The Philosophy of Greencare: why permaculture matters for our mental health

by Rex Haigh, Consultant Psychiatrist in Medical Psychotherapy, Berkshire NHS; Professor of Therapeutic Environments and Relational Health, Nottingham University. 

and David Hare, Social and Therapeutic Horticulturalist and Animal Assisted Interventions Therapist, Growing Better Lives CIC

 

The Retreat is a mental hospital in York that is famous throughout the world for being the start of ‘Moral Treatment’ in the late 1790s. It has always been run by a Quaker charitable foundation. Moral treatment became a worldwide movement which recognised that people with mental health disorders were not to be locked away and treated worse than animals - but that they deserved to be dealt with in a humane way, with compassionate care. Contact with nature was recognised as an important factor:

‘The general effects of fine air upon animal spirits would induce us to expect especial benefit from it, in cases of mental depression; and to pay all due respect to the physician, who, “Gives melancholy up to Nature’s care, and sends the patient into purer air.” (Tuke 1813, p130)

 

In many ways, we have gone backwards and treat human distress is as if we are dealing with faulty machinery (based only on disorders of brain biochemistry). We need a new response to restore a human and spiritual dimension to modern mental health care. What we call ‘greencare’ or ‘ecotherapy’ is just that.

The environmental parallel is easy to make: in the headlong rush for greater efficiency and productivity, everything has been simplified, separated and reduced to disconnected parts. In mainstream agriculture we have fertilisers and insecticides to deal with ‘problems’: in mainstream mental health care we have medications and physical treatments to deal with ‘diagnoses’. The interrelationships between living things and the soil, air and water are not given much thought: the connection between people and their social world, relationships and nature are not taken seriously enough.

The level of control we think we can assert over nature is frightening: the level of control the state has over people and their mental health is just as frightening. Industrial scale technological solutions predominate in farming: standardised and fragmented elements of treatment have replaced continuity of care in psychiatric services.

 

The Concept of GreencareSomething is taken from nature and something is given back. Building a dry stone wall, for example, provides a habitat

Greencare covers a wide range of activities which include various aspects of nature in the maintenance of health and well-being, and prevention, amelioration and treatment of illness. The main activities are social and therapeutic horticulture, animal assisted interventions (including equine psychotherapy) and care farming; others include rural crafts, green gyms, wilderness therapy, forest schools, and environmental restoration.

‘Ecotherapy’ is often used synonymously with greencare, but it carries the ecological system inference and implies a two-way feedback relationship with nature; something is taken from the natural environment and something is given back. This could be the production of compost in horticulture in horticultural therapy, restoration of natural drainage by groups doing it for health benefits, building infrastructure that helps nature such as dry stone walls, or various therapeutic activities which help to prevent carbon dioxide release.

The European Union Cooperation in the field of Scientific and Technical Research Action 866 (Braastad et al.) published a conceptual framework for greencare, which concluded that:

  • “Greencare” is a useful phrase summarising a wide range of both self-help and therapy programmes
  • Research to date has demonstrated correlations of well-being in greencare settings
  • Research that would demonstrate cause-and-effect relationships between greencare interventions and improvements in health and well-being has not yet been carried out

 

It also drew up a value base:

  • Contact with nature is important to human beings.
  • The importance of this is often overlooked in modern living conditions.
  • People can find solace from being in natural places, being in contact with nature and from looking after plants and animals.
  • In addition to this solace, contact with nature has positive effects on well-being, with physical, psychological and spiritual benefits.
  • Existing or new therapeutic programmes could be improved by incorporating these ‘green’ elements.
  • The planning, commissioning and delivery of all health services would be enhanced by consideration of potential ‘green’ factors.

 

This, together with the writings of established greencare researchers such as Joe Sempik and Rachel Bragg (neé Hine), provide a substantial foundation upon which to develop a wider scope for and deeper understanding of greencare and its role in society. Research evidence for the beneficial effect of nature on health is growing, and becoming increasingly recognised (Bragg 2014). A recent report from Natural England commissioned by the charity Mind gives a comprehensive update of the research into nature-based interventions for mental health care  (Natural England 2016).

Greencare umbrella

 

Therapeutic Communities

As mental health services become more ‘industrialised’ (Haigh, 2014), they are becoming psychologically and spiritually impoverished, and are losing important aspects of ‘ordinary humanity’. Therapeutic communities, with their holistic ethos that ‘everything is part of the therapy’ and a primary focus on relationships between members, are a powerful way to deliver intensive group therapy with both psychological depth and ‘therapeutic ordinariness’.                                                                                                          

Therapeutic communities were developed in psychiatric services for battle-shocked soldiers in the World War II (Haigh, Lees 2008). They provide a group therapy setting where people with emotional problems can learn from each other better ways to cope, and more effective and satisfying ways to relate to others. This derives from experiencing a sense of belonging, being in an emotionally safe environment where people can be open and honest with each other, and where everything is open to enquiry and challenge.

Through the strictly democratic procedures and processes of a therapeutic community, members can feel empowered to act in more responsible and mature ways by finding a secure idea of their own identity and a fulfilling place amongst others. The theoretical constructs used to describe this are communalism, democratisation, permissiveness, reality confrontation and a culture of enquiry. In this way, the community itself – with all the feelings, behaviour and relationships within it are the primary therapeutic instrument (Haigh 2013).

 

Our clinical work

Benefits of the great outdoors

Horticulture uses the great outdoors to stimulate, calm, and enable people with complex problems to live lives that are more controlled and positive. It is well researched that being in the garden lowers stress more than being outside in a hard surfaces area. The sensory, emotional stimulus of the natural setting is shown to reduce the negative external stimuli of life in the town. Horticultural therapy takes this beneficial effect of being outside, and in the country, and reinforces it. The combination of the fresh air and physical nature of the tasks energises the physical body while simultaneously reducing stress. 

