philanthropists who would like to have their name on a therapy garden rather than a hospital wing.

Whatever the population served, level of interest in research, or comfort level with funding, there is room for a social worker with curiosity about the emerging field of healing gardens to participate in promoting them. Working with an interdisciplinary team, as many of us do, we can quite literally roll up our sleeves and get our hands dirty to accomplish something wonderful for our clients. We can focus on healing gardens as a way to keep a fresh perspective in our jobs. We may even be able to influence healthcare delivery in the United States.

However we choose to be involved, healing gardens are a step toward the future, a step in the right direction. I’ll bet the next time you come across a garden of any kind, you will pause and consider how it may help you with that difficult client you had just last week.

— Tracy Greene Mintz, MA, MSW, ACSW, is a geriatric social worker with the Motion Picture and Television Fund in Los Angeles.

For more information, visit www.acerinstitute.org.

References
Germain, C. B., & Bloom, M. (1999). Human behavior in the social environment. New York: Columbia University Press.

Hatty, S. (2005). Health and health care: A background paper for the Acer Institute Symposium on therapeutic landscapes. Athens, OH: Author.

O’Donnell, M. & Safford, F. (1997). Death, bereavement, loss, and growth: Two perspectives. In Safford, F., & Krell, G.I. (Eds.), Gerontology for Health Professionals: A Practice Guide (2nd ed., pp. 179-204). Washington, DC: NASW Press.