Green care and mental health: gardening and farming as

Transcription

HORTICULTURAL THERAPY
Green care and mental
health: gardening and
farming as health and
social care
Joe Sempik
Research Fellow at the Centre for Child and Family Research at Loughborough University
Abstract
This article discusses the role that gardening, horticulture and farming can play in promoting mental well-being
and in supporting the recovery of individuals with mental health problems.
Key words
Green care; Mental health; Well-being; Horticultural therapy; Health promotion
A brief history
Both the experience of the natural landscape and
working within it have been associated with physical
and mental health for a long time. For example, in
ancient Greek culture, Epidauros was considered to
be a place of healing and attracted visitors in the
way that modern religious shrines (such as Lourdes)
do today (see Gesler, 1996). The study of Epidauros
and other healing places led Gesler (1992; 1993) to
propose the concept of a ‘therapeutic landscape’,
which has been used to explore how places and
landscapes can influence the perception of health
and well-being. This viewpoint is essentially from
a cultural and spiritual position. The landscape
itself, its cultural context and its significance to the
participant, all play an important role in its perceived
healing properties. The notion of therapeutic
landscapes has been broadened to include many
different settings and environments that provide the
backdrop to human activities (see Williams, 2007).
Various physical environments are, therefore, seen
as ‘inherently healthy’. In some cases, the emphasis
has been on the aesthetic qualities and tranquillity
of the particular spaces. For example, in the Middle
Ages, many medieval hospitals and monasteries were
built with gardens within their grounds that provided
a peaceful and beautiful space that was considered
to promote reflection and healing (see, for example,
Gerlach-Spriggs et al, 1998).
However, it is not only the natural environment
that was considered to be healthy, but also the
Working together at Care Co-ops, Brighton
10.5042/mhsi.2010.0440
Mental Health and Social Inclusion • Volume 14 Issue 3 • August 2010
© Pier Professional Ltd
15
Green care and mental health: gardening and farming as health and social care
Sowing the seeds at Redhall Walled Garden,
Edinburgh
work within it – farming and gardening. Farms
and gardens have existed alongside hospitals and
other formal communities, such as prisons, for
example, for centuries. The produce from the farms
and gardens fed patients and carers and also gave
patients a meaningful occupation. There were
opportunities for physical labour, rehabilitation
and often a pleasant pastime in the company of
other people, frequently drawn not only from the
residents of hospitals, but also from the surrounding
community. So, the gardens and farms satisfied
physical, social and productive needs of patients.
The association of farms and gardens with
hospitals (particularly with the old Victorian asylums)
continued until around the middle of the 20th
century. During that time, many official reports of
the day (the equivalent of today’s reports from the
Department of Health or National Institute for Health
and Clinical Excellence (NICE)) concluded that such
outdoor labour, the natural surroundings and the
fresh air were of prime benefit to the patients (see for
example, Tuke, 1882, pp383–384). Observations of the
benefits of outdoor occupation were also noted in the
medical literature of the mid 20th century. Writing in
1955, O’Reilly and Handforth reported that working in
a gardening group caused a substantial improvement
in the condition of a group of women patients
suffering from mental illness, including schizophrenia.
16
However, a number of factors were already
converging to challenge and displace such
approaches. These included the availability of the
antipsychotic chlorpromazine, already being used
in 1955 in the US to treat schizophrenia (KinrossWright, 1955); the desire to modernise mental
hospitals; and major policy changes taking place
in the UK, most importantly the formation of the
NHS in 1948. The view of the government was that
the Minister of Health did not have the authority
to allow the NHS to farm unless it was absolutely
necessary for the well-being of the patients (Ministry
of Health, 1955). Farming was seen as a commercial
activity that was becoming increasingly mechanised
and therefore provided fewer opportunities for
being ‘therapeutic’. The move to close the farms
proved a protracted and somewhat controversial
process. Exchanges in Parliament reveal closures to
have been the subject of intense debate with some
MPs lending strong support to hospital farms in
their constituencies (see, for example, Hansard, 11
February 1959, cc1317–1318).
In spite of the opposition, most of the farms
and market gardens closed. A few remained
within occupational therapy departments but they
were now considerably smaller and not focused
towards production.
However, many of the people who had been
involved with the old farms and gardens began to
recreate them in a different format. They were led
by the guiding spirit that working with and within
nature promoted health. They were joined by others
from a variety of different disciplines including
horticulture, nursing and occupational therapy, and
influenced by social movements linked to nature,
conservation, community and social gardening, and
allotment keeping. They were also influenced by a
developing pedagogy from overseas, for example
from the US, related to the use of nature as a specific
health intervention. One important influence was that
of ‘horticultural therapy’, which by 1973 had its own
association – the American Horticultural Therapy
Association. The growing movement also began to
attract serious academic research. The modern era of
nature work had begun.
