Our nation has been at war for over six years. The wars have produced numerous casualties, as well as injuries that have begun to strain the healthcare resources of our nation as wounded veterans return home. The proposed Veterans Therapeutic Garden Project is a response to this need. We believe that therapeutic gardens can play a unique role in the recovery of veterans from physical, emotional, and spiritual injuries. Building on work begun by the Healthcare and Therapeutic Design PPN in 2005, this proposal seeks to build both a framework and a movement for introducing therapeutic garden design into Veterans Administration facilities across the nation. This project will also utilize the development of these gardens as a “laboratory” for research into therapeutic design, furthering our understanding and improving our practice in the creation of therapeutic gardens.
Veterans Healthcare: Scope of the Current Problem
The United States Department of Veterans Affairs is currently charged with providing healthcare for nearly 8 million veterans of the US armed forces, from all conflicts. There has recently been an influx of 700,000 active-duty and reserve military personnel who have been eligible for VA healthcare since 2002 from the conflicts in Afghanistan and Iraq. As a result, the number of veterans receiving VA health service has increased from 3 million in 1995 to 5 million in 2006.1 Along with an increase in the number of veterans seeking care, there has been a change in the type of injuries that require treatment. Due to remarkable improvements in battlefield healthcare and body armor, there have been a number of veterans surviving wounds that normally would have been fatal in previous conflicts. The result has, however, been an influx of veterans with ongoing disabilities requiring prolonged healthcare services. In addition to the “visible” wounds of war, there are a significant number of veterans requiring mental health services for psychological trauma. Current studies have estimated that 20.3% of active duty and 42.4% of reserve duty soldiers require mental health services for Post Traumatic Stress Disorder (PTSD). 2 This has placed an enormous additional burden upon the VA system to provide mental health services.
The VA also provides nursing home care to veterans on a short- or long-term basis. The aging of veterans mirrors the demographics of our society in general, resulting in an increase in the demands for long-term care. In addition, many younger veterans with injuries will also require long-term care, further straining the VA’s nursing home care system.
The result of all these factors has been a tsunami of need that the VA is admittedly struggling to meet at a time that financing of the VA system is also under strain. According to a Congressional Budget Office study, in order to meet the demands for care, the budget for the VA would need to grow to 53.4 billion by 2025.3 In addition to funding operations, many VA facilities are more than fifty years old and many require updating and renovation.4 The recent news about conditions at Walter Reed is an example of this problem. This infrastructure will also require additional funding.
The Role of Therapeutic Gardens In the VA System: An Intersection of Need and Opportunity
Given the challenges facing the VA system, we believe that therapeutic gardens have the potential to alleviate suffering, provide for recovery and therapy, enhance the veteran’s experience of care, and reduce costs. In addition to already documented improvements to outcomes provided by exposure to garden environments in healthcare, it is believed that these environments can serve the unique challenges of the VA clientele in the following ways:
1. Stress Reduction and PTSD Treatment: The role of natural environments in alleviating stress responses is well-documented. There currently exists no research into the role of these environments in alleviating or treating PTSD in combat veterans. Current research and funding has focused on “virtual reality” therapy.5 It is proposed that "natural environments” possess similar potential and could significantly aid in the treatment of PTSD of veterans, in combination with standard therapies. Research at the Alnarp rehabilitation garden in Sweden has shown remarkable results for treating a stress-related disorder termed “vital exhaustion” utilizing both natural environments and a horticultural therapy program.6 There have been reported cure rates of 80% for this intractable condition. A similar program of natural environments and standard PTSD therapy could be developed and evaluated through research at VA facilities.
2. Rehabilitation Through Horticultural Therapy: Horticultural therapy already has a long tradition of assisting patients with disabilities. Given the increased need for ongoing care for veterans, horticultural therapy could provide significant benefits for the VA system. Therapeutic environments can be designed to provide a place for these treatments and services. In addition, therapeutic gardens can be designed for other forms of rehabilitation and physical therapy.
3. Relieving Stress in Healthcare Providers: As a system, the VA is under stress in dealing with increasing demands for services with limited resources. Taking care of the injuries caused by warfare is particularly stressful both in the acute and convalescent phase. The VA, like many other healthcare institutions, has been struggling to retain quality staff and providers. Gardens specifically designed to alleviate stress in healthcare workers can improve quality of healthcare delivery and decrease costs associated with turnover—recruiting and training personnel.
4. Therapeutic Garden Research: Many in the field of therapeutic garden design are adopting principles of evidence-based design, using scientific research results to inform design decisions. The VA system, due to its size and to its single unifying organization, represents a unique opportunity to further our understanding of therapeutic gardens. In the current proposal, outcomes research will be a requirement of the program, integrated into the initial design of the gardens.
Integrating Research and Design
To address the lack of information and formally evaluate the effectiveness of the therapeutic garden program, a research component should be incorporated into each design. Post occupancy evaluation would not be sufficient since this often measures “use” but not “effect.” In the VA project, the target symptoms and disease processes that the garden will address are identified at the design stage. Next, a methodology for determining outcomes based upon these symptoms and disease processes is developed. After installation and occupancy, the effect of the garden on these symptoms and disease processes is then evaluated in a systematic fashion. These outcomes are used to validate or refute design assumptions, furthering our understanding of therapeutic gardens.
