Updated: Nov 8
As Occupational Therapists, we are always trying to identify activities that a client might connect with. Gardening is an accessible, adaptable pastime, that many clients have experienced and which an intervention can be built around. However, for many mental health conditions, there are barriers such as volition and fatigue, that need to be overcome in order to engage. These can be minimised by using techniques to encourage engagement, predominantly appropriate for Occupational Therapists, but also Social and Therapeutic Horticulturists.
Depression is a debilitating mental health condition with characteristics that often impact the ability to engage. It can often present itself with reduced mood and cognitive distortion (Gonzalez et al, 2009). 4-10% of people in England will have depression at some time (NICE, 2011) with 7.8% being diagnosed alongside anxiety (HSCIC, 2009). The World Health Organisation (WHO, 2008) predict that depressive conditions will be second major cause of disability in the world by 2020. Any effective intervention should be appropriate to the degree of depression as symptoms are variable.
Evidence that gardening is beneficial for depression
Soga, Gaston and Yamaura (2016) carried out a statistical quantitative research review of the health benefits of gardening and concluded it can provide a reduction in depression.
This supports many of the qualitative experiences of the benefits of gardening with depression: “Gardening is a constant boost to my consciously nurtured optimism, as I am surrounded by the natural world which pursues life with eager enthusiasm” (Mind, 2017).
Gonzalez et al (2009) evaluated the impact of therapeutic horticulture on clinical depression by measuring changes in the severity of the depression and the participants perceived capacity for attention. They found a correlation between the extent to which attention was captured and the reduction in depression. They deduce that this was a result of the disruption to the participant’s ruminations and the effortless attention involved in engaging in gardening.
Berg and Custers (2011) demonstrated that gardening increased positive mood, reducing cortisol levels, and enabled participants to handle acute stress better (Kings Fund, 2016). Providing access to a garden environment, even visiting public areas, can have positive effects on well-being, evoking a sense of identity, meaning and reducing stress. Rostami et al (2014) noted that visitors of garden felt that it reduced their depression by 94%.
The MIND charity and University of Essex have developed an Ecotherapy project including gardening and food growing to support mental health conditions including depression. They found 69% of people experienced significant increases in wellbeing by the time they left the Ecominds project. Their survey of GPs stated that the ecotherapy was a valid and suitable treatment for anxiety (52%) and depression (51%) (University of Essex, 2013).
Thrive (2017) suggest that gardening is an activity that enables a person to often connect with their past while developing personally through their growing horticultural knowledge. It provides essential physical exercise. social and environmental connectedness (Sempik et al, 2005).
How can depressive people be supported to engage?
MIND (2017) describe the following effects of depression, (which may impede effective engagement), asa lack of stamina, low interest and motivation, low confidence, difficulty concentration, and social withdrawal. Glowacki (2017) et al carried out a review of the barriers to physical activity for depressed people. They state that the emotional aspects are an important aspect of behaviour change for engagement but have been under considered (e.g. negative emotions, deprecating self-assessment, outcome expectations.) They recommended further research on interventions focused on emotional behaviour change and the techniques used to facilitate participation. Chen et al similarly state that current traditional theories of behavioural change do not suggest how emotional impact can be managed through interventions.
Ways to facilitate engagement
Behaviour activation is an approach for reducing emotional barriers (e.g. social withdrawal and avoidance) for physical activity with depressed people by scheduling positive activities of daily living rather than emphasising cognitive changes.
Rebar and Taylor (2017) highlight that engagement in physical activity with mental health needs to be tailored to the individual to be effective to reflect their willingness, commitment and contextual opportunities. This suggests a person-centred approach is relevant.
A person-centred approach
Adopting a ‘person centred’ approach (Rogers,1961) may support the identification the areas of interest in gardening for the person with depression and their specific barriers to engaging. Evidence supports this, with Jarrott, and Gigliotti (2010) recommending that effective horticulture activities should be person-centred as it increases the quality of life that the participant considers as important to them. (Fieldhouse and Sempik (2014) that by taking a ‘humanistic’ approach, the person may be able to express his true nature more fully through gardening. A person-centred approach involves establishing a therapeutic relationship with the depressive client involving trust, empathy and acceptance. The sharing of knowledge and enthusiasm for gardening by the practioner utilises the ‘therapeutic use of self’ (Kielhofner,2009) This may facilitate support and communication in the intervention.
