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Stress rehabilitation through garden therapy
Urban Forestry & Urban Greening 11 (2012) 51–58
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Stress rehabilitation through garden therapy A caregiver perspective on factors considered most essential to the recovery process Anna A. Adevi a,∗ , Mats Lieberg b a b
Swedish University of Agricultural Sciences, Department of Work Science, Economy and Environmental Psychology, Box 88, SE-230 53 Alnarp, Sweden Swedish University of Agricultural Sciences, Department of Landscape Architecture, Box 58, SE-230 53 Alnarp, Sweden
a r t i c l e
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Keywords: Exhaustion disorder Garden therapy Stress recovery
a b s t r a c t At the Alnarp Rehabilitation Garden in Sweden, people suffering from stress-related illness are rehabilitated through garden therapy. Empirical data were collected through in-depth interviews and focus-group interviews with the rehabilitation team. The present article is based on team members’ understandings of significant factors to the stress recovery process. On-site observations were conducted to achieve a broader comprehension of the empirical data. The article is based on the caregivers’ points of view, as they are presumed to be close to the course of events occurring in the garden therapy programme as a whole. The results reveal a generally complex picture of the rehabilitation form, but at the same time indicate three factors that are of primary importance: (1) sensory impressions, (2) self-chosen places in the garden, and (3) interactions between concrete and symbolic activities. The garden environment tends to “prepare, receive and open up” the participants before and after therapeutic elements, which is thought to be especially appropriate for this group. The results provide important knowledge about what kinds of factors contribute to relief and recovery from stress-related ill-health in the context of stress rehabilitation through garden therapy. © 2011 Elsevier GmbH. All rights reserved.
Introduction Nature’s role in health Historically, people have always used nature as a powerful healing source and as a resource for recovery (Cooper Marcus and Barnes, 1999; Jakobsson, 2009). Gardens, landscapes and spirituality have been interconnected since ancient times (Tuan, 1976). Natural environments have been thought of as places that can bring people closer to God or other beliefs or as places where one can get in touch with their spiritual self (Janick, 1992; Rosenfield, 1992; Van Zuylen, 1995). Since the mid-1980s, research has indicated that gardens, parks and areas with natural greenery have beneficial effects on human health, well-being and capacity (Wilson, 1984; Kaplan and Kaplan, 1989; Ulrich et al., 1991a). According to Searles (1960), nature plays a significant role in promoting mental health. Studies show that stays in natural environments and gardens offer positive stimulation of emotional, cognitive and physical functions (Ulrich, 1984; Kaplan and Kaplan, 1989). In relation to mental fatigue (Kaplan and Kaplan, 1990) and acute
∗ Corresponding author. Tel.: +46 40415415. E-mail address: [email protected] (A.A. Adevi). 1618-8667/$ – see front matter © 2011 Elsevier GmbH. All rights reserved. doi:10.1016/j.ufug.2011.09.007
stress symptoms (Ulrich, 1999), these positive effects on health achieved through stays in natural environments are called restorative effects. The organization for horticultural therapy in the United States describes horticultural therapy as a process in which plants and gardening activities are used to improve people’s body, mind and spirit (AHTA, 2007). Horticultural therapy is primarily based on behaviour that promotes recovery (Matsuo, 1992). In the field, humans are seen as active beings that experience meaning in life with the help of physical work. According to Kielhofner (2006), humans control their life by choosing their activities, their path of development, and how they will adapt to the surrounding world, which in turn leads to an increased quality of life. Kondo (2002) argues that places containing plants that promote calm may be more effective than parks in their conventional forms. According to him, such places are better able to instil a sense of unity with the natural world. A supportive and health-promoting garden with many green elements may help improve the quality of patient care (Ulrich, 1992a). Most people who are experiencing low psychological power and energy do not wish to process new impressions; they first need to sort impressions they are already familiar with (Grahn, 2005). People undergoing medical treatment often feel a certain psychological vulnerability, which increases their sensitivity to new
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Fig. 1. Illustrated plan of the Alnarp Rehabilitation Garden (illustration by Karin Sunde-Persson, 2010).
and habitual environments (Schroeder and Anderson, 1984; Ulrich et al., 1991a; Ottosson and Grahn, 2008). “The Supporting Environment Theory” (SET) argues that the more mentally fragile and weak a person is, the more they need support from the surrounding environment. SET includes ideas about the self’s communication with the external environment (Grahn, 1991, 2005; Grahn et al., 2010). Stress-sensitive individuals will have more opportunities to recover from stress if they are given the chance to manage a task (Pariola, 2001), if the therapeutic value is perceived as meaningful. Such individuals need to experience a balance between different activities if they are to achieve a sense of well-being (Christiansen and Baum, 1997). Cultivating plants in flowerpots is more effective at reducing negative feelings than is merely looking at plants (Endo et al., 2001). During rehabilitation, humans are supported by the plants in how they orient to reality and in their connection with the surrounding world (Lewis, 1996). Plants may be important to treatment if the focus of the therapeutic process is on how the participants participate, how they perceive and become involved with the plants using their five senses creating something with the plants or taking care of them (Matsuo, 1992).
Knowledge gap Although significant relationships between nature and stress recovery have been identified in quantitative studies (Wilson, 1984; Kaplan and Kaplan, 1989), there is a knowledge gap in this field of research when it comes to explaining the nature of such relationships and why they exist (Magell and Viborg, 2005), especially when therapeutic elements are included. There seems to be a great deal of research on the roles of caregivers within the healthcare sector in general, but a lack of research on the relatively new rehabilitation form garden therapy. Because there has been little research on garden therapy as a whole, it is natural that the caregiver’s perspective in this context has also received limited attention. The aim of the present article is to explore factors within garden therapy that caregivers in the rehabilitation team understand to be the most essential to successful stress-rehabilitation and the recovery process.
Exhaustion disorders Exhaustion disorder is characterized by extreme fatigue, cognitive problems, and disrupted sleep. The condition is caused by prolonged stress and may give rise to episodic cognitive problems, tiredness, lack of empathy, aches and pains for years before the onset of the illness. The course is often prolonged with residual symptoms, mainly, enduring stress intolerance (Asberg et al., 2010). The disease often stems from a strong stress reaction related to the individual’s professional environment. It is also due to the limitlessness of work in contemporary society and the relationships at home or during free time. Severe ill-health caused by stress constitutes an existential crisis; a kind of life crisis (Maslach, 2001). Today, exhaustion disorder is mainly treated using medications such as anti-depressive psychopharmaceutical preparations and/or different forms of therapy, such as psychotherapy. Alnarp Rehabilitation Garden The Alnarp Rehabilitation Garden has been constructed to investigate whether an environment offering separate garden and nature elements can rehabilitate people afflicted by stress and exhaustion disorders. The garden consists of a 2-ha area comprising nature-like areas with restorative characteristics and traditional cultivation areas with flowerbeds, where the focus is on more demanding activities. The nature-like areas include small woods, groves and meadows. The cultivation areas include paved surfaces, traditional cultivating rooms, forest-like garden rooms and botanical rooms (Stigsdotter and Grahn, 2003). The garden is ergonomically designed, providing opportunities for participants to train their physical, sensory and cognitive functions (Abramsson and Tenngart, 2003). Moreover, the distinctive features marking a nature environment versus a garden environment need to be clarified. In brief, nature stands for the wild, non-disciplined; for a natural dynamic and “an unknown gardener”, while garden contains the cultivated and ordered, with characteristics of something designed by “a known gardener”. In the present text, the concept nature is sometimes referred to using the word garden, because garden therapy as it is practised at Alnarp mainly takes place in a garden environment (Fig. 1).
