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92 NATURE THERAPY
Dr. Kellert promoted the idea of building structures with environmentally sensitive materials and designing structures to create an experience with nature when indoors, looking out (Kellert et al. 2008).
Dr. Kellert’s most recent book was published posthumously and is a
groundbreaking guide to understanding a changing perspective in the
way we design and build the environment we live, work, and play in.
The essays examine all aspects of the environment, from home and
work to community and city, proposing that the future built world
should foster the human-nature connection (Kellert 2018).
RELEVANT RESEARCH:
QUANTIFYING THE EFFECT OF
THERAPEUTIC HORTICULTURE
INTERVENTIONS
The seminal 1984 study, “View Through a Window,” examining the restorative effect of a view of nature on surgical patients, was conducted by
Roger Ulrich, Ph.D., a professor in the Department of Architecture and
Centre for HealthcareArchitecture, Chalmers University of Technology, in
Sweden. At an acute care hospital, Dr. Ulrich reviewed medical records for
surgical patients who had gallbladder surgery over the course of a 9-year
period. He and his team were able to narrow the field to 46 patients by
identifying commonalities in the following characteristics: gender, age,
smoker or nonsmoker, obesity or normal weight, and similar traits. In the
postsurgical unit, exactly half the beds faced the sky and trees, and the
other half faced a brick wall. The study was undertaken to determine
whether having a view of nature would have a restorative effect. The researchers identified 23 patients with the natural view and paired them with
23 patients with the wall view. They extracted information from four areas
in each medical chart in order to compare outcomes. Following are the
findings of the “View Through a Window” study (Ulrich 1984).
• Patients with the view of nature were discharged almost 1 full day
sooner than those with the wall view.
• Patients with the view of nature needed a smaller amount and
strength of analgesic medication on days 3–5 (on the first 2 days and
last 2 days, the difference was insignificant).
• Nursing notes indicated more positive comments from the patients
with the natural view and more negative notes from the patients
Horticultural Therapy 93
with the wall view (notes documented mood, level of pain, and need
for nursing attention).
• Patients with the view of nature had fewer requests for additional
medication for anxiety or other minor postsurgical complications.
Another study by Dr. Ulrich showed that after 5 minutes of viewing
a scene with vegetation, stress levels decreased, evidenced by reductions in blood pressure and muscle tension. He encouraged others in
the field, including horticulturists and psychologists, to engage in ongoing research by using physiological and health-related measurements to show tangible evidence of the important benefit of plants to
improve well-being (Ulrich and Parsons 1992).
Environmental psychologist Rachel Kaplan, Ph.D., and her hus-
band, psychologist Stephen Kaplan, Ph.D., studied the restorative experience of being in nature and the psychological benefit of being “nearby
nature” (S. Kaplan 1992). The Kaplans defined “nearby nature” as
vegetation that is experienced in a person’s ordinary day. It can be indoors or outdoors or viewed through a window. After dozens of studies, they found that having access to nature throughout a person’s daily
life is an important factor in satisfaction and well-being at work, at
home, or at play.
Dr. Stephen Kaplan’s work focused on the attention restoration theory,
which posits that people experience directed attention fatigue when engaged in prolonged mental effort. Furthermore, connecting with nearby
nature restores the ability to direct attention or focus. The Kaplans contended that the availability of nearby nature is not an amenity or decoration but an essential human need because of its ability to reduce attention
fatigue. A student studying, an office worker creating documents on a
computer, or a patient staying in a hospital will each find relief from attention fatigue if they can look around at images of nature or through a window at a view of nature (R. Kaplan 1992; S. Kaplan 1992, 1995).
In the early twenty-first century, studies supporting the work of ear-
lier theorists and researchers have been published at a furious pace. Researchers from countries and cultures all over the globe are finding
evidence of the physiological and psychological benefits of being in nature or nearby nature. For example, a 2011 study published in Public
Health found decreased levels of cortisol and pulse rates in participants
when walking in the forest (Lee et al. 2011). Another study discussed at
length later in this chapter found decreased perception of stress, pain,
depression, and loneliness (Figure 5–5) among veterans engaging in
therapeutic horticulture activities such as the grounding activity shown
in Figure 5–6 (Meore et al. 2021).
94 NATURE THERAPY
Therapeutic horticulture: before
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Extreme
distress
Extreme
pain
Extremely
depressed
Extremely
lonely
No
distress
No
pain
No
loneliness
No
depression
1. Circle th e number on
the “thermometer”
that best describes
the overall amount
of stress you have
felt over the past
week
2. Circle the number on
the “thermometer”
that best describes
how much your pain
has interfered with
your daily life inthe
past week
3. Circle the number on
the “thermometer”
that best describes
your overall mood
in the past week
4. Circle the number on
the “thermometer”
that best describes
the overall amount
of loneliness or
isolation you have
felt over the past
week
Therapeutic horticulture: after
10
9
0
1
2
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Extreme
distress
Extreme
pain
Extremely
depressed
Extremely
lonely
No
distress
No
pain
No
loneliness
No
depression
1. Circle th e number on
the “thermometer”
that best describes
the overall amount
of stress you feel at
this moment
2. Circle the number on
the “thermometer”
that best describes
how much your pain
has interfered with
moment
3. Circle the number on
the “thermometer”
that best describes
your overall mood
at this moment
4. Circle the number on
the “thermometer”
that best describes
the overall amount
of loneliness or
isolation you feel
at this moment
Figure 5–5. Participant-reported outcome thermometers for
the four symptom domains (stress, pain, mood, and social isolation) administered before and after each horticultural therapy session.
