BJPSYCH INTERNATIONAL VOLUME 14 NUMBER 4 NOVEMBER 2017 87
Horticultural therapy in a psychiatric
Miguel de Seixas,1 David Williamson,2 Gemma Barker3 and Ruth Vickerstaff4
health, public health and social care. Quality
standards are documents that set out the priority
areas for quality improvement. In 2011 and 2012
NICE published quality standards on service user
experience in adult mental health services (NICE,
2011) and on patient experience in adult care in
the National Health Service (NHS) (NICE, 2012).
Among other points, these documents stress the
importance of access to meaningful activities
for people in hospital for mental healthcare that
should include creative and leisure activities,
exercise, self-care and community access where
appropriate, facilitated by trained health or social
care professionals (NICE, 2011), as well as of effect-
ive interactions with staff (NICE, 2012).
In-patient mental health services have a duty to
constantly seek to improve patient experience
and to assist in the development of new skills
that can aid recovery. Horticultural therapy
can be implemented in an economic, social and
environmentally sustainable way to achieve
In the UK, the National Institute for Health and
Care Excellence (NICE) is a public body of the
Department of Health that provides national
guidance and advice on matters relating to health
and social care. NICE publishes guidance, advice,
quality standards and information services for
Peterborough NHS Foundation
Trust, UK, email miguel.
Therapist, Cambridgeshire and
Peterborough NHS Foundation
Therapist, Cambridgeshire and
Peterborough NHS Foundation
Therapist, Cambridgeshire and
Peterborough NHS Foundation
Anyone who comes into this environment feels that they
are in a place of calm, peace, healing and relaxation, which
is a contrast to how our modern society works, which is
busy, crazy, fast and noisy.
The ﬁndings of this study have important
consequences for the evidence-based design of
healthcare settings aimed at supporting and
empowering users to maintain and enhance their
health and well-being. Apart from the beneﬁts to
users’ mental health and well-being, the symbolic
value of holistic versus medical focus, progressive
ideals and value placed on clients and employees
have strong suggestive power. This, in turn, has
resultant economic implications for healthcare
It appears that time spent in green spaces can
provide people with a range of opportunities
to enhance their mental health. It can increase
people’s capacity to self-manage their mental
illness and acknowledge the realities of their limi-
tations, and their ability to develop the conﬁdence
to seek support from interpersonal relationships
as well as from community-based organisations
(Osborne et al, 2007). Additionally, the Australian
case studies reported here, albeit of limited sample
size, highlight the importance of incorporating
gardens into healthcare settings and contribute to
the green healthcare evidence base accessible to
designers, planners, policy makers and hospital
administrators who aim to create and support
Although the ﬁndings cannot be generalised to
the wider population, as a whole they suggest that
gardens or other green spaces should be included
within healthcare plans. In conclusion, while we
acknowledge that there are a range of considera-
tions in the allocation of healthcare resources and
programmes for maximum beneﬁt, we believe that
those programmes which highlight the beneﬁcial
outcomes for people with mental illness of ‘feeling
blue and touching green’ are worth implementing.
Corazon, S. S., Stigsdotter, U. K, Nielson, A. G., et al (2010)
Developing the nature-based therapy concept for people with stress
related illness at the Danish healing forest garden Nacadia. Journal
of Therapeutic Horticulture, 20, 35–50.
Osborne, R. H., Elsworth, G. R. & Whitﬁeld, K. (2007) The Health
Education Impact Questionnaire (heiQ): an outcomes and
evaluation measure for patient education and self-management
interventions for people with chronic conditions. Patient Education
Counselling, 66, 192–201.
Osborne, R. H., Batterham, R. & Livingston, J. (2011) The
evaluation of chronic disease self-management support across
settings: the international experience of the Health Education
Impact Questionnaire Quality Monitoring System. Nursing Clinics of
North America, 46, 255–270.
Townsend, M., Henderson-Wilson, C., Warner, E., et al (2015)
Healthy Parks, Healthy People: The State of the Evidence 2015.
Report prepared for Parks Victoria, School of Health and Social
Development, Deakin University, Melbourne. Available at http://
strong-link-between-nature-and-human-health (last accessed
van den Berg, A. E., Maas, J., Verheij, R. A., et al (2010) Green
space as a buffer between stressful life events and health. Social
Science and Medicine, 70, 1203–1210.
Velarde, M. D., Fry, G. & Tveit, M. (2007) Health effects of viewing
landscapes – landscape types in environmental psychology. Urban
Forestry and Urban Greening, 6, 99–212.