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The rehabilitation programme A letter of referral is written by a doctor for rehabilitation through garden therapy; this often occurs after non-successful attempts at other kinds of rehabilitation, medical treatments, different therapy forms, etc. Admission into garden therapy is limited as there are so many eligible applicants (those who, according to the insurance office, should be able to return to work following recovery). During a twelve week period the participants are rehabilitated four half-days per week. The basic objective of garden therapy is to strengthen participants’ possibilities to return to work with new knowledge about the tools and coping strategies they can use in stressful situations. The rehabilitation is based on daily routines and encounters with like-minded individuals who are struggling with similar challenges, in close connection with professional therapists who care for the individuals in an accepting, calm and positive manner. The participants receive conversational and picture therapy, physical therapy and relaxation, which take place in close contact with nature and also include activities such as traditional gardening and handicraft activities. The garden therapy activities at Alnarp are divided into concrete, symbolic and selfrewarding activities (Persson et al., 2001). The concrete activities show visible and concrete results, which may be seen as a “finished product”; one example is making pesto from fresh basil. Symbolic activities are something the participant performs, at the same time as he or she evaluates what is happening based on the associations or memories that are triggered. One example is working with clay, through which metaphorical values may emerge. The participants go home each day, or to other housing they have arranged, due to the large number of participants who live in other parts of Sweden. What mainly distinguishes garden therapeutic activities from other therapeutic activities is that activities within garden therapy mainly occur outside. The senses and muscles are activated when participants expose themselves to wind, temperature, daylight, and increased physical activity (such as digging, crawling in flowerbeds, etc.). Because exhaustion disorder was the mental illness most similar to the mental fatigue described by Kaplan and Kaplan (1989), it was decided to rehabilitate people with symptoms of exhaustion disorder at Alnarp. Approximately 80% of the participants in Alnarp are women. The rehabilitation team The rehabilitation team in Alnarp consists of five horticultural therapists with different backgrounds and professional competence. Their main task is to treat or relieve participants’ symptoms, as well as to facilitate participants’ increased understanding of the needs of living things by using plants and nature as examples and symbols. The role of the gardener is primarily to design and care for the garden, which should provide opportunities to alternate between contrast-rich and varying garden areas that affirm both rest and activity. The primary role of the curative teacher is to encourage within each individual the development of a healthy core that can be reached. This is done by guiding the individual and promoting involvement and participation in the entire spectrum of being human: thoughts, feelings and volition. The occupational therapist creates activities that present physical and psychological challenges appropriate to the participant’s level of functioning. Different forms of stress management are taught and practised. The physical therapist’s point of departure is that the body is a physical manifestation of who the individual actually is, but that it simultaneously carries and shelters old learned thought and behaviour patterns. Because exhaustion disorder is a kind of existential life crisis in which previous, ineffective thought patterns need to be changed to more purposeful patterns, the role of the psychotherapist is to help participants put their new experiences
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into words in relation to how life functioned prior to therapy. The argument for focusing on the rehabilitation team members in the present study is that they, as experienced staff, may possess unique knowledge and competence. Within a rehabilitation context, we prefer to refer to the rehabilitation team staff as caregivers, given their closer connection with the participants, although a gardener is not typically seen as a caregiver. Because they are working in close connection with the participants each week, we are convinced that they possess a special kind of knowledge of the recovery process that is important to include in our research. (Another article by the first author, focuses solely on the participants’ point of view concerning important factors for the recovery process; yet to be published.) Methods Research design The study is based on in-depth interviews and focus-group interviews with all members of the rehabilitation team – in total five persons. The interviews were conducted during 2008–2009. In addition, on site observations were conducted during 2009 and 2010 in order to achieve a broader comprehension of the interview data. The caregivers interviewed have been involved in garden therapy at Alnarp since the start in 2002 and have taken care of approximately 120 participants (at the time of interviews) over the years, with approximately 6–8 participants in each group. Two interview guides were used that dealt with the following issues: the situation of the participants and the interplay between participants and caregivers. The interview guides were broad in scope and encouraged an open dialogue. Participants and procedures The interview data are based on five semi-structured individual in-depth interviews with all the members of the rehabilitation team (1 h with each person) and one focus-group interview (2 h with the five persons in the group simultaneously). Interviews were audio-recorded by the first author and a colleague. The reason for conducting a focus-group interview in addition to the individual interviews was mainly to emphasize the significance of interactions and discussions between the rehabilitation team members (Wilkinson, 1998; Bryman, 2008). We were interested in the caregivers’ points of view on the main reasons for stress-recovery through garden therapy. In the focus-group interview, the caregivers were offered opportunities to probe each other’s reason for holding a particular view. When listening to each other’s answers, the caregivers were able to qualify or modify a view or voice agreement with new ideas they may not have thought of without being exposed to the impressions of others. The caregivers were given opportunities to argue or challenge each other’s views. This allowed us to study the ways in which the caregivers collectively discussed the topic in question. The on-site observations were conducted as participant observations (Bryman, 2008), where the first author practised as a garden assistant during the summers of 2009 and 2010 for a period of 24 weeks (two rehabilitation periods of 12 weeks, four days a week, 4 h each morning); a total of 13 (5 + 8) persons participated. The aim of the observations was to learn more about the therapeutic environment and its actors from “within”, and in that way to better understand and interpret the informants’ statements. This approach is sometimes used in “micro-ethnographic” research (Bryman, 2008, p. 403), where the possibility to stay in the environment over a long time period is limited. The observations were
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made openly after consultation with the caregivers and participants, and the findings were documented as written field notes at the end of the rehabilitation day. All interviews and observations were conducted at the Alnarp Rehabilitation Garden. The interviews were transcribed by a person hired for that purpose. Data analysis The recorded material, as well as the field notes, were subjected to qualitative data analyses. The method of inquiry for the study was Grounded Theory (Glaser and Strauss, 1967). Grounded Theory is a research method often used to explain human behaviour in certain physical and social contexts. The method is most appropriate when little is known about the field of research or when the predominant theoretical perspective in the research field is unable to explain what is going on (Bryman, 2008). The research process is inductive in that data are coded and analysed as they are collected (Charmaz, 2003). Preliminary hypotheses about the emerging categories and themes are deductively refined or confirmed in an iterative process, through additional data collection (Denzin and Lincoln, 2005). In this process, the researcher strives to develop explanatory and theoretical key concepts and to explain the relationships among them. The goal is to develop a substantive theory. Themes were generated through an iterative constant comparative process whereby data collection, coding and analysis occurred concurrently. Open and selective coding of the interview material was carried out. This process is also called theoretical sampling (Denzin and Lincoln, 2005, p. 185). Analysis through coding, categorizing and thematisation of the textual material finally resulted in three key explanatory concepts and delimited themes, which are presented in the Results section.
