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Invisible input - healing

Background

Nursing Times - Gardening as a therapeutic intervention in mental health
11 November, 2008

This article describes why one low-secure unit chose to initiate a horticultural therapy project and organise it as a ‘workers’ cooperative’.The therapeutic benefits of gardening are explored, particularly focusing on the social benefits. The article also discusses the issue of hope, which is an intrinsic requirement in gardening.

ABSTRACT
Page, M. (2008) Gardening as a therapeutic intervention in mental health. Nursing Times; 104: 45, 28–30.

AUTHOR
Mathew Page, MSc, DipHE Nursing Studies, Dip Integrated Approaches to Serious Mental Illness, RN, is business development and governance manager, 2gether NHS Foundation Trust, Gloucester.

Background
A number of problems may be considered endemic in many secure mental health facilities, which are often associated with long-term institutionalisation.
The problem of poor physical health in this group (Meiklejohn et al, 2003) is compounded by negative symptomology of serious mental illness and use of high-dose antipsychotics.
For clinicians working in these environments, the issues that need to be considered for patients include lack of motivation, poor work skills, obesity, cardiac problems, poor diet and lack of regular exercise.

Gardening as therapy

While the initial inspiration for this project arose from my personal reflection that gardening is a beneficial experience, an evidence base underpins what is generally described as horticultural therapy.

Enthusiastic gardeners argue that producing one’s own food is a great tonic in a number of ways but specifically this project was interested in the benefits of increased exercise, increased knowledge and skills, and improved diet.

Not long after this project began, Mind (2007) published a report that used research data and case studies to demonstrate that ecotherapy is a simple, cost-effective means of improving well-being.

Alongside horticultural activities, a variety of options such as open air walks were also found to be helpful. Mind (2007) made several recommendations challenging service providers to consider ecotherapy as a viable treatment.

Burls (2007) described some of the benefits of ecotherapy as being associated with the relationship between a healthy environment and the person; the fact that the practice of ecotherapy itself enhances the environment is a secondary benefit.

Horticultural therapy is well established in the UK across a variety of health and social care specialisms. The charity Thrive, a small, national organisation that promotes horticultural therapy, runs two garden projects – one in Berkshire and the other in London. It also supports over 900 garden projects around the UK.

Johnson (1999) considered how horticultural therapy is used in a variety of settings from the published evidence. He noted that its efficacy in elderly care is most well proven but also drew attention to the dearth of research available to establish its benefit to people in a custodial setting.

While this project is not in this type of setting, many residents do come from the prison or secure mental health system and as such there are certain common characteristics. Johnson (1999) reflected on the importance of the physical environment and how people approach other living things.

Interestingly, Fieldhouse (2003) also found the plant-person relationship to be immensely important. He considered the importance of the evolutionary relationship between people and plants and advanced the view that people have a ‘fascination’ with plants.

Fieldhouse found a gardening group has two key benefits: the first involves cognitive benefits of enhanced mood, reduced arousal and improved concentration; the second is the social nature of the group – the need to cooperate with each other to achieve the end goal. Fieldhouse (2003) concluded that this type of intervention is beneficial because it focuses on skills and aspirations rather than symptoms and deficits.

Burls (2005) and Burls and Caan (2004) discussed the process of ‘embracement’ as being about social and personal growth. This process is linked with gardening activities and in fact the authors use the growth of a seedling as a metaphor for a person’s own development.

Phenomenon of hope

One of the key factors associated with recovery is the phenomenon of hope. This is perhaps defined best by Miller (1992), who suggested it is the ‘anticipation of a continued good state, or a release from a perceived entrapment. The anticipation may or may not be founded on concrete real world evidence. Hope is an anticipation of a future which is good and which is based upon mutuality, a sense of personal competence, coping ability, psychological well-being, purpose and meaning in life, as well as a sense of “the possible”.’

There appears to be an intrinsic relationship between gardening and hope. The very action of planting a seed in the soil requires hope; by encouraging and in some senses almost imposing a sense of hope on to someone, a personal journey may begin.

It could be argued that many people in secure mental health environments have very little hope, little to hope for and for whom little is hoped. Encouraging these people to participate in activities essentially based on the practice of hope may well be highly therapeutic.

There are many reasons to conclude that gardening may be therapeutic – there is evidence for physical, cognitive and social benefits. However, there may be something in gardening associated with providing hope for those who may have little else to hope for. This might, ultimately, be the most beneficial aspect of gardening therapy.

The Initiative

Montpellier Secure Recovery Service in Gloucester is a 12-bed, all-male, low-secure mental health unit. The facility is run by 2gether NHS Foundation Trust and serves the population of Gloucestershire. Page (2006) described the service provision in detail including its development, physical environment and admission criteria.

Service users come from a variety of different backgrounds but all have a diagnosis of serious mental illness, which is often associated with a number of other issues such as substance misuse and criminality. They come from three distinct routes: new long-stay patients; prison transfers; and patients coming from medium-secure units.

