PEDIATRIC REHABILITATION, 2004, VOL. 7, NO. 4, 245–260

Horticultural therapy: the ‘healing garden’and gardening in rehabilitation measuresat Danderyd Hospital RehabilitationClinic, Sweden

INGRID SODERBACK, MARIANNE SODERSTROMand ELISABETH SCHALANDER

Accepted for publication: 15 January 2004

Keywords Garden, gardening, healing, neurological diseases,occupational therapy

Summary

Objectives: Objectives were to review the literature onhorticultural therapy and describe the Danderyd HospitalHorticultural Therapy Garden and its associated horticulturaltherapy programme.Design: The literature review is based on the search words

‘gardening’, ‘healing garden’ and ‘horticultural therapy’. Thedescription is based on the second author’s personal knowl-edge and popular-scientific articles initiated by her. Thematerial has been integrated with acknowledged occupationaltherapy literature.Setting: The setting was the Danderyd Hospital

Rehabilitation Clinic, Sweden, Horticultural Therapy Garden.Participants: Forty-six patients with brain damage partici-

pated in group horticultural therapy.Results: Horticulture therapy included the following forms:

imagining nature, viewing nature, visiting a hospital healinggarden and, most important, actual gardening. It was expectedto influence healing, alleviate stress, increase well-being andpromote participation in social life and re-employment for

people with mental or physical illness. The HorticulturalTherapy Garden was described regarding the design of theoutdoor environment, adaptations of garden tools, cultivationmethods and plant material. This therapy programme formediating mental healing, recreation, social interaction,sensory stimulation, cognitive re-organization and trainingof sensory motor function is outlined and pre-vocational skillsand the teaching of ergonomical body positions are assessed.Conclusion: This study gives a broad historic survey and

a systematic description of horticultural therapy with empha-sis on its use in rehabilitation following brain damage.Horticulture therapy mediates emotional, cognitive and/orsensory motor functional improvement, increased social parti-cipation, health, well-being and life satisfaction. However, theeffectiveness, especially of the interacting and acting forms,needs investigation.

Introduction

The value of horticulture therapy is witnessed by thefact that, for their very survival, humans have soughtaspects of nature such as open views, closeness to waterand a place of refuge over the past 40 000 years at least.Horticultural therapy includes interventions mediatedby nature-oriented views and spaces such as gardensand everything associated with them, the plantsand material related to them, garden tools and gardenoccupations performed among disabled people [1–3]for healing and for restoring or improving health andwell-being or for rehabilitation or simply for generalbenefit.

The benefits of using horticulture therapy are that(a) patients may be able to continue the occupationsat home using adaptations learned during therapy ses-sions at a hospital; and (b) such therapeutic sessions are

Pediatric Rehabilitation ISSN 1363–8491 print/ISSN 1464–5270 online # 2004 Taylor & Francis Ltdhttp://www.tandf.co.uk/journals

DOI: 10.1080/13638490410001711416

Authors: Ingrid Soderback (author for correspondence;e-mail: ingrid_soderback@pubcare.uu.se), Dr Med Sci,Occupational Therapist/Licensed, University Lecturer,Responsible Scientific Leader, Department of Public Healthand Caring Science, Uppsala University, Sweden; MarianneSoderstrom, Head occupational therapist, Project Leader,Rehabilitation Clinic, Danderyd Hospital, 182 88 Danderyd,Sweden (died February 2004); Elisabeth Schalander,Occupational Therapist/Licensed, Specialist in Horticulturetherapy, Rehabilitation Clinic, Danderyd Hospital andAcademeia Garden: Inspiration and Design, Akersberga,Sweden.

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easy to vary and adapt to individual’s ability to performthe activities.A hospital healing garden or therapeutic garden is

a nature-oriented space, indoors or outdoors, with atherapeutic or rehabilitative potential [4]. It is a placeof sanctuary where the basic urge for contact withnature can be met [5]. A healing garden seeks to providemaximum influence on health. It should be designedwith a plentiful variety of plant materials that flowerin different seasons, attract birds and butterflies, withleaves or grass that move with a light breeze, pools thatreflect the sky and provide a home for fish. Sculpturesand other designs should be unambiguously positive.The design should facilitate visibility (the garden shouldinvite one to visit it), security and physical comfort. Thegarden should be open to all and give a sense offamiliarity. It should be calm and quiet so that its voices(water-splash, birdsong) can be heard [6]. Optimallydesigned, the gardens facilitate non-discrimination ofthe participants’ age, genus, class, previous occupation,cultural heritage or ethnicity. In addition, at its best,the gardening facilitates social interaction in termsof previous experience of gardens and gardening or ofdisablement. This may provide a common subject fordiscussion and may help participants to find newfriends.A further justification for healing gardens is that the

quality of a hospital’s physical environment affectspatients’ medical outcomes and care quality [7]. In theUSA, for example, paediatric and long-stay hospitalsare expected to have access to grounds, parks andplaygrounds and adjacent countryside [6, 8].A healing hospital garden involves patients, friends,

relatives and staff participating in, for example,planning plant-beds, sowing, tending and watering theplants, harvesting, communicating, etc.The literature shows that therapeutic gardening has

been used for (a) changing mood positively [e.g., 6, 9],(b) influencing health and well-being by viewing photo-graphs, slides, videos of outdoor nature and gardenscenes [e.g., 10, 11] and (c) reaching solace or relief byenvisaging natural scenes of grass, trees, water, sky,rocks, flowers, and so on [7, 12, 13].The general objective of this study was to examine

the rarely-documented descriptions of how gardeningmediates health, well-being and function among peoplesuffering from neurological [14–17] or musculoskeletaldiseases.More specific aims were (a) to briefly review historic

aspects of horticultural therapy and its use amongdisabled people for care or rehabilitation and (b) todescribe hospital therapeutic (healing) garden design

and to summarize experience of its use and of gardening

among patients with neurological and/or musculoskele-

tal diseases from 1983 to the present, with emphasis

on horticultural therapy at Danderyd Hospital

Rehabilitation Clinic.