Results A complex picture of multiple activities emerges from the results; each contributing to stress rehabilitation during garden therapy. Among these activities, three stand out for being particularly salient. These factors are presented here as different themes: (1) sensory impressions, (2) self-chosen places in the garden and (3) interactions between concrete and symbolic activities. Theme 1: sensory impressions The caregivers bear witness to how participants seek and find a sense of belonging in nature’s order, which allows them to feel they are part of something much greater than the immediate environment. At the outset, participants make contact with this new natural environment by acquainting themselves with it in an unplanned and unconscious way. What is really lovely is that they come to the conversation at a very receptive stage . . . they are prepared on a physical level to open up. . . . When one opens up and is so fragile it’s lovely to be touched by great, friendly and soft sensory impressions. (Psychotherapist, woman, 66 years) The unpredictable occurrences of sensory stimulation and memory arousal are considered therapeutic effects in horticultural therapy (Talbot et al., 1976; Lewis, 1996). The caregivers describe this as when “locks are opened”; it tends to be easier to start the healing process. It seems as if the garden environment, with its sensory impressions, helps by offering the keys that are necessary to open up the participant’s existential, emotional and physical sides. It is presumably here the true recovery process begins. The more mentally fragile and weak a person is, the more they need support
from the surrounding environment (Grahn, 1991, 2005). To be able to “open up” for the participant is in line with SET principles. This is what I see as the magic part.- . . . When they leave a session with me I’ve hopefully managed to open them up to their innermost side, to their emotional core. Much would have been ruined if we’d continued talking. . .. The garden is meeting them. . . . It’s here that change is created and it’s a change that exists on the person’s existential foundation. This is unbeatable . . .. (Physiotherapist, woman, 58 years) Frederickson and Anderson (1999) argue that the confrontation with nature is inspired by thoughts concerning spiritual meaning and eternal processes. This is supported by a caregiver in the current study: There is depth to the nature and the trees and the Earth that I did not understand before . . . that it’s about existential questions, it’s very clear that there’s something in this that goes deep that you can get into contact with. That’s it. (Occupational therapist, woman, 60 years old) Reflections, thoughts and ideas concerning existential characteristics that are opened up seem easier to reach when one is surrounded by sensory impressions. Any greater extent of contact or socializing with other people on the part of participants is usually not desirable during the rehabilitation period. Simple, clear and positive impressions are appreciated, as opposed to something or someone who demands something in return. The garden seems to help by approaching the participants’ feelings in a direct and immediate manner (i.e. Gardener, male, 38 years). “The amount of information and knowledge we obtain depends on the variety and degree of contrast in the sensory data that we receive and the extent to which we can differentiate them” (Bell, 1999, p. 41). It’s when you stop and gather around something and start to discuss and look at it that things start happening. It’s very difficult to explain. Often, I feel like the garden and plants speak a language without words, without letters or numbers. They speak directly, so to speak. It takes a shortcut past the language, past something and it goes sort of right into you. It goes directly to your emotions. (Gardener, male, 38 years) The sensory experiences establish a wordless “communication” that to a great degree creates an extended emotional and existential awareness, which in turn creates receptivity to rehabilitation. This receptivity and sensitivity tends to greatly facilitate the remaining rehabilitation work throughout the whole therapeutic process. According to Matsuo (1992), it concerns how the participants relate to the plants within the therapeutic process, and how they perceive and become involved with the plants when using the senses. In the view of the interviewed caregivers, this seems to be a matter of how the participants open up and are receptive and, first within that process, are able to relate to the plants and the garden.
Theme 2: self-chosen places in the garden Humans often develop a feeling of belonging, identity, dependence and a kind of ownership in relation to places that somehow become “their place”, “the favourite place” or “the only place” for a certain type of activity (Lieberg, 1995; Korpela et al., 2001). Place attachment is understood as being an integrated part of human identity (Stewart et al., 2004). Scopelliti and Tiberio (2010, p. 237) define place attachment as “a complex construct that accounts for a person’s affective bonds to place”. This attachment can help to form and preserve the identity of an individual, group or culture (Low and
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Altman, 1992). It can also serve as a defence against identity crises in times of transition between developmental phases (Hay, 1998). The second theme is related to place attachment and the effort to explore the meaning of place. The theme is also connected to the first as it involves sensory impressions from nature. Finding selfchosen places in the garden based on one’s state of mind and needs, not only before but especially after therapeutic sessions, tends to contain an important dimension that allows participants’ healing processes to begin. The participants are encouraged to explore meaning of place and to find a place in the garden they feel attached to. This, in turn, will improve their ability to find these sometimes obscure places. People balance between various emotional states in their daily life, and this is also true during a period of stress rehabilitation. One exercise in the early phases of the stress rehabilitation programme focuses on finding such a place. Over time, the places can be changed or maintained and the participants can happily return to them. This could be, for example, the severely pruned apple trees participants seek out to be able to endure the fact that the trees’ “wings have been clipped”. When they’ve been with me they get in touch with their feelings, thoughts, insights, and experiences; as I’ve understood it, there’s no better way to help a person’s thoughts find a way out of the chaos and make things manageable than allowing them to spend time in nature and choose the way they’re attracted to it. (Physiotherapist, female, 58 years) The self-chosen places that attract participants are described as places that “receive” their current mood. According to the caregivers, reliance on the self-chosen places appears to create greater confidence over time. In the beginning, the participants seek out the garden areas nearby, and with time they venture into areas that are farther away. Cimprich (1993), who looked at cancer patients, argues that these patients improve their spiritual health (among other things) by only passively perceiving nature. The activity of sitting on a bench in a therapeutic garden is of great importance in achieving contemplation and a meditative feeling (Messervey, 1995). Relf (1995) and Liu (1999) and others note how only passive observation of floral and natural areas creates a general feeling of personal well-being. A bench or a shed may be of importance if a place in a therapeutic garden is to be perceived as contemplative and meditative (Messervey, 1995). Searles (1960) argues that nature plays an important role in mental health and Grahn (1989) proposes that the need for familiar surroundings applies to outdoor places as well. Thus, there would seem to be some relation between these notions and caregivers’ ideas about the importance of enabling participants to continuously search for, find and use self-chosen places in the garden environment. Signals from nature shape creative processes and develop a feeling of ‘sense of place’ (Searles, 1960), which are important in the rehabilitation process. The simplest relationships in crises are those that are the least complicated and the least difficult for the individual to deal with. When at their lowest level of mental strength, people derive the most help from simple relationships such as those to water and stones; the most demanding relationship is that to other people (Searles, 1960; Ottosson and Grahn, 2008). Well, just this idea of outside. being able to be outside. And that there are different environments to visit and participants can seek out the environment that speaks to them at the moment. (Curative teacher, woman, 49 years) Which place the participants experience as appropriate is highly individual; one person might prefer to sit in a lawn chair under a large tree, while someone else chooses to walk around in a specially selected garden area. Sometimes there is a need to sit down on the grass and pet the cat or start pulling weeds. Here Tuan’s (1977)
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concept ‘fields of care’ may be useful. Fields of care refers to places in the garden where participants have repeated contact and where the physical environment can evoke affection in them. Such places have often a deep meaning for participants, but may be insignificant to others. The garden changes the starting point for therapy, conversations, activities, etc., by creating a sense of wholeness for the healing process. In that sense the garden becomes an extension of the therapist’s competence. The caregivers’ state that the self-chosen places in the garden, with its constant changes, adapt in a non-threatening way to the participants’ emotional needs at the moment; they explain that the garden’s sublime message is perceived by the participants as comforting. According to the caregivers, participants often experience the places they are encouraged to seek out as especially welcoming. This has parallels with place attachment, in that this is not only a place like many others, but a place felt to be meaningful in the current situation. The self-chosen place seems to offer an individual meaning that has an impact on the stress recovery process as a whole. Kondo (2002) believes that garden environments that are conducive to peace and quiet are more “efficient” than parks, because it is easier to experience harmony through the great feeling of unity between man and nature. Taking inspiration from Kondo and considering the caregivers’ understandings, a carefully structured therapeutic garden offering many opportunities to find self-chosen places based on one’s current mood/needs may serve even better to nurture a feeling of unity than a “common garden” does. In other words, this feeling of unity ought to be very central in the design of therapeutic gardens. Just as there is a wide range of human emotional states, a therapeutic garden should contain a range of opportunities to spend time in attractive areas for sitting or reclining that encourage reflection, all embedded in an environment that is as appropriate and well considered as possible. Theme 3: interactions between symbolic and concrete activities According to the caregivers, helping oneself in a more personal way is a new approach to learning. Participants learn a new way to take advantage of opportunities, different paths one can take and, consequently, different decisions one can make. A newly acquired pleasure and joy of life is often perceived through the natural environment and the activities taking place there. “concrete activities . . . where you see a result from what we’re doing, that can be important in the beginning for those who are used to getting results. That they see the results of their work and then use symbols and metaphors like nature and the garden. Well there’s a lot of this, that we use in rehabilitation. . . . I am also always thinking that they have a value because there is a certain relaxation in doing something that is so clear and having such a clear beginning and end to it. Then you may drop it or as I often see further along in the rehabilitation, they take concrete assignments with them because they are thinking now I’m going to do this from A to B and then put it aside.” (Curative teacher, woman, 49 years) The benefits of interactions seem to refer to a perceived inner freedom and autonomy in combination with not being forced to perform for someone else. This is something those suffering from exhaustion disorder in particular seem to have a great need to genuinely experience. The experience is that the interaction is achieved through natural reflections made in an unconditional way. The ability to cope with a specific task is simultaneously blended with a curiosity about further developing one’s metaphorical reflections. The garden thus appears to offer support during painful symbolic processing, where symbolic values help participants find the right words to depict what is happening within them. And there’s a quality, which of course is visible all the time when it’s expressed. . . Your needs. are always followed up and that is how
