sth award- final
TRANSCRIPT
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Trish Matthews
Award in Social and Therapeutic
Horticulture
Clients with
Mild Common Mental Disorders
September 2015
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Contents
List of Tables ............................................................................................................ 3
Acronyms and Abbreviations .................................................................................... 3
1. Introduction – the target client group .................................................................. 4
2. Support needs of people with CMDs – what works ............................................. 6
a. Current evidence-based approaches to treating CMDs ................................ 6
b. Needs based on CMD symptoms and behaviours ....................................... 6
c. Summary of needs ....................................................................................... 7
3. Benefits of STH for clients with mild CMDs ....................................................... 10
a. STH and Emotional Well-Being .................................................................. 10
b. Comparison between Mindfulness and Restoration theory......................... 11
c. STH and metaphors of recovery ................................................................. 12
d. Review of previous STH projects ............................................................... 12
e. Summary ................................................................................................... 13
4. Factors which influence activity choice ............................................................. 14
5. Seasonal STH programme for clients with mild CMDs...................................... 18
6. Assessment methods ....................................................................................... 24
7. Conclusion ....................................................................................................... 25
8. References ...................................................................................................... 26
9. Appendices ...................................................................................................... 29
Appendix A: Characteristic symptoms and behaviours of mild CMDs .................. 29
Appendix B: Comparison between Attention Restoration Theory & mindfulness . 30
Appendix C: Health and Well-being through Nature and Horticulture .................. 31
Appendix D: PHQ-9, GAD-7 and IPAT assessment measures (Talking therapies,
2014) ................................................................................................................... 32
Appendix E: Warwick-Edinburgh Mental Well-Being Scale .................................. 34
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List of Tables
Table 1: Key demographics and the social and economic impact of CMDs ............... 5
Table 2: Evidence-based treatments for mild CMDs (JCPMH n.d., NICE 2011) ........ 6
Table 3: Key needs of clients with mild CMDs ........................................................... 8
Table 4: Key needs of clients with mild CMDs (continued) ........................................ 9
Table 5: Thrive 5 and the promotion of mental well-being ....................................... 10
Table 6: Outcomes from previous STH projects ...................................................... 12
Table 7: Factors which affect activity choice for an STH programme for clients with
mild CMDs .............................................................................................................. 14
Table 8: Seasonal STH programme for clients with mild CMDs .............................. 18
Table 9: Assessment framework ............................................................................. 25
Acronyms and Abbreviations
ART - Attention Restoration Theory
CBT – Cognitive Behavioural Therapy
CMD – Common Mental Disorder
IAPT – Improving Access to Psychological Therapies
MBCT – Mindfulness-based cognitive therapy
SMART – Specific, Measurable, Achievable, Relevant, Time-bound
STH – Social and Therapeutic Horticulture
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1. Introduction – the target client group
This study looks at the benefits of Social and Therapeutic Horticulture (STH) for
adults with Common Mental Disorders (CMDs) and particularly those with mild or
sub-threshold problems.
CMDs account for 39% of all work-related illness (HSE 2014) and have a significant
impact on productivity and a high cost to the economy (OECD 2014). They are the
reason for one-in-five visits to a GP (NHS 2014a) but three quarters of people with
CMDs receive no treatment (McManus et al. 2009). This may be due to a
combination of poor diagnosis by GPs and of patients’ worries about the stigma of
mental illness (NICE 2011). Additional statistics regarding the impact and
demographics of CMDs are shown in Table 1.
CMDs typically ‘cause appreciable emotional distress and interfere with daily
function, but do not usually affect insight or cognition’ (McManus et al. 2009: 11).
People with mild CMDs may learn to live with their illness (a ‘disability-adjusted life’,
NICE 2011) and are often still in employment but CMDs have a wider impact on
productivity, well-being, family and social life, as well as being a possible precursor
to more serious illnesses (OECD 2014).
Medication is considered inappropriate for mild CMDs (NICE 2011). Conventional
evidence-based treatment involves a mixture of psychological therapeutic
interventions, self-help and the promotion of emotional well-being (Joint
Commissioning Panel for Mental Health, JCPMH n.d.). Recovery rates using these
approaches are high and relapse rates are low (CEP 2012) but if left untreated, or if
people are unable to maintain the approaches, CMDs are likely to lead to long-term
disability and premature mortality (McManus et al. 2009). Mixed anxiety and
depression are the most frequent forms of CMD in England (McManus et al. 2009),
and stress, particularly in the workplace, is often a trigger for these disorders (HSE
2014).
This study outlines an STH programme based on the needs of clients suffering from
mild CMDs, particularly anxiety, depression and stress. It aims to show how such an
STH programme could provide benefits similar to current evidence-based self-help
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treatments. Suggestions are made for an appropriate assessment scheme and how
this programme could be implemented alongside other therapeutic support.
Table 1: Key demographics and the social and economic impact of CMDs
Impact
Work-related stress, depression and anxiety accounted for 39% of all work-related illnesses in 2013/14, equal to 487,000 cases (HSE 2014).
Each year, mental ill health costs the economy an estimated £70 billion, equivalent to 4.5% of GDP, through lost productivity, social benefits and health care (OECD 2014).
Rates of work-related stress, depression and anxiety have remained broadly flat for more than a decade (HSE 2014).
Mixed anxiety and depression have been estimated to cause one fifth of the days lost from work in Britain (McManus et al. 2009).
Productivity loss while at work may be an even bigger issue than sickness absence among those with mental health issues (OECD 2014).
Treatment
Mental health issues, including stress, anxiety and depression, are the reason for one-in-five visits to a GP (NHS 2014a).
Depression is estimated to be the second greatest contributor to disability-adjusted life years and is associated with high levels of morbidity and mortality, and is the most common disorder contributing to suicide (NICE 2011).
Mental illness has the same effect on life-expectancy as smoking, and more than obesity (CEP 2012).
Early intervention can reduce the development of more severe conditions and reduce the need for treatment of physical symptoms and benefit costs (CEP 2012).
Three quarters of people with CMDs receive no treatment (McManus et al. 2009).
Demographics
In a household survey in 2007, women were more likely than men to have a CMD (19.7% and 12.5% respectively), and rates were significantly higher for women across all categories of CMD, with the exception of panic disorder and obsessive compulsive disorder (McManus et al. 2009).
The 45-54 age group had the highest incidence rate for all persons, and this rate was statistically significantly higher than the average for all persons (HSE 2014).
More than half of those with a CMD presented with mixed anxiety and depressive disorder (McManus et al. 2009).
Table conclusions CMDs have a significant economic and social impact which is greater in many cases than common physical illnesses such as obesity or diabetes but can be successfully treated, especially where there is early intervention. The government is increasingly supporting sub-threshold mental health care and the promotion of emotional well-being (IAPT n.d.), particularly through self-referral and social proscribing (Friedli 2009). Most treatments for mild CMD involve self-help approaches requiring commitment and self-motivation from the client. The typical client profile is likely to be female, in the age range 45-54, who is in employment or looking for work and suffering from a mixture of depression and anxiety caused by, or aggravated by, stress, particularly workplace stress. The client would typically not be on medication (see section above) but may be receiving support such as counselling or guided self-help such as CBT. Although this is the typical client, CMDs affect a wide range of age groups, sexes etc. including children and may require different adaptations for these different groups.