Method

For the review part of this study, literature searches

were performed in the Allied and Complimentary

Medicine (AMED) [18] database, the Cumulative

Index to Nursing & Allied Health Literature�

(CINHAL) [19] database, in MEDLINE [20] and

among Internet information from the American

Horticulture Therapy Association [21] and the ‘Lucas’

library of the Swedish Agricultural University, Alnarp

[22]. The search words ‘gardening’, ‘healing garden’ and

‘horticulture therapy’ were used. The CINAHL search

resulted in 87 hits for ‘gardening’. These hits were

restarted by the search words ‘gardening or horticul-

ture’, resulting in 21 hits. A primary selection suiting

the present study subject from the two searches gave 39

articles. The MEDLINE search added one relevant hit,

while the AMED search gave 324 hits for ‘gardening’.

The searches were then restricted to publications after

1990, giving an additional 20 Hits. Only five more pub-

lications were found, most information overlapping

with the CINAHL database. The search in the

American Horticulture Therapy Association gave 52

hits, of which 15 were judged to suit the present subject.

Four hits were added from the ‘Lucas’ search. The arti-

cles finally used are marked in the reference list with an

*. The references from selected literature judged as most

important were further scrutinized, forming a selection

of the most cited literature and authors.

The description of the Danderyd Hospital Rehabili-

tation Clinic horticultural therapy measures is based

mainly on the second author’s (MS) clinical experience

as initiator of horticultural therapy in rehabilitation in

Sweden. Her oral information was supplemented

by popular-scientific publications in Swedish [23–28],

originating from her instructs, plus candidate’s theses

[e.g., 29] and master’s theses [e.g., 30] published between

1989–2000. A short version of the present report was

presented during the Brain Injury Conference in

Stockholm, Sweden, in May 2003 and an abstract was

published [31].

Retrospective data from the medical records of the

Danderyd Hospital Rehabilitation Clinic were used to

describe the horticultural therapy gardening groups.

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Results

literature review

The origins of the healing garden and gardening

The use of the natural environment has variedthrough the centuries and reflected each culture’s beliefsand values. Nature, the green landscape, sunlight andfresh air were from the latter 17th century until themiddle of the 20th century an essential component ofthe healing process in various hospital settings, such assanatorium parks [6, 32, 33].

Mental-hospital aspects of the healinggarden and gardening

Starting with the idea that visiting nature and gardensfor sitting, working and talking about the worldbeneficially influences people’s health, gardening wasa prescribed intervention in mental hospitals from theearly 20th century [24, 33]. The notion originated fromthe Moral Treatment Movement [34]. Patients withmental illness were scheduled to perform occupationssuch as sewing, weaving and woodwork. Being occupiedwas supposed to promote patients’ establishment ofconcepts of time, work and cultural value. Moreover,such occupation was expected to control inactivity andanxiety [34]. The American psychiatrist and neurobiol-ogist Adolf Mayer stated that ‘man learns to organizetime and he does it in terms of doing things’ [34, 35].Performance of these occupations resulted in mentalhospitals becoming self-sufficient communities.As the concept of humanism permeated to German

psychiatric care in the 1920s, this idea of supplyingpatients with occupation spread over the industrialworld. On the premises of mental hospitals, largeparks and vegetable and flower gardens were createdand maintained by the patients, gardening beingperformed by the patients with a disturbed sense oftime and reality. The patients did necessary daily gardenwork such as digging, sowing, weeding, harvesting, etc.There existed the empirical experience that gardenwork helped patients to feel the rhythm of each dayand understand how the garden and gardening shiftedduring the seasons. This idea was adopted in Swedishmental hospitals during the 1940s [32].The notion that the mentally-ill could become organ-

ized by doing gardening was more or less abandonedbetween 1960–1980. A closeness to nature was lostand participation in the natural cycle and absolutehuman dependence on nature was obscured. Further,as psychopharmacology entered mental hospitals,

therapeutic effects on patients were achieved withoutoutdoor activities. Patient labour was no longer con-sidered necessary or desirable. Food was prepared inlarge central kitchens, so that patients no longer parti-cipated in the handling of natural raw ingredients fromthe garden. Finally, the institutional mental hospitalsettings were dismantled. The beautiful hospital parksand gardens became mostly a memory, although someparks still exist to provide recreation [32].

However, the idea that environmental design affectsmedical outcomes has been regaining popularity, sincethe 1960s [7, 36].

Rehabilitative aspects of the healinggarden and gardening

In the 1950s, after the two World Wars, the returnhome of mentally and physically wounded soldiersincreased the demand for rehabilitation. A more activeform of medical rehabilitation started to evolve.Rehabilitative centres began to use elements of natureas therapy in physical, occupational and speech pro-grammes [32]. The therapeutic value of gardening andits place in a rehabilitation plan were described in 1957[37, ibid. 38].

In England in the mid-1960s, hospital gardens werecreated for teaching purposes and were used by organi-zations for advisory services, and for demonstratingthe adaptation of gardening tools [39] and how agood garden design should be accessible to peoplewith disabilities [40]. Interestingly, these services cannowadays be incorporated in an interactive multimedialearning environment, e.g. using the ‘Greenhat DesignGuidelines’ which seek to mediate social interaction andemployment-related skills [41].

The hospital gardens in Oxford and Northwood,Middlesex, were designed for research into the feasibil-ity of using gardening for rehabilitation for ambulant,but crutch-dependent, patients or wheelchair users [40].