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it is so that even in this concrete exercise there’s personal space. And I think that’s very central. We never say ‘Forget yourself now and concentrate on this plant here’. (Curative teacher, woman, 49 years) Because the participants are familiar with performing well, the concrete tasks are of great importance. It is there they get “their rewards” with which they feel familiar and comfortable. The concrete activities are deemed to be of great value, as there is a special kind of rest to be found in doing something that has a clear beginning and end. The importance of the need for interactions between concrete and symbolic activities has its origin in the work of Kielhofner (2006), who argues that how a person experiences and carries out a task depends on the dynamic interplay between the individual, task and environment; as soon as a person performs an action, the result is an experience. The environment affects how the activity is performed, offering an event in which people can choose what to do, or signalling something that more or less forces a behaviour or action (Kielhofner, 1997). According to Christiansen and Baum (1997), a person needs to experience a balance between different activities in order to experience well-being. Within garden therapy like that offered at Alnarp, this balance seems to occur often through the described interactions between activities. “But maybe because of the symbolic exercise they’ve done they’re discovering something completely different so . . . the concrete activity has a value for the person . . . taking care of yourself maybe suddenly there is something to talk about when you’re caring for the plant, and then you draw the parallel. How am I taking care of myself? So even if the totally concrete elementary tasks are different, you get different results depending on who is doing the task” (Physiotherapist, woman, 49 years) In the interviews, it is not clear whether one activity is dominant; the main point is that the interactions can take place continuously and that participants get a sense of liberation from being able to alternate between the concrete and the symbolic. However, the strength seems to be in the symbolic meaning the participants are allowed to experience and relate to through this interaction. Whenever the participants wish, they can let go of one activity and directly find themselves back in another activity. In the interactions between concrete and symbolic garden-related activities, it seems that the sense of freedom is significant for recovery, which tends to reveal the meaningfulness of life itself. People experience an activity as pleasurable when there is a balance between challenge and skill (Csikszentmihalyi, 1996), and the unique element in the interactions between concrete and symbolic activities is that the participants themselves “control” the balance in a nonforced way. This should be done under the proper guidance of caregivers, however, to help participants “land” in the course of events, with the caregiver sometimes putting into words what is happening. When participants allow themselves to pot one plant after another (concrete activity), they easily end up in a state Csikszentmihalyi calls “flow” (Csikszentmihalyi, 1996). The symbolic activity could be compared with what happens during moments of soft fascination (Kaplan and Kaplan, 1989). Flow and soft fascination both stand for something that is often soothing and pleasant, and it is possible to drift off into them and rest from directed attention. Discussion Gustafson (2001) has developed a three-pole model of meanings of place comprising the self, environment and others. The self consists of an individual’s life path, emotions, self-identity and own activity. Other people have their own characteristics and behaviour. The environment comprises the physical features of
SELF
Life path
Anonymity, recognition
Knowledge
Sensory impressions Perceived characteristics Place attachment
STRESS RECOVERY Selfchosen h places
Interactions b between activities
ENVIRONMENT
Participants, caregivers i
OTHERS Atmosphere
Type of inhabitants
Fig. 2. Stress recovery model through garden therapy.
the place, its institutions and events. Fig. 2, illustrating a stress recovery model through garden therapy, is inspired by Gustafson’s model. The model includes information of significance in the form of separate factors when developing meanings of place, but particularly by looking between the poles, where interactions occur between self–others, others–environment, environment–self, and self–others–environment. The synergetic relationship between the three themes in Fig. 2 is an attempt to conceptualize these themes, thereby presenting the essence of a possible stress recovery model. The lowest common denominator within the themes is the ability to continuously achieve a feeling of non-demanding freedom through the senses. This seems to have a decisive influence on the process of recovery from severe stress. In a setting and programme that promote use of the senses, the themes, summarized like this, seem to develop the participants’ innate capacity for natural stress recovery. When the factors (themes) are summarized, the model of stress recovery becomes clearer. It is within the relationship between the three poles that is needed to be discussed. Our revision of the model may act as an explanatory model regarding the complexity of factors that are involved in garden therapy. When the results are placed in Gustafson’s (2001) model, some characteristics may be distinguished. In the context of garden therapy, the self–others pole involves an intense interaction between all the characteristics of life, path, emotion, activity, self-identification, and other participants as well as the caregivers. The impact of being recognized by and recognizing others, and sometimes the simultaneous need to affirm feelings of anonymity, also plays a role in stress recovery through garden therapy. Places such as the rehabilitation garden are “attributed meaning through the perceived characteristics, traits and behaviours of their inhabitants” (Gustafson, 2001,
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p. 10). Our results are in accordance with this, as each of the factors identified seems to influence the stress recovery process, with “signals” being sent from both the environment and others, to and from the self. This goes in line with how place attachment is understood; it can help to form and preserve an individual’s, group’s or culture’s identity (Low and Altman, 1992). Environment–others includes “atmosphere” as well as “type of inhabitant”, which are also significantly involved during the recovery process. The environment includes both humans and nature. Between environment–self, opportunities are offered in accordance with how Gibson explains affordances, i.e., action possibilities that are latent in the environment (Gibson, 1979). A system of synergetic parts is emerging, yet these assumptions are not meant to diminish the strength of other factors of importance to the recovery process, e.g., group dynamics. The study provides one piece of the puzzle of what is occurring in stress rehabilitation through garden therapy and in this, the recipe for the steps towards lasting stress recovery may be hidden. Conclusions The present study supports previous research findings on the importance of garden and nature on health. In addition to the complex whole, this form of stress rehabilitation gives participants different opportunities to have only the garden environment to relate to in connection with therapeutic elements and activities. The results show that a garden environment that they can feel safe in, tends to “prepare, receive and open up” the participants to therapy and activities in a way that seems particularly appropriate. The change seen in the participants tends to provide opportunities for thorough recovery from ill-health due to stress. Therapeutic elements in combination with nature and garden environments do not seem to have previously attracted any serious attention within the research field. This is an important gap in the literature because, as our findings suggest, investigating a wider range of the treatment spectrum reveals important interactive effects that promote improved self-recovery in individuals suffering from stress related ill-health. The results presented in this article are based on qualitative data generated from a single case study, aiming at a deeper understanding of the processes involved in stress rehabilitation through garden therapy. Future research is encouraged to further clarify and study the present findings in terms of the three factors presented here as well as to take into account a wider range of treatment activities and their effects. Until that time, other rehabilitation gardens in particular and rehabilitation centres in general taking care of stress-related ill-health may be helped by our findings. Acknowledgements The authors would like to thank the caregivers at Alnarp Rehabilitation Garden for their contributions. Thanks to Anna-Maria Pálsdottír for helping with the interviews. Thanks to professor Patrik Grahn and professor Eva Johansson for their helpful comments on an earlier draft on this paper. Finally we would like to thank Sensys Research School, Swedish University of Agricultural Sciences for funding the project. References Abramsson, K., Tenngart, C., 2003. Grön Rehabilitering. Behov, förutsättningar och möjligheter för en grön rehabiliteringsmodell (Green Rehabilitation. Needs, Conditions and Opportunities for a Green Rehabilitation Model). Institutionen för landskapsplanering i Alnarp, LRF Sydost, Alnaro (in Swedish). American Horticultural Therapy Association (AHTA), 2007. Retrieved September 9th, 2007 from frequently asked questions www.ahta.org/information/faq.html. Asberg, M., Grape, A., Krakau, I., Nygren, A., Rohde, M., Währborg, P., 2010. Stress som orsak till psykisk ohälsa (Stress as a cause of mental illness). Läkartidningen 107, 1307–1310 (in Swedish).
