Therapeutic garden

Designed for use as a component of a treatment program such as occupational therapy, physical therapy or horticultural therapy programs.

Designed to meet the needs of a specific user or population.

1. Therapeutic gardening Thaneshwari

2. Introduction Over the past decade many people have become aware of the positive effects of human interaction with plants and gardens . Recent surge of interest in this relationship in combination with a great increase of horticultural activities in treatment programmes have led to the use of numerous terms for these programmes and activities such as therapeutic horticulture, garden therapy, social horticulture and therapeutic gardening to name a few.

3. Types of gardens Healing Gardens Therapeutic Gardens Horticultural Therapy Gardens Restorative Gardens

4. Healing Gardens Healing gardens are plant dominated environments including green plants, flowers, water and other aspects of nature. They are generally associated with hospitals and other healthcare settings. They are further divided into specific types of gardens including therapeutic gardens, horticultural therapy gardens and restorative gardens . ( AHTA, 2012 )

5. Therapeutic Gardens Designed for use as a component of a treatment program such as occupational therapy, physical therapy or horticultural therapy programs. Designed to meet the needs of a specific user or population. ( AHTA, 2012 )

6. Horticultural Therapy Gardens Type of therapeutic garden D esigned to accommodate client treatment goals Support primarily horticultural activities A clients themselves are able to take care of plant material in the garden . ( AHTA, 2012 )

7. Restorative Gardens Public or private garden N ot necessarily associated with a healthcare setting . Employs the restorative value of nature The design focuses on the psychological, physical and social needs of the users . ( AHTA,2012)

8. History of Horticultural Therapy and Therapeutic Gardens In the 1100’s St. Bernard described the benefits of a hospice garden at a monastery in Clairvaux, France He mentioned the therapeutic benefits of privacy, green plants, birdsong and fragrance (Kaufman & Warner, 1998 ). In 1812 Dr. Benjamin Rush, published a book “Medical Inquiries and Observations Upon Diseases of the Mind” He stated that “digging in a garden” was one of the activities that distinguished those male patients who recovered from their mania from those that did not ( Rush, 1812).

9. St. Catherine's Garden in the monastic infirmary, London, 1154 Evidence of planned restorative gardens where patients' cells bordered and had a direct access to arcaded courtyard

10. Central courtyard of the Ospedale Maggiore Ca Granda, Milan , Italy. 1456 Throughout the 14th and 15th centuries, hospital buildings have been surrounded by rich gardens in traditional style

11. Garden Lodge of the Royal Hospital, Dublin, Ireland, 1730 E mergence of scientific medicine during the 17th and 18th centuries confirmed the positive impact of nature upon patient's body and soul , which resulted in construction of large city hospitals that incorporated courtyards with long rows of trees

12. In the 1940s veteran hospitals were established by the U.S. government to care for wounded servicemen ( Relf, 2006 ). In 1973 a group of horticultural therapy professionals established the Council for Therapy and Rehabilitation through Horticulture (NCTRH ) In 1988 the organization changed its name to the American Horticultural Therapy Association ( AHTA) ( AHTA,2012) Friends Asylum for the Insane was the first known example of psychiatric hospitals using gardening activities, opened in 1813 in Philadelphia (Friends Hospital, 2005).

13. Fig. left; 27 storeys of the Cornell Medical Center , New York, 1933. Fig. right: Hospital Beaujon, Clichy, Paris, France. 1932-1935 . 20th century was the period of technological advances in both medical science and building construction. Thus , hospitals erected during the Modern Movement resemble high-rise office buildings, with large parking lots that replaced traditional gardens

14. Benefits of horticulture therapy and therapeutic gardens 1.Cognitive Benefits Enhance cognitive functioning (Cimprich , 1993; Herzog et al. , 1997) Improve concentration (Wells, 2000; Taylor et al. , 2001) Stimulate memory (Namazi & Haynes, 1994). Improve goal achievement (Willets & Sperling, 1983). Improve attention capacity (Ulrich , 1999; Taylor et al. , 2001 ) 2.Social Benefits Improve social integration ( Kweon , Sullivan & Wiley, 1998) Increase social interaction (Moore , 1989; Margalis et al., 2000 ). Provide for healthier patterns of social functioning ( Kuo et al. ,1998 ) Improved group cohesiveness (Bunn, 1986)

