Jean M. Larson, Program Manager of the Center for Therapeutic Horticulture at the University of Minnesota Landscape Arboretum
If you are a gardener, or a nature enthusiast at any level, you already know the healing power of plants. Anecdotal evidence, personal experience and common sense support the fact that being around natural environments helps most people feel better. But what does science tell us about the healing power of gardens and landscapes?
Photo 1: John Gregor
Healing Garden and Therapeutic Landscape: Defined
According to Clare Cooper-Marcus (1999, 2002) a healing garden is a general term referring to an over-all sense of well-being in a comfortable and appealing outdoor space. It is a green space that provides relief from physical symptoms and provides stress reduction. It is a secure, visible, and accessible space with ample, well-maintained greenery. A healing garden incorporates unambiguous positive design features with places for people to sit alone or in groups.
Diane Relf (2005) a leading scientist in the field of Human Horticulture defines a healing garden as a “term more frequently applied to a garden at a healthcare facility that is intended for use by staff, visitors, and clients at their discretion, rather than as a part of a treatment plan”(p. 236). She goes on to say how research “has indicated that these types of gardens (healing gardens) are more effective in creating a restoration effect if the various users are directly involved in all aspects of the design, installation and maintenance of the garden”(p. 236).
Photo 2: David Zlesak
Becke Davis (2007) tells us a therapeutic landscape is a supportive design that is used as part of a treatment intervention. The landscape is designed to address a particular aspect of the healing process for a patient/individual. Therapeutic landscape design is more specific and “is used towards a measurable outcome upon a disease process within a given patient and/or group of patients. The therapeutic landscape is less focused on healing in the spiritual context and more kin to the disease model of illness as practiced in most allopathic medical systems” (p. 32).
Cooper-Marcus (2005) suggests that a therapeutic landscape is a green space for passive or quasi-passive activities. Adding that a therapeutic landscape needs to provide a measurable degree of relief from physical symptoms, stress reduction and improvement in overall sense of well-being. Similarly, Elisabeth Palka (1999) defines a therapeutic landscape as a place that promotes wellness by facilitating relaxation and restoration and enhancing some combination of physical, mental and spiritual healing.
Photo 3: John Gregor
Diane Relf (2005) describes a therapeutic landscape as a “garden that is used as part of a treatment program by various members of the medical staff” (p. 236). For example, it may include “walkways and steps or grassed raised bed to use as an outdoor exercise mat designed with the physical therapist as an outdoor exercise room” (p. 236).
Healing Garden and Therapeutic Landscape: Similarities and Differences
A healing garden and a therapeutic landscape share two things in common:
- green space
- both seek to improve a patient’s health, quality of life and well-being.
The essential differences are found in the garden and/or landscape design purposes and how that garden/landscape design is utilized.
While a well designed healing garden could also act as a therapeutic landscape, it is generally conceived as a green space set apart at the hospital or healthcare facility where all people – staff, patients, family, and visitors – can find a sense of restoration and relief.
Photo 4: John Gregor
The therapeutic landscape by distinction has an intentional, purposeful and measurable means to bring about health and well-being, often designed to meet the needs of specific patient populations. The therapeutic landscape is a space designed for a therapeutic treatment to bring about a certain measurable outcome. It can be thought of as similar to a medication taken for a specific disease or illness.
Clare Cooper-Marcus (2006) explains in The Garden as a Treatment Milieu how two gardens at the Swedish University of Agricultural Sciences in Alnarp, Sweden have been designed to observe the healing effects of gardens as part of the treatment intervention for people with a variety of stress-related diseases. There are two groups in the experiment: one group being treated with gardens with the choice to either work (therapeutic landscapes) or relax (healing gardens) under the care of professional staff (occupational therapy, horticultural therapy, physical therapy, psychotherapy), for one half day to four half days a week over a period of twelve weeks. The other group, a control group, is being treated in a more traditional manner including a long period of rest at-home plus typical anti-depressant drugs (Prozac and Zoloft) and five or six sessions of physical therapy or psychotherapy.
Photo 5: John Gregor
The results of the study are yet to be determined but as one of the staff remarked “I’ve been working with stressed and sick people for 25 years and the changes we see here in the garden in three months are faster and deeper than anything I’ve seen before” (Cooper-Marcus, 2006, p.26).
