[Landscape Northwest]
March 31, 1998

The garden as healer

David Evans and Associates

People relate to plants. That is the basis for therapeutic landscape design and horticultural therapy.

Therapeutic gardens are designed for children, for those with temporary or permanent physical disabilities, for patients with Alzheimers disease, for the elderly, for those with terminal illnesses and their families, and for prison inmates. They are large and small, fully accessible or only for viewing, and for day and night use. They are as varied as our culture. Their value lies in the positive associations people have with plants.

Plants have aesthetic, temporal and spiritual qualities. The annual dormancy and rejuvenation of plants mark time, and provides a sense of connection to the earth and to other living organisms.

A garden can restore a sense of order, safety and privacy for those dealing with the chaos induced by illness. The act of gardening produces a peaceful, effortless concentration that increases our capacity to rest. It creates more outward perceptions rather than inward self-consciousness, a valuable balance to the uneasiness of illness. A therapeutic garden creates a complementarity between life and place.

While the therapeutic value of the garden is being rediscovered, it has roots deep in time.

A short history

Evidence of restorative gardens can first be found during the Middle Ages in Europe. Medieval hospices integral to monasteries were the first restorative gardens to appear in the West. Patient's cells bordered an arcaded courtyard that offered sunlight, a lawn, seasonal plants and a place to sit or walk. In addition, the monasteries were traditionally quiet places suffused with mysticism, adding to comfort and hope for patients.

As the care of the infirm changed from monastic institutions to civic and ecclesiastical institutions, landscaped spaces attached to hospitals became simply products of traditional architectural practice. The Ospedale Maggiore in Milan (1458), was built in a cruciform plan with windows too high to view the formal gardens outside.

Then emergence of scientific medicine and of Romanticism in the 17th and 18th centuries brought attention to sanitation and fresh air as well as a new appreciation for the effects of nature upon the body and soul. The pavilion hospital, with outdoor spaces between pavilion wards, became the predominant form throughout the 19th century.

Changes in the treatment of psychiatric patients and in the design of psychiatric hospitals also occurred around the end of the 18th century. Treatment changed from physical punishment to psychological security. Psychiatric institutions were planned with outdoor spaces planted to screen patients from curious spectators. Landscaped views were created to provide comforting experiences. Grounds maintenance, gardening and farming became part of the patient's therapy.

But restorative gardens took a downturn in the 20th century with the technological advances in medical science and in building construction. Low-rise pavilion hospitals were replaced with multistory medical complexes because of advances in high-rise construction, the increased use of elevators within buildings and increased demand for efficiency. The design emphasis shifted toward saving steps for physicians and nurses, and away from the patient's experience with the environment.

By the 1970s, the typical acute-care hospital had become a sealed, air-conditioned edifice that looked like a modern office building. The only outdoor experience was the walk from the parking lot to the front door. Some of these institutions have gardens and courtyard spaces, but they are seldom considered usable outdoor spaces for the treatment of illness or injury.

The exceptions are facilities catering to the care of long-term chronic illnesses. With the rise of the occupational therapy profession in the early part of this century, the rehabilitation practice that was once limited to psychiatric patients was extended to patients with physical problems.

A garden can restore a sense of order, safety and privacy for those dealing with the chaos induced by illness.

After World War II, horticultural therapy programs began utilizing specially designed gardens for work with veterans, the elderly and those with various stages of dementia. Most recently, hospices that cater to AIDS and cancer patients often include gardens for their restorative and therapeutic effects. Ronald MacDonald Houses, temporary residences for children with cancer and their families, normally include a garden in their homelike settings.

Now, in the last decade of the 20th century, the newly emerging integrated health systems are not as interested in creating fee-for-service profit centers. These providers are more focused on patient outcomes, exploring new clinical pathways and reducing costs without sacrificing quality.

The reshaping of their patient's environment to be more consumer-friendly is part of current efforts to promote prevention of health problems. Therapeutic gardens and horticulture therapy programs are another part of this holistic concept of patient-centered care.

Garden guidelines

This abridged list of design guidelines for gardens in health care facilities is adapted from a study by Clare Cooper Marcus and Marni Barnes, and may be used for new gardens or existing gardens in need of renovation.

It does not take into account location or site planning issues, nor does it include policy and maintenance recommendations. Although these are important considerations, space does not allow a complete discussion of these issues. The following guidelines are specific to the design of the space selected for a garden:

  1. Use lush, colorful planting that is varied and interesting to reinforce the image of a garden.

  2. Use flowering plants over several seasons to mark the seasons and provide a sense of cyclical rhythm throughout the year.

  3. Use trees whose foliage moves easily and creates noise even in a slight breeze. Place the trees to create patterns of color, shadow, light and movement.

  4. Use plants and other devices (such as feeders and birdbaths) to attract birds and butterflies. Be careful to avoid plants that attract large numbers of bees or undesirable insects.

  5. Use a harmonious variety of plant textures, forms and colors. Plant them in a pleasing and mindful arrangement that attracts notice.

  6. If possible, add a water feature. Moving water creates a soothing sound and can create a psychological screen that helps the restoration process. Still water can promote meditation and peacefulness. Consider exposure to wind and competing noises when selecting locations for water features.

  7. Create a planting buffer between public garden spaces and private offices or patient rooms bordering the garden.

  8. Provide meandering paths where possible to encourage strolling and reflection on elements in the garden. Where possible, provide a variety of vistas, levels of shade and textures of planting.

  9. Select paving surfaces that accommodate wheelchairs or gurneys. Make at least the main paths wide enough for patients in wheelchairs to pass one another -- at least five feet.

  10. Nighttime lighting allows the garden to be used or viewed after dark. Use low path lighting and low voltage landscape lighting with fixture shields so that glare does not shine into adjacent patient rooms.

  11. Movable chairs or benches placed at right angles provide for more social interaction. Provide seating for varying levels of sociability. Place some seating at the entrance to the garden for those with limited time (such as staff on a short break). Seats should have backs and sturdy arms, and should be made of material that is pleasing to touch.

  12. Provide a variety of shelter and exposure so that the garden may be used in different seasons. People will seek out sunny spots on a cool day and shady areas on a hot day. Covered areas, especially at the entrance to the garden, could allow the garden to be used during a rainstorm.

  13. Take advantage of natural views from the site. If there is no ready view, design a series of experiences and focal points as one moves through the space.

  14. Provide one or two memorable features by which people can identify the garden. Sculpture, sound, water, a profusion of flowers, or an edible vegetable garden will provide strong memories of the garden and the renewal found there.

A landscape architect can be a valuable resource in helping lay out the garden and in selecting the right elements to make the garden a special place.

But the garden must also be well maintained and, to be truly useful, must be known to patients and staff. Directional signs to the garden, perhaps with an identifying symbol, should be posted in the facility.

Finally, the garden must be kept open and available to all those who wish to enter. Appealing gardens behind locked doors are as bad or worse than no garden at all.

Mark Epstein is a landscape architect with David Evans and Associates in Bellevue.

Copyright © 1998 Seattle Daily Journal of Commerce.