Green care: a new set of
nature paradigms
One of the first structured approaches using nature
as therapy was ‘horticultural therapy’. This can
be viewed as a specialised form of occupational
therapy (OT) using plants and horticulture as
its main activity. Related to that is ‘therapeutic
horticulture’, which adopts a more generalised way
of using horticulture and gardening for promoting
health. The distinction is that horticultural therapy
has a predefined clinical goal similar to that found
in OT, while therapeutic horticulture is directed
towards improving the well-being of the individual
in a more generalised way (see Sempik et al, 2003,
p3). Since therapeutic horticulture usually has
an important social context, the term social and
therapeutic horticulture (STH) is generally used in
the UK.
STH is not the only way in which nature
can be used to promote health. Small-scale
agriculture has been widely used in Europe as a
form of rehabilitative social care, particularly for
people with mental health problems and learning
difficulties. In some European countries, this marks
the continued development of hospital farms, while
in others it represents an evolution of agriculture to
become ‘multifunctional’, ie. not simply producing
food but also providing care (Hine, 2008). Such
farms have been termed ‘care farms’ (see Hassink
& van Dijk, 2006) and while this movement started
in Europe it is now active in the UK (Hine et al,
2008a). Alongside farming activities, the animals
themselves have also been used as ‘co-therapists’
for promoting health and well-being within
treatments that are referred to as animal-assisted
therapy (AAT) and animal-assisted interventions
(AAI) (Kruger & Serpell, 2006; Sempik et al, 2010,
pp32 & 38). AAT is structured and formalised, while
AAI involves more general contact with animals that
might be found by working on a small farm. The
rationale for these approaches is that caring for an
animal and responding to its needs and learning to
communicate with it helps to develop psychological
well-being and self-esteem.
Collectively, these and other approaches using
nature have been termed ‘green care’ (see Sempik
et al, 2010). Research into specific interventions and
into the general field of green care has increased
substantially in the last 10 years, as academics have
increasingly seen that it is a ‘legitimate’ field of
Working together at Thrive’s Trunkwell Garden Project
17
Instructing volunteers at Unstone Grange, Derbyshire: using tools can be empowering
study. Parallels have been drawn between green
care and therapeutic communities (Haigh, 2008;
Sempik et al, 2010, p55) since, in most cases,
green care interventions involve the creation of
communities that coalesce around a particular
activity or setting. Indeed, Hickey (2008) has
described a therapeutic community (TC) in a
garden setting. It is both a therapeutic community
and a social and therapeutic horticulture ‘project’.
It is important to point out here that group
therapy is an important feature of TC, however
most green care approaches do not include formal
psychotherapy. The therapeutic potential of green
care is considered to reside within the activities,
the setting and the social environment.
Social and therapeutic
horticulture
Social and therapeutic horticulture (STH) can be
described as a community of vulnerable people
working together on horticultural activities in a
garden or allotment, with the aim of providing
mutual support and benefit to their health and
18
well-being. It is considered that benefits are derived
from the organised structure of the community
that provides meaningful occupation that is similar
to employment but lacks its pressure (Sempik et
al, 2005, pp68–71). The activities and structure
promote and foster the development of skills, selfconfidence and self-esteem. A recent report of
the Royal College of Psychiatrists, Mental Health
and Work, recommended that people with severe
mental illness should have:
‘Access to meaningful occupation such as
voluntary work or other unpaid work. This
work should be of a nature that builds work
skills and confidence and whenever possible
prepares the person for paid employment in
the future.’ (Royal College of Psychiatrists,
2008, p42)
STH projects provide meaningful occupation in
a natural setting and some prepare their clients
for eventual paid employment. However, such
employment is not always desirable or beneficial.
Importantly, STH projects also provide opportunities
for social contact (which is particularly valuable
for people with mental health problems) and
experience of the natural environment, which
provides a psychological and spiritual context. This
connectedness with nature is considered to be an
essential element in STH and in other forms of
green care (see Sempik et al, 2010, p17).
Sempik (2007) has suggested that STH projects
have a number of defining features that can be
summarised as follows.
■ Therapeutic intent and practice – therapeutic
garden projects are intended to promote mental and
physical health and well-being in their clients who
may have mental, physical or social problems. There
is an accepted and organised practice of STH.