The therapeutic garden at Mary Marlborough Lodge,England was used by 5–12 year-old disabled childrenwho were wheelchair users or born with congenitalupper-limb malformations. The garden was initiallyintended for relaxation therapy, but soon became avery suitable hobby area for these children and usedfor training in the use of their prostheses [42].

In the 1970s, in England, the view that gardeningmediates rehabilitative intervention was expandedfor use among patients with rheumatoid arthritis forexample or following hand surgery. Particularly forpatients with hemiplegia, garden tools were adaptedfor use with one hand [17]. Gardening was expanded

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to indoor activities and a choice of suitable plants wasdescribed [43]. During the 1971 Chelsea Flower Show,the garden accessible for handicapped people was aprominent theme [32]. In 1973, in the USA, horticulturewas an accepted part of rehabilitation through theNational Council for Therapy and Rehabilitation [38].Studies during the 1970s seem mainly to describe the

garden design to facilitate patients’ increasing participa-tion in gardening and maintenance of interest inthe activity. However, gardening was now not only apracticable occupation, but also related to therapy. Thetherapeutic use of gardening was expanded to embracean activity in which patients could engage [44] and aform of relaxation therapy. Kaplan [ibid. 38, 45], in1972, made a scientific psychological analysis of thebenefits of participating in gardening. The experienceof plants growing gave the participant satisfaction andmaintained interest in gardening. The analysis wasbased on the statement that ‘humans need a comfort-able and stimulating environment to visit’ [38, 45].Moreover, gardening was adopted in nursing homesfor geriatric patients with decrepitude. In 1979, oneof the first more regular scientific evaluations ofhorticultural therapy was conducted. This was adirect-observation (n¼ 29 experimental group), experi-mental evaluation study of non-engagement or engage-ment in indoor gardening among 32 physically impairedresidents of a nursing home, with a mean age of 81years. The study outcomes were engagement accountedfor in terms of performing daily living activities or usingrecreational material or getting around or interactingwith other residents. Those residents who participatedin weekly gardening sessions were engaged more than90% of the observed time, while non-participating resi-dents were engaged less than 40% of the observedtime. It might be concluded that doing gardeningoverflowed into social and occupational engagementin daily activities among older residents [44].In the 1980s, the value of gardening as therapy was

expanded to include programmes for re-employmentamong people with disabilities. Relf [ibid. 38, 46, 47]emphasized ‘the potential benefits in self-concept, socialinteraction, work habits, academic-skill development,and physical abilities among handicapped individuals’who participated in a horticultural pre- or vocationaltraining programme. In the same spirit, the purposesof gardening were discussed for use in occupationaltherapy. Here, gardening was advocated as a toolfor observing and assessing the patients’ employmentabilities. The people were asked to do garden tasksthat required physical activity such as climbing steps,slopes, walking or otherwise transporting themselves

on various surfaces, bending, lifting and carrying andhandling garden material. The therapeutic approach tousing gardening was also suggested for functionalmotor improvement of limbs. Finally, gardeningwas a rehabilitation-supported activity for patientswith disabilities seeking new recreational hobbies afterdischarge or a way of enabling them to achieve greaterself sufficiency [48]. The first Swedish healing gardenwas created at Danderyd Hospital RehabilitationClinic.

The term horticultural therapy became common inthe health sciences during the 1980s and all forms ofactivity connected with nature, e.g. viewing photoswith natural scenes [12] or visiting (healing) gardens,were included in the therapy sessions. The philosophywas based on the evolutionary belief that human sur-vival and ability to thrive and gain fulfilment dependupon one’s relationship with nature. This—the biophiliaframework—created by the biologist E. O. Wilson [49]mentions ‘the innately emotional affiliation of humanbeings to other living organisms’ [ibid. 50]. Severalscientists have adopted the biophilia theory for demon-strating human [51] interaction with the environment.

As one example, physiological reactions to thecreative and less creative environment were studied for6months among elderly people in a service home. Theexperimental group studied gardening during the winterand practiced it during summer. Coping and signs ofself-esteem improved significantly among the experi-mental group [10, 11].

Another example was people suffering fromAlzheimer’s disease who had access to a healing gardendesigned according to the Environment-Behaviourcriteria, that is to give a sense of nature, weatherand plants, reducing fear and promoting security. Theresidents enjoyed being outdoors and a relaxing effect onhealth and wellbeing was observed in terms of decreasedanxiety and aggression [9]. The outcome of horticultureas a recreation appeared to have beneficial effects onwellbeing [12, 52].

The use of horticultural therapy for children withvarious impairments was extensively described in the1980s. The therapy was used in a transitional employ-ment programme for adolescents with developmentaldisabilities [1] or for children with exceptional [53],cerebral-palsy [54] or behavioural disorders [55]. Atherapeutic gardening programme for children hospital-ized with behavioural disorder emphasized both adiscussion group and an active performing group.Obese children did gardening (cultivating, planting,maintenance and harvesting) for 30–45minutes perday during a summer with the aim of increasing their

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physical activity [56]. The pre-school children’s involve-

ment in plant-stimulated discovery activities [57, 58]

was considered. Williams and Mattson [59] showed,

during a 5-month study, that children participating in

a professionally supervised gardening programme

increased their self-esteem and horticultural knowledge

and that the garden looked better than that tended by

unsupervised participants.

In the 1990s, the trend was [60, 61] to bring nature

back into urban environments. Landscape architects

promoted the building of parks and public gardens,

lined streets with trees and created indoor environments

using plants, flowers and water effects [62]. Aesthetic

hospital environments were promoted [63]. The

purposes were to facilitate life in a healthy and recrea-

tional environment, helping people to recover from

unhealthy stress [64]. Thus, the research focused on

the interaction between the natural environment and

human health [5, 36]. The meaning that green

areas and urban parks connected to institutions and

playgrounds has for children and adults was observed.

