Gardens and health

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					                             Gardens and health
                                   Clare Cooper Marcus, Professor

In past centuries, green nature, sunlight and          patient, visitor, or member of staff can be a
fresh air were seen as essential components of         stressful experience. Access to gardens and na-
healing in settings ranging from medieval mo-          ture can enhance people’s ability to deal with
nastic infirmaries, to 19th century pavillion-style    stress and thus potentially improve health out-
hospitals, to early 20th century asylums and sana-     comes.
toria. By the mid and later decades of the 20th            The reasons for this re-focusing on nature
century, however, access to nature and the thera-      are many, and are interconnected. They include
peutic value of gardens had all but disappeared in     research on the mind-body connection; consu-
medical settings in many Western countries. Air        mer movements demanding more patient-
conditioning often replaced natural ventilation;       centered care; a burgeoning interest in health
outdoor balconies and roof terraces disappeared;       and alternative medicine; and the concerns of
land costs, building constraints, and the demand       the environmental movement. In many Wes-
for parking resulted in large institutional settings   tern countries, the therapeutic benefit of spen-
where views out to trees or gardens became a           ding time outdoors is deeply ingrained in the
rarity; and indoor settings designed for efficiency    culture. It is taken for granted that the single
were often institutional and stressful for patients,   family home will have an attached yard or gar-
visitors, and staff. (Ulrich, 1992; Malkin 1992;       den; that neighborhoods will be provided with
Horsborough, 1995). In the 1990s, however, a           parks; that the public will have access to shore-
reversal of this trend occurred as patient-centered    lines and walking trails. In three types of health-
care became the focus of hospital administrators
and designers. Panel discussions on healing gar-
                                                                         Clare Cooper Marcus
dens were highly attended at the annual conferen-                        Professor
ces of the American Society of Landscape Archi-
tects in 1998 and 1999. Several books on the
therapeutic value of outdoor space in healthcare
settings appeared in the United States in the mid
1990s: Gerlach-Spriggs, N. et al. (1998); Tyson,       Clare Cooper Marcus is Professor Emerita in
M. (1998); and Cooper Marcus, C. and M. Barnes         the Departments of Architecture and land-
(1999). Books also appeared that urged readers         scape Architecture at the University of Califor-
                                                       nia, Berkeley. With degrees in Urban Geography
to consider their own back garden as a healing         and City Planning, she is the author of four
or sanctuary space (Minter, 1993; McDowell             books and numerous articles in the field of en-
and Clark-McDowell, 1998; Jay 1998). Signifi-          vironmental psychology. She has done con-
cantly, an organization that accredits eighty-five     sulting work in Canada, Australia and the U.S.,
percent of United States acute-care hospitals,         and is the recipient of a number of research
                                                       awards. In addition to restorative environ-
now requires that for certain patient groups (pe-      ments, her areas of expertise include housing-
diatrics) and those experiencing long lengths of       site planning, children’s environments, public
stay, the hospital must provide “access to the         outdoor space, housing for seniors, and the
outdoors through appropriate use of hospital           psychology of home and garden. She is co-
grounds, nearby parks and playgrounds, and             author (with Marni Barnes) of the book, “Heal-
                                                       ing Gardens: Therapeutic Benefits and Design
adjacent countryside.” (The Center for Health
Design, 1998). Spending time in a hospital as


