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Landscape design: Patient-specific Healing Gardens

The Sophia Louise Durbridge-Wege Living Garden at the Family Life Centre in Grand Rapids, Michigan, US, is an exemplary facility serving the needs of patients with Alzheimer's Disease and other forms of Dementia
In the last two decades, gardens with therapeutic qualities have begun to appear in US and UK healthcare facilities. Now ‘healing gardens’ are being designed to support the treatment of patients with specific conditions.

The idea that nature has a soothing, restorative effect is nothing new. From medieval monastic infirmary gardens to the landscaped grounds of nineteenth-century mental asylums, enlightened carers have recognised that access to the outdoors has a salutary effect on a person’s mental and physical health. With the onset of modern medicine and its emphasis on treatment via surgery and drugs, this knowledge was lost or deemed ‘unscientific’. High-rise construction techniques created medical settings where patients were divorced from the outdoors.

From the early 1990s a change began to happen in healthcare design – termed patient-centred care, there were marked changes in the interior design of hospitals. Then, in the late 1990s, three books appeared documenting the therapeutic value of outdoor spaces in healthcare1,2,3.

The era of the healing garden had arrived. Characterising the key qualities of a successful healing garden? The basics of healing garden design relate to the issue of stress, as the relief of stress helps to bolster the immune system and stimulate the body’s natural healing proclivity. There is credible scientific evidence that four elements that can be supported by design help reduce stress: the distraction provided by green nature; exercise; social support; and a sense of control4.

The more we are engaged with the environment through all our senses, the lower are our rates of anxiety and the less we are aware of pain. Thus, a healing garden needs to provide a multi-sensory experience with colourful flowers, varying shades and textures of green, the sights and sounds of water, elements that attract birds and butterflies, fragrances, and ornamental grasses which move with the slightest breeze.

This outdoor space needs to be a garden, not a paved courtyard – a lush green setting with an optimal ratio of green to hard surfaces of 7:3. Exercise has many beneficial effects on both physical and mental health. Thus, depending on the size of the garden, there needs to be a variety of longer and shorter pathway loops for strolling and exercise.

These must be surfaced to reduce glare, for example with tinted concrete, and there needs to be attention to details such as edging to prevent those using wheelchairs rolling into planting beds, and expansion joints in paving of no more than one-eighth of an inch in width to prevent the wheels of IV poles getting caught and stuck.

There is also evidence that the more social support a patient receives from family and friends, the better they are able to heal. A garden is one place where a patient and visitor can converse in private in an attractive setting. It is essential that sensitive planting design and site furnishings provide semi-private niches for one or two people or for a family group to be alone. A hospital garden, if sensitively designed, can be a place for a family to visit with an in-patient, perhaps with children and even the family dog in tow; where a person can digest the news of a troubling prognosis; where a family can wait for someone in surgery or an outpatient wait for a prescription to be filled; or where
staff members can relax together on their lunch break.

The Rehabilitation Garden at the Shepherd Centre in Atlanta, USA (left) and the garden at Mount Zion Cancer Clinic in San Francisco

Gaining control

When we enter hospital as an in-patient it is the institution that decides what we wear, when the doctor visits, with whom we share a room and perhaps even what we can eat. In short, we lose control over many issues that were ours to decide at home. The more a patient is able to exert a sense of control, the less they will be stressed. To enhance a sense of control within the garden there should be a choice of different pathways; a variety of semi-private niches to sit in; some fixed and some moveable outdoor furniture; a variety of views to enjoy when seated – some distant, some near at hand.

The material used for seating should not retain heat or cold: wood or hard plastic are preferable, while concrete, aluminium and steel should be avoided. While these form the basics of a healing garden, there are a few more requirements that are really just common sense. The garden needs to be sheltered; provide an ambience of comfort and familiarity; include plant materials appropriate to local climate and culture; have a budget for ongoing maintenance; and avoid the inclusion of ambiguous art pieces onto which sick people can project their feelings of fear and anxiety.

The garden needs to be visible from a well-used interior area (waiting room, foyer, cafeteria etc) or, if not, there needs to  be adequate signage in the building to alert people to its presence. The garden needs to be accessible, not only with an automatic door and low entry lip to facilitate access by those using a wheelchair but it also needs to be unlocked.

This may seem obvious but it is sad to report that many otherwise attractive hospital gardens are kept locked at all times to prevent use. This has specifically been observed at Private Finance Initiative (PFI) hospitals in the UK. One assumes this is so because the owners do not wish to pay for upkeep. This is particularly ironic when increasing evidence points to the stress-reducing qualities of hospital outdoor space, and that this is happening in a country that  has a long cultural history based around a love of gardens.