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Contents lists available at SciVerse ScienceDirect
Urban Forestry & Urban Greening journal homepage: www.elsevier.de/ufug
Stress rehabilitation through garden therapy A caregiver perspective on factors considered most essential to the recovery process Anna A. Adevi a,∗ , Mats Lieberg b a b
Swedish University of Agricultural Sciences, Department of Work Science, Economy and Environmental Psychology, Box 88, SE-230 53 Alnarp, Sweden Swedish University of Agricultural Sciences, Department of Landscape Architecture, Box 58, SE-230 53 Alnarp, Sweden
a r t i c l e
i n f o
Keywords: Exhaustion disorder Garden therapy Stress recovery
a b s t r a c t At the Alnarp Rehabilitation Garden in Sweden, people suffering from stress-related illness are rehabilitated through garden therapy. Empirical data were collected through in-depth interviews and focus-group interviews with the rehabilitation team. The present article is based on team members’ understandings of significant factors to the stress recovery process. On-site observations were conducted to achieve a broader comprehension of the empirical data. The article is based on the caregivers’ points of view, as they are presumed to be close to the course of events occurring in the garden therapy programme as a whole. The results reveal a generally complex picture of the rehabilitation form, but at the same time indicate three factors that are of primary importance: (1) sensory impressions, (2) self-chosen places in the garden, and (3) interactions between concrete and symbolic activities. The garden environment tends to “prepare, receive and open up” the participants before and after therapeutic elements, which is thought to be especially appropriate for this group. The results provide important knowledge about what kinds of factors contribute to relief and recovery from stress-related ill-health in the context of stress rehabilitation through garden therapy. © 2011 Elsevier GmbH. All rights reserved.
Introduction Nature’s role in health Historically, people have always used nature as a powerful healing source and as a resource for recovery (Cooper Marcus and Barnes, 1999; Jakobsson, 2009). Gardens, landscapes and spirituality have been interconnected since ancient times (Tuan, 1976). Natural environments have been thought of as places that can bring people closer to God or other beliefs or as places where one can get in touch with their spiritual self (Janick, 1992; Rosenfield, 1992; Van Zuylen, 1995). Since the mid-1980s, research has indicated that gardens, parks and areas with natural greenery have beneficial effects on human health, well-being and capacity (Wilson, 1984; Kaplan and Kaplan, 1989; Ulrich et al., 1991a). According to Searles (1960), nature plays a significant role in promoting mental health. Studies show that stays in natural environments and gardens offer positive stimulation of emotional, cognitive and physical functions (Ulrich, 1984; Kaplan and Kaplan, 1989). In relation to mental fatigue (Kaplan and Kaplan, 1990) and acute
∗ Corresponding author. Tel.: +46 40415415. E-mail address: [email protected] (A.A. Adevi). 1618-8667/$ – see front matter © 2011 Elsevier GmbH. All rights reserved. doi:10.1016/j.ufug.2011.09.007
stress symptoms (Ulrich, 1999), these positive effects on health achieved through stays in natural environments are called restorative effects. The organization for horticultural therapy in the United States describes horticultural therapy as a process in which plants and gardening activities are used to improve people’s body, mind and spirit (AHTA, 2007). Horticultural therapy is primarily based on behaviour that promotes recovery (Matsuo, 1992). In the field, humans are seen as active beings that experience meaning in life with the help of physical work. According to Kielhofner (2006), humans control their life by choosing their activities, their path of development, and how they will adapt to the surrounding world, which in turn leads to an increased quality of life. Kondo (2002) argues that places containing plants that promote calm may be more effective than parks in their conventional forms. According to him, such places are better able to instil a sense of unity with the natural world. A supportive and health-promoting garden with many green elements may help improve the quality of patient care (Ulrich, 1992a). Most people who are experiencing low psychological power and energy do not wish to process new impressions; they first need to sort impressions they are already familiar with (Grahn, 2005). People undergoing medical treatment often feel a certain psychological vulnerability, which increases their sensitivity to new
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Fig. 1. Illustrated plan of the Alnarp Rehabilitation Garden (illustration by Karin Sunde-Persson, 2010).
and habitual environments (Schroeder and Anderson, 1984; Ulrich et al., 1991a; Ottosson and Grahn, 2008). “The Supporting Environment Theory” (SET) argues that the more mentally fragile and weak a person is, the more they need support from the surrounding environment. SET includes ideas about the self’s communication with the external environment (Grahn, 1991, 2005; Grahn et al., 2010). Stress-sensitive individuals will have more opportunities to recover from stress if they are given the chance to manage a task (Pariola, 2001), if the therapeutic value is perceived as meaningful. Such individuals need to experience a balance between different activities if they are to achieve a sense of well-being (Christiansen and Baum, 1997). Cultivating plants in flowerpots is more effective at reducing negative feelings than is merely looking at plants (Endo et al., 2001). During rehabilitation, humans are supported by the plants in how they orient to reality and in their connection with the surrounding world (Lewis, 1996). Plants may be important to treatment if the focus of the therapeutic process is on how the participants participate, how they perceive and become involved with the plants using their five senses creating something with the plants or taking care of them (Matsuo, 1992).
Knowledge gap Although significant relationships between nature and stress recovery have been identified in quantitative studies (Wilson, 1984; Kaplan and Kaplan, 1989), there is a knowledge gap in this field of research when it comes to explaining the nature of such relationships and why they exist (Magell and Viborg, 2005), especially when therapeutic elements are included. There seems to be a great deal of research on the roles of caregivers within the healthcare sector in general, but a lack of research on the relatively new rehabilitation form garden therapy. Because there has been little research on garden therapy as a whole, it is natural that the caregiver’s perspective in this context has also received limited attention. The aim of the present article is to explore factors within garden therapy that caregivers in the rehabilitation team understand to be the most essential to successful stress-rehabilitation and the recovery process.
Exhaustion disorders Exhaustion disorder is characterized by extreme fatigue, cognitive problems, and disrupted sleep. The condition is caused by prolonged stress and may give rise to episodic cognitive problems, tiredness, lack of empathy, aches and pains for years before the onset of the illness. The course is often prolonged with residual symptoms, mainly, enduring stress intolerance (Asberg et al., 2010). The disease often stems from a strong stress reaction related to the individual’s professional environment. It is also due to the limitlessness of work in contemporary society and the relationships at home or during free time. Severe ill-health caused by stress constitutes an existential crisis; a kind of life crisis (Maslach, 2001). Today, exhaustion disorder is mainly treated using medications such as anti-depressive psychopharmaceutical preparations and/or different forms of therapy, such as psychotherapy. Alnarp Rehabilitation Garden The Alnarp Rehabilitation Garden has been constructed to investigate whether an environment offering separate garden and nature elements can rehabilitate people afflicted by stress and exhaustion disorders. The garden consists of a 2-ha area comprising nature-like areas with restorative characteristics and traditional cultivation areas with flowerbeds, where the focus is on more demanding activities. The nature-like areas include small woods, groves and meadows. The cultivation areas include paved surfaces, traditional cultivating rooms, forest-like garden rooms and botanical rooms (Stigsdotter and Grahn, 2003). The garden is ergonomically designed, providing opportunities for participants to train their physical, sensory and cognitive functions (Abramsson and Tenngart, 2003). Moreover, the distinctive features marking a nature environment versus a garden environment need to be clarified. In brief, nature stands for the wild, non-disciplined; for a natural dynamic and “an unknown gardener”, while garden contains the cultivated and ordered, with characteristics of something designed by “a known gardener”. In the present text, the concept nature is sometimes referred to using the word garden, because garden therapy as it is practised at Alnarp mainly takes place in a garden environment (Fig. 1).
