Kicking off National Landscape Architecture Month with a theme of “Design for Active Living,” the American Society of Landscape Architects sponsored a lecture on “Therapeutic Site Design” and its affects on human health. Dr. Joanne Westphal – the only ASLA member who currently practices both landscape architecture and medicine – shared findings from her recent study on green spaces at a third-stage Alzheimer’s unit.
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“There has been an explosion of interest in therapeutic site design, from healing gardens, restorative gardens, meditating gardens and the like,” Westphal said in her presentation. “Some are very good and others really have no medical basis for their approach. That aspect of moving therapeutic site design into a more scientific form is still in its infancy.”
MENDING THE MIND. Westphal noted that areas of medicine such as psychology, epidemiology and physical therapy could benefit from therapeutic site design, were it not for the fragmented nature of the medical field today. “There’s lots coming to bear on the design process that can keep concepts from moving forward,” she said. “For example, different sets of terminology between the medical practitioner and the designer – or even between different areas of medicine – can create roadblocks.
“There’s also an extreme number of players at each level of health care from the insurance companies to the administrative staff to practitioners and rehabilitation staff.” Westphal continued. “There could be 30 to 40 aspects of health care with their hands in the process from the time a patient arrives to the time they leave. The healthcare delivery system is very fragmented.”
Isolating some of these factors for their research, Westphal and colleague Julie Galbraith conducted a two-year study at the Martin Luther Holt Home in Holt, Mich., to see how access to green spaces affected the home’s late-stage Alzheimer’s patients. The study focused on 18 patients on a secure wing and looked at standard nurses’ records for two years to compare patients’ moods and progress before and after the garden was planted. Fifth-year students from the University of Michigan, where Westphal teaches, designed the $23,000 garden.
“We did a blind review, so each patient was assigned a number and the records were kept anonymous,” Westphal explains. “We started collecting data in 1999 and the garden was built in 2000, so that was the first summer of use. What we did with the data was compare the average length of time each patient spent in the garden to their progress in each of eight variables.”
The variables studied included:
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Behavior – aggressive (abusive) vs. non-aggressive (agitated and inappropriate)
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Medications – physician ordered vs. as-needed
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Pulse rate
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Blood pressure – diastolic and systolic
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Weight change
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On average, Westphal says patients who spent an average of zero to five minutes in the garden per visit showed diminished functioning in five categories. That is, their systolic blood pressure increased, aggressive behavior (such as swearing or hitting) increased, non-aggressive behavior (such as dressing inappropriately or babbling incoherently) increased, pulse increased and weight dropped. Both diastolic blood pressure and requested medications dropped, while physician-ordered medications stayed the same.
Similarly, deterioration in four categories was found among patients who spent an average of 5 to 10 minutes in the garden per visit. However, patients who spent time in the garden space for more than 10 minutes per visit showed marked improvements in all categories except physician-ordered medications, which stayed the same for all patients throughout the study.
“We were really excited about these findings, which show that spending several minutes in a garden on a somewhat regular basis may keep Alzheimer’s patients’ conditions level, as opposed to continuing the downward spiral you would expect for advanced stages of the disease,” Westphal said. “To verify the results, we went back a year later and found the data to be consistent even then.
“What’s important to remember,” Westphal continued, “is that these visits to the garden were not part of an orchestrated program of horticultural activity. Patients may have visited for an hour one day and just a few minutes or not at all the next day.”
SUCCESSFUL SITE PLANNING. Encouraged by the results of her team’s study, Westphal went on to analyze the positive and negative aspects of the Martin Luther Alzheimer’s Garden. Contractors interested in incorporating therapy garden design into their scope of services can use these notes as they build their portfolios and propose new projects to health care facilities.
“There were a number of aspects of this garden that worked well for the patients and the health care workers who use it,” Westphal said. “Primarily, we used 8-foot-wide brushed concrete for the walkways, which allowed a patient in a wheel chair, a visitor and a nurse to walk side by side or pass each other without pausing to move out of the way. This made for more fluid use of the garden. Additionally, there was strong edge deliniation from the walkways to the plant beds and even in the scope of color and texture that was used. In Alzheimer’s patients, this helps with poor vision and can keep them from wandering off the path.”
Other positive elements of the garden included:
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A simple returning-path system in the shape of a figure eight.
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Ample seating in shade and sun.