Source. Reprinted from Meore A, Sun S, Byma L, et al: “Pilot Evaluation of Horticultural
Therapy in Improving Overall Wellness in Veterans With History of Suicidality.” Comple-
mentary Therapies in Medicine 59:102728, 2021 33965561. This article is distributed under
the terms of the Creative Commons Attribution 4.0 International License (http://
creativecommons.org/licenses/by/4.0/).
Horticultural Therapy 95
Figure 5–6. Therapeutic benefits of grounding incorporated
into the horticultural therapy process.
Source. Photograph courtesy of A. Meore.
HORTICULTURAL THERAPY AND
THERAPEUTIC HORTICULTURE:
COMMONALITIES AND
DIFFERENCES
As the profession of horticultural therapy grows, the American Horticultural Therapy Association continues to refine definitions and terminology as it works on developing a credentialing examination. The
96 NATURE THERAPY
American Horticultural Therapy Association has described commonalities and differences between horticultural therapy and therapeutic horticulture, as illustrated in Figure 5–7.
Components of horticultural therapy include the following:
• The participant engages in horticulture-related activities.
• The participant has an identified disability, illness, or life circumstance requiring services.
• The activity is facilitated by an HTR.
• The participation is in the context of an established therapeutic, rehabilitative, or vocational plan, which includes measurable goals
and objectives, assessment, and documentation (Haller et al. 2019).
Components of therapeutic horticulture include the following:
• The participant engages in horticulture-related activities.
• The participant has an identified disability, illness, or life circumstance requiring services.
• The activity is facilitated by an HTR or other professional therapist
with training in horticulture.
• The participation is in the context of the goals and mission of an organization or the needs of the individual or group and may include health
maintenance, well-being, and leisure activity (Haller et al. 2019).
Although there are distinct differences in who is conducting the
intervention and for what purpose, there is a strong overlap in the
methods and materials used in horticultural therapy and therapeutic
horticulture practice. Similar to humanistic psychology, both horticultural therapy and therapeutic horticulture are person-centered practices, and the needs and goals of the individual are the driving force of
the intervention. With the patient considered to be at the center of the
relationship, the therapist’s role in both modalities is to guide and facilitate the engagement with the plant or natural materials, making modifications or adaptations in order to achieve the desired outcome and
considering safety in every step of the process.
Both horticultural therapy and therapeutic horticulture can be
practiced in diverse and wide-ranging settings, from hospitals and specialized residential communities for people with developmental disabilities, older adults, or others with a specific therapeutic need to
correctional facilities, botanical gardens, schools, and community settings (Table 5–1). Programs can be divided into three types: therapeutic,
psychosocial, and educational and vocational.
Horticultural Therapy 97
Horticultural therapyTherapeutic horticulture
The activity is facilitated
by a registered horticultural
therapist or other
professional with training
in horticulture.
The participationisinthe
context of the goals and
mission of the program.
Participant engages in
a horticultural activity.
The participant has an
identied disability, illness,
or life circumstance
necessitating services.
The activity is facilitated
by a registered
horticultural therapist.
The participationisin
the context of an
established therapeutic,
rehabilitative, or vocational
plan.
Figure 5–7. Components of therapeutic horticulture and horticultural therapy.
Source. Definitions have been adapted from P. D’Amico, HTM, Program Coordinator, NYBG Horticultural Therapy Certificate Program. American Horticultural Therapy Association: “Definitions and Positions.” 2021. Available at:
id=86:ahta-definitions-and-positions&catid=20:site-content&Itemid=152.
htt
ps://w
ww.ahta.or
g/index.php?option=com_content&view=article&
98 NATURE THERAPY
Table 5–1 . Populations and settings for therapeutic
horticulture interventions
Community
(social)
Drug and alcohol
rehabilitation
support groups
Community
gardens
Community
centers
Religious
communities
Public parks
LGBTQ+ youths
LGBTQ+ families
Farms
Food-insecure
neighborhoods
Refugee
communities
BIPOC
communities
Day habilitation
programs
Corporate and
other worksites
Note. BIPOC=Black, Indigenous, and people of color.
Residential
(social)
Retirement
communities
Assisted living
facilities
Skilled nursing
facilities
Halfway houses
Community-
based group
homes
Supported
independent
living
Developmental
disability
centers
Residential
schools
Farms
Correctional
facilities
Urban
neighborhoods
Patients’ homes
Homeless shelters
Foster homes
Domestic
violence shelters
Educational
and vocational
Vocational school
Special needs
school
At-risk youth
detention center
Mainstream
school (public
and private)
Incarceration
program
Religious school
Garden center
vocational
program
Prison vocational
training
program
Schools for
autistic persons
Medical
Acute care
hospital
Physical medicine
and
rehabilitation
hospital
Pediatric hospital
Psychiatric
hospital
Long-term care
facility
Intermediate care
facility
Cancer care
Memory care
Hospice care
Practitioner’s
office
• Therapeutic programs follow a medical model. The focus is on recovery from illness, injury, or life circumstances that negatively affect a person’s health.
