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102 NATURE THERAPY
Table 5–2. Potential beneficial outcomes of therapeutic
horticulture interventions (continued)
Psychological
Cognitive
domain
and emotional
domain
Psychosocial
domain
Provide a common
language for
people to share
their cultural
traditions
Have potential to
engage in social
or vocational activities such as
plant sales, harvest fairs, cooking classes,
contests, and social excursions
Physical
domain
PLANNING A THERAPEUTIC
HORTICULTURE SESSION
When a therapeutic horticulture session is being planned, several factors
must be considered in order to effectively create the opportunity for a
positive experience for the participants (Table 5–3). The practitioner first
must consider what the therapeutic goals are, what expected outcome is
sought, and which type of program will be used. Next, the setting and
available resources must be assessed, with a particular focus on potential
safety concerns. Finally, the practitioner must consider the activity itself,
giving thought to necessary space requirements and possible adaptations, as seen in Figure 5–9, and modifications that would foster patient
success. Ideally, a task analysis would be completed before the session to
assist the therapist in planning. Task analysis requires therapists to engage in the specific activity they have chosen for the session. Therapists
will carefully analyze each step they complete and consider how it will
be presented to the participants within the treatment setting. Task analysis examines each step of the process and helps the therapist understand
• Application and benefit
•Complexity
• Most effective mode to present instruction
Horticultural Therapy 103
Table 5–3 . Considerations for planning a therapeutic
horticulture session
Factors to consider Questions to consider
Goal What is the desired patient outcome?
What role does the plant, natural material, or hor-
ticultural activity contribute to goal attainment?
Setting and safety Will the intervention be provided for a group or an
individual patient?
Will the session be conducted indoors or outdoors?
What resources are available to the therapist (e.g.,
plants, a garden, water)?
What safety precautions are needed (e.g., shade for
excessive sun if outdoors, potential toxicity of
plant material, access to sharp tools)?
Activity Will this be a passive experience, such as experi-
encing plants that provide visual, olfactory, tac-
tile, taste, or auditory sensation?
Will this be an active experience? For example, will
the patient engage in caring for the plant, experi-
encing the reciprocal nurturing and giving as-
pects of the relationship, in addition to the
sensory interactions?
What materials and tools will be needed?
What are the step-by-step tasks needed for the ac-
tivity?
Adaptations and modifi-
cations
Will adaptations or modifications be needed to ap-
propriately accommodate the specific needs of
the individual or group?
• Practicality of the desired outcome
• Anticipated modifications, adaptations, or necessary safety precautions
Ideally, any treatment setting would have a garden. A simple 3-footby-4-foot raised planting bed can provide as much therapeutic value as
a horticulturally rich, cultivated garden for growing food or ornamental
plants and flowers. Indoor environments appropriate for therapeutic
horticulture activities could be a plant-filled greenhouse, atrium, or
well-lit room filled with natural light. Plants have the capacity to grow
in conditions we would not expect, like an office with incandescent or
fluorescent light and no windows. With proper care, some indoor
plants will thrive in that challenging environment.
104 NATURE THERAPY
Figure 5–9. Sowing seeds using an adapted tool (seeding
frame) to help patients with visual impairment improve fine
motor control and engage in activity with peers.
Source. Photograph courtesy of A. Meore.
Within the wide spectrum of settings in which therapeutic horticulture engagement can occur, it is helpful to consider that horticulture activities can take place in inpatient and outpatient settings (Table 5–1).
With the effect of the novel coronavirus disease 2019 (COVID-19) pandemic dictating new ways of delivering health care, many horticultural
therapists found success in engaging their patients in horticulture programs virtually. Regardless of the setting, with thoughtful planning and
attention to specific individual needs, the adaptability of therapeutic
horticulture allows the practitioner to empower the patient to continue
engaging with plants beyond the treatment session, such as in the home
or community. In this way, the therapeutic benefit carries over to the patient’s everyday life, and the patient has an opportunity to reinforce and
apply compensatory strategies learned in the therapy session.