None of the above is rocket science but a healing garden needs to be a sensitive combination of restorative elements and must be designed by a landscape architect, the only professional trained to design with plant materials. (Some of the worst healing gardens I have seen were designed by artists, architects or interior designers.)

The Graham Garden at Saanich Peninsula Hospital in Victoria BC, Canada (left) and the children's play garden at Rusk Institute of Rehabilitative Medicine in New York, USA

Patient-specific gardens

In the early years of this century, specialised forms of healing gardens began to appear: gardens designed for the special needs of specific patient groups. Among these are gardens at children’s hospitals, cancer clinics, rehabilitation hospitals, facilities for burn patients, for the frail elderly and for those with Alzheimer’s disease and other forms of dementia. Gardens at children’s hospitals, for example, need to provide for the sometimes conflicting needs of sick children, well siblings and grieving parents.

The park-like gardens at Boston and Atlanta Children’s Hospitals, for example, provide well for parents but do little to distract children. A new play-garden at Seattle Children’s Hospital provides plenty of interest for children but is not a place of solace for worried parents. Legacy Emanuel Hospital Children’s Garden in Portland, Oregon is one of the few that does well on all counts5.

In the patient-specific gardens described in more detail below, the nurses, doctors, physiotherapists, psychotherapists, speech pathologists, horticultural therapists, and occupational therapists who were to guide their patients in the therapeutic use of the garden worked closely together in creating a programme which was then implemented by a professional landscape architect.

The Healing Garden at the Good Samaritan Hospital in Portland, Oregon’s Good Samaritan Hospital was created by landscape architect Ron Mah, David Evans and Associates working collaboratively with a team of hospital staff who now use the garden in their therapeutic work with patients recovering from strokes and brain injuries. These include physiotherapists, speech pathologists, horticultural therapists and spiritual counsellors.

The garden includes elements such as different walking surfaces for those learning to walk again after a stroke with the aid of a walker or cane; differing planter edge heights so that patients learning fine motor control can sit or lean while doing simple gardening tasks; and plant labels that speech pathologists use in their work with patients regarding speech after a stroke6. Similar outdoor facilities at other hospitals include slopes, steps, bridges, a range of walking surfaces and parallel bars to aid in physiotherapy. The one oversight at the Portland garden was that the team did not realise that many of their patients lived in rural Oregon and would need to learn to walk again on surfaces such as gravel or dirt, rather than the concrete of urban sidewalks.

The Play Garden at the Rusk Institute for Rehabilitative Medicine in New York City represents a similar kind of therapeutic outdoor environment, but here it is for children with brain injuries or mobility problems. While children can be led (reluctantly) through therapeutic exercises in an indoor gym, creating a play garden where they naturally engage in similar exercises has proved highly successful.

A team approach to the design ensured that the landscape architects – Johansson and Walcavage – incorporated elements recommended by the hospital staff and that these elements would be so attractive to children that they would exercise certain skills without realising they were doing so.

For example, climbing up a low grassy hill in order to slide down a slide set into the hill or climbing several steps to get into a sandbox – in both cases exercising arm and leg muscles. Turning a frog-shaped knob to start a stream flowing or undoing various bolts and latches in the door of a playhouse encourage fine motor control. In a relatively small urban site a remarkable variety of activities are encouraged while children play in the sunshine and enjoy a relaxed milieu, in contrast to the hospital interior.

The garden of the Oregon Burn Centre in Portland, USA was designed together with staff who use the space for therapeutic work

Therapeutic spaces

For people with mental or psychological, rather than physical, problems, a series of remarkable therapeutic outdoor spaces are beginning to appear. Unique in this category are two gardens in Sweden for those suffering from depression or what is termed in that country as ‘burn-out syndrome’. The Alnarp Rehabilitation Garden encompasses a two-hectare site on the campus of the Swedish University of Agricultural Sciences at Alnarp in southwest Sweden. Staff in the department of landscape architecture – namely, Patrik Grahn and Ulrika Stigsdotter – along with a horticultural therapist, physiotherapist, occupational and psychotherapists have developed a therapeutic landscape divided into a number of garden rooms.

Participants (they are not referred to as patients) who can no longer work because of depression or burn-out are recommended to the garden programme by their doctors, insurance companies or employers. They start by coming to the garden one morning a week, increasing to four mornings over a three-month period. While at the facility, patients can – if they wish – do nothing but relax in the quiet, hedge-enclosed Welcoming Garden; or they can do light gardening tasks in the greenhouse, vegetable garden or orchard; take a walk along a forest path; or relax in a large meadow. Art therapy, relaxation exercises, snacks, etc are available in a traditional house within the garden; weekly psychotherapy sessions take place in a geodesic greenhouse.