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2. Support needs of people with CMDs – what works
Two methods were used to identify the support needs of people with mild CMDs.
a. Current evidence-based approaches to treating CMDs
Since traditional therapies have a good success rate, it seemed appropriate to use
these as a starting point to investigate whether STH might deliver similar
benefits/address similar needs. Table 2 lists the evidence-based strategies for
treating mild CMDs proposed by the JCPMH (n.d.) and self-help activities
recommended by NHS “moodzone” (NHS 2015a).
Table 2: Evidence-based treatments for mild CMDs (JCPMH n.d., NICE 2011)
Treatment Description Activities
Promotion of emotional well-being
Strengthens individuals and increases emotional resilience by improving self-esteem, problem solving and coping skills. Increases inclusion and participation in communities.
Includes any activity which actively fosters good mental health:
Increase protective factors such as meaningful employment
Decrease risk factors (abuse or violence)
Support to manage complex relationships and emotional distress
Self-help
Generally involves making life changes such as improving sleep, regular exercise, techniques such as meditation and learning and practising new ways to think about problems (NHS 2015a).
Learn how to relax
Take regular exercise
Take control, adopt good time-management techniques
Mindfulness & mindfulness practices such as meditation, yoga or tai chi (NHS 2014b)
Peer support groups
Therapeutic interventions
CBT is the main NICE-recommended therapy (CEP 2012). This may be provided face-to-face or online.
Counselling
Cognitive Behavioural Therapy (CBT)
Facilitated self-help & structured exercise programmes
Other self-reflective or talking therapies
Medication May be prescribed to deal with serious health problems, such as high blood pressure, arising from stress, but medication is not commonly prescribed for mild CMDs.
JCPMH (n.d.) also suggest that the key things that clients want include a focus on recovery, spiritual and cultural considerations, an opportunity to regain employment and support on ways to help themselves.
Needs of clients with CMDs are highlighted in purple above.
b. Needs based on CMD symptoms and behaviours
Appendix A lists the characteristic symptoms and behaviours that may arise from the
most common forms of CMD: anxiety, depression and stress. The symptoms for
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these are very similar and clients are often diagnosed with a mixture of CMDs
(McManus et al. 2009). Many of the physical symptoms are due to elevated levels of
stress hormones.
c. Summary of needs
Table 3 summarises the needs of clients with mild CMDs based on the approaches,
behaviours and symptoms described above and suggests the kind of activities which
might address these. Many of the needs are interrelated, e.g. learning new things
may support engagement and motivation, as well as providing a sense of
achievement and increasing confidence and self-esteem.
Adevi & Mårtensson (2013: 230) suggested that recovery from stress may be
‘initiated by more traditional forms of therapies but reinforced and consolidated by
the access to nature and the garden’. Any STH programme for CMDs should,
therefore, work in parallel with, and support, any other therapeutic interventions that
the client is undertaking, e.g. counselling.
Self-help treatment for mild CMDs involves engaging the client in activities which
promote emotional well-being or supports clients to make life changes and develop
new approaches and responses to life’s challenges. The following section will show
how similar activities can be provided through an STH programme in a way that
supports the client to engage with these activities.
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Table 3: Key needs of clients with mild CMDs
Need Symptoms & behaviours Associated needs Activities to address need
Increase levels of exercise
Many of the physical symptoms of CMDs are due to an excess of stress hormones, such as adrenaline and cortisol. Clients may be hyper alert, on edge and unable to relax or may lack energy, tire easily or move slowly.
Improved sleep
Increased energy
Regulation of hyper activity
Reduced muscular tension
Boost immune system
Increase endorphin levels (feel good/improve mood)
Enjoyable exercise/play/fun
Physical exercise
Different levels of activity to suit different energy levels
Anaerobic – Gentle repeated actions may aid relaxation
Aerobic – Heavy physical exercise may improve circulation, release endorphins and encourage constructive tiredness. Deeper breathing may aid physical relaxation
Build self-esteem Clients may feel hopeless and helpless and need frequent reassurance and proof of their worth.
Increase self confidence
Support, encouragement
Frequent reassurance
Proof of worth and being needed
Sense of purpose
Meaningful work
Learning new things
Achievement (of goals)
Contributing to the well-being of others
Develop relaxation skills and distraction from worries
Clients may feel worried or uneasy a lot of the time and are unable to concentrate. They may be on edge and hyper alert.
Reduce stress and anxiety
Learn new ways to think
Reduce rumination on anxieties and worries
Distraction
Reduce need for directed attention
Focus and engagement in activity – Flow1
Mindfulness(see section 3b)
Focus on the immediate moment & awareness of physical sensations and actions (touch, smell etc.)
Engagement with the surrounding environment
Gentle repeated actions which reduce arousal
Being quiet and still, and observing
Attention Restoration (see section 3b)
Improve self-care Clients may also suffer from self-neglect with regards to diet, hygiene etc. CMDs may also lead to substance abuse (alcohol, smoking, comfort eating etc.).
Improve diet
Improve personal care
Manage energy levels
Healthy eating – Increased awareness and
involvement in food and a healthy diet (growing, preparing and nutrition)
Growing things for personal health, herbal products, teas, bath bags etc.)
1Flow (also known as “being in the zone”) is a term from positive psychology. It is the mental state described as an “optimal experience”, where a person is
fully immersed in an activity where they feel ‘a sense of exhilaration, a deep sense of enjoyment that is long cherished and that becomes a landmark in the memory for what life should be like’ (Csikszentmihalyi 1990: 3). Flow is characterised by complete absorption in what one does.
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Table 4: Key needs of clients with mild CMDs (continued)
Need Symptom & behaviour Associated needs Activities to address need
Develop emotional resilience, promote mental well-being
Clients may feel worried or uneasy much off the time, especially when faced with new challenges. They may suffer from obsessive thoughts, guilt or a fear of failure.
Manage emotional distress
Reframing/new ways to think
Dealing with success and failure
Dealing with uncertainty
Improve coping skills
Try new things – Gradually increase level of challenge and risk
Acceptance of success and failure
Acknowledging limitations and working with them
Self-management Clients may find it difficult to concentrate or make decisions. Time management may also be an issue. This can lead to problems at work which, in turn, lead to a loss of confidence. Having routines and staying active can help with depression.
Problem solving
Time management
Concentration
Decision making
Building routines
Setting and achieving goals
SMART, task-based activities
Work-based skills, e.g. completing task on time, problem solving
Choice and control over activities and outcomes
Setting personal goals and planning
Reviews of progress
Engagement & motivation
Clients may lose motivation, interest and enjoyment in ordinary things and experiences. They may neglect previous hobbies and interests.
Rediscover & engage with hobbies & interests
Learn new things/achievements
Regain enjoyment in life
Have fun
Connect to life/re-establish roots
Client-driven activities and choices
Control and ownership of process
Opportunity to learn new things
Sharing learning with family and friends
Engagement with the world around
Connection to others
Clients may become irritable and intolerant of others and withdrawn, avoiding social activities and contact with friends. May lead to difficulties in family and social life.
Reduce isolation
Peer support & participation
Being part of a community
Managing relationships
Working with others to achieve a goal
Inclusive activities (adapted to different needs and abilities)
Peer support & encouragement
Supporting others (or community)
Engaging wider social group (family and friends)
Repper & Perkins (2009: 91) summarise these needs in three interrelated components: 1) Fostering hope and hope-inspiring relationships, 2) Facilitating personal adaptation and taking back control 3) Promoting opportunity and social inclusion.