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The rehabilitation programme A letter of referral is written by a doctor for rehabilitation through garden therapy; this often occurs after non-successful attempts at other kinds of rehabilitation, medical treatments, different therapy forms, etc. Admission into garden therapy is limited as there are so many eligible applicants (those who, according to the insurance office, should be able to return to work following recovery). During a twelve week period the participants are rehabilitated four half-days per week. The basic objective of garden therapy is to strengthen participants’ possibilities to return to work with new knowledge about the tools and coping strategies they can use in stressful situations. The rehabilitation is based on daily routines and encounters with like-minded individuals who are struggling with similar challenges, in close connection with professional therapists who care for the individuals in an accepting, calm and positive manner. The participants receive conversational and picture therapy, physical therapy and relaxation, which take place in close contact with nature and also include activities such as traditional gardening and handicraft activities. The garden therapy activities at Alnarp are divided into concrete, symbolic and selfrewarding activities (Persson et al., 2001). The concrete activities show visible and concrete results, which may be seen as a “finished product”; one example is making pesto from fresh basil. Symbolic activities are something the participant performs, at the same time as he or she evaluates what is happening based on the associations or memories that are triggered. One example is working with clay, through which metaphorical values may emerge. The participants go home each day, or to other housing they have arranged, due to the large number of participants who live in other parts of Sweden. What mainly distinguishes garden therapeutic activities from other therapeutic activities is that activities within garden therapy mainly occur outside. The senses and muscles are activated when participants expose themselves to wind, temperature, daylight, and increased physical activity (such as digging, crawling in flowerbeds, etc.). Because exhaustion disorder was the mental illness most similar to the mental fatigue described by Kaplan and Kaplan (1989), it was decided to rehabilitate people with symptoms of exhaustion disorder at Alnarp. Approximately 80% of the participants in Alnarp are women. The rehabilitation team The rehabilitation team in Alnarp consists of five horticultural therapists with different backgrounds and professional competence. Their main task is to treat or relieve participants’ symptoms, as well as to facilitate participants’ increased understanding of the needs of living things by using plants and nature as examples and symbols. The role of the gardener is primarily to design and care for the garden, which should provide opportunities to alternate between contrast-rich and varying garden areas that affirm both rest and activity. The primary role of the curative teacher is to encourage within each individual the development of a healthy core that can be reached. This is done by guiding the individual and promoting involvement and participation in the entire spectrum of being human: thoughts, feelings and volition. The occupational therapist creates activities that present physical and psychological challenges appropriate to the participant’s level of functioning. Different forms of stress management are taught and practised. The physical therapist’s point of departure is that the body is a physical manifestation of who the individual actually is, but that it simultaneously carries and shelters old learned thought and behaviour patterns. Because exhaustion disorder is a kind of existential life crisis in which previous, ineffective thought patterns need to be changed to more purposeful patterns, the role of the psychotherapist is to help participants put their new experiences
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into words in relation to how life functioned prior to therapy. The argument for focusing on the rehabilitation team members in the present study is that they, as experienced staff, may possess unique knowledge and competence. Within a rehabilitation context, we prefer to refer to the rehabilitation team staff as caregivers, given their closer connection with the participants, although a gardener is not typically seen as a caregiver. Because they are working in close connection with the participants each week, we are convinced that they possess a special kind of knowledge of the recovery process that is important to include in our research. (Another article by the first author, focuses solely on the participants’ point of view concerning important factors for the recovery process; yet to be published.) Methods Research design The study is based on in-depth interviews and focus-group interviews with all members of the rehabilitation team – in total five persons. The interviews were conducted during 2008–2009. In addition, on site observations were conducted during 2009 and 2010 in order to achieve a broader comprehension of the interview data. The caregivers interviewed have been involved in garden therapy at Alnarp since the start in 2002 and have taken care of approximately 120 participants (at the time of interviews) over the years, with approximately 6–8 participants in each group. Two interview guides were used that dealt with the following issues: the situation of the participants and the interplay between participants and caregivers. The interview guides were broad in scope and encouraged an open dialogue. Participants and procedures The interview data are based on five semi-structured individual in-depth interviews with all the members of the rehabilitation team (1 h with each person) and one focus-group interview (2 h with the five persons in the group simultaneously). Interviews were audio-recorded by the first author and a colleague. The reason for conducting a focus-group interview in addition to the individual interviews was mainly to emphasize the significance of interactions and discussions between the rehabilitation team members (Wilkinson, 1998; Bryman, 2008). We were interested in the caregivers’ points of view on the main reasons for stress-recovery through garden therapy. In the focus-group interview, the caregivers were offered opportunities to probe each other’s reason for holding a particular view. When listening to each other’s answers, the caregivers were able to qualify or modify a view or voice agreement with new ideas they may not have thought of without being exposed to the impressions of others. The caregivers were given opportunities to argue or challenge each other’s views. This allowed us to study the ways in which the caregivers collectively discussed the topic in question. The on-site observations were conducted as participant observations (Bryman, 2008), where the first author practised as a garden assistant during the summers of 2009 and 2010 for a period of 24 weeks (two rehabilitation periods of 12 weeks, four days a week, 4 h each morning); a total of 13 (5 + 8) persons participated. The aim of the observations was to learn more about the therapeutic environment and its actors from “within”, and in that way to better understand and interpret the informants’ statements. This approach is sometimes used in “micro-ethnographic” research (Bryman, 2008, p. 403), where the possibility to stay in the environment over a long time period is limited. The observations were
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made openly after consultation with the caregivers and participants, and the findings were documented as written field notes at the end of the rehabilitation day. All interviews and observations were conducted at the Alnarp Rehabilitation Garden. The interviews were transcribed by a person hired for that purpose. Data analysis The recorded material, as well as the field notes, were subjected to qualitative data analyses. The method of inquiry for the study was Grounded Theory (Glaser and Strauss, 1967). Grounded Theory is a research method often used to explain human behaviour in certain physical and social contexts. The method is most appropriate when little is known about the field of research or when the predominant theoretical perspective in the research field is unable to explain what is going on (Bryman, 2008). The research process is inductive in that data are coded and analysed as they are collected (Charmaz, 2003). Preliminary hypotheses about the emerging categories and themes are deductively refined or confirmed in an iterative process, through additional data collection (Denzin and Lincoln, 2005). In this process, the researcher strives to develop explanatory and theoretical key concepts and to explain the relationships among them. The goal is to develop a substantive theory. Themes were generated through an iterative constant comparative process whereby data collection, coding and analysis occurred concurrently. Open and selective coding of the interview material was carried out. This process is also called theoretical sampling (Denzin and Lincoln, 2005, p. 185). Analysis through coding, categorizing and thematisation of the textual material finally resulted in three key explanatory concepts and delimited themes, which are presented in the Results section.