care facilities – the nursing home, the Alzheimer’s      where subjects are subjected to stresses and then
facility, and the hospice – the provision of a gar-      to potential recovery experiences, such as viewing
den seems to be similarly taken for granted, pro-        photographs, slides or videos of outdoor nature
bably because the emphasis is on quality of life         scenes. Physiological changes (e.g. blood pressu-
rather than cure, and the overall image of the en-       re) are recorded, as are speed of recovery from
vironment is residential rather than medical. In         stress, duration of recovery, landscape preferenc-
other types of healthcare facilities, such as acute-     es, etc. Roger Ulrich, Terry Hartig and colleagues
care hospitals, psychiatric facilities, and children’s   are major contributors in this area of research (e.g.
hospitals, the provision of a garden is more pro-        Ulrich 1981, 1984, 1991; Hartig, 1991, 1993).
blematic, however, the emergence of research on          Quasi-experimental studies extend this approach
access to nature and stress reduction is beginning       outdoors with subjects’ physiological changes
to have an impact on their design. Nature-orien-         being recorded by mechanical recording devices.
ted spaces which have the potential to promote           (Hartig, 1996). All the research in this category
restoration from stress via passive contact (such        indicates a distinct and fairly rapid recovery from
as looking out through a window), or via low-            stress and improved health outcomes after vie-
level physical activity such as walking, sitting, and    wing nature scenes, or spending time in a natural
talking, are taking on more significance. Such spa-      setting. This is the most significant body of re-
ces may, or may not, be designated as “healing           search in terms of convincing hospital adminis-
gardens”; they are mostly outdoors, but in latitu-       trators and medical staff as to the healing poten-
des with extremes of heat and cold some are in-          tial of outdoor space. However, other ap-
doors; they vary greatly in size from small roof-        proaches to research provide additional supporti-
top gardens to expansive campus-like spaces.             ve findings.
(For an extensive typology of healing gardens, see            A number of research studies provide self-
Chapter 4 in Cooper Marcus, C. and M. Barnes,            reported evidence of the significance of nature
1999). For purposes of discussion, the term              in stressed, and non-stressed, subjects. A study
“healing gardens” will be used in the remainder          of 154 university students at five different US
of this paper, to indicate outdoor spaces with           locations, found that when dealing with a situa-
therapeutic potential.                                   tion that left them stressed, upset or depressed,
                                                         71% chose to spend time outdoors in a natural
                                                         or semi-natural setting (beach, forest, park, etc.)
Healing gardens and relevant
                                                         to find solace or relief. (Francis and Cooper
                                                         Marcus, 1992). In another study, 300 subjects
A recent report by Johns Hopkins medical re-             recalled a time and place when they, or someone
searchers identified more than seventy scientific        close to them, felt helpless, wounded or in pain,
experimental studies dealing with the effects of         and then visualized an environment that would
healthcare environments on medical outcomes              be healing. Every environment cited envisaged
(Rubin et al., 1997). While none of these rigo-          nature (grass, trees, water, sky, rocks, flowers,
rous studies addressed gardens per se, research          birds) as a significant healing agent. (Olds,
that has considered the effects of light, tempe-         1985).
rature, noise, and music on medical outcomes                  Since contemporary healing gardens are a
has raised the awareness of the positive and ne-         relatively recent phenomena, systematic post-
gative affects of the environment of healthcare.         occupancy evaluations (POEs) of those that exist
    Categorized by methodological approach,              are essential in guiding the work of designers,
there are four types of relevant research that are       though relatively few have so far been published.
significant in the discussion of healing gardens.        Four have been conducted by this author and a
Firstly, there are carefully controlled experiments      colleague in medical facilities in the San Francisco

62                                                                   (IADH) International Academy for Design and Health
                                                                            GARDENS AND HEALTH