Needs which are referred to in section 3 and in the STH programme (section 5) are highlighted in purple.
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3. Benefits of STH for clients with mild CMDs
Sempik et al. (2003: 4) use the term Social and Therapeutic Horticulture (STH) to
describe how plants and horticulture are used to develop well-being, where social
interactions and outcomes are also significant. They suggest that STH has
generalised benefits, while horticultural therapy has a specific clinical goal. This
generalised approach of STH seems appropriate for CMDs, given the overlapping
needs described above.
Research on STH and mental health has mainly been targeted on severe mental
illness (Clatworthy et al. 2013, Sempik et al. 2003, Shapiro & Kaplan 1998). The
following sections look at some of the benefits that may be relevant to mild CMDs.
a. STH and Emotional Well-Being
Thrive (2015) proposes 5 benefits from gardening. These correspond very closely to
the 5 steps recommended by the NHS (2015c, 2014c) for increasing mental and
emotional well-being (see Table 5).
Table 5: Thrive 5 and the promotion of mental well-being
5 benefits of STH (Thrive 2015)
5 steps to mental well-being (NHS 2015c, 2014c)
Physical – Better physical
health through exercise and learning how to use or strengthen muscles to improve mobility.
Be active – Go for a walk or run. Step outside. Cycle. Play a
game. Garden. Dance. Evidence shows that physical activity can: protect against depression and anxiety; cause chemical changes which positively affect mood and improve sleep; and give a sense of greater self-esteem, self-control and the ability to rise to a challenge (Edmunds et al. 2013).
Mental – Improved mental health through a sense of purpose and achievement.
Give to others – Small acts of kindness towards other people, or larger acts – such as volunteering in your local community – can give you a sense of purpose and make you feel happier and more satisfied about life. Volunteering has been shown to be associated with positive mental well-being (e.g. Greenfield & Marks 2004).
Social – The opportunity to connect with others, reducing feelings of isolation or exclusion.
Connect – With the people around you. At home, work, school or in your local community. Research suggests that strong social relationships may be a prerequisite for happiness (Diener & Seligman 2002).
Learning – Acquiring new skills
to improve the chances of finding employment.
Keep learning – Try something new. Rediscover an old interest.
Sign up for that course. Take on a different responsibility at work. There appears to be a clear positive relationship between learning and well-being, although there may also be increased stress and the risk of failure (Field 2009).
Access to nature – Just feeling
better for being outside, in touch with nature and in the 'great outdoors'.
Take notice/be mindful – Be curious. Catch sight of the beautiful.
Remark on the unusual. Notice the changing seasons. Savour the moment. The practice of taking notice is often referred to as mindfulness (NHS 2014b).
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The comparisons in Table 5 suggest that STH naturally encompasses the 5 steps to
emotional well-being and has the advantage of delivering these as part of a single
activity, rather than requiring the individual to focus on each step separately. The
development of a sense of purpose/achievement via giving to others (Table 5, row 2)
suggests that there may be benefits in delivering the STH programme in a
community garden or project, where activities could support and benefit other groups
who use the space. Alternatively, the products of sessions could be given as
presents or sold to raise money for the venue or for charity (e.g. plants, produce).
b. Comparison between Mindfulness and Restoration theory
Table 5, row 5, relates the passive restorative benefits of being out in nature with the
benefits of being actively and mindfully engaged in the world around you.
Wilson (1984) proposed that humans are innately drawn to nature and to the benefits
it offers (biophilia). One of the mechanisms proposed to explain the restorative
effects of these environments is Attention Restoration Theory (ART – see Appendix
B). ART suggests that natural environments encourage the use of involuntary
attention (fascination) which aids recovery from the attentional fatigue arising as a
result of directed attention.
‘All too often the modern human must exert effort to do the important while resisting
distraction from the interesting’ Kaplan (1995:170).
Mindfulness is recommended as one of the self-help approaches for clients with
CMDs (Table 2) and may be promoted by activities such as meditation (see
Appendix B). Martin (1997: 291) defines mindfulness as:
‘a state of psychological freedom that occurs when attention remains quiet and
limber, without attachment to any particular point of view’.
This relaxed form of attention sounds similar to ART’s fascination. One of the
benefits of meditation is an increased ability to sustain task-focused (directed)
attention (Chambers et al. 2008); suggesting it may have similar restorative benefits
to ART.
Mindfulness is cultivated by practice (Brown & Ryan 2003) but becomes effortless
with time, suggesting it has more in common with fascination than directed attention.
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Kaplan (2001) looked at the similarities between meditation and ART and suggested
that individuals could play an active role in the preservation and restoration of
capacity for directed attention. He suggested that mindfulness could play an
important role in reducing drains on directed attention, as well as enabling an
individual to engage with the environment in a passive accepting way that is
conducive to restoration.
This suggests that mindfulness could help an STH project deliver attention
restoration but also that engagement with the natural environment may aid
participants to develop mindfulness.
c. STH and metaphors of recovery
Adevi & Mårtensson (2013: 233) report that participants in their garden therapy
considered the symbolism of nature to be an important part of the process,
particularly in relation to personal growth and the passing of time. Kaplan & Kaplan
(1989) similarly suggest that an additional effect of natural environments is that they
enable individuals to recognise parallels between environmental patterns and their
own concerns. The use of metaphors as part of an STH programme could be made
explicit or left as implicit, depending on the nature of the participants.
d. Review of previous STH projects
Table 6 shows examples of how previous STH projects have addressed the needs
identified for clients with mild CMDs (Tables 3 and 4).
Table 6: Outcomes from previous STH projects
Need Outcomes of STH projects
Exercise
Lin et al. (2008) found that the type of exercise, and particularly the participants’ perception of exercise as either work or leisure, affected whether the activity was beneficial in relieving depression. Intrinsic motivation, control/choice and enjoyment were important factors. Pretty et al. (2007) measured the effects of 10 green exercise studies and found significant improvement in self-esteem and mood (with anger-hostility, confusion-bewilderment, depression-dejection and tension-anxiety all improving post-activity), even among those who were generally active and healthy.
Self-esteem
Aldridge & Sempik (2002) found that teaching horticulture to prisoners gave them a sense of meaningful activity and Clatworthy et al. (2013) report on several studies which suggest that STH can lead to improved self-esteem, changing attitudes to work and learning new skills.
Improving self-esteem, self-confidence and social interaction are also seen as significant outcomes for people with mental health problems (Aldridge & Sempik 2002).
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Relaxation & distraction
Ulrich (1991) found that exposure to films of natural environments resulted in a faster and more complete recovery from stressful experiences. Interestingly, this was effective even when the nature was viewed on film, rather than experienced directly.
Self-care Grahn et al. (2010) describe how clients with stress-related burn out and fatigue can be motivated to take care of themselves by ‘encouraging them to find plants that can be used in teas, ointments and soaps, or which promote sleep or settle the stomach and allow them to ‘work with their own health concerns’ (p132).
Emotional resilience
Participants at a rehabilitation garden in Sweden reported that it ‘offered them a place where they could access tools for working with their unique set of problems on different levels at the same time: cognitively, affectively, physically and socially’ (Adevi & Mårtensson 2013: 235).