Results A complex picture of multiple activities emerges from the results; each contributing to stress rehabilitation during garden therapy. Among these activities, three stand out for being particularly salient. These factors are presented here as different themes: (1) sensory impressions, (2) self-chosen places in the garden and (3) interactions between concrete and symbolic activities. Theme 1: sensory impressions The caregivers bear witness to how participants seek and find a sense of belonging in nature’s order, which allows them to feel they are part of something much greater than the immediate environment. At the outset, participants make contact with this new natural environment by acquainting themselves with it in an unplanned and unconscious way. What is really lovely is that they come to the conversation at a very receptive stage . . . they are prepared on a physical level to open up. . . . When one opens up and is so fragile it’s lovely to be touched by great, friendly and soft sensory impressions. (Psychotherapist, woman, 66 years) The unpredictable occurrences of sensory stimulation and memory arousal are considered therapeutic effects in horticultural therapy (Talbot et al., 1976; Lewis, 1996). The caregivers describe this as when “locks are opened”; it tends to be easier to start the healing process. It seems as if the garden environment, with its sensory impressions, helps by offering the keys that are necessary to open up the participant’s existential, emotional and physical sides. It is presumably here the true recovery process begins. The more mentally fragile and weak a person is, the more they need support
from the surrounding environment (Grahn, 1991, 2005). To be able to “open up” for the participant is in line with SET principles. This is what I see as the magic part.- . . . When they leave a session with me I’ve hopefully managed to open them up to their innermost side, to their emotional core. Much would have been ruined if we’d continued talking. . .. The garden is meeting them. . . . It’s here that change is created and it’s a change that exists on the person’s existential foundation. This is unbeatable . . .. (Physiotherapist, woman, 58 years) Frederickson and Anderson (1999) argue that the confrontation with nature is inspired by thoughts concerning spiritual meaning and eternal processes. This is supported by a caregiver in the current study: There is depth to the nature and the trees and the Earth that I did not understand before . . . that it’s about existential questions, it’s very clear that there’s something in this that goes deep that you can get into contact with. That’s it. (Occupational therapist, woman, 60 years old) Reflections, thoughts and ideas concerning existential characteristics that are opened up seem easier to reach when one is surrounded by sensory impressions. Any greater extent of contact or socializing with other people on the part of participants is usually not desirable during the rehabilitation period. Simple, clear and positive impressions are appreciated, as opposed to something or someone who demands something in return. The garden seems to help by approaching the participants’ feelings in a direct and immediate manner (i.e. Gardener, male, 38 years). “The amount of information and knowledge we obtain depends on the variety and degree of contrast in the sensory data that we receive and the extent to which we can differentiate them” (Bell, 1999, p. 41). It’s when you stop and gather around something and start to discuss and look at it that things start happening. It’s very difficult to explain. Often, I feel like the garden and plants speak a language without words, without letters or numbers. They speak directly, so to speak. It takes a shortcut past the language, past something and it goes sort of right into you. It goes directly to your emotions. (Gardener, male, 38 years) The sensory experiences establish a wordless “communication” that to a great degree creates an extended emotional and existential awareness, which in turn creates receptivity to rehabilitation. This receptivity and sensitivity tends to greatly facilitate the remaining rehabilitation work throughout the whole therapeutic process. According to Matsuo (1992), it concerns how the participants relate to the plants within the therapeutic process, and how they perceive and become involved with the plants when using the senses. In the view of the interviewed caregivers, this seems to be a matter of how the participants open up and are receptive and, first within that process, are able to relate to the plants and the garden.
Theme 2: self-chosen places in the garden Humans often develop a feeling of belonging, identity, dependence and a kind of ownership in relation to places that somehow become “their place”, “the favourite place” or “the only place” for a certain type of activity (Lieberg, 1995; Korpela et al., 2001). Place attachment is understood as being an integrated part of human identity (Stewart et al., 2004). Scopelliti and Tiberio (2010, p. 237) define place attachment as “a complex construct that accounts for a person’s affective bonds to place”. This attachment can help to form and preserve the identity of an individual, group or culture (Low and
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Altman, 1992). It can also serve as a defence against identity crises in times of transition between developmental phases (Hay, 1998). The second theme is related to place attachment and the effort to explore the meaning of place. The theme is also connected to the first as it involves sensory impressions from nature. Finding selfchosen places in the garden based on one’s state of mind and needs, not only before but especially after therapeutic sessions, tends to contain an important dimension that allows participants’ healing processes to begin. The participants are encouraged to explore meaning of place and to find a place in the garden they feel attached to. This, in turn, will improve their ability to find these sometimes obscure places. People balance between various emotional states in their daily life, and this is also true during a period of stress rehabilitation. One exercise in the early phases of the stress rehabilitation programme focuses on finding such a place. Over time, the places can be changed or maintained and the participants can happily return to them. This could be, for example, the severely pruned apple trees participants seek out to be able to endure the fact that the trees’ “wings have been clipped”. When they’ve been with me they get in touch with their feelings, thoughts, insights, and experiences; as I’ve understood it, there’s no better way to help a person’s thoughts find a way out of the chaos and make things manageable than allowing them to spend time in nature and choose the way they’re attracted to it. (Physiotherapist, female, 58 years) The self-chosen places that attract participants are described as places that “receive” their current mood. According to the caregivers, reliance on the self-chosen places appears to create greater confidence over time. In the beginning, the participants seek out the garden areas nearby, and with time they venture into areas that are farther away. Cimprich (1993), who looked at cancer patients, argues that these patients improve their spiritual health (among other things) by only passively perceiving nature. The activity of sitting on a bench in a therapeutic garden is of great importance in achieving contemplation and a meditative feeling (Messervey, 1995). Relf (1995) and Liu (1999) and others note how only passive observation of floral and natural areas creates a general feeling of personal well-being. A bench or a shed may be of importance if a place in a therapeutic garden is to be perceived as contemplative and meditative (Messervey, 1995). Searles (1960) argues that nature plays an important role in mental health and Grahn (1989) proposes that the need for familiar surroundings applies to outdoor places as well. Thus, there would seem to be some relation between these notions and caregivers’ ideas about the importance of enabling participants to continuously search for, find and use self-chosen places in the garden environment. Signals from nature shape creative processes and develop a feeling of ‘sense of place’ (Searles, 1960), which are important in the rehabilitation process. The simplest relationships in crises are those that are the least complicated and the least difficult for the individual to deal with. When at their lowest level of mental strength, people derive the most help from simple relationships such as those to water and stones; the most demanding relationship is that to other people (Searles, 1960; Ottosson and Grahn, 2008). Well, just this idea of outside. being able to be outside. And that there are different environments to visit and participants can seek out the environment that speaks to them at the moment. (Curative teacher, woman, 49 years) Which place the participants experience as appropriate is highly individual; one person might prefer to sit in a lawn chair under a large tree, while someone else chooses to walk around in a specially selected garden area. Sometimes there is a need to sit down on the grass and pet the cat or start pulling weeds. Here Tuan’s (1977)
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concept ‘fields of care’ may be useful. Fields of care refers to places in the garden where participants have repeated contact and where the physical environment can evoke affection in them. Such places have often a deep meaning for participants, but may be insignificant to others. The garden changes the starting point for therapy, conversations, activities, etc., by creating a sense of wholeness for the healing process. In that sense the garden becomes an extension of the therapist’s competence. The caregivers’ state that the self-chosen places in the garden, with its constant changes, adapt in a non-threatening way to the participants’ emotional needs at the moment; they explain that the garden’s sublime message is perceived by the participants as comforting. According to the caregivers, participants often experience the places they are encouraged to seek out as especially welcoming. This has parallels with place attachment, in that this is not only a place like many others, but a place felt to be meaningful in the current situation. The self-chosen place seems to offer an individual meaning that has an impact on the stress recovery process as a whole. Kondo (2002) believes that garden environments that are conducive to peace and quiet are more “efficient” than parks, because it is easier to experience harmony through the great feeling of unity between man and nature. Taking inspiration from Kondo and considering the caregivers’ understandings, a carefully structured therapeutic garden offering many opportunities to find self-chosen places based on one’s current mood/needs may serve even better to nurture a feeling of unity than a “common garden” does. In other words, this feeling of unity ought to be very central in the design of therapeutic gardens. Just as there is a wide range of human emotional states, a therapeutic garden should contain a range of opportunities to spend time in attractive areas for sitting or reclining that encourage reflection, all embedded in an environment that is as appropriate and well considered as possible. Theme 3: interactions between symbolic and concrete activities According to the caregivers, helping oneself in a more personal way is a new approach to learning. Participants learn a new way to take advantage of opportunities, different paths one can take and, consequently, different decisions one can make. A newly acquired pleasure and joy of life is often perceived through the natural environment and the activities taking place there. “concrete activities . . . where you see a result from what we’re doing, that can be important in the beginning for those who are used to getting results. That they see the results of their work and then use symbols and metaphors like nature and the garden. Well there’s a lot of this, that we use in rehabilitation. . . . I am also always thinking that they have a value because there is a certain relaxation in doing something that is so clear and having such a clear beginning and end to it. Then you may drop it or as I often see further along in the rehabilitation, they take concrete assignments with them because they are thinking now I’m going to do this from A to B and then put it aside.” (Curative teacher, woman, 49 years) The benefits of interactions seem to refer to a perceived inner freedom and autonomy in combination with not being forced to perform for someone else. This is something those suffering from exhaustion disorder in particular seem to have a great need to genuinely experience. The experience is that the interaction is achieved through natural reflections made in an unconditional way. The ability to cope with a specific task is simultaneously blended with a curiosity about further developing one’s metaphorical reflections. The garden thus appears to offer support during painful symbolic processing, where symbolic values help participants find the right words to depict what is happening within them. And there’s a quality, which of course is visible all the time when it’s expressed. . . Your needs. are always followed up and that is how
