California Society for Clinical Social Work

Horticulture Therapy Offers Meaning, Healing, and Hope for Millions Living with Mental Illness

12/04/2016 9:30 AM | CSCSW Administrator (Administrator)

Ariel Schneider, ASW

“For the meaning of life differs from man to man,
from day to day, from hour to hour. What matters, therefore, is not the meaning of life in general but rather the specific meaning of a person’s life at a given moment” (Frankl, 1959, p. 108).

Reconnecting people with the outdoors and their food sources is gaining popularity after a long period of mainstream cultural disconnection. The local food movement phenomena popularized by such authors as Michael Pollan, Barbara Kingsolver, and Eric Scholsser, urges us to support sustainable agriculture by eating fresh foods produced by nearby farms (Alkon & Agyeman, 2011).  From the White House initiative to end obesity through fresh food education to a free substance abuse treatment center in Italy that utilizes farm-based work (Pianigiani, 2013), the healing effects of the outdoors are increasingly recognized across disciplines. 

Research tells us that connecting with or being surrounded by the natural world has numerous positive effects.  It produces an increase in the subjective experience of vitality (Ryan, Weinstein, Bernstein, Brown, Mistretta, & Gagné, 2010), a restoration to mental clarity, and a physical healing to the body (Clay, 2001).  Relatedly and perhaps unsurprisingly, these healing qualities of nature have been shown to improve functioning for vulnerable populations, including people with depression (Gonzalez, Hartig, Patil, Martinsen, & Kirkevold, 2010), dementia and Alzheimer’s (Jarrott, Kwack, & Relf, 2002), cognitive delays (Berman, Jonides, & Kaplan, 2008), post-traumatic stress disorder (Lorber, 2011), major mental illness (Simpson & Straus, 1998), and sensory integration issues (Wagenfeld, 2009), as well as for individuals involved with the criminal justice system (Hale, Marlowe, Mattson, Nicholson, & Dempsey, 2005) and living in low-income communities (Hale, Knapp, Bardwell, Buchenau, Marshall, Sancar, & Litt, 2011).

Long before the relatively recent popularization of the positive effects of being in and caring for nature and eating a diet rich in fresh plant foods, the idea existed that people with mental illness might benefit from working outside in a farm-like environment.  About 200 years ago, America’s first Surgeon General, Benjamin Rush, MD, wrote prolifically about the use of farms for the treatment of the mentally ill (Lewis, 1987) and started the first hospital-based garden program in 1817 at Friends Hospital in Philadelphia, Pennsylvania (Taylor, 2009).  Years later, this approach evolved into a more institutionally-based treatment modality routinely implemented by state psychiatric hospitals.  In 1936, the Camarillo State Mental Hospital in Southern California (which closed in 1997) was founded as one of many state hospitals designed to treat patients for months to years to entire lifetimes (Noxon, 1997).  The hospital housed 100 “working patients” to maintain farming operations on its 1200 acres, including 304 acres of alfalfa, 227 acres of vegetables, 178 acres of grain crops, and 80 acres of orchards. 

Hospitals around the country operated similar programs within the context of Moral Treatment, a period of U.S. American psychiatry during much of the 19th century that saw a shift toward more humane treatment of patients.  Under this model, providers developed close personal relationships with their clients, rewarded patients’ positive behavior, and created daily opportunities for purposeful activity (Dunkel, 1983).  Some cite this model as hugely successful for being the first practical effort to provide systematic and responsible care for the mentally ill in the U.S. and abroad (Bockoven, 1963).  Camarillo’s program was drastically reduced in 1969, when new legislation eliminated indefinite commitments of persons defined as “mentally disabled” (Camarillo State Hospital, 1993), though it continued to house patients into the early 1990s.  This time in history marked a significant shift in attitudes and public policies in the treatment of mental illness.

Following the deinstitutionalization of mental health care, therapeutic horticulture has emerged in communities around the world, but lacks any systematic backing from the mental health community.  One such example is the Grow Native Nursery in the Westwood neighborhood in Los Angeles, California that partners with the VA Greater Los Angeles Healthcare System to “maximize veterans’ opportunities in the sustainable horticulture industry” (Rancho Santa Ana Botanic Garden, 2012).  Located within the Veteran’s Garden, capable VA patients are invited to spend a few hours per week at the nursery, engaging in all aspects of nursery business and building skills, that they can then apply in a job once discharged from hospital care.  Similar programs can be found at VA hospitals around the country (Taylor, 2009), but unfortunately they are neither representative of national VA policy nor psychiatric hospital policy in general.