Bay Area (Cooper Marcus, C. and M. Barnes,              The Healing Garden: Essential
1995); one has been conducted at the Children’s         design elements and environmental
Hospital in San Diego (Whitehouse, S., et al.,          qualities
1999); one at a psychiatric facility in Canada (Per-
                                                        Significant in terms of drawing together much
kins, N., in Chapter 6, Cooper Marcus, S. and M.
                                                        of the above-cited research, as well as valuable
Barnes, 1999); one at an urban wildlife preserve
                                                        material from related fields, is Ulrich’s Theory
jointly used by a grade school and a medical cam-
                                                        of Supportive Garden Design. (See Ulrich, R.,
pus (Center for Design Research, 1998); and one
                                                        Chapter 2, Cooper Marcus, C. and M. Barnes,
comparing two small community hospital gard-
                                                        1999). In brief, this framework is based on the
ens in Wales (Singleton, 1994). The findings of
                                                        premise that gardens help to mitigate stress to
such studies are critical in our understanding of
                                                        the extent that they foster a sense of control and
the ways in which garden environments impact
                                                        access to privacy; provide settings where users
garden users. The San Francisco hospital studies
                                                        can gather together and experience social sup-
found, for example, that people appreciated tra-
                                                        port; create opportunities for physical move-
ditional garden designs of lawns, trees, and flo-
                                                        ment and exercise; and provide access to nature
wers and that ninety percent of garden users ex-
                                                        and other positive distractions. This theory starts
perienced a positive change of mood after time
                                                        to provide a structure from which designers can
spent outdoors. Responses suggested that these
                                                        work in creating gardens with therapeutic bene-
natural elements were critical because they repre-
                                                        fits. The following elements and qualities are
sented a complete contrast to the experience of
                                                        drawn from the research findings cited above,
being inside a hospital; they stimulated several
                                                        and from field observations by the author at
senses (sight, sound, touch, smell) and that
                                                        more than 70 healthcare facilities in the US, UK,
seemed to be a precursor to a calming or centering
                                                        Canada and Australia.
experience. The San Diego study found that whi-
le children may be initially attracted to an unusual,   • Opportunities to make choices, seek privacy and expe-
colorful garden setting, when they find that there         rience a sense of control.
is nothing there for them to do, they quickly be-       Stress stemming from lack of control has been
come bored and want to leave. Clearly, many             shown to have negative effects on immune
more POEs are needed to fine-tune what is most          functioning and other physiological measures
appreciated and needed by the users of healing          among patients. (Ulrich, 1999, p. 38), and dec-
gardens, and by particular patient populations.         reased job satisfaction and increased turnover
    Finally, another important research category        among staff. In the 1980’s/-90’s, hospital routi-
consists of consumer research where data is             ne and design promoted a greater sense of con-
collected via surveys or focus groups across a          trol in many facilities. Interviews with hospital-
number of health care settings. MacRae inter-           garden users suggest that regaining control and
viewed former patients differing by age, loca-          thus reducing stress is one of the major motiva-
tion and medical problem and found that their           tions for garden use. (Cooper Marcus and Barnes,
most widely shared preference regarding the             1995). Going outside is a means of escape. A
physical environment of healthcare was for ac-          patient reported: “It’s a good escape from what
cess to nature – gardens, views, balconies, in-         they put me through. I come out here between
door plants and nature pictures. (MacRae, 1997).        appointments.... I feel much calmer, less stress-
    Of necessity, this overview of research that        ed.” (Ibid., p. 27).
can justify and inform the creation of healing               For a garden to foster stress reduction by
gardens is brief. For a fuller discussion see Chap-     providing a sense of control, users must know it
ters 2, 3 and 12 of Cooper Marcus and Barnes,           exists, be able to gain access, and use it in the
1999.                                                   ways they prefer. In addition, a garden design

