Motivation and emotion/Book/2024/Therapeutic horticulture

Therapeutic horticulture:
What is therapeutic horticulture, what are its effects, and how does it work?

Overview

Figure 1. People pottering around in a community garden, laughing and sharing stories. Picture this ... You're 73 years old living in a retirement village, 5 beautiful grandchildren and 3 children who visit you occasionally however are busy in life so only pop by when they get a chance. Finding yourself feeling lonely nearly everyday, the days do somehow seem to pass by with not much to look forward to day by day. Whilst you are surrounded by people, you haven't found much opportunity to create a community of your own amongst the other retirees. When going for your daily walk something catches your eye, a group of 7 or so people in the community garden, laughing and sharing stories about time as it's passed by as they plant bulbs as seen in Figure 1. What a wonderful community they have found? You think to yourself.

Therapeutic horticulture, (TH) historically known as nature therapy was first studied in the 1950's, to help scientists understand why humans enjoyed spending large amounts of time in nature and would travel vast distances to be amongst nature. It wasn't until 1979 when Roger Ulrich, a professor in architecture studied students after exams showing them photos of urbanisation and nature to ascertain whether nature had a calming effect on humans (Ulrich, 1979).

No matter where you find yourself located in the world, gardening has a positive impact on every individual who partakes. Such benefits psychologically, physiologically and socially improves ones life. The feel good reaction many experience when being amongst nature can be influenced by many factors. A sense of feeling competent in a skill, belonging in a community and even the bacteria mycobaterium vaccae in soil has been found to release serotonin, increasing happiness (Lowry et al., 2007).

By utilising nature to improve well-being, mental health, physical health and social lives, therapeutic horticulture is a holistic nature based therapy which is easily accessible and inclusive. Three types of TH can be identified, each one customisable to individual needs (Stewart, 2016):

Vocational Educational and rehabilitation purposes, the goal is to provide individuals with employability skills or promote recovery from injury and improve illness
Therapeutic Holistic approach for overall mental well-being, designed to promote mental illness recovery
Social Supporting overall well-being and improving social connections with others.

TH is a non-pharmaceutical practice with no side effects. Used to aid in improving the lives of those living with mental illness, a coping mechanism for stress and promotes socialisation; particularly for the elderly. However TH is not limited to just the elderly, welcoming and accommodating all ages, backgrounds and abilities. Panțiru et al. (2024) meta-analysis found consistently across 40 studies, the use of TH improves overall quality of life amongst vulnerable populations and the general population via participant feedback before and after participating in HT.

Focus questions What benefits do we experience when being amongst nature? What motivates individuals to participate in therapeutic horticulture? What positive impact can therapeutic horticulture have on individual lives? Is therapeutic horticulture a realistic alternative to pharmaceutical intervention?

Benefits of being amongst nature

Figure 2: Walking with nature.

TH is beneficial in a range of ways encouraging social connection while being outside and promoting physical activity. Inherently, gardening is done outside, exposing individuals to natural sunlight and increasing vitamin D absorption. Vitamin D is essential for bone health, preventing osteoporosis, reducing inflammation and supporting cell mitosis and meiosis (Holick, 2012). Panțiru et al. (2024) Meta-analysis found over-arching positive results of positive psychological and physiological benefits form TH. Populations found to have greatly benefitted from engaging in TH is those with mental illnesses, dementia and older demographics long standing physiological concerns (Pantiru et al,. 2024). By engaging with TH individuals experience greater satisfaction of ones life, increased quality of life and builds a sense of community (Soga et al., 2017).

Psychological benefits

Ulrich (1979) positive findings that having nature easily accessible when individuals are exposed to stressful circumstances, may alleviate feelings of stress while promoting positive well-being. Suggests the use of nature can be utilised to reduced systems of depression and anxiety (Bratman et al., 2015). As being amongst nature provokes feelings of calmness, allowing one to feel safe within their environment. The positive feelings many experience being amongst nature is not a happy accident, but a cognitive function consistently measured as exposure to nature increases attention span, executive function and positive cognitive influence regardless of length of time spent in nature (Jimenez et al., 2021). Such positive benefits have been observed by allied health professionals and academics, who are recommending spending times outdoors and in the garden for individuals to reap the rewards of the positive impacts being outside has and minimising pressure on overworked healthcare systems such as the NHS (Thompson, 2018).