88 BJPSYCH INTERNATIONAL VOLUME 14 NUMBER 4 NOVEMBER 2017
Studies of the use of green spaces in
Population studies have pointed to a positive
impact of green spaces, with a cumulative associ-
ation between access to and quality of green spaces
and lower scores on measures of psychological
distress (Pope et al, 2015), the major determinants
being accessibility of the green space, having sufﬁ-
cient green spaces in the neighbourhood and their
use for relaxation and for recreation. Similarly, van
den Berg et al (2016) have shown a positive associa-
tion between time in green spaces and better scores
on mental health and vitality scales. Nutsford et al
(2013) suggested that green spaces are beneﬁcial to
mental health, in particular in the case of anxiety
and mood disorders, both through people’s par-
ticipation in activities in usable green spaces near
to home and in terms of the proportion of usable
green spaces in a neighbourhood. Similar positive
effects on general health were found by Dadvand
et al (2016). Leck et al (2015) looked at the impact of
‘care farms’ and found that measures of well-being
were positively affected by attendance at these,
with the health beneﬁts mediated by the farm
environment and social interactions becoming
increasingly inﬂuential the longer the participants
attended the care farm.
There is additional evidence suggesting that
several therapeutic goals, such as interaction levels
and self-esteem, can be achieved by gardening
activities (Rappe et al, 2008). These may have a
positive role in the longer-term management of
mental health, with ‘green’ interventions increas-
ingly recognised in the promotion of well-being
(Webber et al, 2015).
Speciﬁcally relevant for an in-patient popu-
lation is a study that identiﬁed the beneﬁts of
bringing horticultural therapy into patient spaces
in a population with dementia (Lee & Kim, 2008).
Ward garden spaces provide opportunity for
graded participation in a number of green activi-
ties (Parkinson et al, 2011). A great beneﬁt of these is
social inclusion, identiﬁed by Caan (2004) as a way
to provide a common identity. The psychological
beneﬁts of indoor plants in a population of ofﬁce
workers were critically reviewed by Bringslimark
et al (2009), with the recognition of the impact on
outcomes such as psychophysiological stress.
The Cavell Centre’s horticultural therapy
The Cavell Centre in Peterborough is one of the
main mental health centres in the east of England.
Among other clinical services, it lodges ﬁve adult
mental health in-patient wards catering predomin-
antly for patients, both voluntary and detained,
from north Cambridgeshire and the Fenlands who
are experiencing an acute deteriora tion in their
mental health. With the awareness of promising
outcomes in a variety of studies and of the afore-
mentioned recommendations from NICE, the local
acute adult mental health pathway team developed
with the available resources a horticultural therapy
project for the acute in-patient general adult
psychiatry wards. Here we describe our pathways
for horticulture therapy, the outcomes and chal-
Our in-patient wards have different pathways for
• plant in your room
• on-ward gardening (individual or in a group)
• on-site garden
• off-site community allotment
• volunteer community gardening
• paid gardening.
These pathways are underpinned by our model
of practice: the Model Of Human Occupation
(MOHO; Kielhofner, 2008). Our therapists work
to improve the patient’s occupational performance
skills. One of the core themes of this model is that
humans are occupational beings and need to ‘do’,
in the sense that there is a need to participate in
tasks that offer a sense of self-worth. This model
looks at behaviour from three key areas: volition,
habituation and performance. The aim is to
deliver meaningful and productive activities that
can enable patients to develop their horticultural
skills, and to do so within the framework of the
triple bottom line of economic, social and environ-
mental sustainability (Elkington, 1994).
As a proxy measure of how well received the
project is, we rely on the average number of par-
ticipants per week. Participation is on a voluntary
basis. We also rely on qualitative statements from
participants to review the role of the horticultural
therapy project in their recovery and make adjust-
ments as necessary, acting on that feedback.
Recent feedback surveys from the off-site allot-
ment group revealed that 83% of 75 respondents
(from a total of 27 documented allotment sessions)
rated the group as ‘helpful’, ‘mostly helpful’ or
‘extremely helpful’. Additional beneﬁts informally
reported to the therapy team included a reduction
in anxiety and in restlessness, and a feeling of
Some comments made by patients concerning
the project are quoted below:
Getting off the ward and focusing on something else.
Perfect practice for when you go home.
Thinking about work and looking forward to getting out
Helping out with the garden and being productive.
Beautiful ﬂowers, beautiful garden, beautiful day, beautiful
The project contributes to a better experience
of the people admitted to our wards at a particu-
larly difﬁcult period of their lives. It also has other
associated gains. It strives to be self-sufﬁcient. This
includes less purchasing of essential resources,
BJPSYCH INTERNATIONAL VOLUME 14 NUMBER 4 NOVEMBER 2017 89
BJPsych International would like to encourage submissions from medical
students, foundation doctors and psychiatry trainees. Those who are
beginning their careers in mental health are often involved in high-quality
projects or have diverse training and clinical backgrounds that would
be stimulating for our readers to discover. They represent a valuable
source of knowledge that can help all professionals to keep abreast of
what is happening in the ﬁeld around the world. We would like to receive
submissions in the following areas, with a focus on international mental
health work: brief literature reviews on mental health policy or services;
reports of elective projects in psychiatry or other experiences of working
or volunteering abroad; reﬂective or descriptive pieces about work
undertaken or experiences or challenges encountered in working around
the world, or in carrying out research in challenging contexts.