    ALTH FA AN               E

    needs to offer choice – places to be private, places   to be alone is not intruded upon. (Cooper Mar-
    to people-watch a variety of walking routes, diffe-    cus and Barnes, 1995).
    rent kinds of seating, and so on. Involving pa-
    tients or residents in designing or maintaining        • Opportunities for physical movement and exercise.
    the garden may also enhance a sense of control.        Exercise is associated with a variety of physical
    (Francis, M., 1989; Hester, R.T., 1984).               and psychological (i.e. stress-reduction) bene-
                                                           fits, including improved levels of cardio-vascu-
    • Opportunities which encourage people to gather to-   lar health, and reduced levels of depression
       gether and experience social support.               among adults and children. (Brannon and Feist,
    A considerable body of research has shown that         1997; Koniak-Griffin, 1994). The implications
    people who receive higher levels of social sup-        for healthcare garden design include looped
    port are usually less stressed and have better         pathway systems offering a variety of routes;
    health than those who are more isolated, and           corridors with views out to nature to encourage
    that higher social support improves recovery or        indoor walking; rehabilitation settings with
    survival rates for various medical conditions.         views out to nature; settings where well children
    (See Ulrich, 1999, pp. 42-43 for discussion of         can run and let off steam; walking routes for
    this literature.) Hence, a marked trend towards        patients recovering from heart surgery labeled
    longer visiting hours, social-support groups, and      for distance and time; and walking or jogging
    more attractive waiting areas in many hospitals.       routes for staff on their lunch hours.
         Studies of urban open space indicate that
    spending time with friends or family is often a        • Engagement with nature.
    primary motivation for use. (e.g. Driver, B.L. ad      In recent years, considerable attention has focus-
    P.J. Brown, 1986; Whyte, 1980; Cooper Marcus           ed on the provision of what have been termed
    et al., 1998). Research on healthcare gardens          “positive distractions” in healthcare environ-
    indicates a high proportion of use revolves            ments, including comedy (Cousins, 1983); com-
    around visitors, patients and staff seeking social     panion animals (e.g. Friedman et al., 1980); art
    contact in a setting which is in marked contrast       (Kaye and Blee, 1997); and music (e.g. Moss,
    to the hospital interior. (Cooper Marcus and           1988). The merits of nature as a positive distrac-
    Barnes, 1995; Singleton, 1994; Paine and Fran-         tion are supported by research as indicating that
    cis, 1990).                                            viewing nature scenes tended to reduce stress (Ul-
         For a garden to foster opportunities for so-      rich et al., 1991; Hartig and Evans, 1993; Hartig et
    cial support it needs to provide sub-spaces and        al., 1996); subjects’ moods in offices were more
    seating arrangements that permit groups of two         positive when plants were present (Larsen et al.,
    or more to sit and talk in relative privacy. A stu-    1998); viewing a fish aquarium reduced anxiety
    dy at a Canadian psychiatric hospital found that       among patients waiting for dental surgery (Kat-
    patients and staff preferred natural, spatially en-    cher et al., 1984); and patients recovering from gall
    closed settings for “talking with others.” (N.H.       bladder surgery who had a view into trees had
    Perkins, in Cooper Marcus, C. and M. Barnes,           fewer post-surgical complications, and needed
    1999, p. 293-304). Studies of non-healthcare           fewer injections of strong narcotic pain drugs
    open space indicate a preference for seating at the    than matched patients viewing a brick wall. (Ul-
    edge of a space, with protection at the back. (Coo-    rich, 1984). These and many other studies linking
    per Marcus and Francis, 1998). In locations where      a view of nature with physiological measures in-
    cultural and ethnic groups favor visiting in large,    dicating a reduction in stress and improved
    extended family groups, sub-spaces need to be          health outcomes provide strong support for
    provided such that the privacy of those who wish       access to gardens and natural areas in healthcare

    64                                                                 (IADH) International Academy for Design and Health
                                                                            GARDENS AND HEALTH