Fatigue is often associated with depression especially through applying directed attention to tasks. Gardening can reduce this, Kaplan (1995) stating that nature has an abundance of factors that support the restorative process from stress requiring a less concentrated and tiring attention. Harris (2017) notes that depressive participants were more engaged by the less threatening gardening environment, finding that Nature evoked a calming effect.
Occupational Therapy uses a range of techniques for making occupations such as gardening easier to partake in. The support of a conducive environment encourages engagement (as part of PEOP consideration). Occupation-based Activity Analysis (Thomas, 2012) enables the breaking down of gardening tasks to tailor them for better uptake by the depressive person, countering a lack of volition through:
Chunking activities into manageable subtasks to counter negative self-esteem and provide the satisfaction of completion. Pacing gardening activities to counter fatigue and lack of motivation often present in depression. Grading gardening activities so they are appropriate and manageable for the individual to maintain interest and motivation, with increasing challenges.
Empowering depressive people can counter feelings of helplessness and low self-esteem. By providing responsibility in developing and planning the activity structure, depressive people may regain control. The act of nurturing and taking responsibility for the plants may counter the self-focus often evident in depression.
Choice allows depressive people to take ownership in remediating their symptoms by gardening (and choosing tasks) when they feel it might be beneficial within a safe, flexible and structured environment. Harris (2017) states that this flexibility regarding when and what to do, empowers depressive people.
Depression can result in social isolation as the symptoms can discourage personal interaction. Therapeutic horticulture can improve social functioning and reduce depressive symptoms (Harris, 2017). Harris identified that a primary faciliatory driver for engagement was social involvement. Whately et al (2015), highlight how community gardening enables occupational engagement and reduces social isolation through an environment that flexibly supports participation, encouraging learning and community cohesion. They conclude that this is a suitable area for occupational therapist to lead on.
Bragg R, Atkins G (2016). A review of nature-based interventions for mental health care – Natural England Commissioned Report 204. London: Natural England. Available at: http://publications.naturalengland.org.uk/publication/4513819616346112 (accessed on 24 April 2016).
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Harris, H. (2017) The social dimensions of therapeutic horticulture. Health and Social Care in the community. 25 (4), pp 1328-1336.
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King’s Fund: Gardens and Health(2016). Available from: https://www.kingsfund.org.uk/publications/gardens-and-health
Mind website: What are symptoms of Depression. Available from: https://www.mind.org.uk/information-support/types-of-mental-health-problems/depression/symptoms/#.WlnnvyOcZt8
NICE (2011). Common mental health disorders: Guidance and guidelines (NICE) [online]. Available at: http://www.nice.org.uk/guidance/cg123 [Accessed 25 Aug 2015].
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Rostami, R., et. al. (2014) The Role of Historical Persian Gardens on the health status of contemporary urban residents. Ecohealth. 11 (3), pp 308-321.
Sempik, J., Aldridge, J., and Becker, S. (2008) Health, Well-being and social inclusion Therapeutic horticulture in the UK.
Soga, M., Gaston, K., and Yamaura, Y. (2016) Gardening is beneficial for health: A meta-analysis. Preventive medicine reports. Elsevier.
THRIVE (2017) website. Using gardens to change lives. Available from: https://www.thrive.org.uk. Accessed: 10 January 2018.
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University of Essex (2013) / MIND Ecominds: Effects on Mental Wellbeing. Available from: https://www.mind.org.uk/media/354166/Ecominds-effects-on-mental-wellbeing-evaluation-report.pdf
Whatley, E, et al (2015) Enabling occupational participation and social inclusion for people recovering from mental ill-health through community gardening. Australian Occupational Health Journal. 62 (6), pp 428-437