Stress rehabilitation through garden therapy: The garden as a place in the recovery from stress

Urban Forestry & Urban Greening 12 (2013) 230–237

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Stress rehabilitation through garden therapy: The garden as a place in the recovery from stress Anna A. Adevi, Fredrika Mårtensson ∗ Department of Work Science, Business Economics and Environmental Psychology, Swedish University of Agricultural Sciences, Alnarp, Sweden

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Keywords: Exhaustion disorder Garden therapy Health promotion Horticultural therapy Place attachment Restoration

a b s t r a c t In a rehabilitation programme for people with stress disorder, a garden room can be an important ingredient. Stress disorder has been the most common cause of sick leave in Sweden since the 1990s. The study is about the therapeutic role of nature in the form of a garden, as participants experienced it during the recovery process. The research subjects were on sick leave due to stress related symptoms and took part in rehabilitation at the Alnarp Rehabilitation Garden in southern Sweden. The article is based on interviews with five participants who describe their experiences of garden therapy and what they perceive as essential for their recovery. The garden was associated with many positive experiences of interacting with people and greenery and perceived as a safe and useful arena in their recovery. The participants described how nature affords positive sensory experiences, physical and psychological well-being, but also how nature and the garden facilitate beneficial social interactions with other participants and caregivers. Importance was also allocated to the symbolism of nature as associated to one’s own growth and the passing of time. They conceptualised the recovery process as initiated by more traditional forms of therapies but reinforced and consolidated by the access to nature and the garden rooms. In a dynamic psychological perspective on place, the study illustrates the potential role of using nature as a venue to facilitate self-regulation of physiological, psychological and social needs. © 2013 Elsevier GmbH. All rights reserved.

Introduction Gardens in health care services reflect a recent development towards a broader concept of health and healing. Hartig and Cooper-Marcus (2006) point out the general neglect of the physical surrounding in medical care and how providers have missed many opportunities to invest in the outdoors when developing new projects. The potential value of implementing gardens in health care services is poorly understood and has to compete with more traditional types of requirements and investments. In Sweden, the common term for a garden in health care is “rehabilitation garden” and the related process aimed at helping people who suffer from stress-related illness, “garden therapy”. In Sweden, rehabilitation gardens were developed when “burnout” and fatigue became common diagnoses among workers on sick-leave in the early 1990s. These stress-related illnesses are associated with physical as well as cognitive and mental problems. In severe cases, the individual becomes indisposed and requires individualised rehabilitation and lengthy recuperation time. The

∗ Corresponding author at: Department of Work Science, Business Economics and Environmental Psychology, Swedish University of Agricultural Sciences, Box 88, SE230 53 Alnarp, Sweden. Tel.: +46 40415453. E-mail address: [email protected] (F. Mårtensson). 1618-8667/$ – see front matter © 2013 Elsevier GmbH. All rights reserved. http://dx.doi.org/10.1016/j.ufug.2013.01.007

commonly used term “healing garden” is a misnomer since the garden facilitates recovery through an individual’s active use of “a place, a process, and their intertwining”, rather than cures as the term healing implies (Hartig and Cooper-Marcus, 2006, p. 36). The tradition of using gardens in health care evolved from horticultural therapy as a part of occupational therapy during the 1930s, becoming a more independent discipline in the 1950s (Shoemaker, 2002). In horticultural therapy, activities such as gardening, raking leaves, sowing seeds and weeding, are assumed to have a remedial effect (Ulrich et al., 1991; Lewis, 1996). It draws on Kielhofner’s theory on the importance of activity, stressing the role of meaningful and enjoyable tasks (Kielhofner, 2006). Relf (1998, 1999) further describes how the activity of working in a garden is a context easily attributed with meaning and has suggested four distinct dimensions of this experience: (1) the beauty of nature with seasonal changes and a multitude of life-forms which fascinates, relaxes and puts worries in life into perspective; (2) the dependence on nature and the cultivation of it, supporting the ecosystems of the planet; (3) the nurturing of plants and attendance to their growth, which creates a feeling of affinity with nature; (4) achieving contiguity with other people through the sharing of experiences such as cultivation and harvesting. Garden therapy as well as horticultural therapy, takes place in close interaction with the natural environment. When nature per se or experiences at places in nature are considered to be