Self-management
Berman et al. (2008) found that engagement with natural environments resulted in an improvement in cognitive functioning and self-regulation as a result of the restoration of directed attention mechanisms. Aldridge & Sempik (2002) describe the development of skills such as responsibility – social skills and a work ethic were positive outcomes of teaching gardening to prisoners.
Engagement & motivation
Ivarsson & Grahn (2010) report that one of the motivating factors of their garden project was a sense of satisfaction and enjoyment associated with a sense of regeneration.
Connection to others
Clatworthy et al. (2013) reported that benefits of STH for mental health included improved social inclusion and the development of social networks and improved social skills.
Integration and support with other therapies
Kim et al. (2009) showed that CBT applied in a forest environment was more effective than CBT in hospitals, and improved patients’ capacity to meditate or reconsider interpersonal problems.
e. Summary
STH provides a very adaptable approach which can be tailored to the needs and
preferences of the individual. Involvement in STH can be active (rehabilitation,
acceptance and inclusion) or passive (tranquillity, peace and spirituality) (Growth
Point 1999: 4, Aldridge & Sempik 2002, see Appendix C), which would suit clients
whose energy level, motivation and engagement may vary at different stages of their
illness.
STH has the potential to provide many of the benefits of conventional evidence-
based approaches to CMDs in an integrated, synergistic fashion and may enhance
some approaches such as mindfulness. People who are reluctant to be involved in
conventional medical treatment or find it difficult to engage with self-help approaches
may find that STH provides many of the same benefits in a way that is more
accessible.
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4. Factors which influence activity choice
There are many factors which affect the choice of activities for an STH programme
for clients with mild CMDs. Many of these are due to the combination of CMDs that
give rise to a variety of symptoms and needs which may vary over time. As well as
planning activities to support the client’s needs, it may also be necessary to adapt
activities “on the fly” depending on how the client is responding, or on the needs they
express. Table 7 lists factors which may affect choice of activity.
Table 7: Factors which affect activity choice for an STH programme for clients with mild CMDs
Client related factors
Energy levels
- Adapt levels of activity and exercise based on clients’ current energy levels & needs
- Provide tasks that require different levels of physical effort
Clients with CMDs may have very different levels of energy and these may vary over the course of the sessions. Some clients may be tired and lethargic with little stamina, while others may be hyperactive and unable to sit still.
For some, relaxing may be the priority, whereas for others, physical activity can be beneficial.
Health issues
- May need to adapt activities to clients’ perception of wellness/capacity, as well as to existing conditions
May be related to CMD (e.g. high blood pressure, phobias etc.) or unrelated (e.g. allergies). Stress and anxiety may depress the immune system, making clients susceptible to illness. CMDs can also make clients more aware of, and concerned about, physical aches and pains. These may limit clients’ initial activity levels. A health questionnaire should be included as part of the intake process.
Requirement for success
- Provide a variety of activities which offer different levels of challenge
Clients with low self-confidence/esteem or motivation may benefit from tasks with a low failure rate (e.g. easy to grow crops). As they progress, more challenging and higher risk activities may be introduced.
Need for routine & capacity for self-management
- Encourage clients to plan and manage their activities and take control
Time and task management are often an issue for clients and can be the cause of a loss of productivity at work as well as an issue in self-care. Tasks which enable clients to manage their work, gain responsibility and a sense of control may be beneficial.
Freedom to choose activities according to mood and reduced external demands also are an important factor in recovery (Adevi & Mårtensson 2013).
Level of demand
- Scale tasks and design site to accommodate different levels of demand
Depending on their current state, clients will be able to deal with different levels of demand. For some, regularly attending a course may itself be a major step forward.
Previous level of knowledge
- Provide information & tasks at different levels for different clients
Clients will come to the project with different levels of gardening experience and knowledge. For some, gardening may have been a hobby which they have lost touch with due to their illness. Others may have little or no knowledge of gardening.
Experienced clients can be encouraged to share knowledge and support others.
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Personal preferences
- Be prepared to adapt tasks to client preferences or encourage participation in group activities
Clients may have personal dislikes of certain activities or preferences for particular tasks. Tasks may be adapted to suit, although encouraging them to participate in necessary but disliked tasks may aid self-management (especially when it supports the rest of the group).
Personal preference may also be important in activities involving smell, taste, plant choice, design etc.
Personal experience and understanding of their CMD
- Listen to the clients and involve them in the choice of activity
- Respect their choices, even if unexplained
Clients bring their past experience of CMD (duration, severity, reoccurrence, specific problems) and experience of previous treatment (what works for them). Their approach to activities may also depend on the trajectory of symptoms – do they consider themselves to be getting better or worse? (NICE 2011) – and social or personal factors that have affected their development of CMD. This may affect their interest in engagement with, and understanding of, gardening as a therapy. These factors may not be known to the therapist.
Therapist related factors
Knowledge of clients
- Involve clients in choice of activity and planning
Therapists will have limited knowledge of the clients at the start of the programme (the enrolment/application process can be used to gather some information about clients). Clients may take time to open up about their issues or may prefer to keep these private.
Personal preference and knowledge
- Be open to other approaches
- Draw out the expertise within the group and encourage sharing
Therapists will have their own beliefs, preferences and areas of expertise that will influence the choice of activity (for example, preference for organic gardening, knowledge of a particular kind of gardening, or preference for particular kinds of plants).
Collaboration with other professionals
- Select or adapt activities to support the work of other professionals and provide an integrated treatment
Clients may be receiving other treatment or may be referred from GPs or other agencies. These may have suggestions for activities or approaches which could aid the client or support other treatments. Feedback from the STH programme (with consent of the client) may also be of benefit.
Programme related factors
Session time
- May need to be adapted to the availability of clients
- Evening sessions may require more indoor/table top activities especially in the winter
Since clients may be in full-time employment (see client profile, Table 1), it may be necessary to provide sessions outside of normal working hours, e.g. in evenings or at weekends.
This may provide an opportunity for increasing the usage of existing STH projects. For example, at Thrive’s Trunkwell Garden project, (Beech Hill, Reading), core clients are on site from 10 am – 3 pm and the garden is rarely used outside of these hours.
Numbers attending
- Choose activities appropriate to staff and client ratios & support needs
- Encourage peer support among clients
The number of clients attending will depend on the needs of the clients and the staffing levels.
Clients with mild CMDs will generally not need individual support but may need occasional individual attention (someone to talk to).
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Duration of session & Length of attendance
- Activities need to be completed in the given session length
- Consider life cycle of plants (how long they will take to grow, will clients see results in the time they attend?)
Working clients and other clients with other demands (e.g. family) may only be able to commit to short sessions on a weekly basis (e.g. 2 hrs per week).
Most conventional programmes for treating CMDs tend to be short term (8-12 weeks) but, since CMDs often develop over a long period and can reoccur or be persistent, longer term interventions may be appropriate.
Grahn et al. (2010) describe a 12 week programme which varies from 1 to 4½ days a week (clients may then attend for an additional 10 weeks, one day a week to ease the transition back to work). STH programmes in Clatworthy et al. (2013) varied from 10 hrs over 2 weeks to long-term ongoing projects.