15. 3.Psychological Benefits Improve quality of life (Willets & Sperling, 1983; Waliczek et al. , 1996) Increase self-esteem ( Feenstra et al ., 1999; Pothukuchi & Bickes , 2001) Improve sense of well-being (Ulrich & Parsons, 1992; Hartig , 2003) Reduce stress ( Ulrich & Parsons, 1992; Whitehouse et al ., 2001; Rodiek , 2002) Improve mood (Wichrowski et al., 2005; Whitehouse et al ., 2001) Decrease anxiety (Mooney & Milstein, 1994) Alleviate depression (Mooney & Milstein, 1994; Cooper Marcus & Barnes, 1999) Increase sense of control (Relf et al ., 1992) Improve sense of personal worth (Smith & Aldous , 1994) Increase feelings of calm and relaxation ( Moore, 1989; Relf et al ., 1992) Increase sense of stabilit y ( Blair et al ., 1991; Pothukuchi & Bickes , 2001) Improve personal satisfaction ( Feenstra et al ., 1999; Pothukuchi & Bickes , 2001) Increase sense of pride and accomplishment (Matsuo, 1995)

16. 4.Physical Benefits Improve immune response (Ulrich & Parsons 1992; Ulrich, 1999) Decrease stress ( Rodiek , 2002) Decrease heart rate ( Wichrowski et al ; 2005) Promote physical health (Armstrong, 2000; Rodiek , 2002) Improve fine and gross motor skills and eye-hand coordination (Moore, 1989) Horticultural therapist Teresia Hazen shows a stroke patient how to use a hand trowel to plant marigolds in a raised bed at one of Legacy’s therapeutic gardens

17. Who are the caregivers that benefit? Physicians Physical Therapists Occupational Therapists

18. Patient groups that can be benefited Physically and cognitively impaired Veteran seniors HIV Physical therapy Neurological Spinal injury Alzheimer Dementia Autistic children Virtually all patient groups Cape Breton Cancer Centre’s Healing Garden (Canada)

19. Rehabilitation Garden at the Shepherd Centre in Atlanta, USA Garden at Mount Zion Cancer Clinic San Francisco, USA. Garden at Rusk Institute of Rehabilitative Medicine in New York, USA Garden of the Oregon Burn Centre, Washington

20. Who else can be benefited? Families and staff Stress reduction Social interaction Solitude and medita - tion Escape from the sterile environment and high pressure setting. Viewing garden can produce substantial restoration effects in 3-5 minutes Hospital Staff in the Healing Garden at Legacy Good Samaritan Hospital

21. View through a window may influence recovery from surgery. (Ulrich, 1984). Ulrich, examined the restorative effect of natural views on surgical patients in a suburban Pennsylvania hospital in the year 1972-1981 . Five types of information were taken from each record; Number of days of hospitalization Number and strength of analgesics each day Number and strength of doses for anxiety, including barbiturates each day Minor complications, such as persistent headache and nausea requiring medication symptoms which are considered to result frequently from conversion reactions All nurses’ notes relating to a patient’s condition or course of recovery.

22. Comparison of analgesic doses per patient for wall-view and tree–view group Analgesic Strength days 0-1 wall tree group group days 2-5 wall tree group group days 6-7 wall tree group group Strong 2.56 2.40 2.48 0.96 0.22 0.17 Moderate 4.00 5.00 3.65 1.74 0.35 0.17 Weak 0.23 0.30 2.57 5.39 0.96 1.09 NUMBER OF DOSES (Ulrich, 1984).