One of the more exciting therapeutic horticultural projects currently underway is the first-of-its-kind sensory garden at the UCLA Resnick Neuropsychiatric Hospital where I work.  Once weekly, adult patients are invited to interact with the garden to the best of their ability whether that means turning the soil, pruning the plants, smelling the herbs, watering, or simply watching other people complete these tasks.  By patient self-report, there is an improvement in patients’ mood and evidence that gardening has reduced the amount of physical and chemical restraints needed on the unit.  We hope to be able to show that our integration of horticulture therapy into our regular milieu program has contributed to a significant reduction in patient heart rate and blood pressure, as well as to an overall positive experience in the inpatient unit.

Logotherapy offers a theoretical lens by which to understand the impact of meaningful horticultural therapies.  Developed by Austrian neurologist and psychiatrist Viktor E. Frankl, logotherapy offers a psychological framework from which to understand how humans can persist through extreme hardship.  Frankl is considered one of the founders of the Third Viennese School of Psychotherapy following Freud, who proposed a “will to pleasure” and Adler, who proposed a “will to power” (Frankl, 1969). Instead, Frankl offers a “will to meaning” based partly on his experiences as a survivor of a concentration camp during the European Holocaust in World War II (Ameli & Dattilio, 2013).

Frankl’s concepts are based on three major tenets, including freedom of will, the will to meaning, and the meaning of life—all of which rest on the core assumption that humans are capable of surviving even the most horrific of experiences if they have an attitudinal belief in a higher meaning (Frankl, 1969).  Similar to the phenomena around vocational horticulture, these three major concepts focus on an individual’s future and the meanings to be fulfilled (Frankl, 1959).  Following diagnosis of a mental illness, individuals have been reported to feel a loss of self, power, meaning, and hope for the future (Slade, 2009), or what Frankl would call the “existential vacuum,” which explains why rehabilitation efforts not addressing these feelings fail (Julom & de Guzmán, 2013). Furthermore, individuals can experience a sense of isolation, rejection, and objectification following a diagnosis.  Horticultural activities provide individuals with meaning via responsibility to plants, animals, and other community members, as well as through a newfound sense of purpose.

There are a number of community-based programs, as well as a growing body of research, that address the increasing desire among individuals with psychiatric disability or mental illness to acquire vocational skills that aim to help people find meaning in their lives.  In fact, Supported Employment is now considered an evidence-based practice with widely-researched outcomes and models for implementing programs in mental health agencies (Becker & Drake, 2003; SAMHSA, 2009).  However, there is an underutilization of this model in mental health treatment in part due to different perspectives between practitioners and consumers about the importance of the consumers’ desire to work (Casper & Carloni, 2007).  In the United States, only two percent of people with serious mental illness receive any form of Supported Employment (Marshall et al., 2013). 

Vocational horticulture is a form of Supported Employment that comes out of the larger field of horticulture therapy.  Vocational horticulture focuses on training individuals to work in the horticulture industry, either independently or semi-independently (Messer Diehl, 2007), as a way to provide rehabilitation for individuals who historically would have been institutionalized for treatment.
There is great need for recovery-oriented alternatives, such as horticulure therapy, within the current landscape of mental health care in this country.  One out of four U.S. American families experience mental illness.  Unlike other ailments, mental illness does not discriminate across race, age, income, religion, or education (NAMI, 2013).  For the nearly 57.7 million adults living with a mental illness in this country (NAMI, 2013), the hopes for recovery are largely dependent on an individual’s access to both pharmacological and psychosocial interventions, an opportunity that may be hard to come by for those without good insurance or access to treatment (NAMI, 2013).  For acute crises, psychiatric hospitals serve as places for stabilization and connection to longer-term options, which often include partial hospitalization programs, board and care facilities, or residential treatment centers, depending on an individual’s diagnosis.  Certainly, these options provide support to individuals who can participate meaningfully, but this is not the case for many psychiatric patients for whom symptoms or social situations are barriers to participation or follow-through. 

