Experiencing a Garden: A Healing Garden for People Suffering from Burnout Diseases Ulrika A. Stigsdotter and Patrik Grahn 2003 : XIV JOURNAL OF THERAPEUTIC HORTICULTURE 39 A healing garden is being laid out at BACKGROUND At the time of this writing, autumn 2002, a garden is being the Swedish University of Agricultural laid out at the Swedish University of Agricultural Sciences’ Sciences’ Alnarp campus. The garden is Alnarp campus in southern Sweden. The garden is intended to be a healing garden: a garden that, in different ways, intended to serve several purposes. It will influences the visitor in a positive way (Cooper Marcus & offer horticultural therapeutic treatment Barnes, 1999). In a prior article “What Makes a Garden a Healing Garden?” (Stigsdotter & Grahn, 2002), the authors programs for people diagnosed as having sorted theories of healing effects of gardens stemming from had burnout disease for an extended different research disciplines into three different schools: period. An interdisciplinary research ■ The Healing Garden School. The health effects are derived program will study how the garden above all from the experiences of the garden room as such, its design, and contents. functions for these people. Scientists ■ The Horticultural Therapy School. The health effects are will test different design hypotheses derived primarily from the activities in the garden room. ■ The Instorative School (formerly the Cognitive School). connected with the garden as well as The health effects are derived from the experiences of the different forms of horticultural therapy. garden room as such, from the activities in the garden room, and the visitor’s background and character: The garden will also serve as an object of experiences of which give the visitor a feeling of study for students. This article describes belonging and identity. and discusses the project’s background The aim of creating the Healing Garden at Alnarp is to and the process leading to the final investigate how well the above-mentioned three schools can predict how participants behave in a garden, what they like design of the garden. and dislike there and, above all, whether, and how quickly, they recover. This aim has directed the design of the garden as well as the activities carried out in it. In some parts of the garden, the design is influenced primarily by the theories put forth by the Horticultural Therapy School, in other parts those of the Healing Garden School or the Instorative School. In the Healing Garden at Alnarp campus, all schools have had an equal amount of influence from the outset. The Healing Garden at Alnarp covers about two hectares and offers both nature-like areas with restorative qualities and more traditional cultivation areas with plant beds and qualities focusing on activity. The garden is intended to: ■ Offer different horticultural therapeutic treatment programs to people suffering from “burnout diseases” ■ Provide a setting for an interdisciplinary research program that will study how the garden functions for these people ■ Allow scientists to test different design hypotheses connected with the garden as well as different forms of horticultural therapy ■ Serve as an object of study for students The design of the garden has been developed under the direction of landscape architect and Associate Professor Patrik Grahn who is responsible for the project. He has worked in 40 JOURNAL OF THERAPEUTIC HORTICULTURE XIV : 2003 close cooperation with landscape architects Sara Lundström, patients. The participants will be referred to the Healing Ulrika A. Stigsdotter, and Frederik Tauchnitz. Other experts Garden at Alnarp from hospitals, social insurance offices, such as physiotherapists and horticultural therapists have insurance companies, and the industrial health service. All been consulted during the design phase. those receiving treatment at the garden must have some type of illness that has been triggered or severely aggravated by The purpose of this article is to describe and interpret the stress. This illness may have been diagnosed as fatigue basic design of the Healing Garden at Alnarp as well as the depression, STFR (stress-triggered fatigue reactions), burnout working process itself. The article consists of two parts. The syndrome, and/or pain in the back or back of the head. They first part describes the project’s theoretical background and must all have stated that they would gladly work with working process and the second part describes, explains, and gardening. In the course of a treatment lasting for a few interprets the garden’s design. months, the participants will work and spend time in the garden together with horticultural therapists for four hours a THE HEALING GARDEN: day. There also will be a comparison group composed of A MULTIDISCIPLINARY PROJECT individuals with the same kinds of stress-related symptoms. The staff of the Healing Garden at Alnarp will be organized All patients in both groups will be selected by a team into two teams: a treatment team that cares for the patients consisting of two physicians (one an expert in psychiatry, the and a research team that follows and evaluates the treatment other in family medicine), one physiotherapist (an expert in activities and how well the design of the garden functions. pain), and one occupational therapist/horticultural therapist. When making the diagnosis, the team members will consider: The Research Team The research approach will be multidisciplinary. The team ■ Diagnosis according to SCID I and II (First, Gibbon, will consist of four landscape architects, two occupational Spitzer, Williams & Benjamin, 1999) and diagnosis of therapists, two psychiatrists, one rehabilitation physician, and somatic morbidity one environmental psychologist. Of these, two landscape ■ Questionnaire of health and function - Tibblin Quality of architects, one occupational therapist, and one psychiatrist Life SF36 (Wiklund, Tibblin & Dimenäs, 1990) will work full-time with these studies. The landscape ■ Diagnosis of global function according to GAF-S and architects, whose research during the past 20 years has GAF-F (Herlofson & Landquist, 2002) focused on restorative rest and visual experiences, will ■ Participant account of medical history collaborate with the occupational and horticultural therapists, ■ Previous history of sick-leave: reasons and time course whose approach has centered on activities. They will also have ■ Blood-tests (such as levels of cortisol, steroids, and peptides) the opportunity to collaborate with a behavioral scientist as well as doctors in psychiatric and rehabilitative medicine. The The comparison group will receive treatment as usual. This landscape architects mainly will test and compare different most often involves remaining at home for a long rest period design hypotheses. The behavioral scientists will focus on how of about ten to twelve months. During this time, patients the garden is used, whereas the occupational therapists and usually receive medical treatment involving selective doctors in rehabilitative medicine will evaluate the patients’ serotonin reuptake inhibitors (SSRI; antidepressants motor activity, pain, and activities of daily living. The such as Prozac and Zoloft), and five to six sessions of psychiatrists will also study the patients’ stress hormone physiotherapeutic and/or psychotherapeutic treatment. cortisol via saliva tests, concentration capacity using various Sometimes receiving treatment as usual implies involvement tests, and mood, sense of coherence, self-esteem, etc. using in a rehabilitation program, which most often consists of a self-estimate tests. The different researchers will work two-week period of rehabilitation. This rehabilitation involves together very closely. treatment from a team consisting of an occupational therapist, a physiotherapist, and an almoner. The estimation is that The Treatment Team about 80% of the comparison group will receive the former The treatment team will consist of two horticultural treatment and about 20% the latter. The research team will therapists, one landscape architect, one occupational follow these groups and study differences and similarities with therapist, and one anthroposophic medical pedagogue. Two respect to both qualitative and quantitative techniques. The days a week one physiotherapist and one psychotherapist will groups will be assessed after four weeks, eight weeks, 16 also be present. Every patient will have a doctor responsible weeks, and 28 weeks of treatment. for him or her. Because the garden will be part of a large project involving The Participants many people, the researchers and designers will need to work The individuals visiting the garden for the purpose of strategically and in parallel, basing their efforts on three rehabilitation will be called participants, not patients. The overall perspectives that will be briefly presented below: intention is to strengthen their image of themselves as non- 2003 : XIV JOURNAL OF THERAPEUTIC HORTICULTURE 41 ■ The needs of the participants leave period. During this time, the individual is often ■ The design requirements of the research studies hypersensitive to stress. ■ The geographical and historical context of the garden What characterizes this condition is that the slightest demand THE NEEDS OF THE PARTICIPANTS may trigger reactions of tears, irritation, immense tiredness, A Picture of the Pathology and/or aggression (Maslach, 2001). At this stage, burned out When designing a healing garden, it is of utmost importance