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The use of nonpoisonous and nontoxic plants (other plants could harm patients dermatologically or by ingestion)
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A planting and work area near the entrance with water and storage facilities
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Maximum perennial plantings and a small amount of grass. More lawn areas and annual plantings would have required extensive maintenance and staff education on how to care for the garden.
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In retrospect, the garden designers found that use of certain landscape and construction materials took away from the benefits of the garden. “The biggest disadvantage was the off-white paving that was used for the walkway,” Westphal said. “The light color ended up being far too bright in the summer and we had to put sunglasses on many of the patients in order for them to use the garden comfortably. There was also excessive bounce light off the structure of the hospital building, which was made from concrete block and also added to the glare. Landscape plantings could cover this, but would take several seasons to grow in and cut down the light effectively.”
Other points contractors should keep in mind for therapy garden design include:
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Using upward bevel edges on concrete walkways. Including this type of design element can keep wheelchairs from rolling into lawns or landscape beds.
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Annual plants present annual problems. As mentioned above, annual plantings require higher maintenance than perennials and hospital staff, which sees frequent turnover, would need to be re-educated on how to properly maintain the gardens. Some health care facilities also may have limited resources to devote to regular maintenance, so plants that avoid becoming overgrown or ratty are preferred.
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Avoiding shadowy areas. Alzheimer’s sufferers or patients with other forms of dementia often have trouble distinguishing between a shadow from a plant and someone hunched over and waiting to attack them, Westphal said. Additionally, shadows from seams in the pavement can appear to be a barrier to these patients who may walk up to the dark lines and not be able to walk farther.
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Some planter materials harbor yellow jackets and other pests. Westphal noted that her design team used concrete blocks for short retaining walls around large plantings. The spaces between each block ended up being hiding places for yellow jackets, which tormented patients and other visitors to the garden.
PROMOTING HORTICULTURAL THERAPY. As landscape designers consider their opportunities at health care facilities, Westphal said they should take the above pointers into account and put themselves in the position of a patient using the garden in order to incorporate useful elements. However, she also notes that designers should be prepared for challenges on the part of health care administrators in opposition to such designs.
“Landscape designers often think very creatively, whereas physicians and other health care practitioners go by the book,” Westphal said. “The two groups speak very different languages, but for good reason. Put yourself in the position of a patient about to undergo gall bladder surgery and ask yourself if you want a physician who thinks creatively and wants to try out a new technique or someone who has taken out thousands of gall bladders with the textbook precision. Both surgeons may be competent, but most patients will prefer someone more practical.”
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As such, Westphal said designers proposing therapy gardens should consider using more conservative language and concepts in their presentations, rather than using the most creative, colorful and exciting ideas they can come up with. While homeowners may take to that approach, it could scare of a hospital administrator. Likewise, providing as much data as possible on the benefits of similar gardens and landscapes is key.
“We need to commit ourselves to evidence-based design from site analysis to user analysis,” Westphal says. “Track and document the concept and post-construction results of therapeutic site design in order to ensure that your designs are meeting the goals that were set and that those and results can be reproduced. It’s also essential to get informed consent from the patients or their guardians when doing such documenting on order to ensure that the findings are valid. From there, report, report, report and make the findings known.”
A three-pronged team of designers, horticulturists and medical professionals is necessary to effectively implement therapeutic site design, though Westphal says it’s up to the designers to push such proposals forward. “Medical professionals aren’t interested in the work of landscape architects and designers,” she said. “But the health care workers you can get on your side are nurses and therapy staff. They’ll be your advocates because not only can they see a difference in the health and recovery of their patients, but healthy patients also lowers their workload and stress levels.”
Nurses and physical therapists also can educate landscape designers on the therapy protocol that their patients’ go through. If a portion of that therapy can be done in the garden or if time in the garden can be used as a reward for often painful therapy, the benefits are there. “These gardens are a tiny portion of construction costs for the whole of a health care complex, even with the maintenance,” Westphal said. “When you consider that it can cost a hospital as much as $75,000 to bring a single new nurse into their system with advertising and other means, the benefits of a $25,000 garden far outweigh the costs.”
Has your company handled therapy garden design on health care sites? Share your experiences on the Lawn & Landscape Online Message Board, or conctact Lauren Spiers to share your thoughts on this aspect of design with Lawn & Landscape.