A research project is under way, comparing patient outcomes at the Alnarp garden with a control group of comparable patients who are receiving the normal treatment – resting at home, using an antidepressant such as Prozac, and having a few psychotherapy sessions. Preliminary results indicate very positive results from the non-drug, garden treatment approach.

A similar approach is being applied at Haga Ha¨lsotra¨dga°rd (Haga Health Garden) where a green therapeutic environment has been created inside a large commercial greenhouse in a Stockholm park. The greenhouse has been skillfully redesigned by Ulf Nordfjell and Yvonne Westerberg into five rooms so that a patient can choose to lie in a hammock among olive trees, relax on a chaise-longue under a palm tree, join a group for coffee and conversation at a candle-lit table, engage in gardening tasks, or create art pieces using plant materials.

As at Alnarp, patients attend programmes for varying lengths of time and, in addition, courses on the therapeutic value of green nature are offered for human relations staff and employers to encourage them to provide green spaces at work where employees can relax at lunch or in break periods. Thus, Haga Health Garden is taking a proactive approach aimed at educating corporate, institutional and governmental employers on the value of green nature in preventative healthcare7.

The Haga Health Garden in Sweden advocates the value
of green nature in preventative healthcare


The increasing incidence of Alzheimer’s disease and other forms of dementia is a phenomenon facing the healthcare institutions of many Western nations. For example, in the US it is estimated that 10% of those over 65 are affected by this disease, while the percentage is nearly five times that (47%) for those over 85. The US Alzheimer’s Association estimates that 12 to 14 million will be affected by the year 2040.

Facilities serving those with Alzheimer’s disease are recognising that a garden can serve a number of beneficial purposes. Firstly, it can provide a place for exercise, especially important for the general health of older adults. It can provide a setting where people can be in sunlight, especially important for the creation of Vitamin D, the promotion of healthy bones and the establishment of regular circadian rhythms and sleep patterns.

A garden can also provide a relaxing locale for staff-led programmes in gardening, crafts, memory recall, etc. In addition, an attractive garden is a pleasant setting for family visits and may encourage such visits. The Sophia Louise Durbridge-Wege Living Garden of the Family Life Center in Grand Rapids, Michigan (Landscape Architect: Martha Tyson) is an exemplary facility serving the needs of patients with Alzheimer’s and other forms of dementia who live with their families but spend each weekday at this day centre8.

One entry door to the garden and a simple looped pathway encourage walking while avoiding the confusion or aggression that can occur when patients have to make a decision to turn left or right, or remember which of several doors to return to. A large gazebo, wired for sound (music is especially soothing) and for fans on hot summer days, is a popular setting for staff-led programmes. A waterfall feature provides the soothing sight and sound of water without the possibility of people getting into it (a problem with some Alzheimer’s patients). A wide variety of perennial flowers popular during the youth of many of the patients provide opportunities for experiences of memory-recall led by the staff.

A small garden and orchard area is the setting for horticultural therapy activities. A recent study at another Alzheimer’s facility with a garden revealed that those who spent as little as five to ten minutes of unprogrammed activity in the garden each day in the summer months showed significant improvements on a number of parameters, including aggressive behaviour, physician-ordered medication, pulse rate, blood pressure and weight gain9. This suggests that this kind of patient-specific garden is not only therapeutic in a general sense but also that it has measurable patient benefits that reduce the costs of drug use and staff time.

The garden of the Oregon Burn Centre offers plenty of sensory stimulation whilst using shading to protect patients with burns or skin grafts from direct sunlight


In Portland, Oregon a unique garden opened in May 2004 for the benefit of burn patients. The Oregon Burn Center Garden was designed by a team including staff treating burn patients, a horticultural therapist and landscape architect Brain Bainnson from Quatrefoil. The resulting 9,000 square foot garden serves patients in a number of ways10. Firstly, it provides walking paths and differing slopes for those learning to walk again (and for those rebuilding strength and endurance). It also has a number of shade structures that provide outdoor seating for patients alone or those visiting with family, as those recovering from serious burns have to stay out of the sun. The great variety of plant materials in the garden allow for sensory stimulation (fragrance, touch, vision, hearing). And because the garden is secure and private it provides a protected space for burn patients to begin taking steps toward community reintegration.

Two patient groups not appearing in the above discussion are those suffering from cancer and HIV/AIDS. What little information exists on the environmental needs of such patients suggests that a garden based on the general properties of a healing garden would serve their needs, with an emphasis on adequate shade since both populations are treated with drugs that require they stay out of the sun. In addition, plants with strong fragrances should be avoided in gardens for cancer patients since they can induce nausea for those taking chemotherapy drugs11.