    This author contends that additional sup-           horizon or to “borrowed” landscape. The garden
port is potentially available if we regard the phe-     layout should be such that walking or being
nomenon of human-nature interaction as one              pushed in a wheelchair through the garden,
of “nature engagement” in addition to “natural          provides a variety of open and closed views, ex-
distraction.” Most existing research measuring          periences of differing sub-spaces, even elements
health outcomes has involved subjects viewing           of positive surprise or whimsy; and for those
nature through a window, or viewing nature              who are seated, views of plants or trees which
scenes via slides or video. This has been necessary     vary in color, texture, size and massing.
in order to control the variables in an experi-
ment, and has of necessity, largely focused on          • Visibility.
sight. Insights from non-experimental evidence          In field visits to over 70 acute care hospitals that
suggests that actually being outdoors, in a gar-        had usable outdoor space, only three (!) inclu-
den or natural area stimulates all the senses, ge-      ded signs to the garden in their way-finding sys-
nerates experiences of the mixing of the senses,        tem, or included information in printed material
and these in turn are less “distracting” than “en-      given to patients and staff. There are two
gaging.” (Sewall, 1999; Abram, 1996).                   aspects of visibility which are important. First,
    “At some point you are seeing so intensely          on entering a building, or moving along the
that you become what you see, you merge into            main circulation routes, people should be able
the drop of water until the ‘you’ disappears.           to see that a garden, courtyard, or natural area is
The hows and whys and wherefores disappear              potentially available for use. Second, as many
too. Yet when you emerge, you are somehow               patient rooms, waiting areas, staff rooms as pos-
replenished.” (Hejmadi, 1990).                          sible should have visual access to a garden, natu-
    Similar experiences of “merging” and reple-         ral area, or segment of “borrowed” landscape.
nishment – more intense, complex and multi-
sensory than “distraction” – are noted in re-           • Accessibility.
search on the psychology of wilderness expe-            In many facilities visited, doors to outdoor spa-
rience, (Segal, 1998) and the experiences of people     ces were kept locked to reduce use and mainte-
who, when depressed or upset, spend time in             nance costs, or because staff were not close
nature as a form of therapy or solace. (Francis and     enough to monitor use. Accessibility can be en-
Cooper Marcus, 1991; Barnes, 1994). The fact that       hanced by ensuring that nursing stations have
a large proportion of those stressed through            good visual access to gardens used by children
anxiety, depression or grief choose to find relief in   or by frail or infirm patients; that maintenance
natural or quasi-natural environments, is further       staff understand the therapeutic value of out-
evidence that humans have some “inner know-             door access; and that the width and materials of
ing” that nature is a powerful antidote to stress.      pathways make them usable by people with in-
    For a healthcare garden to provide maximum          firmities and those using wheelchairs.
therapeutic benefits, it needs to have a plentiful
variety of plant materials, including species which     • Sense of Security.
flower at different seasons; plants or trees which      Hospital patients often feel psychologically vul-
attract non-threatening wildlife (birds, squirrels,     nerable. In addition to a garden being visible
butterflies); leaves or grasses which move with         and accessible, it is essential that users feel a sense
the lightest breeze; views to the sky and changing      of security – both physiological and psychologi-
cloud formations; pools that reflect the sky and        cal – or they will not spend time there. Patients
provide environments for fish or water lilies; ele-     who are elderly, infirm or mobility-impaired need
ments that feature the sight and sound of               the reassurance of handrails, seating at frequent
moving water; and when possible, views to the           intervals (especially near the entry door), and pa-

    ALTH FA A               Y

    ving materials that do not cause excessive glare.      helicopter landing pads. The only exception to
    Patients, staff and visitors also need to feel psyc-   this recommendation is the case of housing or
    hologically secure: a garden space needs to feel and   care facilities for the well-elderly; research indicates
    be safe, with some sense of enclosure and the          that many prefer to sit in a “front porch” location,
    absence of feeling that users are in a “fishbowl”,     watching traffic, deliveries and the activity of the
    being stared at. Given the stress that many expe-      neighborhood. The issue here is that people
    rience in a hospital, the degree of comfort in a       come outdoors to relieve boredom rather than
    garden should be such that – if they wish – an         stress.
    ambulatory patient or staff on a break could
    comfortably close their eyes or lay down in the        • Familiarity.
    sunshine for a nap.                                    When feeling stressed, many seek environments
                                                           that are familiar and comforting. A depressed per-
    • Physiological comfort.                               son may be reluctant to leave their bed; an
    Some patients may be on medications which re-          anxious person may seek the familiarity of home.
    quire that they keep out of the sun; others may        Similarly, those in medical settings who are
    fear they will get chilled sitting outdoors; some      stressed from overwork, illness, or anxiety need
    may have trouble getting up from a seated posi-        to have access to garden settings which are soo-
    tion. At the very least, a garden needs to provide     thing in their familiarity. This could mean an
    for physiological comfort with choices of places to    aesthetic which is rooted in the culture of the ma-
    sit in the sun or the shade; seating that is protec-   jority of patients; spaces which are human- or
    ted from breezes by planting or structures; and        domestic-scaled; plants and furnishings that are
    bench seating which would allow someone to             familiar. These recommendations are especially
    sprawl or lay down, as well as garden seats with       important in hospices for the terminally ill and
    arms and backs.                                        facilities for people with Alzheimer’s disease.
         With the banning of smoking in most
    healthcare facilities, gardens and other outdoor       • Unambiguously positive design features.
    areas are being sought out by smokers. To avoid        There is a human tendency when stressed to
    problems associated with second-hand smoke,            project onto nearby objects and people some of
    smokers need to be accommodated on a patio             the anxiety and discomfort experienced inside.
    or other space separate from the garden used by        Niedenthal et al. (1994) have developed the
    non-smokers.                                           concept of “emotional congruence” – when a
                                                           person is presented with an array of environmen-
    • Quiet.                                               tal stimuli, those parts that match the emotional
    If a garden is to have therapeutic value in a          state of the viewer will most likely be the focus of
    medical setting, it needs to be quiet – a complete     attention. Thus, abstract art that is seen as inte-
    contrast to the public announcements, TVs, and         resting or challenging by a non-stressed person,
    rattling trolleys of a hospital interior. People       may be perceived as frightening or threatening by
    using the garden need to feel a sense of calm, and     someone in a state of anxiety. (Ulrich, 1999, p. 67-
    to be able to hear birdsong, wind chimes, or the       71). Hence in a setting such as a hospital, known
    sounds of a fountain. A study of four hospital         to elevate symptoms of stress, it is essential that
    gardens found that users were disturbed by in-         art, sculpture and other human-made design ele-
    congruent mechanical sounds such as air condi-         ments be unambiguously positive in their
    tioners and street traffic. (Cooper Marcus and         message. Complex abstract art which may be
    Barnes, 1995). At the planning stage, it is essen-     appropriately challenging in a museum or corpo-
    tial that future garden spaces are located away        rate foyer is not appropriate in a hospital. Re-
    from traffic, parking areas, delivery driveways, and   search indicates that patients prefer familiar, re-