■ Location – an outdoor site with shelter to enable
the group to meet together, socialise and eat
together. The presence of a ‘home’ location enables
clients to form a bond with a specific location and
develop a sense of place.
■ The natural environment – as mentioned above,
connectedness with nature is an essential feature of
STH.
■ Democracy and involvement – STH projects
enable their clients to become involved in the
running and organisation of the projects.
■ Social coherence and community – STH projects
foster the development of a community that works
together, and socialises within the boundaries of the
project (and occasionally outside).
■ Production – is an essential part of STH. It enables
clients to develop a sense of identity as workers or
gardeners, however, without the pressure seen in
paid employment.
■ Routine – the activities and procedures at STH
projects are designed to facilitate the development of
routine and there is an expectation of commitment
by the client to a regular, rather than a casual
attendance.
■ Arts and crafts – Many STH projects have facilities
for arts and crafts. These may be linked to the
garden, either by making decorative or practical
items for the garden or using materials from the
garden in the artwork; or they may represent rural
crafts.
Evidence of effectiveness
Sempik et al (2003) conducted an extensive literature
review of STH and horticultural therapy and found
that there had been little in the way of quantitative
studies, but that qualitative work suggested that
STH was highly valued by participants. It was
perceived by them, their families and carers to be
responsible for an improvement in their symptoms
or for preventing deterioration in their condition. The
research suggested, in particular, improvements in
social functioning and quality of life. For example,
Fieldhouse and his co-workers (Seller et al, 1999;
Fieldhouse, 2003) studied an allotment project for
a group of patients with a range of serious mental
health problems. Fieldhouse found that the project
was perceived as ‘a restorative and affirming
environment’, which enhanced mood and selfawareness and consequently ‘underpinned their sense
of meaningful occupation and well-being’ (Fieldhouse,
2003, p286). Similar results were obtained by PerrinsMargalis et al (2000) using semi-structured interviews
and diaries in a heterogeneous group of patients
with chronic mental ill health. Sensory aspects of
horticultural activities – smells, colours and textures
– were considered particularly important, as were
the social dynamics offered by the group. Prema
et al (1986) showed an improvement in social
functioning in 10 schizophrenic patients attending
a horticulture programme. Again, responses were
elicited through interviews.
More recently, Stepney and Davis (2004)
reported perceived improvement in social inclusion
and social functioning in a heterogeneous group
of patients and a fall in some individual scores
for depression, by using the Hospital Anxiety and
Depression Scale (Zigmond & Snaith, 1983; Snaith
& Zigmond, 1994).
Sempik et al (2005) studied a wide range of garden
projects in the UK and concluded that STH projects
promote social inclusion through the dimensions
proposed by Burchardt et al (2002) of ‘production,
consumption, social interaction and political
engagement’. They suggested that STH had many
of the attributes of work ie. meaningful occupation,
development of skills, physical activity, routine and
structure, social opportunities within a framework that
promoted participants to exert a degree of control (the
‘political engagement’ dimension of social inclusion).
In a subsequent study, Sempik (2007) interviewed a
sample of clients of STH garden projects and reported
that all of them considered to have been helped by
STH. Some reported suffering distress when a project
had closed temporarily due to lack of funding.
19
Lee et al (2008) reported that a horticultural
therapy programme improved self-esteem and
depression scores in a group of battered women.
These scores were significantly different from the
control group. Recently, Gonzalez et al (2009)
showed a statistically significant fall in depression
scores in a group of patients with moderate to severe
depression attending a therapeutic garden project.
An evaluation of a garden project for ex-servicemen
with post-traumatic stress disorder reported that
both clinical staff and patients viewed the project as
having ‘positive therapeutic benefits’ (Atkinson, 2009,
p9). Such benefits derived from a sense of purpose,
physical activity, learning new skills and providing
an environment in which patients could ‘immerse
themselves’.
It can be seen that evidence of ‘effectiveness’
is varied, but it is important to remember that STH
is used for a wide range of vulnerable people.
It is usual practice for people with different
vulnerabilities or disabilities to be cared for
together. Even at therapeutic gardens specifically
intended for people with mental health problems,
the population of clients is heterogeneous, with
many different conditions and comorbidities.
STH is a complex intervention that has not
been claimed to address any specific illness or
Woodwork at the Green Health Partnership,
Shipley Country Park
20
condition, but which aims to provide a range of
experiences, opportunities and activities within
an alternative model of social care. Hence, the
construct of effectiveness in this case has not been
defined and is contested. Therefore, exploring
and understanding individual participants’
feelings, emotions and reactions to STH may be
as important as measuring changes in specific
outcome measures.