• Psychosocial programs follow a wellness model. The focus is on introducing a valuable leisure activity that can provide the benefit of
overall well-being and improved physical, mental, and spiritual
health.
• Educational and vocational programs follow an educational model.
The focus is on learning new, meaningful skills in the physical, cog-
Horticultural Therapy 99
nitive, and psychosocial realms that could lead to higher levels of
education, job placement, volunteering, or making a meaningful
contribution to the community (Haller 1998).
With hortophilia at the core of the therapeutic horticulture practice,
horticultural therapists maintain that every patient has the capacity to
tap into their innate connection with plants and benefit from the active
process of engaging with them, as shown in Figure 5–8. However, people who are so removed from plants and nature as to be described as
“nature deficient” (Louv 2008) and averse to nature might need a slow
introduction to becoming aware of their connection with the natural
world. In such cases, a passive nature experience, such as watching a
garden-related video, sampling the scents of the garden, or having a
talk session while walking or seated in a garden or park, might be an
important first step in providing exposure to nature. With this type of
incremental approach, it is likely that plants eventually can be successfully introduced to such a person.
GUIDELINES FOR THE
PRACTICAL USE OF
THERAPEUTIC HORTICULTURE
The process of engaging in a horticulture-related activity distinguishes
therapeutic horticulture from other nature therapies. The practice is
flexible and adaptable and is an appropriate resource to address issues
in nearly every functional domain (e.g., physical, cognitive, psychological, social, emotional, spiritual, vocational, recreational) (Table 5–2).
Therapeutic horticulture is generally practiced as an active experience, and the patient’s relationship with the plant can be multisensory.
In the richest sensory environment, this would take place in an outdoor
garden bursting with diversity, color, scent, texture, and four-season interest. Other types of outdoor gardens, parks, yards, or even small
apartment balconies are adequate spaces in which to engage in a therapeutic treatment session outdoors. An indoor area with plants also may
be an appropriate therapeutic setting (e.g., in a greenhouse, atrium, or
naturally lit room in an office, school, or residence). The beauty of the
people-plant relationship is that even in a room with one plant, a person
can have a meaningful, therapeutic experience in relationship with that
plant under the guidance of a skilled practitioner. If the care and culture
100 NATURE THERAPY
Figure 5–8. Thinning seedlings as an exercise in mindful na-
ture engagement.
Source. Photograph courtesy of A. Meore.
of plants will be a component of the therapeutic practice, it is recommended that the practitioner have at least a rudimentary knowledge of
horticulture and be familiar with the activity, tools, plants, and materials that will be used.
Horticultural Therapy 101
Table 5–2. Potential beneficial outcomes of therapeutic
horticulture interventions
Psychological
Cognitive
domain
and emotional
domain
Psychosocial
domain
Physical
domain
Develop new
interests
Learn new skills
Learn new
vocabulary
Practice following
single-step and
multistep
instructions
Practice
sequential tasks
Practice goal
setting
Stimulate
curiosity and
questioning
Exercise short-
and long-term
memory recall
Improve
sustained
focused
attention
Improve divided
attention
Enhance the
understanding
of abstract
concepts
including time,
growth, change,
and death
Increase
awareness of
our living
environment
Experience an
opportunity to
feel a sense of
wonder and
“being away”
Cultivate well-
being
Reduce stress and
anxiety
Reduce
restlessness
Practice
mindfulness
Improve self-
confidence and
self-esteem
Improve mood
Nurture another
living thing
Explore self-
expression
through a
creative plant-
based activity
Develop a sense
of responsibility
to others and to
our
environment
Practice delayed
gratification and
patience
Lift spirits for
those who have
lost a sense of
purpose or hope
Provide a feeling
of satisfaction at
accomplishing a
set goal
Help to relieve
feelings of
depression
Decrease isolation
Increase
socialization
Promote
interaction
through a
common
interest
Practice and
improve
socialization
skills
Practice group
participation
Practice turn-
taking, sharing,
and teamwork
Provide
opportunities to
practice
leadership skills
Provide an
opportunity to
experience
wonder
Provide an
opportunity to
observe life
cycles
Provide an
opportunity to
make
metaphoric
comparisons to
self
Exercise fine
motor skills
Increase strength
and dexterity in
hands and
fingers
Increase strength
and range of
motion at upper
extremities
Exercise gross
motor skills
(e.g., increase
strength and
range of motion
at lower
extremities and
core and
improve
coordination,
balance, and
stability)
Provide moderate
exercise, helping
to increase
coordination,
strength,
stamina, and
endurance
Provide
opportunity for
sensory
stimulation
(vision, hearing,
touch, taste, and
smell)
Provide outdoor
activity and
access to fresh
air and sunshine
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