My grandmother fetched a rickety, unsafe stepping stool to reach the string trimmer that her son had placed high in the barn, so that his 86-year-old mother could not reach it and injure herself using it. But reach that weed wacker, she did. Grandma was a determined gardener. She grew vegetables and flowers until the age of 92, when one day she began to cook a steak on the stove, then decided to weed the cucumbers a bit and accidentally set her kitchen afire, having forgotten all about the steak.
Eventually my grandmother resided in a long-term care facility. There were therapeutic activities at the facility that she enjoyed, but Grandma really longed to plant and tend and harvest. She missed planning the garden, sowing the seeds, seeing the amazing new life sprout, and watching the plant grow large and bear its fruits heavily. She missed harvesting fresh tomatoes and tasting their intense sugars and acids, so much greater than those of tomatoes from the grocery store. The facility did not have a therapeutic garden of any kind, or activities with plants. Limitations of space, money, and strong backs to do the heavy work prevented organization of a therapeutic gardening program.
Today, I sit at my kitchen table and transplant micro-dwarf tomato seedlings into their permanent pots, which range from large disposable plastic cups to black 1-gallon nursery pots. I have a small pail of potting mix by my side, and a serving spoon as my tool. Each plant is settled into place, and I have not broken into a sweat, nor have I strained a muscle. I have used planning, sequencing, and both fine and gross motor skills in this therapeutic activity. About two months or less from now, I will place a fruit-laden plant on my kitchen table and sit down to pick the ripe fruits. I will eat some of those sweet, juicy cherry tomatoes right then. Again, no sweat will be produced and no muscles will be strained. I wish that my grandma had been afforded this opportunity in her long-term care facility.
“Gardening is holistic; it requires cognition to plan and sequence, physical skills to tend, and emotion to be invested in the process. Gardening promotes engagement and responsibility and stimulates curiosity” (Wagenfeld & Atchison, 2014, p. 1). Gardening is an occupation-based intervention that can provide “…reduced stress on the autonomic nervous system, improved attention and physical capacity, a greater sense of self-satisfaction, diminished aggressive behavior, and improved positive social interaction” (Wagenfeld & Atchison, 2014, p. 3). Today, a person can participate in therapeutic gardening with the most minimal demands of his or her physical capacity, facility space, and project funds, thanks to genetic breeding that has deliberately reduced the size of plants to produce micro-dwarf, mini-dwarf, and extreme dwarf varieties of vegetable and ornamental plants. The purpose of this continuing education course is to instruct and empower the occupational therapist to create a more accessible program of therapeutic gardening, which will allow participation of clients of diverse ages and physical abilities.
Use of Horticulture as a Therapeutic Intervention
Historically, the use of horticulture as a therapy dates back to Mesopotamia in 2000 BC, and more recently, as a psychiatric intervention in the early 1800s (Monroe, 2015). Horticulture therapy continues to exist as an intervention for countering behavioral problems, cognitive decline, and physiological impairments (Gonzalez & Kirkevold, 2014; Yao & Chen, 2017). Shoveling soil and lifting a bag of compost demands gross motor skills. Weeding, pruning, and harvesting utilize fine motor skills as well as hand-eye coordination, sequencing, and planning. Universally, participants in therapeutic garden activities can experience all five senses (Yao & Chen, 2017). The gritty touch of dirt, the fluffy feel of hydrated shredded coir, the sharp-sounding snip of pruning scissors, the warbling of birds and the buzzing of insects provide tactile and auditory stimuli. Tomato foliage has an unforgettably pungent but captivating odor. Flowers and herbs have a unique range of aromas, from sweet to intoxicating to stimulating. Edible vegetables, herbs, flowers, and fruits yield a rich reward of flavors. The vast and often colorful array of visual stimuli found in gardening activities ranges from the largest landscape to the smallest seed in germination.
Who can provide horticultural therapy? Service providers and researchers use various terms to describe a client-centered, garden-related treatment. This may be termed horticultural therapy, therapeutic horticulture or therapeutic gardening (Haller & Kramer, 2006; Wagenfeld & Atchison, 2014). “The focus is to maximize social, cognitive, physical and/or psychological functioning and/or to enhance general health and wellness” (Haller & Kramer, 2006, p. 5).
Can any occupational therapist deliver horticultural therapy to clients? The answer to this question is both “yes,” and “no.” The issue to consider is the definition of the horticultural therapy provider. The practice of horticultural therapy (HT), as defined by the American Horticultural Therapy Association (AHTA), is a registered profession (American Horticultural Therapy Association [AHTA], 2015). A qualified practitioner of horticultural therapy, or Horticultural Therapist-Registered, has at least a bachelor’s degree in horticultural therapy, or a bachelor’s degree in another area accompanied by additional coursework in plant science, human science, and horticultural therapy. Additionally, this HT provider must have completed a lengthy internship in service provision, and attain registration as a horticultural therapist with the American Horticultural Therapy Association (AHTA, 2015).