For those who can even access these services, treatment can be isolative and prevent an individual from engaging in “real-world” pursuits.  Less than 15 percent of people receiving public mental health treatment hold competitive jobs despite the 60 to 70 percent of people who would like to do so.  This is in part due to a lack of vocationally-focused rehabilitative services (SAMHSA, 2009).

As a psychiatric social worker, I have often felt a sense of dissatisfaction upon discharging a patient who I believed might return to the hospital because the discharge plan failed to include sufficient recovery-oriented services.  My toolbox of interventions is limited and frequently dictated by insurance policies.  I often find myself wondering what alternatives exist for people to work toward recovery following discharge.  I strongly believe that horticulture therapies could be one such alternative for many patients.

The current healthcare system is poised to contribute to a shift toward recovery-based mental-health interventions, including horticulture therapy, due to its monetary resources, regular access to the public, and the recent shift in the medical community toward recovery-oriented practices (Barber, 2012).  People look to their doctors and mental health care providers as experts, who therefore have a lot of power when it comes to shaping their patients’ perceptions.  Reaching people within their chosen communities and offering interventions to meet people at the level of engagement in which they are open will further reduce the barriers to receiving care and ultimately help people feel better and live more meaningful lives.

Clinical social work’s whole-person approach to care implies that we must look at complementary and alternative treatment options, such as horticulture therapy, as we work to connect people with the services they need.  Given our ethical standard to “promote wellbeing” and to make “client’s interests primary” (NASW, 2008), social workers are a key link to rehabilitative services.  We are not only able to provide a therapeutic experience while interacting with our clients, but also to offer options about where to receive treatment and where and how the most healing might occur.  The intentional and attuned relationships we build with our clients, similar to the mentorship model employed in horticulture therapy, is core to how social workers are instructed to approach treatment.

Ariel Schneider, ASW is a psychiatric clinical social worker and researcher of nature-based therapies in Los Angeles, California.    She is currently a clinical social worker at the UCLA Resnick Neuropsychiatric Hospital, where she works with adults and older adults admitted for acute psychiatric care.  She studied psychology as an undergraduate at the University of California, Berkeley and completed her MSW in 2014 at Smith College School for Social Work, where she conducted her thesis research on horticulture therapy for adults with major mental illness.  She has worked clinically for many years with homeless adults, school-aged children, and frail older adults in New York City, the San Francisco Bay Area, and Los Angeles.  Ariel commutes to work by bicycle and keeps a small garden of succulents, herbs, and vegetables.  She would love to connect with you to continue the conversation about horticulture therapy or if you are using horticulture practices in your clinical work.  Please contact her at aschneider@mednet.ucla.edu. 

References
Alkon, A., & Agyeman, J. (Eds.) (2011). Cultivating food justice: race, class, and sustainability. Cambridge, MA: MIT Press.
Ameli, M., & Dattilio, F. M. (2013). Enhancing cognitive behavior therapy with logotherapy: Techniques for clinical practice. Psychotherapy, 50(3), 387-391.
Barber, M. (2012). Recovery as the New Medical Model for Psychiatry. Psychiatric Services, 63(3), 277-279.
Becker, D. R., & Drake, R. E. (2003). A working life for people with severe mental illness [electronic resource]. New York, NY: Oxford University Press.
Berman, M. G., Jonides, J., & Kaplan, S. (2008). The cognitive benefits of interacting with nature. Psychological Science (Wiley-Blackwell), 19(12), 1207-1212.
Bockoven, J. (1963). Moral treatment—Forgotten success in the history of psychiatry. In, Moral treatment in American psychiatry (pp. 10-19). New York, NY: Springer Publishing Co.
Camarillo State Hospital. (1993). History. Retrieved from http://repository.library. csuci.edu/bitstream/handle/10139/6151/CSH0006$.pdf?sequence=1
Casper, E. S., & Carloni, C. (2007). Assessing the underutilization of supported employment services. Psychiatric Rehabilitation Journal, 30(3), 182-188.
Clay, Rebecca A. (2001). Green is Good for You. American Psychological Association 32(4). Retrieved from http://www.apa.org/monitor/apr01/greengood.aspx

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