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of therapeutic benefit, “garden therapy”, “healing garden” and “restorative garden” are the terms most commonly used (GerlachSpriggs et al., 1998). These practices often draw on the Biophilia hypothesis (Wilson, 1984) suggesting that humans value nature due to the physical, intellectual and emotional benefits it offers (Corral-Verdugo et al., 2009). Emotionally, the diversity of natural environments provides us with the assurance of survival and allows us to relax (Coss and Moore, 1990; Appleton, 1996; Ulrich, 1999). A cognitive explanation commonly used draws on the way we perceive our surroundings and how we, just as our early ancestors, are easily attuned to different threats and dangers in nature, such as wild animals. In the busy everyday life of today with its huge flood of information, this selection of what stimuli to attend to has become more difficult and demanding however, and we run the risk of depleting this capacity (Kaplan and Kaplan, 1989; Hartig et al., 1996). The ART theory (the Attention Restoration Theory) of Kaplan and Kaplan implies that our visual impressions from nature can restore this form of directed attention, crucial for everyday functioning and well-being (Kaplan and Kaplan, 1989). In empirical studies it is shown that natural environments generally are more restorative than built environments (Hartig et al., 1991; Ulrich et al., 1991; Korpela and Hartig, 1996; Hernandez et al., 2001; Purcell et al., 2001). Van den Berg and De Vries (2000) found indications of larger health differences between green environments and built environments of red bricks, than between green environments with different characteristics. Also, studies connecting epidemiologic data with the quality of the outdoor environment in different urban neighbourhoods have indicated that a higher proportion of green space is associated with better health (Maas et al., 2006; Mitchell and Popham, 2007). In particular, mental health seems to be related to the presence of greenery in a neighbourhood (De Vries et al., 2003). Access to natural surroundings has also been associated with mental restoration in specific populations, as in children (Kuo and Faber Taylor, 2004; Martensson et al., 2009; Faber Taylor and Kuo, 2009), elderly (Ottosson and Grahn, 2008) and in people living under pressure due to a busy lifestyle, severe illness, etc. (Kaplan and Talbot, 1983; Herzog et al., 1997; Ulrich, 2001). Four specific aspects of nature with restorative potential have been suggested: animals, plants, landscapes and wilderness (Frumkin, 2001). Moreover, certain dimensions in the landscape seem easier to reconcile with for people that are psychologically vulnerable (Schroeder and Andersen, 1984; Ulrich et al., 1991). Vistas with large areas covered with grass, which contain some larger trees and water, are generally associated with experiences of protection, peace and quietness (Ulrich, 1999). Kaplan and Kaplan (1989) specify four dimensions in the restorative landscape experience: (1) “Being away” – an experience of distancing oneself from problems. (2) “Extent” – implying a sense of nature being infinitely extended in space, allowing exploration and a feeling of belonging. (3) “Fascination” – to be fascinated by the environment allows people to function without using directed attention. (4) “Compatibility” implying the propensity to “follow” nature and a wish to do the things that nature affords. On the other hand, certain odours, music, colours or places perceived as uncertain, unbalanced or unattractive, can be unbearable for a person who suffers from stress (Ulrich, 2001; Hallsten et al., 2002). Therapy in general is multifaceted and when a whole setting is drawn into the process, as in garden therapy, the path to rehabilitation becomes even more complex. A person can actualise specific affordances from many potential ones in a setting (Heft, 1989) and also make sense of these in different ways and use them in different sequences. A study of the caregivers’ perspective in the Alnarp Rehabilitation Garden, Sweden, shows that activities related to nature and the symbolic meaning making associated with these, are expected to add vital dimensions to more traditional therapies