23. Design principles in therapeutic l andscapes 1.Variety of Spaces : Spaces for both group and solitary occupancy . 2.A Prevalence of Green Material : plant materials should dominate the garden. 3. Encourage Exercise : Garden that encourage walking as a form of exercise. 4.Provide Positive Distractions : ( plants , flowers, water features, working with plants and gardening). 5.Minimize Intrusions : urban noise, smoke, and artificial lighting should minimized in the garden . 6.Minimise Ambiguity : Abstract environments may have counter-indicated effects to the ill (Ulrich, 1999).

24. Design elements in the therapeutic g arden Special entrance Element of water for its psychological, spiritual and physical effects Creative use of colour to elicit emotion and comfort in the visitor Healing garden entrance with arbor at Cortesia’s Healing Sanctuary in Oregon. ( McDowell, 1998).

25. Emphasis of natural features such as rocks, wood, natural fences, trellises, wind and sound Integration of art to enhance the overall mood/spirit of the garden Garden features that attract wildlife and provide habitat to a diversity of wildlife ( McDowell, 1998).

26. General design considerations for hospital outdoor spaces and therapeutic gardens 1. Potentials of the site: Optimal distribution of the total site area of a hospital complex should be as follows: 30 % for the buildings 15 % for internal communication routes and parking 50 % for vacant area out of which 10% is reserved for recreational areas ( Kliska et al, 1961).

27. 2. User groups and their needs: Patients Employees Visitors 3. Types of experiences: Therapeutic garden should be planned according to following requirements: To create opportunities for movement and exercise To offer a choice between social interaction and solitude To provide both direct and indirect contacts with nature and other positive distractions (Ulrich,1999 )

28. 4 . Variety of spaces and their interrelation: Provide a variety of hospital outdoor micro spaces, targeting different needs of their users. Places for both group and solitary occupancy Places in the sunlight or shade Places to pause and experience natural surrounding (Hosking and Haggard, 1999 ) Encourage suitable type of exercise: Looped pathways for shorter or longer routes Settings for physical therapy Playgrounds Meandering garden layout for contemplative walking and jogging trails.

29. Meditation square in the Massachusetts General Hospital , Boston, USA Playground in the Dell Children's Medical Center , Austin, USA Variety of micro-spaces in the Legacy Good Samaritan Hospital , Portland, USA

30. 5. Positive and negative distractions: F eaturing of restorative and positive distractions may effectively induce health restoration (Wieland, 2007) Labyrinth Garden in the Duke Integrative Medicine Center , Durham, England.

31. Olson Family Garden in a children hospital , Columbia. Negative distractions and intrusive stimuli (ambiguous sculptures or designs) may hamper recovery aggravate stress (Ulrich, 2000) Sculpture Garden in the Betsheda Rehabilitation Center.

32. 6.Accessibility , familiarity and security Physically secure Accessible to people of all ages and abilities Familiar and safe: when feeling stressed or depressed, many users search for environments that seem familiar and safe Provision of additional medical support (e.g. oxygen outlets) may allow their extended use and lead to a higher degree of comfort

33. 7 . Planting Green areas According to the Green Guide for Health Care; implementation of healthy ecosystems in hospital outdoor spaces has significant social, psychological and physical benefits derived from physical and visual connection to natural environment. Meditation Garden, City of Hope Cancer Center , Duarte, USA.

34. 8.Green roofs Viewing roof garden, Harrison Memorial Hospital , Bremerton, USA View from a patient's room, Hitchock Medical Center , Darmouth . 9.View out

35. Dementia-specific gardens Estimation of number of Person with Dementia over 60 years in India between 2000 and 2050 (Shaji KS et al.,2010)

36. Estimated of number of PwD >60 years in India, UK and USA (Shaji KS et al.,2010)

37. What to Consider When Planning a Dementia-Specific Garden The key design principles are: • Sustainability • Orientation • Accessibility • Socialisation • Meaningful activity • Reminiscence • Sensory stimulation • Safety (Tara Graham Cochrane,2010 )

38. 1.Sustainability The longevity of a dementia-specific garden is dependent on the understanding of its therapeutic value, activity programs and maintenance regime . The garden’s success is very much dependent upon the staff’s understanding of the design. By recognising the different elements and their functions and use, staff will feel more empowered to develop activities that encourage the use of the gardens. Use predominantly low maintenance plants except in interactive garden beds used for horticultural therapy activities. Locate a garden shed in or nearby the garden.

