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Horticultural therapy in a psychiatric in-patient setting



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 those goals.
Horticultural therapy in a psychiatric
in-patient setting
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
those goals.
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
1Consultant Psychiatrist,
Cambridgeshire and
Peterborough NHS Foundation
Trust, UK, email miguel.
2Specialist Occupational
Therapist, Cambridgeshire and
Peterborough NHS Foundation
Trust, UK
3Specialist Occupational
Therapist, Cambridgeshire and
Peterborough NHS Foundation
Trust, UK
4Advanced Occupational
Therapist, Cambridgeshire and
Peterborough NHS Foundation
Trust, UK
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
health-promoting settings.
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
September 2017).
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.
Studies of the use of green spaces in
mental healthcare
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 suf-
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
horticulture therapy:
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
general well-being.
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
of here.
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,
Global Echoes
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 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
services-2098485311173 (accessed November 2016).
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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.
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benefits of horticulture in a mental health service. British Journal of
Occupational Therapy, 74, 525–534.
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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.
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Visiting green space is associated with mental health and vitality: a
cross-sectional study in four European cities. Health Place, 38, 8–15.
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allotment gardeners: a mixed methodological study. Ecopsychology,
7, 20–28.
... Larger numbers of days per week with activities in the TH group decreased the social loneliness and global loneliness and increased the happiness perspective compared to peers, probably because social interaction helps to tackle social isolation and increase social inclusion, contributing to the individual's recovery (Seixas et al., 2017;Sempik et al., 2014). The social value of horticulture in mental health projects may outweigh the perceived value of the physical environment or the demands of the occupation itself (Harris, 2017;Parkinson et al., 2011). ...
Introduction Therapeutic horticulture (TH) can be considered a non-pharmacological approach to support psychiatric treatments for the improvement of physical and mental health, but information is lacking on whether it has advantages as compared to more conventional occupational therapies (OTs). Method The study focused on institutionalized 25 clients attending TH among other OTs and 15 clients attending OT other than TH. The measures used were the ‘Subjective Happiness Scale’ (SHS) and the ‘Social and Emotional Loneliness Scale for Adults’ (SELSA-S), along with sociodemographic and clinical data. The study design was descriptive, observational and cross-sectional. Results Scores obtained from the SHS and SELSA-S were generally similar for both groups, although 40% of clients in the TH group perceived relaxation. These are in agreement with previous studies performed with chronic schizophrenia clients reporting that TH might effectively decrease depression/anxiety symptoms, but the feeling of hopelessness and quality of life did not change, probably due to long-term institutionalization and required medication that may limit other effects. Within the TH group, clients preferred specific horticultural tasks and more days/week attending activities decreased loneliness and increased happiness. Conclusion TH interventions as an integrative treatment option merits further study on both process and outcome evaluation, to maximize its effectiveness.
... Nature-based therapies have a long history in mental health care, and horticulture was a core programmatic element of many of the now-closed public hospitals of the 19th-and 20thcenturies (Corazon et al., 2010;van Bilsen, 2016). Beneficial effects have been widely documented for nature-based therapies in care settings for older adults and dementia-care patients (Eggert et al., 2015), but few studies document the impact of such programs in inpatient mental health (Pieters et al., 2019;Seixas et al., 2017). Grounded theory method is process oriented, focusing on agency, action, networks, setting, and biography (Charmaz, 2006). ...
Nature-based therapies have a long history in mental health care. Beneficial effects have been documented for nature-based therapies in a variety of other health care settings. The aims of this grounded theory study were to understand the processes of maintaining nature-based therapeutic groups and the value of the activities to patients in a psychiatric inpatient setting. Over a nine-month period, semi-structured surveys of patient responses to nature-based activities were administered to patients in a pilot therapy group assessing the feasibility of a nature-based group program. Findings indicated that the group promoted use of the senses, social interaction, and care of self/others. Perceptions of benefits led to a nuanced understanding of the effects of being in contact with nature. Based on our findings we offer a preliminary theoretical model for patient engagement with nature-based programming in inpatient mental health care.
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Historical environments / cultural built heritage areas are the accumulations and products of the civilizations of the human communities who lived in the settlement areas from prehistoric to the present. Cities gain their own identity with these values. For these reasons, historical environments / cultural built heritage areas are the mirrors of social identity, and they must be carefully protected, guarded and handed over to future generations under better conditions than they are handed over to us, by taking precautions to keep the verbal, written and especially architectural culture within them alive. Based on the theory that cities are living organisms and that historical environments / cultural built heritage areas are an important part of this system, a proposal process that includes different stages, methods and interventions has been developed for the conservation of historical environments / cultural built heritage areas with different characteristics through the treatment process of a living organism. The aim of this study is to discuss "the concept of conservation qualitatively" with the questions of what, why, how and for whom we should conserve in the proposal process. This discussion fictionalizes the intervention types in urban conservation, especially the demolition and reconstruction intervention and the intervention process through the organ transplant analogy.