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(Adevi and Lieberg, 2012). The perspective of this article is that recovery evolves in an interactive process between the therapeutic garden as a physical environment, social environment, and as an object part of the wider socio-cultural context. Attention is paid to the emotionally nurturing bonds that potentially evolve between person and place, and the meaning making associated with this process, without neglecting the benefits of visually experiencing greenery and the exercise associated with gardening. There are numerous concepts to describe how people get emotionally attached to a place. The concept “topophilia”, in which “topos” means place and “philia” means “love of”, describes emotional bonds between people and place (Tuan, 1974) and “sense of place” refers to the meanings associated with specific environments (Relph, 1996; Farnum et al., 2005). People can attribute meaning to a site and then derive meaning in their lives from the place created (Stedman, 2003; Davenport and Anderson, 2005) and it can be endowed with both individual and collective meanings (Low and Altman, 1992; Johnson and Zipperer, 2007). Place is sometimes regarded as integral to the development of self (Fried, 1963; Relph, 1986; Twigger-Ross and Uzzel, 1996) and the process of human identity formation (Steward et al., 2004). In this tradition, a person’s “place identity” contains information about how to relate to the physical surroundings in a way that is in accordance with their attitudes, values, thoughts and behavioural tendencies (Prohansky et al., 1983). Place contributes to purpose in life by functioning as a storage for emotions and relationships (Williams and Vaske, 2003) reminding us of and confirming who we are (Belka, 1988). A place can serve as a defence against identity crises (Hay, 1998) and become so important that we hardly can imagine a meaningful existence without it. On the other hand, unwanted modifications of a place or interruptions in its use can cause extended periods of grief and severely threaten identity (Brown and Perkins, 1992). Fried argued already in 1963 that human well-being in relation place is vital for psychological and social well-being, and elaborated on how physical surroundings take part in identity formation and the construction of a self, so called “place attachment” (Korpela, 1989; Twigger-Ross and Uzzel, 1996). According to Winnicott (2003b) there is a transition area of experiences in which “objects” in the environment, can take on a mediating role between an individual’s fantasy and reality. In order to understand the therapeutic potential of place such attachment theories (Bowlby, 1969) and theories on personal ties (Weiss, 1982; Hay, 1998) have been suggested as theoretical and empirical points of departure (Steel, 2000). We expect place attachment to contribute to restoration through a complex process including cognitive, affective, social and behavioural components (Scopelelliti and Giuliana, 2004). Important is the concept of “self-regulation”, conveying how an individual strives to improve his/her situation by making active choices and modifications, also regarding place use and choice of immediate physical surroundings (Korpela, 1989). Interesting in this context is the fact that when given the opportunity to choose sites for recreation, people are likely to choose a type of landscape similar to the one they grew up in (Adevi and Grahn, 2011; Adevi, 2012). Added to the documentation of how there is a general renewal of cognitive capacity in green surrounding, positive emotions associated with a specific place or a specific type of place (e.g. a garden), are expected to increase wellbeing in ways that further facilitate an individual’s higher level problem-solving, self-reflection and agency. While there are many anecdotal accounts of how experiences in a garden associated with the cultivation and contemplation of nature are beneficial to an individual (e.g. Knopf, 1987; GerlachSpriggs et al., 1998; Cooper-Marcus and Barnes, 1999), there is little systematic documentation of effects for patients with specific diagnoses. To understand the interaction between people and

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place, researchers have called for qualitative strategies in collecting, analysing and interpreting data (Cheng et al., 2003). In this study, former patients diagnosed with exhaustion disorder and taking part in a programme at the Alnarp Rehabilitation Garden, were asked what they perceive as important factors in their recovery and what role nature, as part of a garden, played in this process. Understanding the potential role of a garden as a place in the very personal journey towards health and well-being is important in the further development of health services. Aim This article explores the impact of garden therapy on stress rehabilitation with special focus on the role of nature as part of the garden. The following research questions were examined: (1) What do participants experience as active dimensions in their recovery that is specific for garden therapy? (2) How do participants describe the role of the garden and its natural environment as part of their path to recovery? and (3) Is it possible to relate the parameters of the recovery process described as essential by the participants, to theories on restoration and place attachment? Materials and method Five participants diagnosed with exhaustion disorder from the Alnarp Rehabilitation Garden were interviewed during 2003. The sample was selected out of those 48 people who had undergone rehabilitation at the time of the interviews. The participants recruited were “hand-picked” by the manager of the rehabilitation garden, making it into a convenience sample with some element of purposive selection as the manager was informed of the purpose with the study (Polit and Hungler, 1999). They were between 25 and 60 years old, had been on sick-leave for two to three years and had recently (0.5–1.5 years prior) completed rehabilitation. The selected persons were all keen to take part in the study and four of them have also handed in a written consent form. The interviews were semi-structured, lasted 45–60 min and took place in the homes of the participants (four) or at Alnarp (one). The interviews were recorded and transcribed. The interview protocol used for the present study included questions on the following themes: initial expectations on the rehabilitation programme, an overall evaluation of the rehabilitation, experiences of how the rehabilitation had implications on their health and well-being, specific settings, events and situations deemed important and the specific role of the garden site. Special attention was paid to situations and events associated with positive or negative emotions. The recorded material was subjected to a strategy of qualitative data analyses in the vein of Grounded theory (Glaser and Strauss, 1967). Grounded theory is appropriate when little is known about a field or when the predominant theoretical perspectives in the research field are unable to explain what is going on (Bryman, 2008). In addition, the researcher should strive to develop substantive theory by developing explanatory and theoretical key concepts and to explain the relationships between them. An interpretation model of open coding recommended by Starrin et al. (1991) was applied. The material was analysed line by line and word by word. This was done in order to stay attentive to the wording of the interviewee and the specific meanings it implied. New themes gradually emerged and were preliminarily coded until so called “saturation” was reached, characterised by there being no new themes arising. During the final step of coding, themes with common denominators were collected into a few different branches with specific properties (Alvesson and Sköldberg, 1994, p. 86). The strategy resulted in two key explanatory categories that were used to organise the result section. Citations were selected to

