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The therapeutic values of plants

Article in Pediatric Rehabilitation · July 2005

DOI: 10.1080/13638490400011140 · Source: PubMed

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Pediatric Rehabilitation, July 2005; 8(3): 235–237
COMMENTARY
The therapeutic values of plants
PAULA DIANE RELF
Virginia Polytechnic Institute and State University, Blacksburg, USA
The article ‘Horticultural therapy: the ‘healing
garden’ and gardening in rehabilitation. Measures at
Danderydd Hospital Rehabilitation Clinic, Sweden’
by Soderstrom et al. in issue 7:4 of Pediatric
Rehabilitation brings together a great deal of existing
information and clearly illustrates the need for more
research and professional publication in this field.
A review of the literature is an integral part of the
understanding of any therapeutic modality and over
the years a number of literature reviews have been
published or made available electronically [1–4].
However, these literature reviews have been broad-
based and comprehensive collections of articles from
many sources that are not easily available to the
general public, thus giving the impression of a wider
body of knowledge than is actually available to
researchers in healthcare. The importance and
advantage of the current article is that the authors
focused primarily on medical databases (AMED,
CINHAL, MEDLINE) and limited their search to
the three terms that should be in common usage in
any articles related to the therapeutic value and uses
of horticulture and gardening: ‘gardening’, ‘healing
garden’ and ‘horticultural therapy’. This choice of
approach by the authors brought into clear focus
the extremely limited information readily available to
members of the medical professions and the need for
high quality, rigorous research that can be published
in peer-reviewed healthcare and medical journals.
Perhaps the greatest hindrance to wider applica-
tion of healing gardens and horticultural therapy in
health care is the lack of documentation of the
efficacy of these techniques utilizing medically
acceptable research methods. As pointed out by
Frumkin [5], for a long time medical practice ‘relied
on some combination of inductive reasoning and
seductive beliefs’. In a similar fashion, practitioners
Correspondence: Diane Relf. Ph.D, H.T.M., Department of Horticulture, Virginia Polytechnic and State University, Blacksburg, VA 24061, USA. E-mail:
pdrelf@vt.edu
Received for publication 26 June 2004. Accepted 2 July 2004.
ISSN 1363–8491 print/ISSN 1464–5270 online 235–237 ß 2005 Taylor & Francis Group Ltd
DOI: 10.1080/13638490400011140
in horticultural therapy and users of healing gardens
tend to write and lecture on their benefits without
research-based documentation on the efficacy, in the
mistaken belief that the benefits and efficacy are so
obvious that further documentation is not required.
However, as Frumkin elaborates regarding medicine,
‘in recent years, more and more treatments have
been subjected to rigorous deductive study. The goal
here is evidence-based medicine’ because ‘those
who pay for health care—employers and insurance
companies in the US, national health care systems in
most other countries, and patients themselves in
some places—don’t want to pay without evidence of
value’. The same applies to the practice of horticul-
tural therapy and implementation of healing gardens;
it will not be paid for by anyone without strong
evidence supporting its efficacy.
Properly designed, randomized controlled trials
can establish the value of an intervention. Exceptions
to this research design have been used effectively in
cases where randomized treatments occurred seren-
dipitously, despite the fact that the variable being
analysed was never part of the original plan of the
treatment. The classic example of this type of post-
treatment analysis taking advantage of years of
clinical data resulting in meaningful research results,
is the study by Ulrich [6], in which he reviewed the
records over a 10-year period of cholecystectomy
patients who were assigned at random to rooms
facing either a stand of deciduous trees or a brown
brick wall, based on room availability. By restricting
his study to matched pairs of males in the hospital
during summer months when the trees were in
foliage, he was able to determine statistically
significantly positive effects of the view of trees. A
more recent study at Johns Hopkins University [7]
used nature scenes and sounds as an intervention
236 Comment
in a randomized control design implemented to
specifically test this variable with similar results.
Another factor in the field of people-plant inter-
actions that needs clarifying is an international
consensus on the meaning of terms used within
the overall subject area of the therapeutic role of
gardens and gardening in health care. Among the
terms in common usage, there are many terms
describing the various levels of interactions between
plants and gardens, the patient and other individuals
within the health care community. I propose the
following as a starting point for an understanding
of different terms:
. Mediation gardens and restoration gardens are terms
often applied to public and private gardens that are
not affiliated with healthcare but designed with the
idea that the users would experience an exceptional
level of mental and/or physical enhancement due
to experiencing a period of time as a visitor in the
garden. The Kaplans’ studies of the restorative value
of trees in communities and public parks underlie
much of the knowledge of restorative gardens.
. Healing garden is a term more frequently applied to
a garden at a healthcare facility that is intended for
use by staff, visitors and clients at their discretion,
rather than as a part of a treatment plan. Although
often designed and cared for by professionals,
research has indicated that these types of gardens
are more effective in creating a restoration effect if
the various users are directly involved in all aspects
of the design, installation and maintenance of the
garden.
. Therapeutic garden describes a garden that is used as
part of a treatment programme by various mem-
bers of the medical staff. For example, it may
include walkways and steps or grassed raised beds
to use as outdoor exercise mats designed with the
Physical Therapist (PT) as an outdoor PT room.
. Wandering gardens are a specific example of a
therapeutic garden designed for Alzheimer patients
to help reduce symptoms associated with the
disease. These types of gardens are frequently
designed and maintained by professionals in the
landscape industry rather than by the medical
professionals or patients.
. Horticultural therapy gardens are designed specif-
ically for the use of patients for the care and cultiva-
tion of plants as part of a treatment programme.
The goals of the programme vary from one facility
to another and address physical, emotional, social
or intellectual needs of the patient. The goal may
be as simple as ‘having fun’, something very
difficult for a large number of people in treatment,
but certainly healing.
. Horticultural therapy is a treatment modality used
by many different professionals as a part of their
overall treatment regime. To be considered as truly
horticultural therapy, a programme must have
three elements: a client in treatment for a defined
problem, a goal the client is trying to achieve and
the responsibility by the client for the care of living
plants.
It should be noted that the same garden might
serve all four functions, but would need to be
designed with special consideration. The garden
may be open to the general public for restoration, but
this use should not interfere with the use by staff or
family members at the healthcare facility who may
need privacy for grieving or for intimate talks with
loved ones who are using the garden as a truly healing
space. Patients who are participating in treatment
with therapists may not be comfortable to have the
public watch them utilize the therapeutic elements of
the garden as they learn to walk again. Similarly, if
the horticultural therapy garden is public in nature
there may be a strong temptation on the part of the
staff to assume responsibility for the life of the plant
from the patient in order to keep the garden ‘looking
nice’ for the public. This, of course, eliminates the
therapeutic benefit to the patient of the nurturing of
the garden. In effect, it turns the horticultural
therapy garden back into a healing landscape with
very different goals and effects.
The second part of the article will prove useful to
those interested in establishing similar hospital
gardens. The authors’ work will help readers to
understand the evolution of their garden, the design
of the tools that they use, the methods of cultivation
and the participants in the programme, as well as the
therapeutic and educational uses of the garden.
Although the greatest need for successful develop-
ment of horticultural therapy as a professional field
is rigorous research, the importance of sharing
programming and design information cannot be
emphasized too much. Successful implementation
of a programme is dependent on understanding
the best techniques and tools to use, as well as the
optimum goals for various populations of individuals
in treatment. Being able to review the programmes of
others greatly facilitates this process. In addition, the
explanation of the goals of the programme serve as an
excellent starting point for the design of research
studies to test the efficacy of the activity in
accomplishing its intended goal.
In their discussion section, the authors reach
conclusions that indicate that the current research
is beginning to provide an evidence base that
supports early models proposed for understanding
the areas of impact of horticultural therapy [8] and
the mechanism by which horticultural therapy brings
about change [9]. These conclusions provide strong
evidence for the need for expanding and enhancing