Gathering research data is difficult, and this
is one reason why methods such as randomised
controlled trials (RCTs) have not yet been used in
this area. Indeed, in this respect STH shares some
of the difficulties with therapeutic communities
where the issue of RCTs has proved problematic
(see Manning, 2004, p119).
Funding
While results from an RCT of therapeutic
horticulture would be desirable, there are issues
of costs and funding of such a study; and also
difficulties caused by the heterogeneous mix
of clients. As for therapeutic communities, the
evidence base for STH is slowly building through
smaller studies and assessments. There is a hope
that a stronger evidence base will eventually lead to
more funding for the area and greater accessibility
for clients. Most garden projects in the UK currently
struggle for funds, and often their existence is
precarious. Fees paid by health trusts and social
care agencies rarely meet running costs, and many
STH projects survive by raising additional funds
through a variety of activities – grants, donations,
sales and others.
There are around 1,000 therapeutic garden
projects in the UK that provide a service for 22,000
individual clients each week, equivalent to around
one million sessions each year (Sempik et al, 2005).
Almost half of these projects (41%) provide a
service for clients with mental health problems.
Our research has shown that in 2004/05, the
cost of STH per session was similar (at around
£50) to the cost of day care at a centre. However,
the range of fees charged was wide, with a mean
of £27 per session, equivalent to approximately
half of the cost of actual service delivery. Hence,
around £27 million is spent on STH by way of
fees paid by health and social care departments
and an additional £23 million is spent by the
general public or received as grants from charitable
institutions. Therefore, considering that around
41% of STH provision is for people with mental
health problems, £11 million is spent annually by
government on mental health services by way of
therapeutic horticulture; this is almost matched by
money collected from the public. Considering the
cost to society of services for people with mental
health problems, this is a very small amount
indeed. For example, Thomas and Morris (2003)
calculated the cost relating to depression alone in
England and estimated that direct treatment costs
to the NHS were £370 million. This excluded any
social care costs. Including these, McCrone et al
(2008) estimated that the cost of treatment and care
amounted to £1.7 billion annually.
Social and therapeutic horticulture is an
inexpensive way to treat and care for people with
mental health problems, and there is considerable
room for expansion of service provision, should
adequate funding become available.
To some extent, social and therapeutic
horticulture is a grassroots movement that
continues to function and provide care because
of the dedication and beliefs of those involved.
Much of the evidence that provides the impetus
for those working in the field comes from their
own personal experience and practice. Many of
the beliefs centre around an environmentalist
viewpoint, and garden projects often use organic
methods and sustainable practices, such as
recycling and wind power (see Sempik et al,
2005). Indeed, Sempik et al (2005) have noted
that some volunteers were attracted to particular
gardens specifically because of those practices, and
some project workers felt that such an approach
contributed to the well-being of clients. An organic
philosophy promotes engagement with nature and
concern for it. This also fosters a connectedness
with nature that is considered to be important
for human well-being (see, for example, Mayer &
Frantz, 2004). Recently, Hine et al (2008b) have
shown that connectedness with nature is related
to an increase in both awareness of environmental
issues and in ‘environmentally friendly behaviour’.
The underlying philosophy of therapeutic garden
projects encourages such behaviour and therefore
promotes connectedness with nature. STH is
one way in which people with mental health
problems can engage with nature and extend
their connectedness with it. It also enables
their participation in a variety of activities that
promotes their inclusion within their community
and within society.
References
Atkinson J (2009) An Evaluation of the Gardening Leave
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at a shelter in Korea. Acta Horticulturae 790 139–142.
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Dr Joe Sempik is a Research Fellow at the Centre for Child and Family Research
at Loughborough University. His research interests are in the field of environment
and open space, and its influence on health and well-being. He has been
involved in research into social and therapeutic horticulture since 2002, when he
and his colleagues conducted the Growing Together study of gardening projects
in the UK. He is chair of the working group on the health benefits of green care
as part of COST 866 – Green Care in Agriculture. His other research interests are
in the evaluation of the costs and effectiveness of services for vulnerable children
and adults.
A history of hospital farms and gardens
Joe is interested in writing a history of hospital farms and gardens. If you worked in a hospital farm or
garden as a member of staff or as a patient and would like to share your memories, please contact him
on 01509 223671 or email j.sempik@lboro.ac.uk. If you have any photographs or documents relating to
the farms and gardens they would be very welcome. All original material will be returned.
22

Green care and mental health: gardening and farming as

Transcription

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