Physiological benefits

The level of physical activity required is not strenuous, allowing TH to be inclusive for individuals with mobility and accessibility concerns to easily partake in TH. Prior to commencing TH patients should be asked about prior experience spent outdoors, as individuals history may impact how much physiological benefits they experience. Lim et al. (2020) participants unexpectedly had spent a limited amount of time outdoors prior to participating, resulting in participants not experiencing the expected benefits from spending time outdoors and reported low connection to nature. With this being said, low level physical activity makes TH accessible and may promote an increased level of physical activity individuals lives.

The most prevalent physical results found is TH improving an individuals ability to control their weight management. By growing fruit and vegetables, allows for the uptake of consuming a balanced diet to be more financially accessible. Zick et al. (2013) compared 3 groups BMI and whether they were gardeners, spouse of a gardener or an unknown neighbour. Statistically significant findings were observed from the hypothesis that those who grow food had smaller BMI results to those who don't grow their own food, spouses of gardeners also had lower BMI's (Zick et al., 2013). These findings indicate that by having fresh fruit and vegetables readily available makes an individual advantageous to a balanced diet. However the use of BMI to calculate a persons overall health is misleading as this doesn't consider ethnicities outside of the country it was created in, Belgium (Humphreys, 2010).

Social benefits

Social benefits from TH particularly are useful for encouraging inclusion of groups normally isolated or vulnerable. An opportunity to be apart of community gardening or TH provides individuals with an opportunity to engage and learn from others. Increasing a sense of competence, by learning a new skill and relatedness through finding oneself amongst a group of individuals with likeminded goals. Providing individuals with a sense of autonomy over their work, especially important as it is not uncommon for individuals to feel a loss in independence and alienated when partaking in traditional therapy (Bryant et al., 2004).

Figure 3: Copious amount of vegetables, ready to be shared

However, not everyone that participates in TH experiences increased social benefits, Siu et al. (2020) found participants only engaged socially when discussing the end product produced e.g. plants, fruits and vegetables. The products produced, provided the participants with produce and experiences they are able to share with friends and family (Siu et al., 2020). Suggesting that rather than sharing individual feelings and experiences amongst others, TH is best used for increasing social interactions outside of TH groups and increasing social connections with friends and family. As seen in figure 3, a large quantity of vegetables grow in gardens allowing for extras to be shared.

Social benefits have found to vary in relation to the demographic participating in TH, this should be consider when providing TH. For example, some individuals experiencing mental illness or general sickness may not be seeking social connections during TH sessions and would benefit from a one on one session, allowing the individual to take home the produce to then share. In comparison to an older age group who seek out social connections would benefit from group TH sessions to build relatedness, autonomy and competence.

Figure 4: A group of elderly ladies enjoying time spent in the garden.

Alternative to pharmaceutical intervention

Preventative measures

Incorporating gardening into ones life promotes public health and should be utilised as preventive measures (Soga et al., 2017). Particularly for the older generation as they face cognitive and physical decline, the improved quality of life TH offers may be the answer to assist in slowing the declining process (Heród et al., 2022). Currently there is limited research to recommend TH clinically and TH faces limited knowledge of the benefits to include it as part of health care plans, especially as traditional medical methods remain prominent when treating patients (Wood et al., 2024). The social and physical benefits of TH are crucial for those requiring low impact fitness and social connection to improve related. It is recommended for future research to investigate how TH can be used as a preventative measure to preserve health and be incorporated in health care plans. To decrease and prevent loneliness amongst the ageing population and those in aged care facilities, a community garden alongside a TH program is recommended in order for social connections to be developed amongst the community to increase relatedness with one another and share knowledge to build competence.

Dementia

Those diagnosed with dementia are a population whom greatly benefit with participating in TH. Improving cognitive function, decreased agitation and increased social engagement with positive emotional outcomes when having completed horticulture therapy (Zhao et al., 2022). To limit the negative effects of ageing, gardening has been found to positively promote health with the physical and psychological benefits (Lu et al., 2023). Such improvement to life quality should encourage age care facilities to adopt TH programs (Lu et al., 2023). Dementia patients benefit from being active and reduction of time spent being inactive whilst participating in TH programs (Lu et al., 2020).

Mental illness

It is estimated that 43% of Australians have experienced mental illness at some point in their life (Australian Institute of Health and Welfare, 2024). This number will not decrease, as predictions are set to see depression and anxiety to become more prevalent by 2030. By having a long term project and caring for a life which yields results when cared for properly promotes individuals to a carrying role, providing responsibilities (Australian and New Zealand Mental Health Association, 2018). Globally 1 in 8 people (970 million people) live with a mental illness, this number has increased significantly since 2020, Covid -19 (World Health Organization, 2022).