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Psychological distress (PD) (mental ill-health) has a frequency between 5 and 25% in urban populations, and there is mounting evidence that access to green space might reduce its occurrence. Evidence suggests that the quality of green space is as important as accessibility in promoting mental well-being. A pilot study for EURO-URHIS 2 allowed investigation of access to green space in relation to PD in a deprived urban population in the UK. An adult urban health indicator questionnaire, including the GHQ-12 and validated questions on access to and quality of green space, was sent to a stratified random sample of 1680 adults drawn from one general practice list in Sandwell, UK. Multivariable logistic regression was used to determine associations between attributes of green space and PD adjusting for age, sex and levels of deprivation. There were 578 (35%) completed responses. The reported prevalence of PD [n = 131 (22.7%)] was significantly greater than national England and Wales estimates. As well as accessibility (OR = 0.58; 95% CI = 0.35, 0.96) and sufficiency (OR = 0.12; 95% CI = 0.39, 0.89) of green spaces, having the ability to use them for relaxation and recreation were significantly associated with reduced PD [OR = 0.13 (0.42, 0.94) and OR = 0.11 (0.34, 0.80), respectively]. In addition, a dose-response relationship between number of positive green space attributes and PD was identified (P < 0.05). This population-based study in a deprived urban UK population demonstrates an association, and some dose-response relationship, between access to and quality of green spaces with reduced PD. The cross-sectional design and use of subjective measures limit interpretation of causality. More knowledge is needed on how UK planning affects green spaces and the potential mental health consequences. © The Author 2015. Published by Oxford University Press on behalf of the European Public Health Association. All rights reserved.
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Objectives Care farms enable people who are in some way vulnerable to engage with agricultural places and farming activities. This study investigates how this impacts on the health and well-being of service users and explores associated processes and outcomes.DesignA mixed methods design was adopted that allowed for the integration of quantitative measurements of change with qualitative descriptions of this change. A pragmatic approach provided sufficient flexibility to support the investigation of complex contexts.MethodsA total of 216 service users completed an initial questionnaire, and 137 (63%) of this number provided comparative data in a follow-up questionnaire. Questionnaires contained multiple choice and open-ended questions alongside standardized health and well-being measures requiring Likert-format responses. Semi-structured interviews with 33 service users allowed personal experiences to be detailed.ResultsStatistical analysis of well-being measure scores identified significant positive relationships with the length of time people had been attending the care farm. Questionnaire and interview data presented health benefits as being enabled by the farm environment, the positive experience as supporting personal development, and associated social interactions as becoming increasingly influential as time progressed.Conclusions The health and well-being outcomes that result from participating at a care farm influence multiple elements of the human condition and apply amongst vulnerable people with a wide range of personal needs. Care farms have access to a potentially unique range of resources that can support many service users in becoming happier and healthier individuals.Statement of contribution What is already known on this subject? Care farming is increasingly practised and is suggested to support the health and well-being of people who are in some way vulnerable. Care farms utilize agricultural spaces and activities to provide benefits that are presented as having relevance to public health and social inclusion agendas. What does this study add? This is the first longitudinal study to include participants with such differing personal needs.Associated outcomes are explored to provide an understanding of how they impact on health.People and place are found to be mutually supportive in facilitating positive change.
Green spaces are associated with improved health, but little is known about mechanisms underlying such association. We aimed to assess the association between greenness exposure and subjective general health (SGH) and to evaluate mental health status, social support, and physical activity as mediators of this association. This cross-sectional study was based on a population-based sample of 3461 adults residing in Barcelona, Spain (2011). We characterized outcome and mediators using the Health Survey of Barcelona. Objective and subjective residential proximity to green spaces and residential surrounding greenness were used to characterize greenness exposure. We followed Baron and Kenny's framework to establish the mediation roles and we further quantified the relative contribution of each mediator. Residential surrounding greenness and subjective residential proximity to green spaces were associated with better SGH. We found indications for mediation of these associations by mental health status, perceived social support, and to less extent, by physical activity. These mediators altogether could explain about half of the surrounding greenness association and one-third of the association for subjective proximity to green spaces. We observed indications that mental health and perceived social support might be more relevant for men and those younger than 65years. The results for objective residential proximity to green spaces were not conclusive. In conclusion, our observed association between SGH and greenness exposure was mediated, in part, by mental health status, enhanced social support, and physical activity. There might be age and sex variations in these mediation roles.