Integration with other therapies
- Develop contacts with other therapists
- Integrate other therapies depending on clients’ needs
Consider whether to integrate other therapies with the STH project. For example, Adevi & Mårtensson (2013) included art therapy & relaxation activities with their nature-based therapy to help clients’ work life and reduce stress.
Escalation routes
- Ensure therapists have clear routes to escalate issues, arrange referrals etc.
CMDs are complex conditions and may require medical intervention if they escalate. Therapists need to be clear about when they need to refer, and to whom, and clients need to be aware of the limits of confidentiality. Make sure processes are in place to manage any need for escalation and that the chosen activities and environment take these into account.
Site related factors
Indoor/table top delivery vs outdoor activities
- Design programme to suit the availability of clients
- For longer term interventions, using a single site may be appropriate, as clients develop a beneficial emotional bond with the venue (Adevi & Mårtensson 2013)
Short-term interventions could be delivered in a variety of locations, not necessarily a garden setting.
Kaplan (1995) suggests that one of the requirements for ART is extent, but this does not mean that the environment for STH has to be large; it just has to be rich. Miniaturisation can provide a feel of a whole different world, as can introducing wider concepts (plant history, folklore, soil science etc.).
Studies have suggested that viewing pictures of nature produces the same benefits as physically being out in nature (Ulrich 1991, Pretty et al. 2005), so working with pictures of nature may also be beneficial (catalogues, magazines, collages etc.).
Accessibility
- For short (2 hr) sessions, encourage clients to be on time.
- Structure activities to allow for late attendees & disruption
Site needs to be easily accessible for clients, preferably by public transport, in order to encourage them to make the effort to attend.
An enclosed site may provide a sense of security and “being away” (Kaplan & Kaplan 1989) for some clients. Clients in general will not have mobility problems but may have other needs due to CMD symptoms (for example, staying close to a toilet).
Site design & facilities
- Indoor space needed for evening activities or poor weather
- Design activities to suit the site and available resources
The size, layout and design of the site will influence the activity choice. Activities will depend on availability of space for storing resources and for looking after plants after an activity (is there a greenhouse? Who will look after plants between sessions?). Clients with CMDs may find it difficult to remember to bring plants back to future sessions. Plant choice and gardening activities will depend on the availability of space, aspect, usage etc.
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Sole use or shared facility?
- Engage with other users of the site and select activities to fit the overall plan for the site
If clients are only be present at the site for a short period each week, it may be preferable to choose a site, such as a community garden, where there are other people involved in the regular maintenance. This could also help clients by giving them a sense of engaging with and supporting others (see needs in Tables 3 and 4) but without the stress of maintaining the site (Adevi & Mårtensson 2013).
A site designed specifically for clients with CMDs might include features such as garden rooms designed for different levels of stimulation and to suit different moods (Ivarsson & Grahn 2010).
Session related factors
Weather
- Fall back activities required for poor weather
Inclement weather (rain, snow, excessive heat and sun) may make working outside inappropriate (unpleasant, safety issue etc.). Clients’ willingness to endure bad weather may also vary depending on their condition.
Preparing & eating produce
- Ensure correct qualifications and standards are in place for the preparation of food
Table 3 suggested that one of the approaches to encouraging self-care may be to prepare and eat food grown on site.
Risk management
- Create risk assessments for activities and refer to these when planning sessions
Gardening activities have inherent risks (e.g. use of tools, chemicals etc.). Risks may also vary depending on the clients involved in the group and their individual needs.
Funding
- Design activities to fit with budget
- Consider money saving activities such as use of recycled materials and working with local garden centres
Finances for the project may be limited, depending on how it is funded. Working clients who self-refer may be willing to pay for sessions.
Clients may be able to bring some of their own resources (although remembering this may be challenging for some clients with CMDs).
There may also be hire costs for the use of the site.
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5. Seasonal STH programme for clients with mild CMDs
Table 8: Seasonal STH programme for clients with mild CMDs
Notes The choice of activities will be dependent on the site available and on the structure of the programme as described above. Sites such as the Alnarp Rehabilitation
Garden in southern Sweden (Adevi & Mårtensson 2013) are specifically designed for clients recovering from stress and the design of the garden forms part of the treatment. Alternatively, working in a community garden gives participants a sense of connecting with others and meaningful work.
The example activities chosen below focus primarily on metaphors of renewal and new beginnings, choice and control, and self-care and personal health. The garden environment will naturally tend to encourage relaxation, distraction from worries and mindfulness (see discussion on ART above). Working in a group and sharing activities will encourage connection to others and support relationship building. Activities with end products that can be given as a gift or which improve the garden environment will provide meaningful work and a sense of contributing to others.
It may also be beneficial to integrate other self-help approaches to CMDs, such as group meditation as a start or end to a session, reflective diaries (including lists of achievements and gratitudes), activities to postpone worries (such as listing worries and leaving the list at the entrance to the garden), and relaxation techniques. Therapeutic approaches such as CBT could also be included, if therapists had appropriate training or if other professionals were involved in the project.
Some adaptations for indoor gardening are described in the table below, but the example activities assume that the programme is being run at a site which has outside space, as well as space indoors for table top activities suitable for inclement weather or clients with low energy.
Activities are arranged by season, but the same topics are covered for each season with appropriate seasonal adaptations. This gives a cycle of topics for short-term interventions (8-10 weeks) but which would also be suitable for longer term participants. A section is also included for activities which are not seasonally dependant and which may be suitable for indoor gardening (e.g. in inclement weather).
Short-term interventions may need activities which provide results on that timescale, while longer term projects can work on a more seasonal cycle, for example seed sowing through to harvest, and gathering green waste to compost and then feeding the soil.
Connections to the needs of clients with CMDs (described in section 2) are highlighted in purple.
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Season independent / indoor table top activities
Topic Task Activities Outcomes Metaphors Adaptations
Seeds Growing seeds for nutrition
Discuss how seeds grow – cut open soaked seeds or grow beans in a jar.
Set up jars with sprouting seeds.
Sow speedy veg suitable for growing on windowsill, e.g. peas, shoots, cress.
Make and share a meal using seeds & seed-based food.
Understand seeds, why plants create them and their importance in human diet – learning, self-care.
Looking after seeds and seedlings – self-management, achievement.
Share produce with others – connection, meaningful work.
Sowing seeds – flow, mindfulness.
New beginnings.
Looking to the future.
Allow clients to choose from the variety of the speedy veg available – choice/control.
Most speedy veg have a high success rate. Clients who can accept a higher risk of failure could also try planting pips and seeds gathered from food, e.g. orange, melon, avocado etc.
Herbs Herb craft Discuss the benefits & uses of herbs (medicinal, culinary, spiritual).
Gather available herbs.
Make bouquet garni.
Make lavender oat bath bags.
Make pot pouri from fresh or dried herbs.
Understand herb use for health and well-being – learning, self-care.
Gathering herbs – exercise, passive restoration.
Sensory experience of herbs – engagement, relaxation, preferences.
Creativity – achievement.
Taking control of own health and well-being.
Self-help and capability.
Herbal products can be given as gifts, if participants do not want to use them themselves – contributing to others.
Go for a walk to look for hedgerow herbs (ensure proper identification before use) – exercise.
Container planting
Create a garden in a dish
Select an appropriate container & compost or oasis.
Design & “landscape”.