People with access to this kind of facility spent more

time outdoors, increased their concentration and slept

better than these without this possibility [65, 66].

Theoretical explanations of why people in a nature

environment experience relief of stress release and

healing were further developed, enriched, debated and

tested during the 1990s. Relf [67] states that the positive

emotional effect of participation in nature or a nature-

related environment was explained by several underpin-

ning theories, as follows:

(a) Kaplan’s [68] ‘evolutionary theory’ states that:

‘visual patterns of the natural environment are

easiest to interpret because a human uses his

involuntary attention’. This form of attention is

preferable and may release negative stress. This

assumption is explained by the brain’s pre-

programmed preparedness to sort out different

stimuli in a natural environment, where man

was originally meant to live. The opposite is

directed attention, which occurs when humans

are bombarded by information from the urban,

artificial, environment which has to be sorted

out. This attention requires much energy leading

to overloading and negative stress, i.e. easy dis-

traction, difficulties in planning and implementing

and to feelings of impatience and irritability [33].

Kaplans’ theory shows that natural environments

have a positive influence on the participants’

ability to concentrate.

(b) Ulrich et al.’s [13] ‘psycho-evolutionary theory’states that: ‘humans have long adapted positivelyto nature for survival and therefore react withpositive emotional physiological responses when

in natural or nature-related environments whichinfluence intellect, meaning and behaviour’(present author’s translation). This theory has

been proved acceptable through several studies[12, 13, 52, 69, 70].

(c) According to Relf’s [67] ‘cultural learning theory’,

‘a human adapts to the natural environment wherehe or she developed, and which led to a preferencefor familiar trees and flowers’. This statement con-tributed to the formulation of the theory of ‘the

living environment’ [65]. This theory prompted thesuggestion that environments should be created tofacilitate memories of competence and experience

among people with dementia. Noteworthy is thestudy by Ottosson [16]. He himself suffered frombrain damage which caused aphasia (inability to

read and write), spatial dysgnosia (difficulties inorientation in the near environment) and lack ofcontrol over life. Using an introspective self-studymethod he investigated the importance of visiting

nature, which influenced all his senses, gave himfeelings of well-being and helped him to overcomehis life-crisis.

Originating with Smith [71], the idea of usinghorticultural therapy as a stress management pro-

gramme for emotional relief was transferred to rehabili-tation programmes in Sweden for people suffering fromburnout [72].

The restorative value of participation in nature was

examined with the keywords; (a) being away—from an

urban stressful environment to spend time in natural

surroundings, (b) extent—the environment absorbs

humans mentally and physically and, therefore, the

environment visited should include some new things

to explore and discover, (c) fascinating—the environ-

ment should include stimuli that fascinate the visitor

and encourage attention and concentration, and

(d) compatibility—the environment meets the

individual’s goal [33, 67, 73].

Research also emphasized the design of a healing

garden [74–76] and the concept of horticulture therapy

was scientifically evaluated according to theory. It has

been recommended that the physical design of a healing

garden should be according to the ‘theory of supportive

health care design’ [69]. This theory stresses the environ-

mental characteristics that support or facilitate coping

and restoration following illness and hospitalization.

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A supportive health care physical environment should

facilitate privacy, promote social support and natural

distractions, give opportunities for physical movement

and provide involvement with nature. Patients’ out-

come in terms of health and wellbeing has been proved

to be positively influenced if they can see or have access

to natural surroundings (trees, flowers and water) or

regularly spend time in healing hospital therapeutic

gardens [65, 69]. Further research results show a very

high likelihood of reduced stress and anxiety, improve-

ment of patient satisfaction, a high likelihood of

sleep improvement and a moderate likelihood of pain

reduction and infection occurrence [6, 7, 11, 70]. The

emotional healing effect of horticultural therapy was

further investigated by Barnes [64]. Even a low degree

of ‘passive’ participation in the nature environment may

influence emotional restoration [64].

Moreover, horticultural therapy is world-wide [77]

in varying health care and hospital settings, for

example acute care [4] and hospice care [78], and is

being extensively studied among adults with visual dis-

abilities [79], elderly people with diagnosed dementia

[80, 81] and people with autism [82] or sensory

deficits [83].

From 2000 until the present (2004), the same trends

in horticultural therapy continue. How hospital healing

(therapeutic) gardens should be designed has been

further investigated [7, 70]. Whether or not participants

are disabled (e.g. frail elderly people [84] or AIDS suf-

ferers [85]), their perception of experience [86] and

meaning [51, 87, 88] in terms of health benefits [89,

90], wellbeing [91], reduced stress [92, 93] or improved

quality of life [94] are described. Studies of horticultural

therapy for people with neurological diseases are still

rare [14–16]. However, Sarno and Chambers [15] have

outlined a horticultural therapy programme for individ-

uals with aphasia.

In Sweden, in day nursery homes and primary

schools, children with physical disabilities (walking

with sticks, wheelchair users, the visually impaired)

or mental retardation are integrated with ‘normal’

children. This raises issues of legitimate claims upon

accessible playgrounds and school yards [95]. An out-

door pathway in a wood passing through a whale, a

pergola and a dinosaur bridge have been laid out

in connection with Bracke Ostergard, a children’s

hospital in Goteborg, Sweden. Here the children

can drive their PermobileTM (electric wheelchairs)

themselves because a light-beam sensor under the

wheelchair corresponds to a reflector at the edge of

the pathway [96].

the healing hospital garden and the use of

horticultural therapy at danderyd hospital

rehabilitation clinic

Background

Organized by the occupational therapy department ofthe Rehabilitation Clinic, Danderyd Hospital, the firstSwedish Horticulture Therapeutic Garden (DHHTG)was opened in 1986. The DHHTG was designedfor patients with physical disabilities, mainly followingcognitive and/or musculoskeletal impairments. Thisgarden and its associated activities constituted a supple-mentary activity among others of daily life and handi-craft which mediated the patients’ rehabilitation.