    66                                                                  (IADH) International Academy for Design and Health
                                                                                 GARDENS AND HEALTH

presentational nature or landscape themes and               amples exist in UK hospitals built on the low-
that patients recovering from heart surgery expo-           rise, chequerboard model.
sed to landscape photographs of water and trees                  The monastic cloister garden is an excellent
had lower anxiety and required fewer doses of               (and rarely used) model that would be appropri-
strong pain killers than those in control groups            ate in a chronic-care or geriatric facility, with the
with no pictures. (Ulrich, et al., 1993). A classic         roofed cloister forming a sheltered and secure
case of the “wrong” kind of art occurred in a US            environment from which to sit, walk and view
hospital where abstract figures of birds in a court-        the garden. The English strolling garden, with
yard were viewed with dislike and fear by cancer            lawns, flowers, trees and winding paths is suita-
patients in adjacent wards, and eventually had to           ble in many healthcare settings since it can provide
be removed. (Ulrich, 1999, pp. 70-71).                      for all four of the elements of Ulrich’s Theory of
                                                            Supportive Garden Design – exercise, social sup-
                                                            port, privacy, and natural distractions – and is a
Design themes in existing healing
                                                            form which is familiar in many Western cultures.
                                                            It is a particularly supportive environment for
Field observations of healthcare gardens in four            staff and visitors in acute care and hospice facili-
English-speaking countries (USA, Canada, UK,                ties, enabling them to “get away” to an environ-
and Australia) suggest that designers draw upon             ment in complete contrast to the building inte-
a variety of themes in their work. It is impor-             rior. (A particularly good example is the garden at
tant to consider these, however briefly, since few          Trinity Hospice, London.).
existing gardens have been informed by the re-                   The urban park is a suitable model, assu-
search-based recommendations cited above, but               ming the site is sufficiently large. At St. Mary’s
– to varying degrees – they do provide well-used,           Hospital, Newport, Isle of Wight (UK) the ex-
potentially therapeutic environments.                       tensive grounds double as a public park for
    Traditional approaches used by landscape                neighboring townspeople and enfold the facility
architects to design a garden or public open space          into the community. The botanical glasshouse or
include drawing on historic precedents, domestic pre-       glazed atrium is a highly suitable solution for
cedents or regional attributes, or creating an innovative   northern latitudes where cold weather precludes
“signature” design.                                         outdoor use for many months. (Some excellent
    In the case of healing gardens, some historic           examples in Canada include Toronto Children’s
precedents are more appropriate than others;                Hospital, and the Royal Alexandra Hospital,
some are good approaches for certain patient                Glenrose Rehabilitation Hospital, and Lynwood
populations, but not for others. The building-              Convalescent Home in Edmonton). Another
enclosed courtyard, which appears in many cul-              urban precedent – the plaza – is not a good model
tures over many centuries, is a very suitable model         for a hospital, given that it is predominantly
for all kinds of healthcare settings as long as it is       hard-surfaced, and usually adjacent to city streets.
large enough (and adjacent buildings low                         Shifting out attention to domestic prece-
enough) to receive some sunlight and as long as             dents, the front porch/garden and the back garden
the privacy of adjacent rooms is not intruded               are very appropriate models in certain circum-
upon by people in the courtyard, or vice versa.             stances. Outdoor space with seating at a building
The courtyard is an enclosed and sheltered set-             entrance is highly valued in facilities for the elderly,
ting; is clearly the territory of the buildings that        and in acute care or chronic care settings where
surround it; and can be designed to be both vi-             some patients appreciate being able to interact
sible and accessible from adjacent rooms or cor-            with “the outside world,” and outpatients can
ridors. Some good, and some rather poor ex-                 wait to be picked up by buses or taxis in a pleasing