Purpose: The potential for ‘‘green’’ interventions to promote mental wellbeing and reduce mental distress is increasingly being recognized. Preliminary evidence suggests that allotment gardening activities may have a significant effect on mental well-being, but a need for further research has been highlighted. This study investigated the relationships between allotment gardening, feeling connected to nature, and well-being.Design: A mixed-methods design was utilized. Measures of subjective well-being (quality of life), eudaimonic well-being, and connectedness to nature were administered, and qualitative data were collected via a cross-sectional online survey of 171 allotment gardeners in the United Kingdom.Findings: Allotment gardeners’ eudaimonic well-being and quality of life in the environmental domain were significantly higher than population means reported in the literature. Regression analysis showed that the amount of time gardeners spent on their allotment during summer predicted eudaimonic well-being. This relationship was fully mediated by feelings of connectedness to nature. Four main themes emerged from the qualitative data: allotments provided a space of one’s own, meaningful activity, increased feelings of connectedness, and improved physical and mental health. Conclusions: The results suggest that allotment gardening is associated with increased eudaimonic well-being but not subjective wellbeing.Furthermore, a mechanism through which allotment gardening enhances well-being is suggested: increased connectedness to nature.Limitations of the study and clinical and research implications arediscussed.
This study aims to find whether proximity to urban green spaces is associated with human mental health. A cross-sectional examination of the relationship between access to urban green spaces and counts of anxiety/mood disorder treatments amongst residents (aged 15 years and over) in Auckland City, New Zealand. Anxiety/mood disorder treatment counts by three age groups were aggregated to 3149 small area units in Auckland. Six measures of green space access were derived using GIS techniques involving total green spaces and useable green spaces. Negative binomial regression models have been fitted to test the relationship between access to green space and area-level anxiety/mood disorder treatment counts, adjusted for age and area-level deprivation. Anxiety/mood disorder treatment counts were associated with three green space measures. The proportion of both total and useable green space within 3 km and distance to nearest useable green space all indicated a protective effect of increased access to green space against anxiety/mood disorder treatment counts. Access to total and useable green space within 300 m did not exhibit significant associations. This study found that decreased distance to useable green space and increased proportion of green space within the larger neighbourhood were associated with decreased anxiety/mood disorder treatment counts in an urban environment. This suggests the benefits of green space on mental health may relate both to active participation in useable green spaces near to the home and observable green space in the neighbourhood environment.
From the sustainable development policies of far-sighted governments to the increasing environmental awareness—and cynicism—of consumers, a range of pressures is being brought to bear on business to improve its environmental performance. This article traces the development of some of those pressures, highlighting industries in the firing line, and examining some of the concerns of consumers. It looks at the ways in which companies can turn the environment game into one in which they, their customers, and the environment are all winners. It also explores the rapidly expanding area of corporate environmental reporting, including forms of environmental disclosure, target audiences, and leading exponents of the field.
Introduction The use of horticulture in mental health settings is widespread. Moreover, its effectiveness is supported by a body of qualitative evidence. Aims The investigators in this research study sought to determine those aspects of their horticultural projects that conferred the greatest therapeutic benefit to their clients. They used outcome measures to rate the responses of participants, paying particular attention to the participants' expressed motivation. Method Qualitative and quantitative methods were used to evaluate six horticultural projects. Ten participants were interviewed, using an adapted version of the Work Environment Impact Scale (WEIS) to rate factors that supported their motivation. Fifty participants were assessed, using the Volitional Questionnaire (VQ) to observe and rate the extent of their motivation. Findings The therapeutic value of horticulture arose from a complex interplay of personal factors, including gender-based preferences, individual interests and social needs. Conclusion The benefits of engaging in horticultural activity are not automatic. The external environment provides challenges, which can be graded by the facilitators to maximise the therapeutic benefit.
Certain observations arose from the implementation of multicentre research on ‘ecotherapy’. Very diverse community groups of people with a range of disabilities, undertaking horticulture and nature conservation as a therapeutic and social enterprise, provided an unexpected conception. We coined the term embracement to capture the meaning of an activity we found in many ‘bottom-up’ examples of social inclusion. Self-organizing groups grow by the members’ choosing to embrace a common identity, which included and integrated health, social and environmental dimensions. Embracement is self-directing, spontaneous and collective, with the potential group members being the driving force.