Purposes of the DHHTG

The purposes of the DHHTG concept were(a) therapeutic; as a meeting point for relaxation, reliefand rehabilitation and (b) for training team membersin horticultural therapy.

Several requirements for use of the garden were:

. accessible for visiting and gardening apart fromdisability,

. adaptation of garden tools for use among patients,

. visitors offered a non-demanding, calm and silentnatural environment,

. gardening as a leisure activity preserved orencouraged as a new leisure interest with the inten-tion of being continued after discharge,

. gardening mediating occupational therapy, and

. as a centre for education in concept of healingtherapeutic garden [25, 28, 97] for, among others,patients and rehabilitation teams in Sweden.

Design of the DHHTG

Landscape architect Gustav Alm designed theDHHTG as a result of close team work with therelevant staff of the Danderyd Hospital RehabilitationClinic. The DHHTG has been improved over the yearsin step with increased experience of horticulturaltherapy. The DHHTG is situated in a north–southorientation between two blocks of Danderyd Hospital.It measures 20� 30metres (figure 1).

The garden has extensive access to sunlight and issheltered from severe winds. The ground is accessiblefor wheelchair users and for people using walking aids,according to the principles that (a) all differences inlevels are avoided or clearly marked and with guide-rails, (b) the walkways are paved with concrete slabs

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Figure 1 The Danderyd Hospital Horticultural Therapy Garden (DHHTG). A—H are plant-grounds with various heights; A¼ ground level,B¼ variable level 20–75 cm, C¼ 68 cm, D¼ 60 cm, E¼ 40 cm, G¼ 85 cm, H¼ 70 cm, I¼water pond with a waterfall, J¼ a garden tool shed,K¼ 15m2 greenhouse and L¼water reservoir.

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and are slightly inclined to avoid slippery surfaces,(c) there is enough space between the plant beds toallow two wheelchairs to meet easily.In one corner of the garden is a long, 108-square-foot

tool-shed with a sedum covered roof and two compostbins. The tool-sheds are well stocked with gardeningtools and other material. The placing of each tool ismarked with symbols, for easy finding and replacement,and at a height reachable by all users. The hooks forhanging the tools on are designed for ease of handling.Another part of the garden is screened off by a

robust, 2metre-high, 6metre long trellis, serving as anaid to standing. A 160-square-foot round greenhouseallows cultivation experiments protected from theNordic climate. A pond and a waterfall heighten thenatural impression. Nearby garden furniture invitesone to relax, calm down and be sociable. A bouletrack encourages activity.The bedding areas and flowerbeds have five different

working heights allowing various working positions(e.g. standing up, bending or sitting). The highest bed-ding areas are tables, which a wheelchair user can drivebeneath and round. A wooden bench for sitting andresting and for putting material down on surroundsthe larger bedding areas. There is an electric point onthe shed wall. Watering is performed from a tap on theshed or from a covered water tank with a tap [28].

Design of gardening tools for the DHHTG

Ergonomically [98], the DHHTG seeks (a) to use themost ergonomical garden tools for the various elements:digging, cultivating, sowing, planting, watering, raking,loosening or breaking up weeds, trimming or cutting,cutting faded or fresh flowers and vegetables, mowinggrass, moving garden material, tools and oneself about,covering new plants [25] and (b) the most appropriateergonomical body positions.Most DHHTG garden tools (the plant/beds out, try or

tables, mini-garden-house-boxes; watering cans, varioustypes of spade, rake, pitchfork, pruning shears, wheel-barrow, carts or baskets and/or aprons with big pocketsfor tools and material and for protection gloves) wereavailable on the market. However, the selections werebased on principles of occupational-therapy ergonomics[98] and adapted for use among patients with neuromus-culoskeletal and movement-related impairments.The ergonomics included the principles that [24, 28]:

(a) all tools were as light as possible (figure 2a),(b) tools with separate handles are used to facilitate

the adaptation of exchangeable handles. This

allows adaptation to the individual patient’s needfor purposeful training (figure 2b),

(c) the tool allows optimal biomechanical body posi-tions (e.g. suitable handle lengths for sitting orstanding working positions) (figure 2c),

(d) the design permits the lowest possible workload(e.g. less muscle strength is required when bothhands and one foot are used for making holes inhard earth and with a curved rake handle) (figure2d),

(e) the tools useable with a two-hand-grip by peoplewith a weak or paretic arm and hand (figure 2e),

(f) the angle between the tool head, e.g. spade andhandle allows optimal work functions—a neutralbody position in the forearm when gripping (figure2f), and

(g) wooden tool-handles designed to suit various gripfunctions and functional use and in neutral handpositions (figure 2g).

Cultivating in the DHHTG

Different methods and materials are used forcultivating, where possible at different heights andreachable from some distance. Examples are (a) theuse of raised cultivation beds, (b) movable mini-hot-houses and hot-beds, (c) square-foot cultivation inframes or (d) cultivation directly in a sack at groundlevel near the trellis, (e) in a box, (f) in pots arrangedin a rotation system or (g) in a hanging pipe orbasket [28].

Seeds for the DHHTG

Seeds and plants were chosen to reflect the varioustherapeutic approaches described in table 1.

Participants in and organization of DHHTG gardening

Participants. The patients, aged 18–65 years, takingpart in the Danderyd hospital horticultural therapyrehabilitation suffered from pain- or movement-relatedimpairments (hemiparesis or paraplegia) and/or cogni-tive (speaking, reading spatial orientation, memorydysfunction, attention, concentration and logicalreasoning difficulties) and/or were depressed. Disabil-ities ranged from major to minor insufficiency. Thus,some patients were wheelchair users, but others had amajor memory disability with no movement-relateddisability. Patients’ families and friends and staff werealso welcome to participate.