the theoretical models used as the basis for research
and programme implementation in this field. In the
earlier paper on mechanisms [9], it was proposed
that the benefits of horticulture were based on three
factors: Interaction, Action and Reaction. In this
early model, the Interaction was seen as the social
exchanges that occurred as a result of work with and
around plants. The Action was the physical, emo-
tional and mental commitment to the care of the
living plant. The Reaction was the response to plants,
either through a window or in closer proximity by
walking in a garden or park. Currently, the greatest
amount of research has focused on reaction to plants
either as live material or simulations such as pictures,
slides or video. This area of Reaction in the Relf
paper encompasses the first three areas in the current
paper (i.e. virtual or representational elements,
viewing through a window or visiting a garden). It
is important to recognize that researchers, such as
Ulrich and the Kaplans, have indicated that, while
they use pictures as representations of nature as a
research tool, they are not advocating this as an
option for restorations or treatment in place of live
plants outside of the research setting. The current
authors do not identify social interactions as one of
the intervention approaches associated with the
research. This fact indicates a need for further
research in this area or a modification of the early
theory. Similarly, the paper by Hefley (Relf )
identified the four effects or benefits as emotional,
physical, intellectual and social, parallelling the
findings of the current authors and indicating a
structure for future research.
View publication stats
Comment 237
The authors are to be complimented for the
compilation of this information through their work.
They are now in a position to contribute significant
valuable knowledge to the field of horticultural
therapy through rigorous deductive studies at their
facility. The ‘evidence-based’ findings that they can
produce through the well-designed, randomized
controlled research that they are in a position to
implement will be of international significance. I look
forward to the opportunity to continue to read of
their progress.
References
1. Markee KM, Janick J. A bibliography for horticultural therapy
(1970–1978): comparison of literature search techniques in
an interdisciplinary field. HortScience 1979;6:692–696.
2. Relf D, Dorn S. Horticulture: meeting the needs of special
populations. HortTechnology 1995;2:94–104.
3. People Plant Council. Annotated bibliography of horticultural
therapy (Blacksburg, VA: Virgina Tech), 1993.
4. Sempik J, Aldridge J, Becker S. Social and therapeutic
horticulture: evidence and messages from research
(Leicestershire, UK: Thrive), 2003.
5. Frumkin H. White coats, green plants: clinical epidemiology
meets horticulture. Acta Horticulturae 2004;639:15–27.
6. Uirich R. View through a window may influence recovery
from surgery. Science 1984;224:420–421.
7. Diette G, Haponik E, Rubin H. Distraction therapy with
nature sights and sounds reduces pain during flexible
bronchoscopy. Chest 2003;3:941–948.
8. Hefley (Relf) D. Horticulture: a therapeutic tool. Journal of
Rehabilitation 1973;1:27–29.
9. Relf D. Dynamics of horticultural therapy. Rehabilitation
Literature 1981;5–6:147–150.