Submissions should be between 500 and 1500 words and original
pieces. Email firstname.lastname@example.org. Submissions will undergo peer review. See
the online BJPsych International guidelines on format and style (http://
reduced travel times and having a low carbon
footprint. Produce harvested provides ingredients
for cooking sessions, which in turn give an oppor-
tunity to teach basic cooking skills.
Challenges and limitations
We have encountered different challenges that we
tried to address through better multidisciplinary
work within the ward teams and communication
with the in-patients. These include professionals
overestimating the abilities or misinterpreting the
skill set required for participation, the need for
one-to-one input while in a group setting when
there is only one facilitator available, the absence
of appropriate clothing and footwear, and reduced
motivation of some patients, leading to low partici-
pation rates at times.
Another limitation is the level of psychiatric
disorder in our in-patient population, sometimes
incompatible with participation in horticultural
therapy due to factors such as reduced concen-
tration, reduced executive function, inability to
sustain activity for prolonged periods, reduced
strength or stamina, risk of aggression and of
absconsion, as well as, at times, intentional or
unintentional destruction of the task environment.
The project originally started as a tentative
small occupational therapy group running off the
ward. Given that horticultural therapy is one of the
aspects of treatment on offer among a plethora of
intensive interventions available in an in-patient
unit, it becomes difﬁcult to measure the particular
impact of this speciﬁc intervention.
Finally, time limitations and weather can also
affect the ability to complete necessary tasks, such
as digging over an entire allotment ready for
The horticultural groups have a positive impact on
the care provided, and contribute to the achieve-
ment of good vocational and educational outcomes.
Patients can work vigorously and energetically or
take a steadier approach. Our patients report that
the project helps and supports the wider in-patient
community, and describe pride and a sense of
achievement when returning from these groups.
Meaningful and purposeful goals are beneﬁcial
to all involved, although doing things just for the
pleasure of it is an often-understated gain. Social
interaction takes place in all the pathways – with
services, peers or members of the public. This
helps to tackle social isolation and increase social
inclusion, contributing to the individual’s recovery.
Bringslimark, T., Hartig, T. & Patil, G. G. (2009) The psychological
beneﬁts of indoor plants: a critical review of the experimental
literature. Journal of Environmental Psychology, 29, 422–433.
Caan, W. (2004) Social exclusion and embracement: a helpful
concept? Primary Health Care Research and Development, 5,
Dadvand, P., Bartoll, X., Basagana, X., et al (2016) Green spaces
and general health: roles of mental health status, social support, and
physical activity. Environment International, 91, 161–167.
Elkington, J. (1994) Towards the sustainable corporation: win–
win–win business strategies for sustainable development. California
Management Review, 36, 90–100.
Kielhofner, G. (2008) Model of Human Occupation: Theory and
Application. Lippincott Williams and Wilkinson.
Leck, C., Upton, D. & Evans, N. (2015) Growing well-beings:
the positive experience of care farms. British Journal of Health
Psychology, 20, 745–762.
Lee, Y. & Kim, S. (2008) Effects of indoor gardening on sleep,
agitation, and cognition in dementia patients – a pilot study.
International Journal of Geriatric Psychiatry, 23, 485–489.
NICE (2011) Service User Experience in Adult Mental Health
Services (Quality Standard 14). National Institute for Health and
Care Excellence. Available at https://www.nice.org.uk/guidance/
services-2098485311173 (accessed November 2016).
NICE (2012) Patient Experience in Adult NHS Services (Quality
Standard 15). National Institute for Health and Care Excellence.
Available at https://www.nice.org.uk/guidance/qs15/resources/
Nutsford, D., Pearson, A. L. & Kingham, S. (2013) An ecological
study investigating the association between access to urban green
space and mental health. Public Health, 127, 1005–1011.
Parkinson, S., Lowe, C. & Vecsey, T. (2011) The therapeutic
beneﬁts of horticulture in a mental health service. British Journal of
Occupational Therapy, 74, 525–534.
Pope, D., Tisdall, R., Middleton, J., et al (2015) Quality of and
access to green space in relation to psychological distress: results
from a population-based cross-sectional study as part of the EURO-
URHIS 2 project. European Journal of Public Health. Epub ahead of
Rappe, E., Koivunen, T. & Korpela, E. (2008) Group gardening in
mental outpatient care. Therapeutic Communities, 29, 273–284.
van den Berg, M., van Poppel, M., van Kamp, I., et al (2016)
Visiting green space is associated with mental health and vitality: a
cross-sectional study in four European cities. Health Place, 38, 8–15.
Webber, J., Hinds, J. & Camic, P. M. (2015) The well-being of
allotment gardeners: a mixed methodological study. Ecopsychology,