Therapeutic Gardens

When I was 16 and my mother was just 39, she was diagnosed with an aggressive form of breast cancer. She lived with the diagnosis and the disease for close to 16 years. Surgical and chemotherapy interventions gave us the gift of those additional years. But in my mind, and I would wager in hers too, strategically deployed gardening interventions also played a major role in her longevity and vibrancy living with the disease at a time when few women with that form of cancer were so blessed.

My mother was flower folk. From early in her life, she gravitated toward plants and as an adult maintained a floral or garden-related career. And we always had a large home garden complete with vegetables, fruit, and—always—flowers.

Mom’s final years were spent in relapse and in rounds of experimental chemotherapy. At that time, my parents lived on the coast of South Carolina; my mother was working in her dream garden by the sea along a tidal marsh. Her three daughters, my father, and my mother’s friends took turns going with her for her weekly chemo appointments.

As anyone who has experienced a chemotherapy protocol knows, the treatments are long, boring, cold, and depressing. And the longer you’ve been in treatment, the more stressful each appointment becomes because you know what is coming—the setup, the needles, the tedium, and the resulting fatigue, nausea, and loss of appetite.

Some people read, some people sleep, and some people chat to get through these appointments. But not my mother. Her instinct was to lean into her garden. As she told me the first time I went to a treatment appointment with her, she “visited gardens.”

Each chemo treatment would find her wandering around her own garden—in her mind and her heart—noting those things that were working well or not, making a to-do list—what to cut back, propagate, plant, or pick up at the nursery. After she got through her own garden, she would visit gardens from her past: her parents’ garden on Long Island, New York, her previous home garden in the mountains of Colorado, her grandparents’ garden in England, her sisters’ gardens, and so forth.

I remember thinking, “That is crazy genius.”

Now, after reading the work of Clare Cooper Marcus, a leading researcher of how gardens in healthcare facilities produce measurable positive effects on our bodies and immune systems, I know my mother’s day-to-day gardening and mental-garden-touring during chemo were important to her overall medical plan. And perhaps, as a result of that, my mother and family got 16 more years of her gardening life.

[pullquote] 90 percent of garden users experienced a positive change of mood after time spent outdoors.[/pullquote]

Gardens as healing or therapeutic prescriptions

In a 2010 Landscape Architecture Magazine article about Cooper Marcus’s work in the expanding field of therapeutic gardens, writer and horticulturist Bill Marken referenced a study she conducted in 1994, which looked at the impact of four hospital gardens from a user’s perspective.

“Among the study’s findings: ‘90 percent of garden users experienced a positive change of mood after time spent outdoors.’ The study added weight to the burgeoning awareness of the shortcomings of contemporary healthcare facilities. As Cooper Marcus wrote, ‘In past centuries, green nature, sunlight and fresh air were seen as essential components of healing in settings ranging from medieval monastic infirmaries…to pavilion-style hospitals, asylums and sanitoria of the 19th and early 20th centuries… From approximately 1950 to 1990, the therapeutic value of access to nature all but disappeared from hospitals in most western countries. High-rise hospitals built in the International Style resembled corporate office buildings.’”

That study led to the publication of Healing Gardens: Therapeutic Benefits and Design Recommendations, (John Wiley & Sons, 1999). Roger S. Ulrich, a pioneering behavioral scientist and professor in the Department of Architecture and the Department of Landscape Architecture and Urban Planning at Texas A&M, was a major contributor to the book. In Marken’s story, Cooper Marcus credited Ulrich for his groundbreaking research that demonstrated the positive benefits of experiencing a garden, including stress reduction and relief from some physical symptoms.

Therapeutic landscapes today

I caught up with Clare Cooper Marcus by phone from her home office in Berkeley last spring to follow up on the advances (and some losses) in the field since her first book on the subject was published in 1999.

Now in her 80s, Cooper Marcus remains involved in the field and passionate about current research on designing the most effective healing gardens for healthcare facilities staff, patients, and visitors. Since she first started working on healing gardens she notes, “There’s been a lot more research about just how these healing garden spaces work, and a lot more implementation by hospitals and other forms of healthcare such as skilled nursing and memory care facilities. Some of it very good, some of it downright terrible.”

In Cooper Marcus’s mind, ongoing evaluation and assessment is crucial to improving and increasing the numbers of gardens in healthcare facilities. In 2014, she collaborated with co-author Naomi A. Sachs, who has a PhD from Texas A&M, on a second book, Therapeutic Landscapes: An Evidence-Based Approach to Designing Healing Gardens and Restorative Outdoor Spaces (Wiley Press, 2014). Although Cooper Marcus and Sachs focus on gardens in healthcare facilities, they are excited about the many implications of the research, case studies, and potential design guidelines for therapeutic gardens in other areas, such as homes, schools, community centers, urban open spaces, places of worship, and more.

Changes in the field

In Marken’s 2010 article, Cooper Marcus stressed that a healing landscape should be welcoming, comfortable, familiar, and filled with plants. She said, “You want a garden, not a plaza,” and she suggested a 7:3 ratio of plants to hardscape.

Since the publication of her first book in 1999, much has happened in terms of building these gardens and post-occupancy evaluations of these spaces. The 2014 book has many more detailed design guidelines to help the landscape architect or garden designer create user-friendly settings. A notable shift in therapeutic landscapes at healthcare facilities over the past 18 years is in the specificity of the language. Cooper Marcus shared with me that today “therapeutic,” rather than “healing,” is the preferred term, in order to not confuse or make claims on the level of medical effectiveness. “Gardens and nature produce powerful and measurable effects on our moods, our bodies’ response systems, our overall resiliency and ability to handle stress and fight disease, but this is complementary to and supportive of medical tools and skills like surgery and pharmacology. We are looking at measurable restorative and therapeutic effects.”