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Organization. The patients gardened as one of severalself-chosen activities during the sessions. These wereorganized in groups whose composition changed atintervals during the term. The organization andparticipants are shown in table 2. From February tomid-November 2003, 72 patients (23men) sufferingfrom brain damage (e.g. stroke, haemorrhage, braintrauma), aged 18–65 years, participated in one ofthree gardening groups. Each patient participated as agroup member, but was prescribed individual garden-ing work: his or her ‘therapeutic tonic’. Thisindividual work was intended to be done at othertimes than the group meetings.

All the gardening tasks were performed in a neutral

way. They were graded from easiest to most difficult.

For example, the patient was asked to plan a flowerbed

with only one plant species. The degree of difficulty of

this activity increased when the same flowerbed was to

be planned for year-round flowering with spring tulips,

early summer herbs, summer flowers and finally autumn

flowers for drying.

Therapeutic use of the DHHTG. As indicated above,the DHHTG gardening concept was used as a tonic.The therapeutic purposes were individualised to oneor a combination of (a) mental healing, (b) recreation,(c) social interaction, (d) sensory stimulation, (e)cognitive re-organization, (f) sensorymotor function,(g) assessment of pre-vocational skills and (h) teachingof ergonomical body positions.

The DHHTG as a place for mental healing. It was pre-sumed that time regularly spent in the DHHTG maypositively influence visitors’ minds and may cure oralleviate physical illness [99], especially among thosewith severe brain damage. The DHHTG was afavourable place frequently visited for resting, medita-tion and relaxing relief; or for meeting family andfriends in a non-hospital environment. There are manyfragrances in a garden regardless of season, affordingtopics for conversation and prompting memories.Grass and dew, flowers and berries, these things are

Figure 2 a. Lightweight garden tools are required, e.g. from the left: Lightweight (3.8 kg) wheelbarrow in cloth, with raised handles for optimalergonomic standing or walking position; Medium-weight (about 9 kg) ‘easy wheelbarrow’ can be pushed or pulled with one hand (in hemiparesis);Standard weight (about 12 kg) wheelbarrow shown for comparison. b. Garden tools with detachable handles allow individual adaptation. c. Suitabletool lengths facilitate optimal biomechanical body positions such as standing and sitting. Marks for easy lengthening or shortening of telescopichandle. d. Garden tools should facilitate as low a work load as possible. For example digging is facilitated when both hands and one foot. e. Gardentools adapted for use with a two-hand-grip. Slings can be added to afford a useful grip for weak arm and hand muscles. f. Garden tools for work in aneutral body position are recommended, for example gripping the handle of this cultivator. g. The handles of these garden tools are enlarged withsoft plastic, decreasing the grip muscle strength required.

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often connected to events of long ago. For a whilethese environmental perceptions may help the patientsto forget his/her disabilities and concern about thefuture.

The DHHTG garden and gardening for recreation.These were used for patients undergoing a transitionfrom working life to a life with decreased oppor-

tunities to carry on with previous leisure activities.Gardening was presented as a new leisure activity,available despite present disabilities. Any gardening-associated activity was counted, such as sitting andlooking, walking, eating, talking, sunbathing, reading,listen to music, playing games in the garden, whichthe patients did for pleasure [3, 100]. It was presumedthat the patients’ participation in gardening would

Table 2 Organization of the DHHTG during a year (2003)

Time Group ParticipantsMeetingsper week

Total numberof meetings

5 February–15November 2003

Morning group 12 men, 12 women(wheelchair users=3)

One per week 30

16 April–27August 2003

Afternoon group 7 men, 5 women(wheelchair users=0)

One per week 13

30 June–15August 2003

Summer group 7 men, 3 women(wheelchair users=1)

Three per week 21

Table 1 Examples of the DHHTG seed or plant material, its purposes and main therapeutic usefulness

Main therapeutic use Purposes of the seed or plant materialExamples of seed or plant materialused (Latin names)

Mental healing, recreation,cognitive re-organization

Good germinativeness Calendula officinalisSuitable hardiness for the climate zone TagetesWell-known and therefore enables patients torecognize the plants and flowers used forsquare cultivation

Impatiens walleriania

Cognitive re-organization; memorystimulation

Arouse childhood memories Tropaeolum pereqrinumAntirrhinum majusRaphanus satiuus

Mental healing, recreation, socialinteraction

Beautiful colour Impatiens hawkeri (red, pink,white, violet)

Sensory stimulation Wonderful scent Lathrus adoratusHeliotropium arborescensNicotiana sylvestrisMatthiola

Teaching of ergonomic bodypositions

Climbing plants and low height placing allows workwith different body positions at the same time

Nicotiana sylvestris

Ipomea tricolorCosmos bipinnatusHelianthus annuus

Social interaction, cognitivere-organization, training ofsensory-motor function,teaching of ergonomicalbody positions

Vegetables for use in the kitchen designedfor ADL training

Anethum gravealen

Petrose linum (CrispumLactuca (sativa)Beta vulgaris

Sensory stimulation Seeds of various sizes, form, surface Pelargonium�hortorumSenecio sineraria

Social interaction, pre-vocationalskills assessment

Fast-germinating seed for a new collectionevery autumn

Tropaeolum

Calendula officinalisPhaseoulus occineusTagets ‘Silvia’

Non-specific Seeds from exotic plants for use in the garden house Physalis perurianaCitrus

Non-specific Seeds for Swedish cultural plant species Linum (usitatissimum)Recreation, leisure activity According to patient’s wishesCognitive re-organisation Reading instructions and interpreting the pictures

on seed packets

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involve, amuse and satisfy them, give them pleasureand promote their creativity and wellbeing. In addi-tion, the garden flowers may inspire patients to tryother leisure activities such as painting or paintingtherapy. Other patient groups aimed for transition ofnew leisure activities using the flowers and harvest forfloral decoration and cooking.