The American Horticultural Therapy Association recognizes that there are individuals without professional credentials who represent themselves as practicing horticultural therapists having completed a certificate in horticultural therapy. While a certificate is of value in providing the horticultural therapy education, a certificate does not provide education in horticulture, human science, nor provided practical experience. The Association does not support the use of horticulture as therapy by individuals who do not have the required educational background nor possess professional credentials.
The Association recognizes that there are professionally credentialed practitioners who use horticulture as a therapeutic tool in their practice. Many credentialed professionals have completed a horticultural therapy certificate program. While the AHTA accredited certificate coursework provides valuable education, to develop a thorough understanding of the discipline, coursework in horticulture and human science is necessary. The Association welcomes, and encourages, credentialed professionals to pursue professional registration with the American Horticultural Therapy Association. (AHTA, 2015, para. 3-4)
An occupational therapist may attain this registration and practice horticultural therapy. However, occupational therapists who do not possess the credentials of a Horticultural Therapist-Registered may still provide valuable therapeutic interventions that are centered around the occupation and engagement of a client in goal-driven, gardening-related therapeutic activities (Kamioka et al., 2014). Occupational therapists have used gardening as a therapeutic intervention since at least 1932, as recorded in historical literature and evidenced in photograph archives (Wagenfeld & Atchison, 2014).
Role of Occupational Therapy in the Use of Horticulture as a Therapeutic Intervention
Creating or facilitating opportunities for occupation is recognized and supported as treatment within the scope of occupational therapy practice, and is explained in the Occupational Therapy Practice Framework: Domain and Process (3rd ed.; American Occupational Therapy Association [AOTA], 2014): “Occupational therapy intervention focuses on creating or facilitating opportunities to engage in occupations that lead to participation in desired life situations” (p. S4).
Occupational therapists are unique creators and providers of therapeutic environments that give meaning to or facilitate occupational performance. “Overall, the environment in which an individual participates in an occupation has a great effect on that individual and can promote or hinder an individual’s engagement in a valued occupation” (Royeen, 2016, p. 4). Using micro-dwarf tomato plants, an occupational therapist can create a therapeutic gardening environment in diverse and portable locations.
Evidence-Based Practice of Therapeutic Horticulture
What client populations have benefitted from plant-centered therapeutic activities? Clients with depression have demonstrated positive effects such as decreased depression, decreased loneliness, and increased feelings of well-being. Clients with chronic pain reported reduced anxiety, depression, and fatigue (Quick, Robishaw, Baylor, Snyder & Han, 2017). Therapeutic weed-pulling was shown to decrease hair-pulling in a client with trichotillomania (Packer, 2017). Military veterans recovering from substance abuse have successfully utilized gardening therapy to reduce stress (Lehmann, Detweiler & Detweiler, 2018). Horticultural therapy was shown to improve the self-concept of children with physical disabilities (Beela, Reghunath, & Johnson, 2015). Horticultural group activities have benefitted older adults by improving their physiological, psychological, and cognitive functioning (Yao & Chen, 2017). Hospitalized clients who were status-post stroke have responded to horticulture therapy with reduced heart rate and lowered blood pressure (Yao & Chen, 2017).
Horticultural therapy and therapeutic gardening have not been well-supported in systematic reviews. Although these reviews recognized that garden-related therapeutic activities may benefit clients with dementia, schizophrenia, depression, or terminal cancer, definitive and conclusive support of this therapy was not given due to poor methodological and reporting quality and heterogeneity of the articles reviewed (Detweiler et al., 2012; Gonzalez & Kirkevold, 2014; Kamioka et al., 2014; Whear et al., 2014). “Much of what has been published is self-report and qualitative, with few randomized control trial experiments” (Wagenfeld & Atchison, 2014, p. 3). If programs were made easier to set up, manage, and access, more occupational therapy practitioners could feasibly provide this treatment as well as test it more effectively.
Why Vegetable Gardening and Why Tomatoes?
Gathering food can be seen as an instinctive survival behavior. In the early days of human existence, survival depended one’s ability to forage for food. Hunting and gathering changed over time to agriculture, both of which are practices driven by the instinctive need to efficiently locate, acquire, and consume food (Brunstrom & Cheon, 2018). Harvesting food has a greater instinctive pull than enjoying the sight and fragrance of flowers. The promise of eventually eating something both healthy and tasty is a strong motivation to participate in a therapeutic gardening program. From the therapist’s perspective, participating in vegetable gardening may engender healthier eating habits and greater activity in clients (Quick et al., 2017). In terms of occupational therapy, therapeutic gardening “… is sustainable and supports healthy eating, exercise, elevation of mood, and social engagement” (Wagenfeld & Atchison, 2014, p. 1).