Fig. 1. The Alnarp Rehabilitation Garden, Alnarp, Sweden.

well illustrate dimensions in garden therapy that participants experienced as effective for recovery. The study was approved by the Ethical Committee of Lund. Staff members are referred to as “caregivers” and people participating in the rehabilitation programme as “participants”. Description of the participants Here follows a description of the five participants according to gender, work life and type of symptoms reported. To maintain anonymity, abbreviations (A–E) are used to denote each participant. Person A: A woman who at the time of the interview was working as an economist. She describes a “remarkable tiredness” but also how life had become more pleasant and gratifying. She now works as a stress consultant. Person B: A woman working as a human resource manager. In the past she struggled with her psychological “boundaries” in relation to other people. During her worst period she did not eat and seemingly minor things caused her to cry, such as when the postman came or the telephone rang. She is now a student. Person C: A man working with the construction of outdoor settings. He describes how he still feels fragile, in need of being alone and avoid noise. Person D: A woman working on her Ph.D. She says she feels calmer, is clearer in her head, has more energy, and makes more of an effort to have fun than before the rehabilitation. Person E: A woman working as a nurse, but still on sick-leave. She says all her symptoms remain, but are not as strong. Description of the rehabilitation garden The Alnarp Rehabilitation Garden consists of a two-hectare area with separate garden rooms. The garden contains natural areas with properties assumed to be restorative and traditional cultivation areas with growing beds for more demanding activities. The area also includes groves and meadows. The garden is ergonomically designed and aimed at being especially useful for people with exhaustion disorder and their particular sensitivity to the physical environment. The garden rooms are surrounded by fences, hedges and rows of fruit trees. Decisions about the design and arrangement of the garden have been made by researchers in consultation with the caregivers (Abramsson and Tenngart, 2003; Stigsdotter and Grahn, 2003; see Fig. 1).

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garden rooms and elements of nature. They described how they find their favourite places, feel joy in the sensuous touch of nature, but also enjoy more rough and repetitive garden work, such as raking leaves. One woman described her delight in taking part in the whole process; from harvest to finally making juice of fruits and vegetables. We made apple juice after gathering all the fruit. I felt fine. I was out walking among the apple trees, picking up as much as I wanted; the smell taking me home. (D) Participants associated time spent outdoors being active in the garden with improvements in sleep and mood. One participant described it as a direct physical reaction to the setting which both “triggers new things and has a calming effect”. The soft colour tones of nature are contrasted to those of more “artificial environments”. They talked about the garden as a personal relationship in which the garden is a responsive partner, allowing them to be themselves and to talk freely. Such dialogues seem to evolve as they find a place in the garden that reflects their mood. They described it as a dialogue between them and nature and at times the experience of nature being a patient receiver while they express their feelings, unconditionally and without judgement. All the different rooms and parts of the garden that could fit the mood I was in at that moment. So, a garden does not ask for something back. I could talk, I could say what the hell I wanted to the pine trees there, and they didn’t shout back at me. (C)

Fig. 2. Different group activities are organised in the Alnarp Rehabilitation Garden.