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it is so that even in this concrete exercise there’s personal space. And I think that’s very central. We never say ‘Forget yourself now and concentrate on this plant here’. (Curative teacher, woman, 49 years) Because the participants are familiar with performing well, the concrete tasks are of great importance. It is there they get “their rewards” with which they feel familiar and comfortable. The concrete activities are deemed to be of great value, as there is a special kind of rest to be found in doing something that has a clear beginning and end. The importance of the need for interactions between concrete and symbolic activities has its origin in the work of Kielhofner (2006), who argues that how a person experiences and carries out a task depends on the dynamic interplay between the individual, task and environment; as soon as a person performs an action, the result is an experience. The environment affects how the activity is performed, offering an event in which people can choose what to do, or signalling something that more or less forces a behaviour or action (Kielhofner, 1997). According to Christiansen and Baum (1997), a person needs to experience a balance between different activities in order to experience well-being. Within garden therapy like that offered at Alnarp, this balance seems to occur often through the described interactions between activities. “But maybe because of the symbolic exercise they’ve done they’re discovering something completely different so . . . the concrete activity has a value for the person . . . taking care of yourself maybe suddenly there is something to talk about when you’re caring for the plant, and then you draw the parallel. How am I taking care of myself? So even if the totally concrete elementary tasks are different, you get different results depending on who is doing the task” (Physiotherapist, woman, 49 years) In the interviews, it is not clear whether one activity is dominant; the main point is that the interactions can take place continuously and that participants get a sense of liberation from being able to alternate between the concrete and the symbolic. However, the strength seems to be in the symbolic meaning the participants are allowed to experience and relate to through this interaction. Whenever the participants wish, they can let go of one activity and directly find themselves back in another activity. In the interactions between concrete and symbolic garden-related activities, it seems that the sense of freedom is significant for recovery, which tends to reveal the meaningfulness of life itself. People experience an activity as pleasurable when there is a balance between challenge and skill (Csikszentmihalyi, 1996), and the unique element in the interactions between concrete and symbolic activities is that the participants themselves “control” the balance in a nonforced way. This should be done under the proper guidance of caregivers, however, to help participants “land” in the course of events, with the caregiver sometimes putting into words what is happening. When participants allow themselves to pot one plant after another (concrete activity), they easily end up in a state Csikszentmihalyi calls “flow” (Csikszentmihalyi, 1996). The symbolic activity could be compared with what happens during moments of soft fascination (Kaplan and Kaplan, 1989). Flow and soft fascination both stand for something that is often soothing and pleasant, and it is possible to drift off into them and rest from directed attention. Discussion Gustafson (2001) has developed a three-pole model of meanings of place comprising the self, environment and others. The self consists of an individual’s life path, emotions, self-identity and own activity. Other people have their own characteristics and behaviour. The environment comprises the physical features of
SELF
Life path
Anonymity, recognition
Knowledge
Sensory impressions Perceived characteristics Place attachment
STRESS RECOVERY Selfchosen h places
Interactions b between activities
ENVIRONMENT
Participants, caregivers i
OTHERS Atmosphere
Type of inhabitants
Fig. 2. Stress recovery model through garden therapy.
the place, its institutions and events. Fig. 2, illustrating a stress recovery model through garden therapy, is inspired by Gustafson’s model. The model includes information of significance in the form of separate factors when developing meanings of place, but particularly by looking between the poles, where interactions occur between self–others, others–environment, environment–self, and self–others–environment. The synergetic relationship between the three themes in Fig. 2 is an attempt to conceptualize these themes, thereby presenting the essence of a possible stress recovery model. The lowest common denominator within the themes is the ability to continuously achieve a feeling of non-demanding freedom through the senses. This seems to have a decisive influence on the process of recovery from severe stress. In a setting and programme that promote use of the senses, the themes, summarized like this, seem to develop the participants’ innate capacity for natural stress recovery. When the factors (themes) are summarized, the model of stress recovery becomes clearer. It is within the relationship between the three poles that is needed to be discussed. Our revision of the model may act as an explanatory model regarding the complexity of factors that are involved in garden therapy. When the results are placed in Gustafson’s (2001) model, some characteristics may be distinguished. In the context of garden therapy, the self–others pole involves an intense interaction between all the characteristics of life, path, emotion, activity, self-identification, and other participants as well as the caregivers. The impact of being recognized by and recognizing others, and sometimes the simultaneous need to affirm feelings of anonymity, also plays a role in stress recovery through garden therapy. Places such as the rehabilitation garden are “attributed meaning through the perceived characteristics, traits and behaviours of their inhabitants” (Gustafson, 2001,
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p. 10). Our results are in accordance with this, as each of the factors identified seems to influence the stress recovery process, with “signals” being sent from both the environment and others, to and from the self. This goes in line with how place attachment is understood; it can help to form and preserve an individual’s, group’s or culture’s identity (Low and Altman, 1992). Environment–others includes “atmosphere” as well as “type of inhabitant”, which are also significantly involved during the recovery process. The environment includes both humans and nature. Between environment–self, opportunities are offered in accordance with how Gibson explains affordances, i.e., action possibilities that are latent in the environment (Gibson, 1979). A system of synergetic parts is emerging, yet these assumptions are not meant to diminish the strength of other factors of importance to the recovery process, e.g., group dynamics. The study provides one piece of the puzzle of what is occurring in stress rehabilitation through garden therapy and in this, the recipe for the steps towards lasting stress recovery may be hidden. Conclusions The present study supports previous research findings on the importance of garden and nature on health. In addition to the complex whole, this form of stress rehabilitation gives participants different opportunities to have only the garden environment to relate to in connection with therapeutic elements and activities. The results show that a garden environment that they can feel safe in, tends to “prepare, receive and open up” the participants to therapy and activities in a way that seems particularly appropriate. The change seen in the participants tends to provide opportunities for thorough recovery from ill-health due to stress. Therapeutic elements in combination with nature and garden environments do not seem to have previously attracted any serious attention within the research field. This is an important gap in the literature because, as our findings suggest, investigating a wider range of the treatment spectrum reveals important interactive effects that promote improved self-recovery in individuals suffering from stress related ill-health. The results presented in this article are based on qualitative data generated from a single case study, aiming at a deeper understanding of the processes involved in stress rehabilitation through garden therapy. Future research is encouraged to further clarify and study the present findings in terms of the three factors presented here as well as to take into account a wider range of treatment activities and their effects. Until that time, other rehabilitation gardens in particular and rehabilitation centres in general taking care of stress-related ill-health may be helped by our findings. Acknowledgements The authors would like to thank the caregivers at Alnarp Rehabilitation Garden for their contributions. Thanks to Anna-Maria Pálsdottír for helping with the interviews. Thanks to professor Patrik Grahn and professor Eva Johansson for their helpful comments on an earlier draft on this paper. Finally we would like to thank Sensys Research School, Swedish University of Agricultural Sciences for funding the project. References Abramsson, K., Tenngart, C., 2003. Grön Rehabilitering. Behov, förutsättningar och möjligheter för en grön rehabiliteringsmodell (Green Rehabilitation. Needs, Conditions and Opportunities for a Green Rehabilitation Model). Institutionen för landskapsplanering i Alnarp, LRF Sydost, Alnaro (in Swedish). American Horticultural Therapy Association (AHTA), 2007. Retrieved September 9th, 2007 from frequently asked questions www.ahta.org/information/faq.html. Asberg, M., Grape, A., Krakau, I., Nygren, A., Rohde, M., Währborg, P., 2010. Stress som orsak till psykisk ohälsa (Stress as a cause of mental illness). Läkartidningen 107, 1307–1310 (in Swedish).
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