Cooper-Marcus (2006) summarizes with “these gardens are in the vanguard of a whole new movement – the treatment of physical and psychological problems through non-drug interventions”(p.36). She encourages Landscape Architects “to be aware of this movement to design healing gardens and therapeutic landscape nature experiences that serve as treatments for a variety of psychological and physical symptoms. They may well become the ‘pharmacists’ of the future” (p.37).
Photo 6: David Zlesak
Healing Garden and Therapeutic Landscapes: History
Healing gardens and therapeutic landscapes have a similar historical tradition in healthcare over time. For example, the healing powers of plants found in pharmacopeia can be traced as far back as ancient China and the Ayurvedic traditions of India (Gesler, 1992) while the Asclepieia of ancient Greece are considered to be the first healthcare facilities of Europe designed with the healing powers of nature in mind (van den Berg, 2005).
The middle ages brought two important features which helped pave the way for healing gardens and therapeutic landscapes – the “doctrine of signatures” (Potterton, 1983) and monastic infirmaries. During this time medical care was often carried out by religious institutions, administered by nuns and monks, where the standard treatment was to heal patients with medicinal plants, ritual and prayer. The design of these monastic infirmaries adhered to important aspects of monastic life, including a garden for medicinal plants, and patient rooms designed to be facing the south, adjacent to a central courtyard or garden.
Photo 7: David Zlesak
The garden for medicinal plants was used by the monks and nuns for medical treatments. The medical treatments at the time were systematized based on a practice known as the “doctrine of signatures.” The “doctrine of signatures” is based on the belief that objects in nature which looked similar to human organs were thought to be divinely given, and could be used for cures (Gesler, 1992, Potterton, 1983).
Patient rooms were placed adjacent to a central courtyard or garden to encourage the patient’s contemplation of and spiritual connection with God. The rooms faced south so patients could be warmed by the sunlight and to keep them in a well-ventilated environment. The courtyard was often designed to symbolize the Garden of Eden (van den Berg, 2005).
Photo 8: David Zlesak
The monastic tradition gave way to the pavilion style hospitals in the late 17th early 18th century hospitals. The pavilion style was developed in France and included design features similar to monastic infirmaries in that the design made use of the natural environment as a therapeutic instrument for patient healing. The natural environment was used for its three characteristics: sunlight, fresh air and peaceful green surroundings (Cooper-Marcus & Barnes, 1999).
Florence Nightingale became an internationally renowned advocate for healing environments that took full advantage of nature’s three elements: sunlight, air, and green space (Dossey, 2000). Dossey writes how Florence witnessed the poor conditions of British military hospitals and mandated the introduction of hygienic standards that saved the lives of thousands of patients around the world. She ingeniously used statistics to calculate mortality rates and learned the disparity was largely due to differing physical environments. Dossey describes how in Notes on Hospitals, Nightingale asserts how important it is to maintain low patient densities in hospital wards, circulation of fresh air, adequate light, good drainage, clean kitchens and laundry rooms, and gardens for contemplation and restoration (Dossey, 2000).
Photo 9: David Zlesak
During the late 19th and early 20th century there was a movement to reform psychiatry which sought to shift treatment of people with mental illness from the institution out into the community. This movement was called moral treatment and was begun in reaction to the dehumanizing methods of care commonly applied to people with mental illness (Gesler et. al., 2004). At this time in the United States, Dr. Benjamin Rush, a physician with training in psychiatry, used the agrarian fields of Pennsylvania for his patients with mental illness. The farm setting was thought to be a calming place and a curative setting for patients with mental illness (Simon & Straus, 2003).
Photo 10: John Gregor
By the early to mid-20th century, after World Wars I and II, gardens designed for rehabilitation and therapeutic purpose came about as a result of the many people with physical disabilities returning from combat. The expansion of rehabilitation hospitals in the 1940’s and 1950’s did much to expand and improve the practice of healing gardens and therapeutic landscapes (Simon & Straus, 2003).
Healing Gardens and Therapeutic Landscapes: Present
Today, healing gardens and therapeutic landscapes base their conceptual framework on the work of Roger Ulrich (Ulrich 1999, Gesler et. al., 2004). Both the literature for healing gardens and therapeutic landscapes cite Ulrich’s seminal work “A Room with a View” as the preeminent research study supporting the potential for nature to heal.