DHHTG gardening for social interaction. Participationin a gardening group was also prescribed for itsassociated psychosocial benefits. It was presumed thatpatients’ interpersonal relations would be strengthenedthrough mutual communication about the DHHTGwork and observable in an increased sense of self-worth, the release of hostility and aggression, sharedcontrol of self and environment, the experience ofchoice, increased socialization, practice in copingskills, increased tolerance of other group members,conscious intellectual stimulation [100], feelings oftogetherness and teamwork. For example, the thera-pist gives the group members ‘garden-related home-work’ to be performed. This task was often used forpatients with aphasia encouraging them to talk andcontinue their interaction.

DHHTG gardening for sensory stimulation or integra-tion. Patients with severe brain damage and decreasedawareness were presumed to receive sensory stimula-tion [101] through the reticular activating system, viaresponses to different plant material [80, 83]. Sensorystimulation was performed in a systematic way. Thetherapist asked the patient questions related tothe plant material and the garden environment. Thepatients’ tasks were to compare or identify variationsof the material. The flowers offered opportunities forstimulation through smelling and seeing. Memoriesconnected to the sense of smell would increase arou-sal. Butterflies and insects would trigger eyes to followthem. Vegetables and spices grown in the gardenwould stimulate taste. Leaves from different species,with rough or smooth or hairy surfaces would stimu-late touch in the hand. Sand, soil and water would sti-mulate sensations in bare feet. Water, birds,bumblebees and soils make sounds that stimulatehearing and sound orientation. Bamboo and reedsmoving in the wind make music that may stimulateauditive perception.

The DHHTG gardening for cognitive re-organization.Different gardening activities such as planning aflowerbed, calculating the depth and distance between

plants, reading instructions on the seed packages orlistening to oral or written instructions for doinggardening were used for patients’ cognitive re-organi-zation therapy of attention, spatial, verbal, numerical,praxis, memory and logical impairments. In this thera-peutic approach, the patients systematically learnstrategies for a new way of performing the activity[102]. For example, special education strategies forplanning the growing process in a flower bed givesopportunities for the patient suffering from frontalbrain damage to re-organize his logical order ability.

The DHHTG gardening for training of sensory-motorfunctions. The various elements of gardening, used ina neutral way and with increasing efforts, werepresumed suitable for training and improvement ofmobility, muscle strength and balance, fine, gross, bi-lateral and eye-hand motor co-ordination, plus rangeof motion. For example, a patient with a right hemi-paresis may overcome and possibly improve muscleweakness of arm and hand by using a high-gearedpair of pruning shears when harvesting tomatoes. Inaddition, for patients with a hemiparesis, gardeningactivities were used with the traditional sensorimotortreatment strategies which are presumed to developthe motor function and motor control, including theapplication of sensory stimulation to muscles andjoints which would facilitate specific motor responses[103]. For example, the patients stand and balancewhen removing faded leaves from the climbing plants,whereas the trellis give support and safety.

The patients had the opportunity to practice ways ofusing adaptations and coping behaviour for performingof the gardening elements [98]. These adaptations wereboth physical and mental. For example, the next groupmeeting was planned such that all group members wereinvolved and all were responsible for a task which wascompatible with their ability.

The DHHTG gardening for assessment of pre-vocational skills and or pre-vocational training.Gardening was prescribed as a part of establishing thepatients’, with pain-related impairments, work toler-ance. The patients’ ability to perform gardeningelements including lifting, reaching, carrying, pushing,pulling, sitting and standing and work tolerancewas observed [98]. With these purposes, digging,re-construction and repairing of paving, drawing thelawn mower, moving or mounting shelves, carryingboxes and moving sacks with soil were common work

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tasks. The observed results were presumed to contri-bute to defining the individual patient’s capability[104] to perform employed work.

DHHTG gardening for teaching ergonomic bodypositions. The various gardening occupations were usedfor work-tolerance training. However, the emphasishere was on the most appropriate ergonomic bodyposition and use of garden tools following anthropo-metric principles. For example, during gardening, thejoints were in neutral positions; the gardener directlyfacing the job without twisting his or her body, back,neck or hips. The knees were preferably bent (whenpossible) when picking up items from the ground [98].Kneeling was avoided with the use of raised plant-beds and a garden stool. Further, the gardeners weretaught to work in the most comfortable way [24].It was presumed that this ergonomic approach wouldprevent injuries to muscles and bones and mightafford pain relief. Teaching ergonomic body positionswas used for 45 minutes once a week individually orto groups. The patients with Rheumatoid Arthritisand Chronic Obstructive Lung Disease were giveninformation about suitable tools and working methodsbut did not do gardening.

Educational use of the DHHTG

During a 3-day seminar, rehabilitation team staffwere taught about gardening and the design of a gardenfor horticultural therapy. The members of these teamswere interested in starting their own horticulturaltherapeutic gardening programmes. The results ofthis training contributed to the introduction of �300horticultural-therapeutic gardens throughout Swedentoday. The concept of DHHTG horticultural therapyhas spread and is now in use in nursing homes, rehabili-tation clinics and acute care among people with infirmi-ties, mental retardation, mental illness, neurologicaldiseases such as dementia, multiple sclerosis, strokeand brain damage and musceloskeletal diseases suchas rheumatoid arthritis [24]. DHHTG has been furtheradapted by agricultural training establishments inSweden. The ALNARP campus of the SwedishUniversity of Agricultural Sciences offers a half-termuniversity course ‘Tradgard och park som rehabiliter-ing’ (Gardens and Parks as Rehabilitation) (http://www.movium.slu.se) and the ULTUNA campus inUppsala a quarter-term course in ‘Skoltradgardskurs’(Gardens in the Swedish School System).