Gather appropriate plant material (living or cuttings), e.g. moss for grass, seasonal wild flowers etc.
Plant garden.
Plan for ongoing care.
Understand the needs of plants growing in shallow containers & transient nature of cut plants – learning, acceptance.
Making decisions and expressing personal preferences – choice, control, engagement, mindfulness.
Ongoing care – self-management, responsibility, ownership.
Building the life you want.
Transient nature of things.
Acknowledging personal preferences.
Could be extended to a small personal plot in the garden.
Gardens could be created for seasonal or spiritual festivals, e.g. Easter/spring, Christmas/yule –engagement.
Horticultural shows often include this as a category which clients could enter – achievement, challenge.
Propagation Leaf cuttings
Select appropriate material (avoid damaged or diseased material).
Prepare pots or trays with free draining compost.
Make leaf cutting.
Water & drain. Place in propagator or plastic bag out of direct sunlight.
Understand propagation methods – learning, achievement, engagement.
Fine motor skills – focus, mindfulness.
Trying something new – emotional resilience, challenge.
Care – connection to life/roots, responsibility & being needed, self-esteem.
New beginnings.
Renewal.
Creating new life.
Best taken early spring/summer but can be taken anytime. Part leaf
cuttings, e.g. Streptocarpus, whole
leaf cuttings, e.g. money plant (Crassula ovate).
For short-term interventions, clients can pot on plantlets from previous cuttings – achievement, self-esteem.
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Winter activity programme
Topic Task Activities Outcomes Metaphors Adaptations
Seeds Creating a planting plan and ordering seeds
Investigate garden areas to be planted.
Discuss plant choices, labour required.
Create a planting plan for the available space.
Order seeds from seed catalogues.
Check any seeds collected or left over from previous year.
Spend time outdoors exploring site – exercise, mindfulness, relaxation.
Understand seasonal nature of gardening & healthy seeds – learning, care.
Practise choice, planning and decision making – self-management.
Looking to the future.
Cycle of life.
New beginnings.
Creating garden mood board/collage using pictures from magazines may help clients who have difficulties making decisions – engagement, motivation.
Vary length of time outdoors based on clients’ energy levels.
Choose seeds with different success rates – risk, challenge.
Herbs Planning & growing a herb garden
& winter tonics
Discuss: what is a herb?
Look at traditional herb garden layouts (visit local herb garden) – design own traditional knot herb garden.
Explore garden for evergreen herbs.
Make rosemary teas (and discuss other winter tonics).
Look at supermarket living herbs & discuss forced growing.
Understand how to grow herbs and links to traditional uses – learning, self-care, engagement, roots.
Gathering herbs – exercise, engagement, relaxation, preferences.
“Rescuing” forced herbs – care, rescuing, contributing.
Taking control of own health and well-being.
Self-help and capability.
Overcoming circumstances.
Christmas – investigate mythology & symbolism of greenery used for decorations – learning, engagement.
Allow clients to choose herbs (take into account medical issues).
Living herbs are available all year round.
Container planting
Plant an alpine container
Discuss the origins and needs of alpine plants.
Select appropriate container and potting material.
Clear and clean container as needed.
Select alpines and plant container.
Plan for ongoing care.
Understand the requirements of alpines, space, growing conditions etc. – learning.
Understand the need for good hygiene in containers – care.
Responsibility of caring for plants in containers – self-management.
Finding the right environment.
Everyone has their own needs.
Growth even in tough conditions.
May be given as gifts – meaningful work.
Larger containers or outside areas could be planted as a group activity – connecting to/working with others.
Allow clients to choose plants & design – focus, choice.
Propagation
Take hardwood cuttings
Discuss types of cuttings and when to take them.
Explore garden to identify suitable cuttings (e.g. rose, buddleia).
Take cuttings.
Prepare compost and containers & plant cuttings.
Arrange for ongoing care.
Understand plant dormancy and when to take cuttings – learning.
Observing garden – passive restoration, mindfulness, exercise.
Trying something new – emotional resilience, challenge.
Having agency, making a difference – control, engagement.
New beginnings.
Renewal.
Creating new life.
Can be taken from mid-autumn to late winter. Suitable for most deciduous shrubs.
Choose cuttings that have a good success rate if clients need low risk activities.
May be a group activity (e.g. plan for a new hedge, new rose bed etc.).
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Spring activity programme
Topic Task Activities Outcomes Metaphors Adaptations
Seeds Sowing seeds
Discuss seed requirements.
Prepare for task (read packet instructions & refer to planting plan).
Select healthy seeds.
Prepare compost and fill appropriate containers or prepare outdoor seed bed.
Plant seeds & arrange for ongoing care (watering, protecting).
Label seeds.
Understand requirements for storing and growing seeds – learning.
Use of fine motor skills, soft focus concentration on repetitive activity – mindfulness, relaxation, flow.
Planning for future / gifts for others – meaningful work.
Exercise (if planting outside)
Following instructions to complete task – self-management.
New beginnings.
Looking to the future.
Cycle of life.
Use different sized seeds. Larger seeds are easier to handle and require less concentration.
Choose seeds with high success rate/low risk where achievement important.
Pots of seeds could be given as presents – contributing to others.
If working outside, can share planting of an area – connection to others.
Herbs Planning and planting a herb garden
Discuss needs for growing different herbs (sun, drainage etc.).
Select and prepare appropriate area. Select herbs and plant based on plan.
Plan for ongoing care.
Understand needs for growing herbs – learning, engagement, care.
Working with others on a common goal.
Exercise (if planting outside).
Growing healthy.
Out with the old and in with the new.
Herbs can be planted in appropriate containers, if no ground available.
Allow clients to select herbs and layout – choice, control.
Container planting
Plant hanging baskets for summer
Discuss choice of basket & liner, appropriate plants, compost & additives (water retaining granules, plant food etc.).
Select appropriate plants.
Plant & arrange for ongoing care (watering, deadheading, feeding).
Understand needs of plants in hanging basket – care, learning.
Select basket & plants – choice, control.
Planting design – creativity, engagement, mindfulness, distraction.
Ongoing care – self-care, responsibility, self-management.
Gathering the things you need.
Creating the life you want.
Making the most of your space.
Allow clients to select plant – choice, control.
Protect from frost if planting early – care, responsibility.
Vary plants to increase challenge/risk, emotional resilience.
Work outside at table in garden or greenhouse – passive restoration, mindfulness, distraction.
Propagation Divide summer/ autumn flowering perennials
Explore garden to identify plants for dividing & decide where to replant.
Decide on appropriate method to divide.
Select appropriate tools, split plants.
Replant or pot up.
Decide on aftercare, keep moist.
Understand when, why and how to divide perennials – learning, care.
Explore garden – exercise, engagement, mindfulness, passive restoration.
Aftercare – care, self-management, planning.
Making space.
Renewal.
Sharing.
e.g. agapanthus, crocosmia geranium.
May be divided any time if kept well-watered afterwards but best when not in active growth.
Pot up split plants and sell/share – contributing to others, meaningful work.
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Summer activity programme
Topic Task Activities Outcomes Metaphors Adaptations
Seeds Sow & grow salad seeds
Discuss salad needs and problems (successive planting, pests etc.).
Select appropriate area or containers.
Choose appropriate salad and method.
Prepare seed beds or containers.
