Horticultural therapy

Horticultural therapy also known as social and therapeutic horticulture, is defined as the process of utilizing “horticultural activities” such fruits, vegetables, flowers and plants facilitated by a trained therapist or healthcare provider, to achieve specific treatment goals or to simply improve a person’s physical and mental wellbeing of an individual ¹. Horticultural therapy is defined by the American Horticultural Therapy Association as the engagement of a person in gardening‐related activities, facilitated by a trained therapist, to achieve specific treatment goals ². Therapeutic horticulture is defined as an open program “a process that uses plant‐related activities through which participants strive to improve their well‐being through active and passive involvement”, which can be easy implemented and performed by a variety of healthcare providers ³. Flournoy ⁴ broadly describes horticultural therapy as the process of utilizing fruits, vegetables, flowers and plants. Horticultural therapies have been shown to have a statistically significant positive effect on health outcomes, including an increased satisfaction with life and improved quality of life, as well as a decrease in depression and anxiety ⁵. Horticultural therapy has been widely recognized as an effective form of therapy since the ancient Egyptian era. Back then, physicians were already prescribing walks around gardens for patients with mental health problems. Today, therapists continue to recommend horticultural therapy for those who are stressed, depressed, recovering from surgery or other trauma. However, a 2014 Cochrane Review ⁶, based on the current very low quality data, there is insufficient evidence to draw any conclusions on benefits or harms of horticultural therapy for people with schizophrenia. According to the review authors horticultural therapy remains unproven and more and larger randomized trials are needed to increase high quality evidence in this area ⁶.

Horticultural therapy is based on the therapeutic value of participating in garden activities such as growing fruit or vegetables and/or flowers. Gardening is thought to improve people’s well‐being through being a recreational and sociable activity which may lead to improvements in people’s thinking, new friendships and more positive emotions. Gardening reduces stress, which is important because stress can often lead to mental illness. Gardening is also hard work and a physical activity, and so motivates people with mental illness who often feel tired and apathetic. Weight gain is common for people with mental illness and gardening is good physical exercise.

When people participate in horticultural therapy, they take on a care-giving role. By tending to a garden, people receive an increased sense of responsibility and purpose. Gardening helps improve your motor skills and being amongst nature has a general calming effect on the soul. Some studies suggest that this is because being outdoors exposes you to more sun, and in turn vitamin D ⁷.

Horticultural therapy benefits

Barley, Robinson and Sikorshi ⁸ contended that horticultural therapy could improve the mood and well‐being of people with mental, physical and social problems in the community. Engaging in this rehabilitative activity generated a feeling of pleasure in patients with cancer. Several studies found that horticultural therapy helped various groups of people to manage severe stress, promoted relaxation and social interactions among individuals with mental illness and improved their life satisfaction and well‐being ⁹.

Horticultural therapy was also found to be effective at improving attention and depression scores among a group of clinically depressed, community‐dwelling people ¹⁰, achieving statistically significant improvements in psychological well‐being ¹¹ and leading to better affect and prolonged engagement among people with dementia ¹². More recently, Kamioka et al.’s ¹³ systematic review concluded that horticultural therapy resulted in statistically significant improvements in mental health outcomes and behaviors of participants with dementia, severe mental illness and stroke with hemiplegia. Same, Lee, McNamara and Rosenwaz ¹⁴ reported that gardening and related activities had a positive impact on the independence and emotional well‐being of frail older adults living in the community.

Therapeutic gardening for seniors

Horticultural therapy enhanced the quality of life of residents ¹⁵, improved their self‐rated health and happiness ¹⁶ and significantly improved their life satisfaction and social networks ¹⁷. However, its use among older people who are frail and institutionalized remains under‐studied and under‐reported. There is limited evidence on how this disadvantaged group views the effects of horticultural therapy.

This qualitative study ¹⁸ was among the first to explore the effects of horticultural therapy on frail older Chinese people in residential homes. The findings from international studies are not suitable for direct comparisons because of cultural differences ¹⁹. Lai et al. ²⁰ took a quantitative approach in their study and measured loneliness, life satisfaction and social networks. Raske’s study ¹⁵ was a qualitative one, but the sample consisted of a diverse group of residents, family members, staff and people in the community. The other study with which compares horticultural therapy on frail seniors is that by Collins and O’Callaghan ¹⁶. Their findings, from a different population group, echo the observations that engaging in indoor gardening brought happiness to older people in assisted living.

It appeared that in the horticultural therapy program, the color, texture, vibrancy and scent of the plants was a source of enjoyment to the participants that was not readily available in their institutionalized life. More importantly, horticultural therapy gave many of them something to do to pass the time in a place where nothing much was happening. To a certain extent, the participants valued therapeutic activities that could purposefully engage them. They felt useful and had something to look forward to. This was particularly true for those frail older residents who were physically challenged, because their choice of activities in the home might have been significantly limited due to their health status.

The findings of the study suggest that most of the frail/pre‐frail nursing home residents experienced happiness and enjoyment from participating in the horticultural program. They expressed that the horticultural therapy program provided them not only with a certain degree of leisure, but also a meaningful use of time in the home. These perceptions of beneficial effects to the participants should inform healthcare practitioners and policymakers of the importance of the personal preferences and values that older people may attach to their daily activities when implementing interventions for this particular group who are frail.

In many developed regions, the number of older people living in nursing homes is increasing as the population ages. Nursing homes are at the heart of the long‐term care continuum ²¹. As such, interventions must be developed to promote quality care for nursing home residents and to maintain their physical and cognitive functions. Tolson, Rolland, and Andrieu ²² stated that meaningful activities, such as physical and mental exercises, could enhance the quality of life of nursing home residents. In the same vein, horticultural therapy, found in this study ¹⁸ to have engaged the participants physically and mentally by giving purpose and meaning to their lives, should be used more widely in local communities.