39. 2.Orientation People with dementia often forget where they are going and from where they’ve come. By designing a garden that enables users to orientate themselves through visual cues they will gain a sense of control and in-turn self confidence. Locate gardens where they can be easily viewed from inside to encourage people with dementia to venture out. Simple looped path system to lead users along a journey of interesting focal points and then return them to a point from where they began. Ensure the entry/exit is obvious, clearly marked and open at all times to ensure that users do not feel trapped.

40. 2.Orientation Locate garden elements where they can be seen from numerous vantage points to encourage users to explore and also to orientate themselves. Edge paving and paths with a contrasting colour or raised edge. This will support way-finding and define the change from paving to garden Screen fences with plants to make them less obvious. This will minimise feelings of enclosure. Use signs that lead users to entries and key locations.

41. 3.Accessibility Accessibility affects people with dementia on both a physical and mental level. Make gardens accessible all year round by incorporating greenhouses and indoor planting. Ensure main paths are wide enough for two users either walking or in wheelchairs to pass easily. Choose garden furniture that is of a sturdy timber construction with armrests for ultimate comfort and accessibility.

42. Offer a range of garden beds at differing heights for ease of access Intermittently placed handrails or waist height structures to enable users to rest or balance themselves as they move throughout the garden. Ensure there is plenty of shade for sunny days and warm sitting areas in the winter. Locate seating at regular intervals for resting . Supply tools that are designed specifically for limited strength and mobility . 3.Accessibility

43. 4.Socialisation Enhance the quality of life Include interactive garden features such as men’s shed, raised garden beds, flower gardens, bird feeders and bird baths. Include elements that encourage interaction between family members and people with dementia such as child-friendly elements and areas for pets. Include quieter, passive areas for refuge and large activity areas for groups.

44. 5.Meaningful Activity Include home-like activities in the garden to engage users in daily chores such as posting a letter, making a telephone call, washing the car, gardening, hanging out washing, watering the plants and feeding the birds. Include garden features that require daily interaction such as a bird feeder, herb garden, bird aviary or fish pond. People with dementia still have the energy and desire to remain active and involved in the world around them.

45. 6.Reminiscence For people with dementia encouraging the act of reminiscence can be highly beneficial to their inner wellbeing and their interpersonal skills. It involves exchanging memories with others and the passing on of information, wisdom and skills. By incorporating reminiscence elements and activities, people with dementia are able to engage with the world around them and retain feelings of value, importance, belonging and peace. Plant the gardens with plants that are familiar to the age and culture of the users. Ensure garden elements are of an era, style and material familiar to the users .

46. 7.Sensory Stimulation Sensory stimulation is important in the overall emotional wellbeing of people with dementia. Sensory stimulation is the engaging of any of our five senses – sight, sound, taste, touch and smell. Include garden elements that are interactive. Ensure that gardens can be viewed from inside so that watching the rain or wind in the trees can be enjoyed by people with dementia even when it’s too cold to go outside.

47. 8.Safety Ensure paths and paving are level, smooth, slip resistant and low glare. Ensure there are no obvious locks or handles Ensure that all plants are non-toxic . Safety can be the defining factor in whether a garden is allowed to be used or not. Ensure that all potential safety issues are addressed in the planning process of the garden.