Growing a vegetable that has significantly better flavor and quality at fresh harvest than when obtained from a grocery store increases the motivation and enjoyment of clients participating in therapeutic gardening. The tomato is an example of this vegetable selection, and it is often eaten without requiring cooking or other extended food preparation.
Barriers to Implementing Therapeutic Gardening/Horticulture Programs
Barriers to client participation in therapeutic gardening/horticulture programs include intolerance to heavy physical work, lack of transportation to the garden site, and poor physical access to the plants within the garden (Quick et al., 2017). Facilities with excellent funding can create large garden environments adapted to clients with physical disabilities or pain. “The whole horticulture project was a team work of three groups of professionals such as child development experts, horticulturists and special educators” (Beela et al., 2015). A level surface is required to allow access to plants within the garden by clients with ambulatory limitations (Quick et al., 2017). Producing a level and firm large-scale gardening surface is physically very difficult as well as expensive, involving moving sod, dirt, and landscape rocks, pebbles, or tiles.
Accessible raised beds are at least 2-feet high, preferrably with a foot-wide ledge around the top so patients can sit while gardening (Quick et al., 2017). The raised beds are expensive and require skilled labor to build. They also require a strong back to fill the beds with dirt. The raised beds in my main garden are 8-inches deep and receive soil and amendments each year. These are heavy substances that pack down with time. Tall raised beds will require significant additions of soil annually for some time as the soil packs down and the level sinks. Growing plants outdoors also involves an element of risk, given variable weather conditions and catastrophic damage from disease or insects. One memorable spring I lost 98% of my tomato crop, over 400 mature plants, to the tomato yellow leaf curl virus (TYLCV) due to my first experience with whiteflies. One fall I lost 225 plants loaded with green fruits to an unseasonably cold and early 3-day freeze. Losses of this magnitude can prematurely end a therapeutic horticulture/gardening program. “Unfortunately, gardening does not guarantee 100% success, and grave disappointments may follow months of hard work” (Packer, 2017, p. 2). The more money and effort that are put into a program, the more money and effort are lost when garden devastation occurs. This may preclude repeated attempts.
Wagenfeld and Atchison (2014) surveyed occupational therapists who utilize therapeutic gardening for clients with dementia. Participants listed the following garden features as significant challenges to client participation: distance to clinic; unlevel pathways; narrow pathways; no railings; varied walking surfaces; no places to sit and work; seating and table options do not allow for flexibility; lack of raised beds/planters; and clients cannot sit and work in the garden safely and comfortably (Wagenfeld & Atchison, 2014).
A Micro Solution
Growing micro-dwarf and extremely compact plants provides many opportunities for solutions to the barriers listed previously. These plants require less soil to grow in their small pots, which means that soil may be purchased and handled in smaller, lighter quantities. As time goes on, I am finding myself less able to lift and maneuver 40-pound bags of soil. Creating a therapeutic horticulture program does not have to involve the use of paid laborers with strong backs, or the delivery and distribution of cubic yards of soil.
The small pots are quite portable, and the plants can be brought indoors and placed on any surface for tending by those clients who cannot physically access an outdoor garden. This includes those clients with autoimmune conditions, which react pathologically with sun exposure (Kreuter & Lehmann, 2014; Yang, Bernstein, Lin & Chong, 2013). I experience this autoimmune reaction to ultraviolet from the sun myself, and so my work in the main garden is confined to 1 hour per day, beginning at sunrise. Determined gardener that I am, I have attempted gardening prior to sunrise, but quickly decided that I did not like being unable to see snakes on the ground, wasp nests in the plants, and fire ant mounds next to my hands.
My micro-dwarf tomato plants are located indoors, in the garage, and along shelves against the west wall of the house. That area receives dense shade until approximately 11am, significantly increasing the time I can tolerate working outdoors with these plants. For clients conducting gardening as therapy, the activities must occur generally during business hours, which comprise the brightest and hottest part of the day. Being able to perform these activities in a sheltered, shaded outdoor environment or completely indoors greatly increases the potential number of clients who are physically able to participate.
If grown outdoors, micro-dwarf and extremely compact plants may reside on inexpensive plastic shelving units in partial to full sun, at heights easy to access standing or sitting. Watering is performed on a smaller scale, and may involve use of smaller, lighter watering vessels. In fact, the small plants require less of most items that are costly for upkeep, such as fertilizer or solutions sprayed to prevent foliar diseases and insect damage.