PROGRAM EXAMPLE:
PSYCHOSOCIAL THERAPEUTIC
HORTICULTURE PROGRAM
The Therapeutic Horticulture and Rehabilitative Interventions for Veteran Engagement (THRIVE) Program provides an example of the way
an in-person therapeutic horticulture program can be developed to
Horticultural Therapy 105
foster continued benefit through at-home nature engagement. The
THRIVE Program began in January 2020 as a partnership between a renowned botanical garden and a local urban Department of Veterans Affairs (VA) Medical Center. The purpose of this program is to increase
veteran community engagement, promote mentorship and group cohesion, and teach skills rooted in engagement with the natural world that
promote a reduction in suicide risk factors.
Once a week, veterans attend a 3.5-hour class with a small cohort of
peers at an herb and vegetable garden located within the botanical garden (Figure 5–10). The cohort meets for 4 weeks (Figure 5–11). Each
month, a new cohort attends the program. The primary goal of the
THRIVE Program is to increase veteran resilience and decrease suicidal
ideation through a combination of experiential, didactic, and teambuilding methods.
Each week’s session began with a quiet, contemplative walk around
the garden’s perimeter, allowing for observation and reflection, culminating in a period of journaling in response to a focus question. After a
group sharing of journal responses, participants were introduced to
concepts related to the therapeutic nature of the people-plant relationship and engaged in an activity that exemplified the theoretical framework. A second experiential activity followed the lunch break. Lunch
was an informal gathering, allowing the veterans to socialize, develop
relationships, and deepen cohort bonds. Sessions concluded with group
reflections on the day’s experience.
The veterans participating in the THRIVE program reported sustained reductions in baseline stress, pain, depression, and loneliness
from the first to the fourth week of the program. Additionally, participants reported acute improvement from baseline in symptom domains
following the therapeutic horticulture intervention (Figure 5–12).
Clinical Translation: Case Example
Ms. D, a 52-year-old African American woman, has lived her entire life
in an urban setting with little access to nature. She is a veteran of Oper-
ation Iraqi Freedom and served in the U.S. Air Force. She lives in secure
permanent housing with her husband and mother-in-law and has one
adult daughter who was recently in an out-of-state inpatient rehabilita-
tion facility for addiction treatment. Her daughter’s battle with addic-
tion has been a great source of stress.
Ms. D is a full-time employee of the federal government and worked
remotely during the COVID-19 pandemic. She describes this as being a
difficult time for her, and eventually she was unable to work because of
mental health issues.
106 NATURE THERAPY
Figure 5–10. Veteran potting seedlings in a therapeutic
greenhouse setting.
Source. Photograph courtesy of A. Meore.
Ms. D came to the VA Medical Center in 2009, postdischarge from
active service, and was screened by Transitional Care Management. She
remained in the Air Force National Guard until 2020. She had been receiving monthly treatment from one psychiatrist at the VA Medical Center since 2009. In addition, she had been seeing a social worker weekly
for therapy related to issues of depression and anxiety since 2001.
Ms. D came to the THRIVE Program with diagnoses of chronic
PTSD and adjustment disorder with mixed emotional features, a history
of sexual trauma, and documented alcohol abuse. She described her alcohol consumption as becoming a problem in 2018, when she began hid-
Horticultural Therapy 107
Ice breaker and
introductions
Theory
Exercise or
activity
Break
Week 1
Cohort arrival and
orientation
Journaling and reection
Theory
Break/lunch
Garden walk
Soil experiential exercises
Increase a sense of familiarity and relationship with the
garden environment.
Introduce focus question for journaling and reection.
Share reections and establishing space, place, and
onging.
bel
Promote group safety and support.
Review past concepts.
Introduce concepts: attention restoration theory.
Promote cohort relationships and cohesion.
Increase familiarity and comfort level in garden spaces.
Attend to what we pay attention to.
Create a restorative nature planting.
Learn about care and culture of succulent plants.
Orientation
Journaling
and reection
Week 2
Cohort arrival and
orientation
Journaling and reection
Ice breaker and
participant introductions
Theory
Break/lunch
Greenhouse orientation
Soil experiential exercises
Orient participants to environment. Introduce focus
question for journaling and reection.
Acknowledge the presence of feelings and emotions as
they relate to exposure to nature and the garden.
Establish a sense of space and place.
Multisensory, tabletop plant exploration.
Engage participants in learning how to “listen” to
emotions as they arise.
Introduce concepts: Biophilia.
Introduction of horticultural therapy as it applies to the
A’s Whole Health Model of Care.
V
Promote cohort relationships and cohesion.
Familiarize participants with greenhouse space and plant
maintenance tasks.