Plant salad seeds & arrange ongoing care.
Harvest & successively plant.
Healthy eating & improved nutrition – self-care.
Choice, control and decision making – self-management, achievement.
Outdoor plantings – exercise.
Care of growing crops (watering, feeding, harvesting) – self-care.
Focused activity & distraction – mindfulness & relaxation, flow.
Continuous renewal/Start again.
Cycle of life.
Nurturing.
Allow clients choice of salads to grow – engagement.
Share the produce grown (communal meal?) – connection to others.
Grow in containers, undercover (polytunnel or greenhouse), or outdoors depending on clients’ energy levels.
Pest problems & crop failures can be used to develop emotional resilience.
Herbs Sowing & using annual herbs, harvesting lavender
Successional sowings of summer herbs such as basil in windowsill pots.
Gather herbs for summer salads.
Harvest lavender, dry and strip heads.
Understand the needs of summer herbs in pots – learning, engagement.
Healthy eating & improved nutrition – self-care.
Gentle exercise.
Repetitive sensory activity – relaxation, mindfulness, passive restoration.
Gathering what I need from the world around me.
Self-care & nurturing.
Make lavender sugar or other recipes with the fresh stripped lavender – contributing to others.
Make window sill herb containers, e.g. from recycled tins – learning.
Basil can be sown as companion plant for tomatoes along with calendula (edible flowers).
Containers Caring for plants in containers
Check containers in the garden.
Clear spring bulbs, once foliage has died back.
Deadheading.
Planting to fill gaps.
Arrange watering and feeding (investigate automatic systems or rotas).
Understand needs of plants in containers – learning.
Aftercare – care, responsibility, being needed, self-management.
Working with others to share jobs – peer support, working with others, relationships.
Automatic systems – problem solving.
Clearing things that no longer serve.
Renewal.
Looking after.
Making life easier.
Spring bulbs can be grown in liner pots in larger containers so they can be easily removed – management.
Vary amount of responsibility on client for care of containers (based on motivation, ability to cope with demands and responsibility).
Propagation Take semi-ripe cuttings
Discuss semi-ripe cuttings & explore garden.
Take cutting & place in plastic bag.
Prepare cutting.
Plant in suitable container/compost.
Plan for aftercare.
Understand when to take cuttings – learning.
Explore garden – passive restoration, mindfulness, engagement, exercise.
Trying something new – emotional resilience, challenge.
New beginnings.
Renewal.
Creating new life.
e.g. lavender, rosemary, hebe, erica.
Taken from this season’s growth (late summer). In early summer, take softwood cuttings.
Allow clients choice of material – control.
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Autumn activity programme
Topic Task Activities Outcomes Metaphors Adaptations
Seeds Harvest seeds
Discuss how to collect, dry & store seed heads & issues of growing from seed. Collect seed heads from garden. Collect weed seeds & look at different dispersal mechanisms & how to prevent weeds. Separate out seeds. Store in appropriately labelled packets.
Understand seed propagation (seed types F1, breeding true) – learning. Harvest seeds and prepare for next cycle – exercise, achievement & meaningful work. Focused concentration on repetitive activity – mindfulness, relaxation. Share seeds with others (in group or as gifts) – connection, meaningful work. Seeds as food – self care.
Reaping rewards. Acknowledging success. Preparing for the future. Cycle of life.
Use different sized seeds. Larger seeds are easier to handle and require less concentration. Seed heads can be collected and dried ahead of time or clients can gather dried seed heads from site – planning. Allow clients to select seeds which are meaningful to them – choice, roots. Encourage clients to swap seeds or give as gifts – contribute to others.
Herbs Harvest and store herbs
Discuss how to store herbs for winter and which need to be stored. Gather appropriate herbs and dry. Work with dry herbs to store appropriately. Make a dried herb wreath. Clear and prepare herb beds for winter.
Understand drying and storing herbs – learning, engagement. Choose and gather herbs to store – exercise, fine motor skills. Dry & store – planning and goal achievement, creativity. Sensory experience – relaxation, mindfulness.
Preparing for the dark times. Reaping rewards. Living in season/cycle of the year.
Dried herbs or herb wreaths can be given as gifts – connecting/contributing to others. Allow clients to select their preferred herbs – choice, control. Look at cooking with dried herbs or make winter tonics such as rose hip syrup – self-care, health.
Containers Plant a hanging basket for winter /spring
Discuss choice of basket & liner, appropriate plants, compost. Clear & clean basket if needed. Select appropriate plants & bulbs. Water well & allow plants to establish. Arrange for appropriate ongoing care.
Understand needs of plants & bulbs in hanging basket – care, learning. Select basket & plants – choice, control. Planting design – creativity, engagement, mindfulness, distraction. Ongoing care – self-care, responsibility, self-management.
Promise of spring. Looking to the future after the dark times. Renewal.
Allow clients to select plant – choice, control. Under-plant winter plants with miniature spring bulbs.
Propagation
Propagate strawberry runners
Discuss how strawberry plants propagate. Select appropriate pots & compost. Select plantlets nearest to mother plant with reasonable root growth and insert into compost, water well. Remove unwanted runners.
Understand plant propagation & reproduction – learning, engagement. Select plants to propagate – control, decision making. Aftercare – care, self-management, planning.
New beginnings. Renewal. Creating new life. Preparing for the future.
Later summer or early autumn. Plants can be given away as gifts contributing to others or moved to a new location in the garden. Could be part of larger activity such as planning to renew fruit beds.
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6. Assessment methods
Assessment is an important part of STH programmes which
Enables the therapist and client to identify what works, measure progress, provide
encouragement and to adapt the programme accordingly.
Provides a measure of the ROI (return on investment) for those investing in the
programme and feedback to other professionals involved in the clients’ care.
Adds to the evidence-base for the benefits of STH.
Assessment can be subjective (based on the clients’ self-reporting) or objective (external
reporting by therapist or other professionals). Objective assessments such as cortisol
swap analysis have been used to measure the level of anxiety in patients with PTSD
(Kotazaki 2013). This is probably unnecessary, unless the project is part of academic
research.
For short-term interventions, self-reporting may be preferable, as it will take time for the
therapist to get to know the client. Several well validated self-reporting tools are
commonly used by GPs and counsellors for assessing and monitoring CMDs (NICE
2011). These include tools such as the 9-item Patient Health Questionnaire (PHQ-9), and
the 7-item Generalized Anxiety Disorder scale (GAD-7) (see Appendix D) and it may be
appropriate to use these if working with other professionals.
A simpler approach might involve a general mental health scale such as the Warwick-
Edinburgh Mental Well-Being Scale to measure changes in mental well-being
(WEMWBS, Appendix E, Maheswaran et al. 2012). This would be completed by the client
as part of the intake process and repeated at each session and a record of the scores
used to measure progress.
Another useful approach for longer term interventions may be for the therapist to record
observations on the clients’ behaviour and abilities at the end of each session using a
tool such as Thrive’s Insight tool (Sempik et al. 2014). This scores the client for specific
behaviours (communication, social interaction, motivation etc.) on a linear scale, using a
series of predefined descriptors. The set of descriptors should be appropriate to the
range of behaviours expected of the client group being considered. This helps
standardise the approach to scoring.