One of the residents stated that she disliked the program because it clashed with her other routines. Although here was an isolated case, her opinion should not be taken lightly, but rather should remind healthcare providers of the need for person‐centered care. The re‐engineering of tasks could be relevant to identifying solutions for rearrangement of residents’ daily activities.

Summary

The horticultural therapy findings showed positive influences and expanded the existing state of knowledge on the use of horticultural therapy in long‐term residential care. They are also of importance in enabling healthcare providers to develop appropriate and meaningful nursing practice to improve frail residents’ perceived quality of life in the institution they now call “home.”.

References

1. Lo SKL, Lam WYY, Kwan RYC, Tse MMY, Lau JKH, Lai CKY. Effects of horticultural therapy: Perspectives of frail and pre-frail older nursing home residents. Nurs Open. 2019;6(3):1230–1236. Published 2019 Jul 3. doi:10.1002/nop2.323 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6650752
2. American Horticultural Therapy Association. https://www.ahta.org
3. Gonzalez MT, Hartig T, Patil GG, Martinsen EW, Kirkevold M. Therapeutic horticulture in clinical depression: a prospective study. Research and Theory for Nursing Practice 2009;23(4):312‐28.
4. Flournoy RL. Gardening as therapy: Treatment activities for psychiatric patients. Hospital & Community Psychiatry 1975;26(2):75‐6. https://doi.org/10.1176/ps.26.2.75
5. Soga M, Gaston KJ, Yamaura Y. Gardening is beneficial for health: A meta-analysis. Prev Med Rep. 2016;5:92–99. Published 2016 Nov 14. doi:10.1016/j.pmedr.2016.11.007 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5153451
6. Liu Y, Bo L, Sampson S, Roberts S, Zhang G, Wu W. Horticultural therapy for schizophrenia. Cochrane Database Syst Rev. 2014;2014(5):CD009413. Published 2014 May 19. doi:10.1002/14651858.CD009413.pub2 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6544783
7. What is Horticultural Therapy and How Does it Work? https://anzmh.asn.au/2018/06/19/horticultural-therapy/
8. Barley E. A., Robinson S., & Sikorski J. (2012). Primary‐care based participatory rehabilitation: Users’ views of a horticultural and arts project. British Journal of General Practice, e127–e134. 10.3399/bjgp12X625193
9. Parkinson S., Lowe C., & Vecsey T. (2011). The therapeutic benefits of horticulture in a mental health service. British Journal of Occupational Therapy, 74(11), 525–534.
10. Gonzalez M. T., Hartig T., Patil G. G., Martinsen E. W., & Kirkevold M. (2011). A prospective study of group cohesiveness in therapeutic horticulture for clinical depression. International Journal of Mental Health Nursing, 23(4), 312–328.
11. Heliker D., Chadwock A., & O’Connell T. (2001). The meaning of gardening and the effects on perceived wellbeing of a gardening project on diverse populations of elders. Act Adapt Aging, 24(3), 35–56.
12. Gigliotti C. M., Jarrott S. E., & Yorgason J. (2004). Harvesting health: Effects of three types of horticultural therapy activities for persons with dementia. Dementia, 3, 161–180.
13. Kamioka H., Tsutani K., Yamada M., Park H., Okuizumi H., Honda T., & Mutoh Y. (2014). Effectiveness of horticultural therapy: A systematic review of randomized controlled trials. Complementary Therapies in Medicine, 22(5), 930–943.
14. Same A., Lee E. A. L., McNamara B., & Rosenwax L. (2016). The value of a gardening service for the frail elderly and people with a disability living in the community. Home Health Care Management and Practice, 28(4), 256–261. 10.1177/1084822316652575
15. Raske M. (2010). Nursing home quality of life: Study of an enabling garden. Journal of Gerontology Soc Work, 53(4), 336–351.
16. Collins C., & O’Callaghan A. (2008). The impact of horticultural responsibility on health indicators and quality of life in assisted living. Horttechnology, 18(4), 611–618.
17. Tse M. M. Y. (2010). Therapeutic effects of an indoor gardening program for older people living in nursing homes. Journal of Clinical Nursing, 19(7–8), 949–958.
18. Lo SKL, Lam WYY, Kwan RYC, Tse MMY, Lau JKH, Lai CKY. Effects of horticultural therapy: Perspectives of frail and pre-frail older nursing home residents. Nurs Open. 2019;6(3):1230–1236. Published 2019 Jul 3. doi:10.1002/nop2.323 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6650752/#nop2323-bib-0027
19. Wong K. C. (2001). Culture and educational leadership In Wong K. C., editor; , & Evers C. W., editor. (Eds.), Leadership for quality schooling. (pp. 36–53).London, UK: Routledge.
20. Lai C. K. Y., Kwan R. Y. C., Lo S. K. L., Fung C. Y. Y., Lau J. K. H., & Tse M. M. Y. (2018). Effects of horticultural therapy on frail and pre‐frail nursing home residents: A randomized controlled trial. JAMDA, 19, 696–702.
21. Morley J. E. (2010). Clinical practice in nursing homes as a key for progress. Journal of Nutrition, Health and Aging, 14, 68–73.
22. Tolson D., Rolland Y., & Andrieu A. (2011). The International Association of Gerontology and Geriatrics/World Health Organization/Society Française de Gerontologie et de Geriatrie Task Force, International Association of Gerontology and Geriatrics: A global agenda for clinical research and quality of care in nursing homes. Journal of American Med. Dir. Association, 12, 184–189.