In spring 2007 the unit leadership obtained permission to begin using a former garden within the hospital, only a few hundred yards from the unit. The low-secure unit is part of a larger psychiatric hospital. Despite being overrun with brambles, the garden had two commercial quality greenhouses, a polytunnel and running water. Patients and staff worked hard to clear areas of the large site ready to start using it.

We secured the services of a volunteer with years of expertise as a professional gardener and nurseryman. Within a month, the first seeds were sown and bedding plant plugs were picked out ready for sale.

The garden has two areas of activity. The vegetable area aims to produce as much food as possible to eat at the unit during various cooking groups, and the flowers and plants area aims to maximise revenue by producing high-quality products to sell.

The principle of a workers’ cooperative is not new but organising the residents of a secure mental health unit into one is. From April 2008 all residents at Montpellier have had the option to become members of the cooperative. By contributing a minimum of one unit of labour (one hour’s work), they are given the status of members, have voting rights and have a say in how the business is run. There are no restrictions, and providing that risk-management considerations are satisfied, all patients have access to the project. The multidisciplinary team operates a progressive approach towards risk taking, to promote positive behaviour through giving patients valued opportunities.

The business currently operates within the confines of the hospital selling flowers, plants and pre-prepared tubs. Income and expenditure are recorded and profit calculated. Cooperative members then receive a dividend payment commensurate with the number of hours of recorded work they have completed.

Cooperative rationale

The current drive towards clients having a say in how services are run is encouraging managers to find new and innovative ways to involve them. There is, of course, a danger that efforts can appear as tokenism, especially in services where imperatives such as safety and security are paramount. The idea of using a cooperative model to organise the gardening project was not based on any firm evidence, except that it would provide a means of service users having an influence on what they did.

As the cooperative’s principles developed, it became clear this would be a good way to improve vocational skills, as well as providing a small amount of remuneration.

As these values were considered, it became clear they sit comfortably with the principles of recovery on which the Montpellier service is founded. According to the National Institute for Mental Health in England (2005), recovery-oriented services will focus on people, their strengths, collaboration and promote autonomy. What was most attractive was that through cooperative membership, members might learn how to live in a more mutual way.

While the use of group-based interventions in mental health is well established (Yalom and Leszcz, 2005), there is no evidence base for the benefits of cooperative membership as therapy. However, it is hoped that this project might develop the principles in a way that demonstrates benefit and ultimately lead to research.

Managers and clinicians working within any inpatient mental health setting will be aware of the constant need to find effective activities for patients (Janner, 2007). Many hospitals now operate group programmes and try to ensure a spectrum of activities throughout the day and week.

In a secure unit further challenges exist as the issue of security is constantly of concern. Within secure mental health care ‘relational security’ is considered to be one of the chief means of preserving the safety of patients, staff and the public. Low-secure services such as Montpellier rely significantly on relational security to a much greater extent than the other two domains of physical and procedural security.

Relational security is chiefly concerned with the relationships that staff are able to develop with patients. As such, I believe this is best achieved through providing opportunities for meaningful engagement between the two. Perhaps more than many group activities, gardening develops relationships as staff and patients have to work as equals.

Project benefits

The issue of fascination (discussed earlier) led me to consider further the relevance of horticultural therapy in working with people with enduring serious mental health problems. On the basis that fascination by definition excludes other concerns, I was motivated to try to extend the remit of the gardening project.

By giving each patient a chilli plant to care for in their bedroom, it was hoped that a fascination might develop that would be helpful in minimising some effects of psychosis. As an added incentive a competition was run, with prizes for the first ripe, longest and greatest number of chillis. No research was undertaken but patient feedback was positive and the competition received much attention, even in the media including Society Guardian (Brindle, 2008).

Future plans

Sustaining a project such as this with a relatively small cohort (a maximum of 12 people) requires a significant amount of effort by professional staff at the unit.

As such, this particular scheme will only ever be semi-autonomous but this is a model that, if proved, may be of benefit to other services.

The issue of social enterprises is currently popular, and it is conceivable that other areas looking to develop vocational day services might look to a cooperative model.

For the Montpellier project, the first priority must be to sustain the existing work and look at ways of developing it and making it more attractive to most patients at the unit. The second must be to evaluate the project and consider using a qualitative research methodology to establish whether there are benefits specific to the cooperative model.

Conclusion

The provision of meaningful activity within low-secure mental health services is a constant challenge to those who run such facilities. Their particular nature means there are very specific needs for activities that promote mental, physical and social health/welfare.

The project described in this article aims to address each of these concerns. Research has established that gardening has qualities that promote mental health and it is hoped that by operating the scheme in a cooperative model the social benefits found in earlier research will be increased. In addition, the intrinsic hope of gardening is potentially therapeutic to people with enduring mental health problems.

The project remains in its infancy and requires a great deal of reflection and development, and the cooperative model in particular would benefit from formal evaluation. It has demonstrated that innovative solutions can be found to significant problems, using existing staff and financial resources. It has also shown it is possible to run such projects for patients in secure mental health services. This is often the sector of inpatient mental health care with the most limited access to activity and arguably the greatest need for it.

The source of the experience

Concepts

Symbols

Science Items

Activities

Overloads

Suppressions

Commonsteps

References