Specific language is used to refer to different categories of healing gardens: “A healing, therapeutic, or restorative garden (used interchangeably throughout the 2014 book) is one that users, whether residents or visitors or staff, experience anyway that they want: to sit, walk, look, listen, talk, meditate, take a nap, explore. Therapeutic benefits are derived from just being in the garden…. In an ‘enabling’ garden, by contrast, activities are led by a professional horticultural therapist (HT), occupational therapist (OT), or physical therapist (PT), or other allied professionals in collaboration with the other clinical staff.”

Evidence-based design 

Another recent shift is the emphasis on “evidence-based design.” In Therapeutic Landscapes Cooper Marcus and Sachs delve into what does and does not work.

Much like her first book, Healing Gardens, Therapeutic Landscapes provides a history of gardens as healing spaces from ancient times to today, and how advocacy for these spaces has grown and then lost ground (literally) to political or economic shifts. The authors discuss design philosophies, processes, and the specific research and needs of different health care settings and populations, including children, cancer patients, dementia patients, mental and behavioral health patients, burn patients, trauma (including returning veterans) patients, hospice patients, and all of their care and support staff.

What becomes clear in Therapeutic Landscapes is that no single ideal of a garden is an effective healing space for all situations. Issues of climate, location, and very importantly, the specific needs of different patient and staff populations can change everything.

“Hospitals and the designers they hire can put in any kind of garden they want, and they can market it as a ‘healing garden’ but that doesn’t mean it will, in fact, produce the restorative effects, or be used or enjoyed by patients,” Cooper Marcus says. Each of these populations has very specific sensitivities and needs. If you are on chemo or some other medical regime producing nausea, you might not find strong fragrance of any kind therapeutic. If you are a trauma patient, noise—or a gardens proximity to loud noises—may counteract any therapeutic benefits of the garden’s plants or aesthetics. If you are frail, or suffer from dementia, the ability to get to and around the garden becomes paramount and any sense of mystery or privacy created by hidden spaces less helpful.

Participatory design process

Perhaps more than anything, it’s the data about the design process that is the most telling. Research about gardens in healthcare settings shows conclusively that the most effective healing gardens are ones in which a participatory design process was used from the outset. “Participatory design is an approach to design that actively involves all stakeholders (e.g., employees, partners, customers, and other end users) in the design process to help ensure that the product designed meets the needs of the users and is usable.” While she notes that a participatory process is more complex, the benefits are significant and costly mistakes can be avoided.

Many aspects of a healing garden will be viewed differently by different users, for instance—being able to find the garden, ease of access and navigation once there, private versus social space, visibility and safety, or quiet versus engaging space. These different perspectives may not be apparent to designers or administrators tasked with creating an aesthetically pleasing space.

In the sections of Therapeutic Landscapes titles “So, How do We Start” and “Key Points for Designers,” the takeaway is to include all stakeholders, ask for their input, and then listen.

In this day and age of patient-centered care, healthcare administrators compete for patient and insurance dollars. One of the great advances in the field of healing garden design and implementation in healthcare facilities is the economic value of effective healing gardens to patients, medical practitioners, and hospitals trying to market their facility to a broad audience. But with limited resources, one of the vulnerabilities of healthcare facility gardens is whether or not they are more of an economic benefit than other facility needs such as parking or a new MRI machine.

In chapter four, “Types and Locations of Therapeutic Landscapes in Healthcare,” different types of gardens are described along with potential advantages and disadvantages to keep in mind. These gardens—large, small, outdoor, indoor—include Extensive Landscaped Grounds, Borrowed Landscapes, Nature and Fitness Trails, Setbacks, Entrance Gardens, Courtyards, Atriums, Plazas, Roof Gardens, and others. One of the main disadvantages of many of these categories is that they are viewed as potential opportunities for future facility expansion.

On the day we spoke, Cooper Marcus had recently learned that a multi-year battle over the Prouty Garden, a 60-year-old endowed garden at Boston Children’s Hospital had been lost and a proposed building expansion would move forward. In late April, the garden was bulldozed, including the removal of a 60-year-old dawn redwood tree. “The Prouty garden was one of the best,” Cooper Marcus said.

Another constant dilemma is how to respond to talk about so-called “healing gardens” that are anything but. “Every facility wants to claim they have a ‘healing garden’—but without widely accepted guidelines, third-party evaluation, and incentives for voluntary compliance, the reality of “healing” gardens can be hit and miss. I would say that about three-quarters of the current gardens designated as healing are, in fact, good or fair. The other one-quarter are not,” Copper Marcus shared.

Hopes

One of Cooper Marcus’s hopes for the future is education—her published works and collaboration with other professionals are guiding lights in this educational field. Another of her hopes is a third-party certification or rating system.

Since 2001, Cooper Marcus has been one of a team of eight healing garden educators who convene annually in Chicago to lead the Chicago Botanic Garden’s Health Care Garden Design Certificate program. The program is aimed at professional designers who want to focus on healthcare. In the eight-day intensive course, students learn about the needs and issues specific to acute care facilities, dementia care, long-term care, children’s hospitals, and horticultural therapy. Final projects put students in teams to redesign a garden for the frail elderly. Each student earns a certificate upon completing the program.

Further resources

Therapeutic Landscapes, an Evidence-based Approach to Designing Healing Gardens and Restorative Outdoor Spaces, by Clare Cooper Marcus and Naomi A. Sachs, 2014, Wiley Press

Therapeutic Landscapes Networks: The resource for gardens and landscapes that promote health and well-being

Chicago Botanic Garden Health Care Garden Design Program

And listen in to Cultivating Place for a discussion about the value of therapeutic gardens between Clare Cooper Marcus and contributor Jennifer Jewell.