Conclusions
Patient-specific gardens encompass a general understanding of the restorative benefits of nature12, together with the recognition of the needs of a particular patient population.

In each of the cases described above, the garden has become a potent treatment milieu, complementing the provisions located indoors. In this respect, such gardens represent a third stage in the recognition and acceptance of nature-based therapy in healthcare. The first stage is encompassed by examples of eighteenth- and nineteenth-century hospitals where views and access to nature were intuitively considered therapeutic, but with no understanding of why. The second stage was prompted by the emergence of credible scientific evidence that views to, or even brief visits in, a green, garden setting can have measurable physiological effects such as on blood pressure and the immune system13.

The garden at Tabor Hills Healthcare Facility, Bohemian Home
for the aged in Naperville, Illinios, USA

This, together with a move to more patient-centred care in hospital design, starting in the 1990s, prompted the provision of usable outdoor spaces, sometimes termed healing gardens. We are now in what might be termed a third stage, in which the needs of very specific patient populations are being considered in the design of healthcare outdoor space. In future work, healthcare professionals, designers and researchers need to collaborate in discerning the therapeutic benefits of gardens specifically designed for those patient populations whose needs have not yet been widely discussed or explored, including children with autism, cystic fibrosis or cerebral palsy; patients with schizophrenia or Parkinson’s disease; and patients recovering from heart surgery.

There are three points to add to this brief discussion. The first point is that healing gardens are on the verge of becoming a ‘fad’. Articles on hospitals featured in glossy design magazines often tout the fact that they have a ‘healing garden’, but when photos of such gardens are examined (or the actual garden is visited), it is sometimes anything but healing in terms of the criteria mentioned above. Perhaps we will soon need to create a certification process, not unlike the Leadership in Energy and Environmental Design (LEED) Green Building Rating System, to ensure that healing gardens meet certain basic criteria.

A second point that cannot be emphasized enough is that a healing garden must be designed by a landscape architect, and preferably one who holds a certificate in Healthcare Garden Design similar to the one offered through an intensive course at the School of the Chicago Botanic Garden (www.chicagobotanic.org/school/certificate). Such a design professional also needs to be well-versed in participatory design. All of the successful patient-specific gardens have come about as the result of a carefully orchestrated participatory process involving the designer, clinical staff, current or former patients and family members.

Only through such a process can a garden successfully meet the needs of the patients it is intended to serve.




Clare Cooper Marcus, Professor Emeritus, Departments of Architecture and Landscape Architecture, University of California, Berkeley





References

1. Cooper Marcus C, Barnes MA (Eds.).  Healing Gardens: Therapeutic Benefits and Design Recommendations. New York: John Wiley and Sons; 1999.
2. Gerlach-Spriggs N, Kaufman RE, Warner SB. Restorative Gardens: The Healing Landscape. New Haven: Yale University Press; 1998.
3. Tyson MM. The Healing Landscape: Therapeutic Outdoor Environments. New York: McGraw Hill; 1998.
4. Ulrich RS. Effects of gardens on health outcomes: Theory and research. In Cooper Marcus C and Barnes M (Eds.): Healing Gardens: Therapeutic Benefits and Design Recommendations. New York: John Wiley and Sons; 1999.
5. Cooper Marcus C. Healing Havens: Two hospital gardens in Portland win awards for therapeutic values. Landscape Architecture Magazine 2003; 93(8).
6. Cooper Marcus C. Healing Havens: Two hospital gardens in Portland win awards for therapeutic values. ibid.
7. Cooper Marcus C. Gardens as treatment milieu: Two Swedish gardens counteract the effects of stress. Landscape Architecture Magazine 2006; 96(5).
8. Cooper Marcus C. No Ordinary Garden: Alzheimer’s and other patients find refuge in a Michigan dementia-care facility. Landscape Architecture Magazine 2005; 95(3).
9. Galbraith J and Westphal J. Therapeutic garden design: Martin Luther Alzheimer Garden. Proceedings of American Society of Landscape Architects Conference, Salt Lake City; 2004.
10. Cooper Marcus C. For burn patients, a place to heal. Landscape Architecture Magazine 2008; 98(4).
11. Cooper Marcus C. Hospital Oasis: Through a participatory design process, a failed Tommy Church garden in San Francisco is reconfigured as an exemplary therapeutic landscape. Landscape Architecture Magazine 2001; 91(10).
12. Ulrich RS. op cit.
13. Ulrich RS. ibid.








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