Engage in multisensory individual and group experiences
u
tilizing soil and planting mix composition.
Figure 5–11a. Description of weekly horticultural therapy di-
dactics and activities.
VA=Department of Veterans Affairs.
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.” Com-
plementary 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/).
ing her drinking from those around her. In one incident, her mother
confiscated her car keys to prevent her from driving under the influence. Ms. D did report a reduction in alcohol use prior to beginning the
THRIVE Program in 2020. Both her social worker and psychiatrist had
referred Ms. D to the THRIVE Program because of her mental health
symptoms, which were debilitating at times and prevented her from
working. She was prone to panic attacks, exacerbated by her history of
asthma. When the COVID-19 pandemic was initially discovered in 2020,
108 NATURE THERAPY
Ice breaker and
introductions
Theory
Exercise or
a
ctivity
Break
Week 3
Cohort arrival and
orientation
Journaling and reection
Aromatherapy exercise
Nutrition and cooking
Break/lunch
Mindful breathing and bulb
plan
ting exercise
Promote memory formation and reection on garden
experience.
Introduce focus questions for journaling and reection.
Share reections and establishing space, place, and belonging.
Promote group safety and support.
Engage in multisensory experience using culinary spices.
Reinforce the connection between the sense of smell and
memory/emotional recall.
Engage participants in preparing food in groups; educate
and provide nutritional information for body and mind.
Promote cohort relationships and cohesion through the
sharing of food and beverages made collaboratively.
Reinforce learned horticultural skills and relaxation
techniques.
Acknowledge and express feelings of gratitude and
appreciation.
Orientation
Journaling
and reection
Week 4
Cohort arrival and
orientation
Journaling and reection
Theory
Mindful seed harvesting
Break/lunch
Mindful seed sowing
Increase a sense of familiarity and relationship with the
garden environment.
Introduce focus question for journaling and reection.
Share reections and establishing space, place, and belonging.
Promote group safety and support.
Recap biophilia, attention restoration theory.
Introduce mindful nature engagement.
Instill an acceptance of personal imperfection and
encourage a sense of self-compassion.
Foster a sense of purpose and empowerment.
Engage in mindful seed harvesting practice.
Promote cohort relationships and cohesion.
Allow for the acknowledgment of emotion and permission
t
o release it through mindful seed sowing practice.
Bolster a sense of empowerment and skill mastery through
seed sowing practice.
Figure 5–11b. Description of weekly horticultural therapy di-
dactics and activities.
VA=Department of Veterans Affairs.
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.” Com-
plementary 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/).
stay-at-home mandates were issued throughout the world. Ms. D reported feeling increased anxiety as a result of the high risk of complications she might encounter if she were to contract the virus.
Ms. D also reported difficulties with attention and memory recall
that had interfered with her work performance for many years. These
difficulties worsened with the increase in psychosocial stressors and exacerbation of depressive symptoms. She was referred for neuropsychological evaluation by her psychiatrist to assess cognitive function and to
support differential diagnosis and treatment planning.
Horticultural Therapy 109
Stress Pain
A B
6-
6-
4-
Average score
2-
0-
1
Session
Depress Lonely
C D
5-
4-
3-
2-
Average score
1-
0-
1 2–4
Session
2–4
Time
Time
pre
post
pre
post
4-
2-
Average score
0-
4-
2-
Average score
0-
1 2–4
Session
1 2–4
Session
Time
pre
post
Time
pre
post
Figure 5–12. Plots showing data on pre-post patient-reported
outcome scores for four symptom domains—(A) stress,
(B) pain, (C) mood, and (D) social isolation—at baseline (session 1) and subsequent sessions 2–4 merged, depicted as bar
plots for average values from the mixed effect model for each
domain with corresponding standard error.
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. Copyright 2021, Elsevier. This article is distributed under the terms of the Creative Commons Attribution 4.0 International
License (http://creativecommons.org/licenses/by/4.0/).
No areas of cognitive impairment were found during the assessment, but Ms. D did show a weakness of memory processes that was
attributed to her experiences of severe emotional distress. The neuro-
110 NATURE THERAPY
psychologist agreed that these memory lapses are often heightened in
daily life when one is constantly required to process multiple sources of
information at once. Ms. D was strongly encouraged to continue participating actively in her mental health treatment, with a focus on strengthening coping mechanisms for managing psychosocial stressors. It was
hoped that therapy would aid in decreasing her experience of cognitive
difficulties in daily life. After this appointment, Ms. D was recommended to the THRIVE Program.