The most common mental health illnesses and responses which gain positive experience when partaking in TH are:

Across multiple studies, participants with chronic schizophrenia have reported that participating in TH experienced a reduction in symptoms of anxiety and depression, quality of life did not improve (Mourão et al., 2022). By participating in TH programs individuals with chronic schizophrenia had increased social connection and experienced feelings of relatedness (Mourão et al., 2022). In attempt to create structure and clinical programming Oh et al. (2018) explains several studies that explore different lengths of TH programs on participants with chronic schizophrenia. Studies discussed by Oh et al. (2018) explain 16, 24 and 10 session TH programs, all of which had positive outcomes on psychiatric symptoms, improved interpersonal relationships and significantly positive improvement of general symptoms. There was no discussion as to what the planned structure of these programs were or if they held similarities, thus making the findings comparable difficult, to improve this limitation in TH literature a meta-analysis should be written to compare program structure in which an ideal program length of time may be established.

Lu et al. (2023) has started to bridge this gap in research, by establishing through a meta-analysis of stress reduction from TH the ideal length of time to see the best effects for stress relief using TH is 100-500 minutes a session. Male identifying and participants over 60 years old were found to have greater stress reducing effects due to differences between how males and females cognitively process stress (Lu et al., 2023).

Wellbeing

Amongst literature on TH, positive effect on wellbeing is a widespread theme. Anytime spent in a garden has ongoing positive shift of physiological and psychological health, regardless of demographic, thus improving individuals' wellbeing (Pantiru et al,. 2024). With this being said there is also criticism of literature thus far being broad and inconsistencies in how research has been conducted, resulting in limiting the ability for TH to become a mainstream approach for therapy (Pantiru et al,. 2024). Future research should consider utilising longitudinal studies and clinical trials to create structured program for TH service providers to deliver (Pantiru et al,. 2024). As TH is easily accessible due community gardens being common and providing TH services expects no need to be a registered or clinical psychologist (Therapeutic Horticulture Australia, 2024). While this creates affordability and TH easily accessible, concerns should be raised about the quality of service provided and what benefits are being had by individuals engaging in TH which may not have regulations to abide by.

Motivation to engage in therapeutic horticulture

Motivation

Figure 5: fostering the three basic needs to be motivated

Motivation is the intrinsic drive to take action and complete tasks (Ryan & Deci, 2000). Characterised into two classes to be motivated or unmotivated.

Motivation springs one out of bed in the morning at 5:45am to get to Pilates at 6:15am, it keeps one accountable for long term projects ensuring work is not being completed the night before a deadline. For example a health student may be highly motivated to achieve high academic grades in order to be accepted into a highly competitive physiotherapy program.

Intrinsic motivation

Characteristics of intrinsic motivation is taking part in actions out of genuine interest in the outcome such as watering your garden every morning because you love to grow flowers and watch the process of them growing (Ryan & Deci, 2000).

Extrinsic motivation

Extrinsic motivation is the act of partaking in actions because of the motivation to complete a task because of a outcome which doing so will bring to you such as being motivated to work because of the financial reward working brings so one can then pay off their mortgage (Ryan & Deci, 2000).

Self-Determination Theory

The Self-Determination Theory explains factors responsible for motivation, developed from social contexts and individual differences to fulfil three basic human psychological needs (Ryan & Deci, 2000). Suggesting that everyone experiences three psychological needs, autonomy, competence and relatedness (Ryan & Deci, 2000). When such needs are fulfilled, individuals experience psychological well-being and feel overall motivated, compared to if these needs are not met, individuals are faced with unnecessary stress and decreased motivation (Ryan & Deci, 2000).

Competence

To be competent is to executive a task with a high level of skill (Lopez-Garrido, 2023). Competence allows individuals to feel confident within their ability to achieve the task at hand (Lopez-Garrido, 2023). Being amongst the garden and learning from others is intrinsically motivating for individuals as they are learning a new skill because of the emotional connection or to learn a new skill, thus fulfilling the psychological need of competence (Ramirez-Andreotta et al, 2019).

Relatedness

Relatedness allows individuals to have a sense of belonging to a group or attachment to others who share similar interests or circumstances, creating closeness and connections amongst others (Lopez-Garrido, 2023). Learning and building upon a skills with others also increases social connections and a feeling of belongingness within a group. Teig et al. (2009) found that community gardeners had an increased sense of belonging and experienced pro-social connections. As a result of sharing a common interest resulting in the same goal, increased trust amongst others (Teig et al., 2009).