Description of the therapy At the Alnarp Rehabilitation Garden, therapy is combined with an interdisciplinary research project investigating the garden’s role in the rehabilitation process for people on long-term sick leave with stress related diagnoses mainly. The purpose of therapy is to facilitate the participant’s return to work life and to improve their strategies for coping with stress. The rehabilitation programme includes professionals from horticulture, physiotherapy, occupational therapy, medicine and psychotherapy. Art therapy and relaxation are examples of activities offered besides nature assisted therapy and traditional gardening. The rehabilitation process aims to stimulate all senses, increase self-esteem, self-awareness, and help participants to create positive habits and routines for daily life. The participants make individual appointments with the physiotherapist and psychotherapist. Group gatherings to share experiences and train social skills are other parts of the programme (see Fig. 2). The reports on symptoms and progression by the participants in this study (Ossiansson, 2004) have similarities with other reports from garden therapy. Grahn et al. (2010) describe how participants in the beginning of the rehabilitation process experience a reduction in cognitive functions and a weakened state of physiology that include a lack of mental and reflective capacity. Fatigue, poor selfesteem and considerable sensitivity to stress are hallmarks. After time, usually a few months, body awareness increases and they start to reflect over their life and gain new insights. For some, rehabilitation ends up in a change of life focus. Results The garden and me – sensuous, moods and symbolism of nature There are specific garden qualities useful for recovery pointed out by the participants. Some of the most verbose descriptions concern impressions, feelings and moods associated with various

The satisfaction of positively influencing the growth of plants is another aspect of the garden that they frequently brought up. One man described how important plant care was to his self-esteem. That I actually gave life to something. That I did something, even though I was daft in the head. Self-esteem is at its lowest point. I am alive and life is good and you can help it along the way by watering. And so you will be needed. It was a really bad feeling not to be needed and to know that I will never be able to come back. Nobody wants me. I’m over fifty and burned out! But here I was needed. The plants needed me, they needed water, they needed to be planted. (C) People having had contact with nature as part of their jobs, in a factory packaging peas and in garden construction, described how incompatible these job experiences were with appreciating the aesthetics and symbolism of nature. They described how they had started to appreciate new dimensions of nature in their everyday life. A change of season now containing beauty had before only been associated to a change of jacket. Such experiences of nature being loaded with meaning and beauty seemed new and surprising. It feels meaningful, giving life to something. You get back a sense of purpose in life. It grows and it is important. (C) They also tended to personify their descriptions of how flora grows in a garden, making it into a narrative about their own growth and development. It [the garden] almost confirmed my own growth. In this way, I think it interacts with me. So we grew together, so to say. There is something with this growing, I think, that made it fun. (D) Another important dimension in the symbolism of a garden is the perspective of time, nature having its own unswerving rhythm. I think it moves nice and slow. I can‘t see the colour combination directly, as I had wanted to do before, it takes some time. And I have accepted this. (A) They described how the rhythm of nature initially was perceived as annoying, but how it later turned into insights about life. They spoke about gaining patience with themselves and the

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circumstances of life – the slow pace of progressions – and finding a better balance between rest and activity in their everyday life. The time perspective in gardening, speaking about five, ten or even twenty years, were experienced as absurd in relation to the demands of working life and society at large. Here two women describe how the perspective of time changed when the garden entered their life. That’s what it’s like with a garden. You can hurry things up until the time for planting, and then everything stops. Then you just look at it. And it provides a perspective. The garden helps you get a perspective on time. The time scale is important with a garden, it cannot be accelerated. It is possible to rush, up to the point of planting, but then you have to be quiet and wait. Possibly fertilize so that the process speeds up. I have learned that the process is slow and only changes slowly. It takes as long as it wants. (C) You can’t speed nature up in any way. But see this slow, regular, repetitive communication of nature. You can’t speed it up. And it’s an amazingly nice thought. It’s very pleasant. It makes you put your brakes on. (A) In summary, the participants described how contact with nature during various garden activities contributed to feelings of vitality and increased well-being. They associated the positive outcomes with different activities in the garden and the sensory experiences that came along with these, but also the sometimes newfound beauty and symbolism of nature. In particular, they found representations in nature of their own needs. As in nature at large, they experienced that nurturance and patience were needed in their own life. Together in a garden – the garden, the caregivers and the group Besides the specific benefits of interacting with nature, the garden served as a “backdrop” to social life and different therapeutic activities which were also part of their rehabilitation. The garden was described as the heart of their rehabilitation, where all the activities and interactions between participants, caregivers and nature took place. They described it as an accessible and useful arena with many possibilities: It’s not enough to go walking around in my own garden doing nothing in particular, because then I would never have become sick. There are three key elements in this situation: Other people with the same problem, the garden and the caregivers. Without all of these the garden would not have been alive; it would have been more a question of just passive care. (C) They contrasted the richness and the variation of the garden setting with indoor settings used in other treatments. The indoor environment was described as less varied and with fewer things to do. The garden was described as a useful backdrop to social life and different organised activities. Therapy minus the garden would not be worth a tenth of what it is now. Without the garden, we would have been just a group of people sitting and staring at each other in a barn. Now I knew. Every morning we would begin with a relaxation exercise that lasted half an hour. I knew that afterwards we would be out in the garden. And it was very nice. (C) The rehabilitation was described as characterised by peacefulness, quietness and absence of demands. Participants said the garden made it easier to “let thoughts float freely”. They also stressed the importance of being able to move freely about in the environment and seek out their own places in the garden according to their whims, needs, and mood that specific day. The freedom allowed them to try out productive ways of relating to people, in