Within her mental health treatment plan, Ms. D expressed that she
wanted to focus on taking more responsibility for the changes in her life.
In addition, she wanted to understand how to use better communication styles and process the deaths of family and friends. During the
3.5 weeks she participated in the THRIVE Program, Ms. D engaged in
weekly mindful walks through the garden and wrote her responses to
the session’s focus question in a journal. All participants’ responses
were shared within the safety of the group. Each session included an introduction to the theory of the “people-plant relationship” and how it
benefits mental health wellness. This was followed by a hands-on, experiential activity, including
• Sensory engagement with plants to identify feeling states
• Activities promoting self-expression and the sharing of “my
story” represented in the creation of a tabletop garden
• Mindfulness and grounding practice through a repotting
planting exercise
• Creation of an aromatherapy jar using botanicals, which
evoked a relaxed and focused response
Ms. D and her fellow veterans were given a lunch break, which allowed
the group to socialize, develop relationships, and deepen cohort bonds.
Sessions concluded with group reflections on the day’s experience.
Each week during the THRIVE Program, Ms. D engaged in verbal
interaction and self-expression. She was initially quiet and hesitant to
share and speak with other veterans and staff in the program but
quickly showed increased interest in the class content, as evidenced by
increased eye contact, smiling, verbal contributions, and in-depth writing. She expressed, on several occasions, how the garden made her feel
calm and relaxed. During the classes and lunch periods, she engaged socially with the group and openly shared how she felt more socially connected and less lonely being in THRIVE.
During one visit, Ms. D had a few periods when she appeared to
have a panic attack. Her breathing quickened, and she had to sit down.
She was able to access her inhaler, and the health coach present from the
VA Medical Center guided her through a breathing exercise to reduce
her anxiety and respiratory discomfort. Ms. D expressed feeling overwhelmed because the garden was a reminder to her of her deceased
grandmother, which resurrected a grief reaction related to the more
recent deaths of her father, friend, and dog. She expressed that the
THRIVE Program assisted her during these feelings and that she was
grateful for the supportive presence and experience.
Horticultural Therapy 111
Ms. D attended a discharge education course called Next Steps,
which asked her to identify what matters to her and why she wants to
remain in good health. During this class, existing VA wellness and support offerings were explained, and she agreed to continue with virtual
yoga, exercise, and meditation classes, as well as use VA apps such as
PTSD Coach or Mindfulness Coach, in addition to continuing to pursue
her new interest in plants and nature.
Per her psychiatrist and social worker, Ms. D has not engaged in any
drinking since beginning the program and shared that she greatly benefited from the program. She said that the program introduced her to
new things and was “great medicine.” She has been able to return to
work and expressed that her next plan is to move closer to where her
daughter is living so as to have more of an opportunity to repair their
relationship and focus on their health and well-being. Ms. D has been
attending mental health appointments and weekly wellness classes offered at the VA hospital and continues to show progress in managing
her anxiety and depression.
Although Ms. D has a complex medical and personal background,
this is not uncommon for the veterans seen in the THRIVE Program.
Multiple mental and physical health comorbidities and impaired social
relationships are shared by most of the veteran population. Ms. D is one
example of how engagement in horticultural therapy can have a profound effect on mental and emotional health and well-being and how
these effects can generalize to positively affect other areas of one’s life
(Byma 2021).
THIS MOMENT: A RESURGENCE
OF THE CRITICAL ROLE OF
HORTOPHILIA IN DAILY LIFE
Beginning in February 2020, the world experienced a global pandemic,
resulting in an abrupt halt to the hectic pace that Western culture has
come to know. Quarantine mandates, mask-wearing requirements, social distancing, and thousands of jobs lost forced people to stay at home,
away from others. This left many feeling alone and isolated. For those
who had the technical knowledge and capacity to do so, computerbased contact was one of the few ways to connect with others. Our
homes were transformed into the workplace, the classroom, the gym,
and the playroom. All but essential businesses were closed, and hundreds of thousands of our loved ones, friends, and neighbors were losing
their jobs or becoming ill and dying. People were frightened, lonely, angry, confused, and bereft of the human relationships that help define us.
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