Discussion

Restrictions in the literature search and the literatureavailable in the databases used made it difficult to detect

past and present trends in horticultural therapy.

However, the results of this historic review indicatedfour different intervention approaches: (a) ‘Virtual’

elements from nature in the form of pictures, reading

or discussion [10], (b) viewing nature through films orwindows [12, 13], (c) interacting, i.e. visiting a hospital

healing garden and receiving impressions and experi-

ence [44, 80, 94], and (d) action through doing garden-ing jobs [87, 94]. The latter approach was strongly

suggested [4, 87, 92, 105–107], but its use was sparsely

demonstrated, which justifies this description of garden-ing in DHHTG related mainly to patients suffering

from brain damage. The literature suggests or describes

horticultural therapy as a mediator intended to affectpatients’ (a) emotional functions such as stress [75, 84,

93], increasing wellbeing [87,91] or influencing healing

[4], (b) sensory-motor functions and activities [48, 80,83], (c) cognitive functions and activities [14] and

(d) promoting participation in social life, such as

prevocational training [14] or the avoidance of socialisolation [10] or the promotion of human habits [108].

The descriptions concerned people with mental [94, 106,

107, 109] or physical illness requiring vocational train-ing [1, 14, 46].

However, there were very few descriptions of howhorticulture therapy has been used for people with

brain damage. Consequently, the present study may

contribute with its description of how horticulturaltherapies are being organized at Danderyd Rehabili-

tation Clinic. The patients with brain damage interacted

in the garden, mediating healing and social interactions.They interacted by doing gardening jobs, mediating in

reaction the training of sensory stimulation, cognitive

re-organization, sensory-motor functions and pre-vocational skills. The presentation is based on personal

communication and popular-science articles [23, 24,

26–28] in Swedish, combined with acknowledgedoccupational therapy literature. However, it would

have been desirable to use direct observation or medical

records for analysis. Therefore, even if full identificationof this horticultural-therapeutic approach and its effec-

tiveness is still incomplete, it may be helpful to plan and

conduct such direct studies.

Many of the articles reviewed include recommenda-

tions for planning horticultural therapy [110], the

designing of a hospital healing garden [6, 75] in theform of herb [111] or hospice [78] gardens, suggestions

for suitable plant material [112], methods and tools

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adapted for people with various disabilities [113]and, finally, exploration of the importance of speciallandscapes (adventure playgrounds, children’s farms,ecological parks or landscaped school grounds) tofacilitate children’s learning [114].Another value of the DHHTG was its use for training

in horticultural therapy for rehabilitation team mem-bers. This has resulted in the establishment of newhospital gardens in Sweden. A similar process hasbeen going on over the past 16 years in the UK,where the project strongly promotes its healthbenefits [115].The articles used in this study for reviewing the

literature of horticultural therapy represent severaldifferent disciplines: anthropology, environmentalpsychology, horticulture, landscape architecture, medi-cine [67] and occupational therapy. This in turn mayhave influenced the selection of articles and restrictedthe review. However, the findings presented above arecomparable to those of an integrative literature reviewby Jones and Haight [108] published in 2002. Theseauthors reviewed 24 articles on the use of the naturalenvironment in the form of plants or plant material astherapeutic interventions, either virtually or actually,among resident patients with altered mental healthstatus or learning disabilities: older adults with alteredlevels of impairment.Although horticulture therapy was strongly advo-

cated, its effects were less established, except for theenvisaging and viewing aspects. It was suggestedthat the envisaging and viewing form of horticulturaltherapy, based on the hypothesis of a beneficial rela-tionship between humans and the natural environmentpositively affects mood and provides mental restora-tion. This tallies with Relf ’s [67] review (see above)that ‘views of nature have positive, psychologicalresponses, physiological impacts (lower blood pressure,reduced muscle tension), and a reduced need formedical treatment occurs’.The interacting form of horticulture was evaluated

[115] among 22 patients on a geriatric ward who hadaccess to an indoor conservatory garden connectedwith an outdoor garden. The patients behaviour wasobserved regarding their movements on the ward1 month before the gardens were installed and 1 and 6months thereafter. The results demonstrated positivereactions and increased the number of visits to theoutdoor garden following installation of the indoorconservatory.Elderly people’s (n¼ 24) action was assessed during a

3-month structured gardening intervention, showing asignificant improvement (p<0.000) in wellbeing [87].

A study with an hermeneutic phenomenologicalresearch approach [94] was conducted among peoplewith chronic mental illness (n¼ 10) who were membersof a club. The aims were to explore the participants’experiences of gardening.

When horticulture was used in this group-basedsetting immediate and positive effects were observed interms of quality of life, well being and self-concept.

Summary

This article (a) gives a broad historic overview ofhow horticultural therapy has been used; (b) describesthe design and organization of Danderyd HospitalHorticultural Therapeutic Garden and (c) for patients’with brain injuries, outlines how gardening as a tonicoffers a supplement to their rehabilitation, in terms ofmental healing, recreation, social interaction, sensorystimulation, cognitive reorganization, training ofsensorimotor function, pre-vocational assessment andthe teaching of ergonomics. However, the effectivenessof these intervention approaches remains to be proved.

Acknowledgements

Our deep thanks for financial support are due to the Rehabilitation

Clinic, Danderyd Hospital and to Stiftelsen Oskar Hirsch Minne (The

Oskar Hirsch Memorial Foundation).

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