In this study, Ulrich (1984) conducted an experiment with matched groups of patients recovering from gall bladder surgery. Of the 46 patients, 23 looked out a hospital room into nature while the other 23 looked at a brick wall. The group that looked out their hospital window into nature had shorter hospital stays, received fewer analgesic medications, received fewer negative comments in nursing notes, and had a shorter length of stay then the other 23 people who looked at a brick wall.
Photo 11: David Zlesak
Even though therapeutic landscape and healing gardens come from similar but different principles, both base their conceptual framework on Ulrich’s theory of supportive design (Gesler et. al, 2004, Ulrich,1999, 2000, 2002). While speaking at the Investigating the Relationship between Health and the Landscape conference (2000) Ulrich said:
“What is the theory of supportive garden design? It is a garden that is supportive of patients coping with the major stress that always accompanies illness. Supportive garden design helps patients reduce stress and its negative effect and hence, improve patient outcomes” (p.34).
Figure 2: Ulrich’s Theory of Supportive Design (1999)
Ulrich’s Theory of Supportive Design (see Figure 2) proposes the following four stress coping mechanisms must be in a garden design to support the goal of stress reduction:
2. Social Support
3. Movement and exercise
4. Access to Nature and/or other distractions
Photo 12: David Zlesak
Control: According to Roger Ulrich (1999, 2000, 2002) people have a strong need for a sense of control with respect to their surroundings. Ulrich cites a textbook by Gatchel et.al. (1989) as an essential resource for understanding how control refers to a person’s real or perceived need to influence their situation and have a voice in determining what others may do to them. In general, when a person is engaged in a situation with uncontrollable conditions, stress is increased, which may lead to an increase in negative effects (i.e. depression, high blood pressure, reduced immune function), which then may potentially worsen patient outcomes.
Photo 13: David Zlesak
Ulrich (2000) explains:
“Have you ever considered the loss of control the patient feels when going to the hospital? From giving up what you wear to when you wake-up or retire-to bed, all the things a patient is required to do are processed according to bureaucratic methods and procedures; a depersonalization that takes away a sense of control” (p.42).
Improved health outcomes that come from experiencing a sense of control may include better health and a reduction in feelings of helplessness (Haller & Kramer, 2006). A garden designed to increase a patients sense of control can help to reduce patient stress. For example, Ulrich asserts these specific design elements as essential to addressing patient sense of control: way-finding signs and hospital maps, convenient accessibility for people using wheelchairs or other medical devices, easy access to dining or staff lounges, a variety of garden spaces that enable users to choose privacy and/or adequate space to prevent crowding for large group gatherings (Ulrich, 1999).
Photo 14: David Zlesak
Social Support: Ulrich et. al. (2004) says social support is well documented in the mind/body medicine literature at improving health outcomes. Generally the mind/body literature shows that contact with caring, emotionally supportive and instrumentally helpful people are good for improving health outcomes and overall wellness. While few studies have focused on features of social support in gardens, Ulrich asserts garden designs that foster social support will improve patient outcomes. Garden features necessary for the enhancement of social support include: a variety of spaces for sitting with comfortable moveable chairs, garden location close to and accessible to waiting areas for family/visitors and patient rooms, and garden spaces that consider the cultural/ethnic issues associated with patients served (Ulrich,1999).
Movement and Exercise: Ulrich (2000b) further explains the theory of supportive design include garden areas for exercise and movement. Research shows that even a few minutes of mild exercise improves mood, reduces stress and how regular exercise is known to lower levels of depression. A garden serves as a pleasant place for patients/family to move in their wheelchairs or walk. In particular, gardens which promote patient accessibility and independence through a well-designed pathway system will help to motivate a patient to get up and out to move their body.
Photo 15: John Gregor
Nature: Lastly, positive distractions refer to a small set of environmental features or conditions that has been found to effectively reduce stress (Ulrich, 2004). As Ulrich (2000b) explains:
“…humans have evolved features that effectively and quickly produce restoration from stress. Most phenomena that have been important to humans throughout evolution are distractions such as laughter, art, music, companion animals and nature all feature effective and quick restoration from stress. The focus here is on nature” (p.54).
Photo 16: David Zlesak
Many studies have found that even a brief encounter with nature will reduce stress within three to five minutes (Ulrich, 2004). Research scientists have been reporting the stress-reduction and restorative benefits of viewing nature contribute to a cluster of positive emotional and physiological changes (Ulrich, 2004). Laboratory and clinical studies have shown that viewing nature reduces stress and is made evident in reduced blood pressure and heart activity (Ulrich, 1999).
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