In the proposed VA project, PTSD would be one such target disease. The proposed gardens would provide a place to ameliorate the symptoms associated with PTSD. Measurement of PTSD symptoms, quality of life, and functioning of an individual will be measured post occupancy to assess the gardens’ effectiveness. Other symptoms or disease processes may also be evaluated at the same site with the same therapeutic garden in a parallel fashion, or a completely unique garden (i.e., amputee rehabilitation or brain injury) may be proposed to treat the selected condition. In either case, a requirement for inclusion in the project would be a methodology for evaluation that includes specific health outcomes. Each participating VA facility would also be required to participate in the research component of the project The Institutional Review Board (IRB) would need to provide clearance for each facility to allow research involving human subjects.
The research team would proceed as follows:
1. Evaluate the patient group or disease.
2. Create the design and methodology for evaluating outcomes.
3. Evaluate the outcomes after the gardens are installed and used.
In addition to its focus on evaluation of outcomes, the proposed project would also utilize a multicenter design. Multicenter research trials are commonly used in evaluating healthcare treatments. This process involves application of the treatment process at multiple healthcare institutions. The advantages of this methodology are:
1. It creates a larger number of participants in the study, improving the statistical power of the study in detecting an effect of the treatment.
2. Due to the inclusion of a wider range of patients across geographic areas, it can increase the generalizability of the study.
3. It allows the comparison between treatment centers to determine which effects are determined by factors related to particular patient groups.
By developing similar gardens in VA facilities across the nation and evaluating their effects, this data can then be pooled and analyzed. This would increase the database for therapeutic garden research and address the need for a better understanding of its impact on patient outcomes.
Standardization of Design Criteria
To make reasonable correlations between the design of a garden space and outcomes, the study would require specific design criteria. Many so-called “healing gardens” lack basic design elements. For this study, design criteria will be based upon six principles of therapeutic design developed and supported by the research of Dr. Roger Ulrich.7 These design criteria are broad enough to allow for design interpretation and site requirements unique for each project, yet provide some commonality among the designs to allow for inclusion in a larger research project.
These criteria are that the garden should:
1. provide a sense of personal control by creating a variety of spaces from which to choose,
2. provide a setting for social support,
3. provide for physical movement and exercise,
4. provide for access to nature and positive distraction,
5. minimize ambiguity and be readily interpretable by a majority of people, and
6. minimize intrusive stimuli.
It is anticipated that each design will fulfill these criteria in different ways, but in any event, some aspect of the design and programming should address each criteria.
Establishing the Gardens
Funding will be the greatest obstacle for the establishment of these gardens. As discussed previously, the VA is experiencing financial strain due to the heavy demand for its services, so it is unreasonable to expect it to bear the full costs associated with garden design and construction. As currently envisioned, this project would have a strong service component from members who choose to participate. Members of the ASLA Healthcare and Therapeutic Design PPN will be specifically solicited to assist with the program; however, all members of ASLA will be encouraged to volunteer for the program. While it would be reasonable for participants to be reimbursed for material outlays related to their services, they should not expect to be compensated for design work. Funding will need to be developed locally. Veterans groups, local garden clubs, nurseries, and other volunteer groups can serve as important resources. Site selection, programming, and other aspects of design will be negotiated with each VA site individually. Each site will need to develop a project team. This team will vary from site to site, but should include representatives from administration, healthcare providers, maintenance, patient representatives, and local veterans groups.
Developing the Research
A separate team should be established to develop research protocols, coordinate research, and develop funding for the research through grant writing. This team will operate independently from the design teams, but will review designs to ensure they meet the criteria for entering the study. The research team will be responsible for data collection, analysis, publication, and for getting approval for the study from the local IRB.
If you are interested in participating, please contact Steve Mitrione at firstname.lastname@example.org.
Steve Mitrione, Associate ASLA, is a practicing family physician with Aspen Medical Group in St. Paul Minnesota. He received an MLA from the University of Minnesota in 2006 and was a research fellow at the College of Design at the University of Minnesota from 2007 to 2009. He is currently serving on the board of the American Therapeutic Horticultural Society.
1. American Medical News, December 2007 pp. 5-6.
2. Milliken, C.S., Auchterloinie, J., and Hoge, C.W (2007). “Longitudinal Assessment of Mental Health Problems Among Active and Reserve Component Soldiers Returning From the Iraq War.” JAMA, vol. 298, no. 18.
3. “The Potential Cost of Meeting Demand for Veteran’s Health Care,” Congressional Budget Office Report, March 2005. In 2009, the VA budget was $47,231 million. See: http://www.gpoaccess.gov/usbudget/fy09/pdf/appendix/vet.pdf.
4. Glendinning, D. American Medical News, December 2007 p. 5-6.
5. “Novel Approaches to the Diagnosis and Treatment of Posttraumatic Stress Disorder.” (2006), NATO Security Through Science Series E: Human and Societal Dynamics Vol. 6. Ed. Michael Roy. pp. 135-235.
6. Grahn, P., Bengtsson, I.L., Welen-Andersson, L. et al. (2007). “Open Space/People Space: Innovative Approaches to Research Excellence in Landscape and Health.” See: http://www.openspace.eca.ac.uk/conference2007/summary/Grahn.htm.
7. Ulrich. R. (1999). Effects of Gardens on Health Outcomes: Theory and Research. In: Healing Gardens: Therapeutic Benefits and Design Recommendations. Eds. Clare Cooper-Marcus and Marni Barnes. John Wiley, NY, pp. 27-86.