As well as these quantitative measures (numerical scores), qualitative measures such as
reflective diaries or interviews may give a more general insight into emotional well-being
25
(e.g. Adevi & Mårtensson 2013) since CMDs relate to personal feelings. These can also
have therapeutic benefits by giving the client a different perspective and encouraging
reflection.
The assessment method needs to be appropriate to the clients and should be tailored to
fit into the programme and not be too intrusive or time consuming, so that it does not
become a source of stress. Table 9 suggests a suitable assessment framework for the
programme described above.
Table 9: Assessment framework
Stage Frequency/Time Assessment method
Initial intake On referral to programme
WEMWBS
Create an individual development plan in consultation with the client – what are their goals?
Weekly sessions At each session WEMWBS (an online tool would make this faster and more convenient)
Reflective diary – record activities
Periodic review Long-term interventions – every 2 months
Short term once at mid-point of course
Review and update IDP
Review WEMWBS scores and discuss reflective diary
Exit On leaving the programme
Summarise WEMWBS and lessons learned
Create action plan for future activities
Follow up 2-3 months after leaving project
Follow-up questionnaire or interview
7. Conclusion
This study has shown that the benefits and approaches of STH are very similar to those
of the recommended self-help treatments for mild CMDs. An STH programme similar to
the one outlined above may provide an integrated, holistic approach to making these self-
help treatments accessible and acceptable to clients with CMDs, as well as supporting
them to implement these in a sustainable manner.
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9. Appendices
Appendix A: Characteristic symptoms and behaviours of mild CMDs
CMD Characteristic symptoms and behaviours
Anxiety
NHS (2015b)
Psychological symptoms can include:
feeling worried or uneasy a lot of the time
unable to concentrate
irritability
being extra alert, feeling on edge/unable to relax
needing frequent reassurance
tearfulness Physical symptoms can include:
difficulty sleeping/tiredness
pounding heartbeat, palpitations or chest pain
breathing faster, hyperventilation, feeling faint
feeling sick, “butterflies", needing the toilet more frequently
headaches, sweating, loss of appetite
Depression
NHS (2014d),
MacManus et al.
(2009)
Psychological symptoms include:
continuous low mood or sadness
feeling hopeless and helpless, not getting any enjoyment out of life
having low self-esteem
feeling tearful, guilt-ridden, irritable and intolerant of others
having no motivation
loss of interest and enjoyment in ordinary things and experiences
finding it difficult to make decisions
feeling anxious or worried
having suicidal thoughts Physical symptoms include:
moving or speaking more slowly than usual
change in appetite or weight
constipation
unexplained aches and pains
lack of energy or lack of interest, disturbed sleep
Impaired physical well-being, self-care and behaviour Social symptoms include:
not doing well at work
taking part in fewer social activities and avoiding contact with friends
neglecting hobbies and interests
having difficulties in home and family life
Stress
(NHS 2014a)
Common symptoms of stress
sleeping problems, sweating, loss of appetite and difficulty concentrating
irritability, worrying
low self-esteem
headaches, muscle tension or pain, or dizziness
unhealthy coping methods, such as drinking or smoking
long-term stress or anxiety, potentially causing serious complications, such as high blood pressure or a weakened immune system
Many of these symptoms are due to extended periods of elevated stress hormones, such as adrenaline and cortisol. These cause the physical symptoms of anxiety, such as an increased heart rate and increased sweating.
30
Appendix B: Comparison between Attention Restoration Theory & mindfulness
Att
en
tio
n R
es
tora
tio
n T
he
ory
(K
ap
lan
19
95
, 2
00
1)
Kaplan (1995) suggested that attentional fatigue can arise when individuals are required to use directed attention to focus on complex problems and to inhibit undesirable information.
He suggests that engagement with involuntary attention (fascination), which requires no effort, restores the system and that this latter kind of attention is used when engaging with natural environments (Attention Restoration Theory – ART). Kaplan (1995: 173) differentiates between hard fascination (watching an auto race) and soft fascination (a walk in nature). Fascination (Containing patterns that hold one's attention effortlessly) is a central component of a restorative experience but Kaplan suggests that it also requires three other components:
Being away – freedom from mental activity which requires directed attention. Being distinct,
either physically or conceptually, from the everyday environment.
Extent – a rich environment that provides enough to see, experience and think about that it
occupies a large proportion of one’s mental capacity (thoughts, attention etc.) and creates a sense of exploration and a feeling of belonging. Having scope and coherence that allows one to remain engaged.
Compatibility – an environment which fits with one’s inclinations, preferences and
purposes, so that activities are natural and comfortable. This reduces the need for selectivity and directed attention. Fitting with and supporting what one wants or is inclined to do.
Kaplan (1995:179) discusses the interaction of stress and attentional fatigue and concludes that the two are interrelated and that while recovery from stress may occur faster, recovery from mental or attentional fatigue may be more durable and that restorative environments may contribute to both of these.
Min
dfu
lnes
s
(D
avis
& H
ayes 2
01
1,
Bro
wn
& R
ya
n 2
003
)
Mindfulness originated as a Buddhist concept but has become part of mainstream psychotherapy (Davis & Hayes 2011). It ‘involves paying more attention to the present moment – to your own thoughts and feelings, and to the world around you’ (NHS 2014b) and is the moment-to-moment awareness of one’s experience without judgment. Mindfulness is a state which may be promoted by certain activities (e.g. meditation, yoga, tai chi, qigong) rather than to a specific activity. It has gained recognition in psychology particularly through programmes such as mindfulness-based stress reduction ((MBSR) and mindfulness-based cognitive therapy (MBCT) (Davis & Hayes 2011:198).
Empirically supported benefits include significant improvements in self-reported mindfulness, depressive symptoms, rumination, and performance measures of working memory and sustained attention (Chambers et al. 2008).
It is suggested that the effects of mindfulness are explained through neuroplasticity – the rewiring that occurs in the brain as a result of experience. The individual plays an active role in this process, but it can become effortless over time.
Even short (eight week) courses of mindfulness meditation may change the way that emotions are processed and regulated by the brain (Williams 2010).
Meditation (one of the common approaches to mindfulness) often involves focus on (fascination) patterned movements such as breathing or the sensory inputs from the environment. It avoids calling on tired cognitive patterns (avoiding the unnecessary use of directed attention) and is best practised in a supportive environment, free of distractions and everyday concerns (being away), which provide sensory experiences which have extent, are compatible and engage fascination (biophilia) (Kaplan 2001).
Note: Several other theoretical concepts exist for the mechanisms underlying STH such as “scope of
meaning” – the way the self extends into, identifies with and communicates meaning to the surrounding physical space (Grahn et al. 2010) and Aesthetic-Affective Theory – where we are unconsciously conditioned by evolution to respond to particular natural environments in a way which encourages rest and hence decreases stress (Ulrich 1991, 1999). These have not been considered in this study.
31
Appendix C: Health and Well-being through Nature and Horticulture
Simple model of some of the processes, activities and outcomes of Social and
Therapeutic Horticulture, as described in the literature showing the interconnectedness of
all elements (Aldridge & Sempik, 2002).
32
Appendix D: PHQ-9, GAD-7 and IPAT assessment measures (Talking therapies,
2014)
33
34
Appendix E: Warwick-Edinburgh Mental Well-Being Scale. This is free to use but
users must register at http://www2.warwick.ac.uk/fac/med/research/platform/wemwbs/