48. COMFORTABLE SEATING OLD CAR ENTRY/EXIT WITH DOOR AWNING BIRD BATH DIRECTIONAL SIGN LAMP POST BIRD FEEDER GAZEBO ARBOUR WALK WITH SCENTED CLIMBER VIEWS OUT FROM WINDOWS WATER FEATURE SENSORY PLANTS DECIDUOUS TREES Barbecue WALL MOUNTED HEATERS UNDERCOVER MULTI-USE PAVED ARE ENTRY/EXIT WITH DOOR AWNING SMOOTH LOW GLARE PATH WITH EDGING FRAGRANT FEATURE PLANTS RAISED WALL LAMP POST SCULPTURE LETTER BOX OPEN LAWN RAISED GARDEN BEDS PLANTED WITH HERBS OR VEGETABLES GARDEN/MEN’S SHED UNDERCOVER WORK AREA RAINWATER TANK FRUIT TREES OLD WHEELBARROW FEATURE SHADE TREES Basic garden design ideas Large garden HIGH BOUNDARY FENCE WITH SCREEN PLANTING (Tara Graham Cochrane,2010 )

49. Plants Enhancing the sense of sound to calm the nerves Rustle in the wind Bamboos Magnolia grandiflora Peltophorum ferruginium Platanus orientalis Musa paradisiaca Sweet corn Attract buzzing bees Lavendula officinalis

50. Enhancing the sense of smell to relax and reminisce scented flowers: lavender Lavendula officinalis Rosa damascena Centaurea cyanus L. Mathiola incana L.

51. Scented Climbers Trachelospermum jasminoides Quisqualis indica Tecoma jasminoides Solanum jasminoides Hiptage benghalensis Lonicera japonica

52. Abelia x grandiflora Gardenia jasminoides Murraya exotica Jasminum sambac Cestrum diurnum Cestrum nocturnum Scented Shrubs

53. Adding sweet smelling fruits and herbs ; Thymus vulgaris Solanum lycopersicum Fragaria x ananassa Lavendula officinalis

54. Enhancing the sense of taste increasing our enjoyment of food and drink Fruit and vegetables Tropaeolum majus Ornamental plums Ornamental Peaches Ornamental Cherry

55. Lavandula officinalis Ocimum sanctum Valeriana officinalis Passiflora sp. Rosemarinus officinalis Melissa officinalis Matricaria recutita Piper methysticum Anti-stress herbs

56. Trees for shade Alstonia scholaris (Tropical region) Pongamia pinnata (Tropical region) Azadirachta indica (Tropical area) Plant with a higher phytoncide emission Pinus roxberghii Quercus spp.

57. Safe plants Popular toxic plants Non-toxic alternatives Bluebells ( Hyacinthoides non- scripta ) Poisonous Fritillaries ( Fritillaria ) Siberian lily ( Ixiplirion tataricum ) Anemone Christmas rose ( Helleborus niger ) Poisonous Skin irritant Crocus ( Crocus sieberi ) Barrenwort ( Epimedium ) Wake Robin ( Trillium grandiflorum ) Daffodils ( Narcissus ) Poisonous Skin irritant Fritillaries ( Fritillaria ) Daphne ( Daphne odorata ) Poisonous Skin irritant ( Mahonia japonica ) Winter Jasmine ( Jasmine nudiflorum ) Wintersweet ( Chimonanthus praecox ) (Kim Grove, 2012)

58. Flowering Quince ( Chaenomeles x superba ) Thorny Flowering currant ( Ribes sanguineum ) Foxgloves ( Digitalis ) Poisonous Hollyhock ( Alcea rosea ) Gaura ( Gaura lindheimeri ) Holly ( Ilex aquifolium ) Poisonous,Thorny ( Cotoneaster salicifolus ) Christmas box ( Sarcococca confusa ) Iris ( Iris ) Skin irritant Day lily ( Hemerocallis fulva ) Montbretia ( Crocosmia x crocosmiiflora ) Larkspur ( Delphinium ) Poisonous Hollyhocks ( Alcea rosea ) Mullein ( Verbascum ) Tobacco plant ( Nicotiana sylvestris ) Poisonous Snapdragons ( Antirrhinum majus ) ( Fuchsia ) ( Penstemon ) Lupins ( Lupinus ) Poisonous Hollyhocks ( Alcea rosea ) Mullein ( Verbascum ) (Kim Grove, 2012)