Autonomy

Figure 6 : A simplified version of the Self-Determination Theory

Autonomy provides individuals with capabilities to feel in control of their own future, fuelled by initiative and discipline (Lopez-Garrido, 2023). When individuals are able to exercise autonomous behaviour and make choices upon their own free will, a feeling of independence is commonly experienced (Lopez-Garrido, 2023). Autonomy is greatly influenced by intrinsic motivations and hindered by being extrinsically rewarded (Lopez-Garrido, 2023). For example, imagine an individual is intrinsically motivated to grow roses because they adore their fragrance. Their neighbour notices how beautiful these roses are and offers to pay for a weekly supply of fresh roses, the relationship changes. What was once intrinsically motivating by the joy brought by roses becomes extrinsically motivating by financial incentive. Due to such shift in incentive the individual may find themselves no longer enjoying the smell of roses and despises the thought of growing them, causing the once joyful task to become a stressful commitment.


Case study edit Betty is 86 years old, finding herself just moved into an aged care facility after living independently for 17 years. She was resistant to moving out from her long standing home due to a fear of loosing her independence, however after many falls and a loss of mobility a hard decision had to be made for her safety. Betty quickly found herself being agitated and hostile, having loss control of her own routine and abiding by others schedules. This carried on for a few months, Betty's isolation left her experiencing depression and loneliness after isolating herself while struggling to cope with her change in circumstance. After a few visits from the GP who's assisting Betty manage her new life and decline in mental health, noticed Betty had pictures of flowers in her room. Betty mentioned how much she loved her garden back home, that every morning she would wake up, go outside to water her garden, and watch birds play in the bird bath because she loved watching nature grow around her. Betty's GP explained that the aged care facility had a therapeutic horticulture program run every second day for residents and that Betty should take part in it as it may help her feel like herself again. Shortly after this conversation Betty found herself amongst a new group of people and often in the garden, her sense independence had come back as she was able to utilise her skills and return to her old routine of being in the garden every morning. Her social life had increased and betty was feeling the most confident she had in years as she was teaching others what she knew about gardening. By being given the skills and knowledge taught by other skilled gardeners, Betty had a sense of autonomy as she was able to take the knowledge and apply it to their own projects.

Conclusion

TH has seen overwhelmingly positive results in research, especially for the older populations, people who are vulnerable and those with mental illness. At this point in time TH is not a suitable alternative to pharmaceutical intervention for mental illnesses, however may act as a supporting factor to decrease symptoms of depression, anxiety and loneliness. Older generations were repeatedly found in research to be the population who benefit the most from participating in TH, with extensive recommendations for aged care facilities to incorporate community gardens with TH programs. The Self-Determination Theory explains why TH aids in increasing social connections and improving overall motivation through increased autonomy, relatedness and competence. With mental illness trending to increase globally, easily accessible interventions such as TH could be a affordable solution which will improve individuals overall life satisfaction.

References

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Ryan, R. M., & Deci, E. L. (2000). Intrinsic and extrinsic motivations: Classic definitions and new directions. Contemporary Educational Psychology, 25(1), 54-67. https://doi.org/10.1006/ceps.1999.1020

Si, A. M. H., Kam, M., & Mok, I. (2020). Horticultural therapy program for people with mental illness: A mixed-method evaluation. International Journal of Environmental Research and Public Health, 17(3). https://doi.org/10.3390/ijerph17030711

Soga, M., Gaston, K. J., & Yamaura, Y. (2017). Gardening is beneficial for health: A meta-analysis. Preventive Medicine Reports, 5, 92-99. https://doi.org/10.1016/j.pmedr.2016.11.007

Stewart, M. (2016). Horticulture therapy workbook: Discovering new ways to enrich nature and garden activities for people of all ages and abilities. Antioch University New England.

Teig, E., Amulya, J., Bardwell, L., Buchenau, M., Marshall, J. A., & Litt, J. S. (2009). Collective efficacy in Denver, Colorado: Strengthening neighborhoods and health through community gardens. Health & Place, 15(4), 1115-1122.

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Wood, C. J., Morton, G., Rossiter, K., Baumber, B., & Bragg, R. E. (2024). A qualitative study of the barriers to commissioning social and therapeutic horticulture in mental health care. BMC Public Health, 24(1), 1197. https://doi.org/10.1186/s12889-024-18621-8

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Zhao, Y., Liu, Y., & Wang, Z. (2022). Effectiveness of horticultural therapy in people with dementia: A quantitative systematic review. Journal of Clinical Nursing, 31(13-14), 1983-1997. https://doi.org/10.1111/jocn.15204

External links

Therapeutic horticulture Australia