    ALTH FA AN               E

    outdoor environment. Outdoor space modeled             den designer to subordinate or align his or her
    on the domestic back garden is particularly            personal tastes to the paramount objective of
    appropriate in a hospice facility, where visitors      creating a user-centered, supportive environment.
    and patients seek privacy and solitude; and in faci-        Another set of themes which have informed
    lities for Alzheimer’s patients where a securely       the design of healing gardens can be termed eco-
    enclosed garden visible from a nurse’s station is      logical or botanical. The use and labeling of medi-
    essential for cognitively-impaired residents.          cinal plants has been used in a number of recent
    (Some particularly good examples can be found          healing gardens. (For example, Oncology Radia-
    in Victoria, B.C., Canada – a city favored by          tion Marin General Hospital, Greenbrae, CA,
    retirees.).                                            USA; and the Healing Garden at Good Samaritan
         A design based on local regional attributes can   Hospital, Phoenix, AZ, USA). The assumption
    create an environment which is familiar and            is that seeing the natural plant sources of drugs
    comforting as long as basic human needs are            will demystify them and make treatment more
    recognized. A Zen-like roof terrace at Harrison        acceptable. There is no research to support, or re-
    Memorial Hospital (Bremerton, WA, USA)                 fute, this assumption.
    echoes the nearby rocky shores of Puget Sound.              A potentially positive approach is to design
    The Leichtag Family Healing Garden at San              all the outdoor areas of hospitals to be ecologi-
    Diego Children’s Hospital presents a colorful,         cally sustainable, thus placing people in a setting
    California beach scene, but lack of shade and          where attention is focused on the continuing
    greenery, and the lack of things for children to do    health of all living beings. The Gardens of Ma-
    renders it less than satisfactory. (Cooper Marcus      kahikilua at North Hawaii Community Hospital
    and Whitehouse, 2000).                                 have been designed on this theme, though not
         Recognition in the design fields often comes      yet built. (O’Neill, 1996).
    with creating innovative “signature” designs, de-           Finally, some gardens have been created that
    liberately breaking with precedent and making an       draw upon knowledge of the progression of a di-
    artistic statement that no one has attempted be-       sease, or on stages in psychological healing. Many re-
    fore. While this is not in, and of itself, a “wrong”   cent gardens for Alzheimer’s patients have
    approach in a medical setting, the environments        drawn upon what is known about the stages of
    that have so far resulted from this model have         cognitive impairment in the development of
    been markedly unsuccessful in terms of fulfilling      that disease. (See chapter on “Alzheimer’s Treat-
    user needs. For example, parallel rough stone          ment Gardens” by John Zeisel and Martha Ty-
    walls that arc up into one courtyard to disappear      son in Cooper Marcus and Barnes, 1999). Some
    and re-appear in two adjacent courtyards do not        facilities for AIDS patients have used data on
    provide a familiar, stress-mitigating environ-         the effects of the disease to guide the design of
    ment. (West Dorset Hospital, UK). Tilting slabs        outdoor space – for example, the Joel Schapner
    of travertine leaning out over a rather bleak, for-    Memorial Garden at Cardinal Cook Medical
    mal courtyard at a Cancer Clinic do not create an      Center, New York City. Finally, design of a
    environment for solace and repose. (Alta Bates         remarkable garden at the Institute for Child and
    Hospital, Herrick Campus, Berkeley, California).       Adolescent Development, Wellesley, MA, USA,
         The above examples were created by an artist      employs the use of landscape archetypes (moun-
    and an architect, respectively, pointing up the im-    tain, cave, ravine, etc.) to create settings where se-
    portance of employing professionals who know           verely traumatized children can choose their own
    plant materials and are trained to design gardens      spaces in which to do therapy.
    – that is, landscape architects. They also remind           Hopefully, more gardens in the future will
    us that to use the term “healing” in the context       draw upon existing research to inform design
    of healthcare gardens ethically obligates the gar-     decisions. As Ulrich reminds us:

    68                                                                  (IADH) International Academy for Design and Health
                                                                              GARDENS AND HEALTH

    “Designers who succeed in creating healing          ments or forms can help alleviate different stress-
gardens will usually be those who seek input            related emotional states.
form patients and staff, and assiduously utilize             We need to encourage designers to work
the available research to inform their creativity       with potential garden users in a participatory
and design approach.” (Ulrich, 1999, p. 30).            design process; to annotate their garden plans
                                                        with presumed health benefits; to disseminate
                                                        this information to medical and maintenance
                                                        staff; to work with their clients to conduct
Clearly there is a need for more research.              postoccupancy evaluations; and to disseminate
“...there is no question that the future importan-      this information to their peers.
ce of gardens in healthcare facilities will be               Clearly, more research is needed, but we
strongly affected by the extent to which sound          cannot wait until such studies are completed.
and credible research shows that gardens can            The evidence we do have warrants continuing ef-
promote improved health outcomes, foster                forts to establish healing gardens in healthcare fa-
higher patient/consumer satisfaction with               cilities so that users might benefit and re-
healthcare providers, and be acceptably cost-effec-     searchers have more possibilities of assessing
tive.” (Ulrich, 1999, p. 31).                           their benefits.
     The healing garden refers to both a process
and a place. Discussions of such a facility are at
the meeting place of medicine and design.               REFERENCES
Some of the problems involved in the success-           Abram, D. (1996). The Spell of the Sensuous: Perception
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                                                        Barnes, M. (1994). A Study of the Process of Emotional
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                                                        Healing in Outdoor Spaces and the Concomitant Landscape
of place but sometimes overlook how these can           Design Implications. Masters Thesis, Department of
affect mood and behavior.                               Landscape Architecture, University of California,
     Both professions would benefit from more           Berkeley.
research. It is critical that we learn more about
                                                        Brannon, L., and J. Feist. (1997). Health Psychology, 3rd
the specific needs of different patient popula-
                                                        ed. Pacific Grove, CA: Brooks/Cole.
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patients, psychiatric patients and those recovering     Cooper Marcus, C. and M. Barnes. (1995). Gardens in
                                                        Health Care Facilities: Uses, Therapeutic Benefits, and De-
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                                                        Health Design.
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                                                        mendations. New York: John Wiley & Sons.
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anxiety and fear in an acute-care setting; to depres-   Cooper Marcus, C., and C. Francis (Eds.) (1998, se-
sion among patients with chronic illness; to            cond edition). People Places: Design Guidelines for Ur-
burnout among healthcare staff; and boredom             ban Open Space. New York: Wiley.
among nursing home residents. (Ulrich, 1999,
pp. 34-35). An important area of needed research
is to consider if, and how, different garden ele-

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    70                                                                         (IADH) International Academy for Design and Health
                                                                                  ARDENS AND HEAL US
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