this case the staff and other participants. When a session was at risk of becoming stressful, the garden rooms represented an escape. Going out into the garden they could “get away” from too demanding tasks and social interaction. I could not manage people. And then there is, of course, nature. Something you can associate with. And it requires nothing of me. But people do. (A) Participants described how the rehabilitation period taught them how to make better use of nature as a way to increase their well-being. It is suggested that contacts with gardens or other settings in nature, both during and after the rehabilitation, could consolidate the effects gained during other therapies. I appreciate my own garden more than I did before. It gives strength to various moods. If you are happy and look at lots of flowers, then you will be even happier. (C) The garden consolidates and enhances the effects of relaxation exercises. The garden was like a curative balm. At times when I was terribly sad and had been seeing the psychotherapist, the garden was there to comfort me. I could seek out any part of the garden – choosing garden [room] according to my particular mood and feelings at the moment. It was a wonderful feeling of security. And it was greatly strengthened by the garden. Like a big embrace. (C) Belonging to a group of people facing similar difficulties in life was described as an important aspect of the programme. In certain situations this sense of fellowship became especially salient, as when challenges were overcome together. For example, participants associated eating a piece of bread that they baked together in the garden with the Holy Communion. They joked about a common tendency to be self-effacing and they exaggerated rude behaviours that they thought were typical during certain stages of rehabilitation. They described how the ability to socialise was built up slowly when they got the opportunity to try out different strategies. By contrast, they referred to other rehabilitation programmes where negative thoughts from other participants became a burden. One participant described how she found herself trying to act the role of a therapist during her own treatment. The participants described the rehabilitation garden as a microcosm of “everyday life” and a “lab” in which they could try out and test new roles and strategies. The caregivers were also described as essential to recovery, both the professional therapists and persons in the staff mainly working with gardening. They described situations in the garden when trust was built and how they were comforted through this informal socialisation, besides the therapeutic activities. It was deemed crucial that staff took responsibility for the overall maintenance of the garden, while leaving all tasks optional for themselves. Together this turned the garden into a stimulating, but not demanding environment, in which participants could try out what they needed and wanted in order to become more comfortable. The garden is patiently waiting for us—when we are ready. We do not need to satisfy it. The staff takes care of that. But we are able to jump between things and get involved: Well, now I want to do this or do that. It’s important to know what you want. (D) In summary, for the persons taking part in garden therapy, the place, people and activities of the garden were experienced as making up a secure arena ripe with opportunities to be used according to their specific needs, moods and interests. Discussion A garden is the result of people’s dynamic interaction with green surroundings in the continuous shaping of different rooms and the

