green care and mental health: gardening and farming as...

Mental Health and Social Inclusion • Volume 14 Issue 3 • August 2010 © Pier Professional Ltd 15

10.5042/mhsi.2010.0440

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

A brief historyBoth 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

Green care and mental health: gardening and farming as health and social care

HORTICULTURAL THERAPY

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

Working together at Care Co-ops, Brighton

Mental Health and Social Inclusion • Volume 14 Issue 3 • August 2010 © Pier Professional Ltd16


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 (Kinross-

Wright, 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 paradigmsOne of the first structured approaches using nature

as therapy was ‘horticultural therapy’. This can

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.

Sowing the seeds at Redhall Walled Garden, Edinburgh



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

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

Working together at Thrive’s Trunkwell Garden Project



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, self-

confidence 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.

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 horticultureSocial 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

Instructing volunteers at Unstone Grange, Derbyshire: using tools can be empowering



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 effectivenessSempik 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 self-

awareness and consequently ‘underpinned their sense

of meaningful occupation and well-being’ (Fieldhouse,

2003, p286). Similar results were obtained by Perrins-

Margalis 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.



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).

FundingWhile 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

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



their participation in a variety of activities that

promotes their inclusion within their community

and within society.

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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



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care in England to 2026. London: The King’s Fund.

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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 [email protected]. If you have any photographs or documents relating to

the farms and gardens they would be very welcome. All original material will be returned.

green care and mental health: gardening and farming as...

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