Design in health care settings is typically the work of garden or landscape designers rather than landscape architects. This is because of the general perception that gardens are amenities rather than an integral part of the therapeutic regimen. When gardens are categorized as “extras,” competing priorities work strongly against their inclusion and without institutional commitment and funding, they become small-scale, low budget, even volunteer projects.
The potential for landscapes to become an important element in health care delivery may rest on the definition of the therapeutic garden, and its distinction from other garden types—healing, meditation, contemplation, and restorative. When differences are examined, it becomes clear that the complexities of and collaboration required for the design of therapeutic gardens demands a level of professionalism that is the rightful territory of the landscape architect. It is up to the individual landscape architect to identify the therapeutic role of nature and ensure that therapeutic gardens successfully compete with other uses of institutional space and money.
Health care gardens are described by a broad and vague collection of overlapping terms that obscure fundamental aspects of the purpose and design of these important spaces. Healing, meditation, contemplation, and restorative gardens all have their place in the medical endeavor. It is the therapeutic garden, however, that requires the greatest design expertise. It is the most goal-directed of the garden types and should be the domain of the landscape architecture profession. It is here that landscape architects are challenged to make the greatest contributions and where they most distinguish themselves from garden or landscape designers.
A healing garden is a somewhat vague term lacking precise design implications, but its purpose is to support generalized healing by helping patients become healthful, well, and whole. A meditation garden is likely to encourage inwardly focused attention for the purpose of deepening personal knowledge and attaining peace with oneself. A contemplation garden provides an ambience conducive to examining issues beyond and/or larger than oneself in a thoughtful, deliberate, perhaps religious or mystical way. When creating any of the above garden types, a designer’s intention is to present elements that serve as catalysts, inspiring individuals to reach further out and thus get closer to their individual goals.
The field of environmental psychology provides insights regarding the experience of restoration and specifically the restorative garden. Generally speaking, restoration describes a return to an ideal or normal state from a stressed or agitated one, or from boredom and/or an inability to focus. Restoration is measured by both self-reporting and objective physical measures. Environmental psychologists have identified four components essential for restorative environments: being away (i.e., physical or psychological escape), extent (i.e., connectedness and scope, sense of a whole other world), fascination (i.e., involvement), and compatibility (i.e., environmental support of intended activities). In a designer’s vocabulary, a restorative space may best be described as a coherent design in a “place away,” with gentle, undemanding stimuli where an individual can do what he/she needs in order to recover. As is the case with meditation and contemplation, these concepts can be variously interpreted and given physical form. Landscape architects frequently and intuitively meet the environmental psychologist’s criterion for restoration when designing. A well-designed garden in a health care setting may indeed be the ideal place to restore one’s equilibrium, effectively mitigating the often almost unbearable stress of illness and institutional environments.
Elizabeth and Nona Evans Restorative Garden in the Cleveland Botanical Garden. This lush, verdant, fully accessible garden is a setting for horticultural therapy, independent exploration, and quiet repose. Photo courtesy of Dirtworks PC.
The term “therapeutic,” however, suggests more than healing, meditation, or contemplation. The therapeutic garden may, and most likely should, include aspects that promote restoration, but it is more than any of these other garden types. When landscape architects enter the realm of health care to design therapeutic gardens, they do so to assist the medical profession as it strives to meet its goals. Underlying the purpose of the therapeutic garden is the intent to support the patient’s cure and recovery in the medical environment.
Designating a garden as “therapeutic” demands that it conform to the medical model. Just as one can ask if the medication has relieved pain or cured infection, one should be able to ask if walking in the garden has improved strength and balance in an individual or decreased incidence of deep vein thrombosis in a group of post-operative patients. One should also be able to measure whether activities in the garden lessen social isolation or improve mental alertness. “Therapeutic” implies treatment or a remedy with the expectation of a positive measurable outcome. This requires assessment and understanding of the medical condition with its typical course, treatment, and prognosis. Successful therapeutic gardens require designers to work closely with health care professionals to identify goals and measurable outcomes.
Many types of gardens can support the efforts of health care delivery depending on an institution’s mission and the “level” or type of care it provides. Not all gardens need to be therapeutic. For example, the landscape or garden in an acute care facility may address function, presentation, or marketing needs and use the landscape to facilitate ease of use or imply a superior level of patient care. There may be no further expectations.
A long-term care center or hospice is likely to focus on quality of life issues relating the landscape to particular needs of patients as their physical and cognitive abilities diminish. Gardens in these facilities may also be places of restoration for families and other caregivers.
A rehabilitation center may have therapeutic goals challenging the designer to work with nurses, physical, occupational, and horticultural therapists as they develop their therapy programs in a garden that may simultaneously serve as a respite or antidote to the rigors of therapy sessions.
While imprecise, each term applied to gardens in health care settings implies at a minimum a safe, comfortable space, and in the best of all possible worlds, also a beautiful one. It is up to the landscape architect, however, to distinguish the differences, determine what is most appropriate, and suggest ways to maximize the potential for therapy. It is the landscape architect who will both define and design the therapeutic garden for the client.
For more information on restorative environments see Stephen Kaplan's article, "The Restorative Benefits of Nature: Toward an Integrative Framework," in the 1995 Journal of Environmental Psychology, 15, 169-182. Also see additional works of Rachel and Stephen Kaplan, Roger Ulrich, Clare Cooper Marcus, Terry Hartig, Robert Ryan, among others.
Nancy Gerlach-Spriggs is author of Restorative Gardens: The Healing Landscape. She works for Dirtworks PC and teaches at the New York Botanical Garden. She can be reached at firstname.lastname@example.org.
Vince Healy researched the benefit of gardens to hospice patients and has served on the Board of Directors of Elizabeth Kübler-Ross’s nonprofit Shanti Nilaya. He can be reached at 510-465-8722.
Vince Healy and Nancy Gerlack-Spriggs. Image courtesy of Sally Shute.