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cultivation of plants. The perspective documented in this study is that this makes a garden into a rich and varied physical and social arena for people to use to their own benefit during times of stress. The participants in garden therapy not only described the garden as a useful environment for acute stress relief, but also a useful “lab” for trying out new strategies to increase well-being and improve everyday functioning. The garden, the caregivers, and the group of participants together make up an arena which combines structure with freedom of action, in which the participant get the chance to regulate their needs and aspirations. Important seems to be that they can choose if they want socialise or withdraw, get involved in an activity or just rest. It is important for the participants that the caregivers are responsible for the overall maintenance of the garden and that they get involved in more defined daily chores. They contrast “the calmness and kindness” of the garden with the harsher circumstances of their life at large. For some, the garden becomes a temporary supportive community that compensate for the loss of trust in working life. One way to understand this is to conceptualise the garden as a “holding environment” in which the security a young child feels when taken care of attentively, is recreated (Freshwater and Robertson, 2002). As people become “inner objects” of attachment (Winnicott, 2003a), it is possible that also objects in the physical environment – as nature and a garden – turn into stable inner objects of attachment, so called “transitional objects”. The participants talking about people and greenery as a caring environment might be referring to a psychological experience where the garden becomes such a holding environment. The participants describe how the garden, with its different rooms and natural elements, makes up an arena that facilitates the process towards recovery by allowing the participants to confirm for themselves the positive steps taken in other therapeutic sessions. The garden makes up a tranquil restorative background, at the same time as it is a useful “partner” with whom they can try out how to use their body and their senses to stay comfortable. The garden is also a place for personal and collective meaning making, as described by Relf (1999). It is charged with symbolic significance in which they resemble their own existence with those of seeds and plants growing and withering, making it easier for them to reconcile with their own life. The grandeur of nature is experienced as representing their own strength and the realisation that the plants need their nurturance, make them realise how they themselves can make a difference to people. The association between their own personal development and growth in nature is one of those experiences that seem to take on a strong emotional character. A potential limitation of the study is that all participants had an overall positive experience of the rehabilitation and that the selection procedure did not counteract this risk. All of the participants who agreed were recruited by the rehabilitation garden manager. It is possible that social desirability made the participants report more of their positive experiences out of loyalty to the garden manager and that her choice fell on participants likely to give such answers. To some extent these concerns were mitigated by the fact that interviews were carried out by a student from another discipline (medicine) and university, who was not taking part in the later analysis. However, as the aim of study was to further our understanding of how and why people benefit from garden therapy, not strictly evaluate it, the predominantly positive experiences have been useful to explore. The general descriptions of garden therapy should make it easier to relate results to practice. Some of the participants were knowledgeable about the restorative benefits of greenery as elaborated in the theories of Kaplan and Kaplan (1989) and Ulrich (1999). Such direct effects of greenery seemed to be taken somewhat for granted, while they expressed surprise of having developed emotions associated to the dynamic

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Fig. 3. The Alnarp Rehabilitation Garden is an arena for interacting with people as well as greenery as part of self-regulation.

interaction with the garden as a place. At its best the rehabilitation garden seems to have offered them a place where they could access tools for working with their unique set of problems on different levels at the same time: cognitively, affectively, physically and socially. A conclusion from this study is that investigations of nature assisted therapies should pay further attention to the role of emotional bonds to place and study the outcomes and interactions between more passive strategies of relaxation (“being in nature”) and more activity oriented strategies (e.g. gardening), the latter probably more dependent on the bonds of place attachment. Through processes of self-regulation an individual tries to balance pleasant and unpleasant emotions and maintain a coherent experience of self (Korpela, 1989). We suggest self-regulation and place attachment to be two useful concepts in the study of effective parameters during nature assisted therapies (see Fig. 3). Studies taking departure in the parallel pointed out by Izard and Kobak (1991), between early processes of a child’s privacy regulation and self-regulation in general, could probably further highlight the role of place attachment (Harris et al., 1996). The results so far support the claim that a garden used for therapy can be so much more than an enriched environment of fascinating natural elements, passively restoring the participants from fatigue. The emotional bonds with place seem to help the person to resolve more personal issues that have surfaced during the crisis, prompt the development of new useful competencies and boost self-esteem. We suggest further investigations into the dynamic qualities a garden offer as a cherished place and the active role of the person taking part in the therapy that is associated with this. Acknowledgements The authors want to thank Margareta Söderström from the Department of Family Medicine at Copenhagen University who has contributed the interview data that made this study possible. We also want to thank all the participants who generously shared their rehabilitation experience. Our gratitude also goes to the SENSYS Research School for their financial support. References Abramsson, K., Tenngart, C., 2003. Grön Rehabilitering. Behov, förutsättningar och möjligheter for en grön rehabiliteringsmodell (Green Rehabilitation. Need, Requirements and Possibilities for a Green Rehabilitation Model). Institutionen för landskapsplanering i Alnarp, LRF Sydost, Alnarp (in Swedish). Adevi, A.A., Grahn, P., 2011. Preferences for landscapes: a matter of cultural determinants or innate reflexes that point to our evolutionary background? Landscape Research 37, 36–52. Adevi, A.A., 2012. Supportive nature and stress: wellbeing in connection to our inner and outer landscape. Doctoral Dissertation, Swedish University of Agricultural Sciences, Alnarp, p. 11.

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