There are physical, emotional and spiritual benefits to working outside on the land. With horticulture new skills can be learnt and new experiences encountered. Digging, or transporting objects is invigorating hard work. It has a physical impact, providing fitness through muscle toning and calorie burn. The positive effect of a hard day's manual labour includes improved sleep, which is often problematic for people with complex needs diagnoses. Gardening also improves motor skills, helping hand eye co-ordination and benefiting core strength. Exposure to sunlight increases vitamin D production, whilst reducing osteomalacia and bone softening. The positive effect of the sun can be seen in people who suffer seasonal affective disorder (SAD), and it has been proven that lack of sunlight improves the likelihood of clinical depression. For people with a complex diagnosis, who are particularly susceptible to depression and suicidal ideas, being in the sunlight is of clear beneficial effect.

The emotional effect of horticulture is seen in reduced stress and increased calm experienced in the garden setting. Growing plants gives feelings of accomplishment and increased self esteem as you cook vegetables  you nurtured from seed. There is also increased acceptance that things go wrong that you cannot have any effect on; not all seeds germinate, even if you provide the best conditions you can. If it does not rain you have to water, if it rains too much you can do nothing, being in connection with nature calms the stressful attainment culture of modern life, we cannot affect the weather.

Horticulture also gives structures and some repetitive exercises that do need little brainpower, but are therapeutic in their action. Planting seeds, transplanting seedlings, digging the ground, are all activities that are calming, peaceful, repetitive tasks. Improved personal responsibility, making choices, taking responsibility and taking initiative are all important factors in horticulture. Seedling

In addition, horticultural therapy improves teamwork and communication. In our teams in Slough we make it a rule that people must work in teams of at least three. This is very beneficial to people for whom trust and cooperation are often alien ideas, as well as being for safety (as people can be spread over the site doing different tasks). Working together supports communication, learning to trust each other, developing positive relationships and supporting each other in the task.

Horticultural therapy also allows people to choose. Although the range of tasks is often limited by the season, being able to choose what you want to do gives responsibility and self worth to people who do not believe they are worth anything. People can also to choose to do nothing for the moment, they may need to reflect, to be quiet, practise ‘mindfulness’, or take time out. They are able to do this and the quiet, serene atmosphere of the garden experience has been seen to improve one’s ability to contemplate and think clearly. 

Although we are not able to work with animals on our current site, there are cows and horses on the adjacent farm who sometimes come to the edge of our site to see what we are up to, and we attend an annual lambing day to an educational farm nearby. For an adult who has never been well-cared for  it can be a very moving experience to feed an orphan lamb – and think about the psychology of attachment. We were also delighted to find species of protected newts in our pond, and to examine the seething micro-life from our compost bins under the classroom microscope. Together with the spiritual nature of growing seeds, of the fantastic diversity of plants, nature and the environment, we can give people a positive picture of the complexity and beauty of life itself, which has so often been cruel and painful to them in the past.

 

Overcoming obstacles in the NHS

In developing a therapeutic community programme for the NHS in Slough, the use of ‘greencare’ as part of the therapeutic programme was not seen as a relevant part of statutory services, and it did not meet numerous health and safety physical requirements such as ‘absence of ligature points’. We therefore started  a social enterprise and community interest company, called ‘Growing Better Lives’, to provide a treatment programme which combines elements of therapeutic communities and the principles of greencare. We were successful in bidding for one of the EcoMinds grants in 2010 (Farmer 2014), which marked the beginning of our clinical work.

 

Nature as a part of intensive therapy programmes

By adding therapeutic community practices to a greencare group (such as horticultural therapy or animal assisted interventions), a powerful programme has been developed which is holistic, sustainable and effective. We have installed a large yurt (7m diameter) in a local environmental centre where we hold weekly greencare sessions. 

 

Our team was awarded the Royal College of Psychiatrists’ 2014 award for sustainability. The extensive scope that we believe is possible for this work is illustrated in our statement of purpose:

 “We offer a holistic and economically viable alternative to treatment with medication and hospitalisation. Sustainability is about connecting people to each other and to nature, helping people to see that there is a life worth living, and on a planet that is worth living on.”

The greencare programme has been incorporated into the development of a local Recovery College, in which the underlying principles of relational practice and sustainability are fundamental.

 

The group therapy programme

Currently, our main group runs every Thursday from 10am to 4pm, for up to 15 people and with three regular staff – an ‘expert by experience’ (who has graduated from an NHS therapeutic community herself), a horticultural therapist, and a psychotherapist. Occasionally, a researcher and a medical psychotherapist attend, and the staff team have monthly clinical supervision from an external psychotherapist. The therapy is run as a ‘slow open’ group, meaning that it has a rolling membership, with members staying in it as long as they wish. Members all have long-standing emotional difficulties, often with diagnoses of personality disorders, and have not been sufficiently helped by statutory mental health services.

Yurt set outThstaff gather at about 9.30am to prepare (and light the wood-burning stove in winter), and members start arriving at 10am. When everybody is present, we have a community meeting. There is a ritual to start this: once everybody has sat down, whoever first mentions that we need to do the check-in, the main part of the meeting, gets to choose who starts. After their turn, they choose whether to pass it to the right or the left – and it progresses round the circle. Everybody says what their last week has been like: how they have been feeling since the last meeting and whether anything important has happened to them. Once everybody has spoken – however much or little they choose – the members of the group spend a few minutes supporting each other if needed. Then the staff, generally led by the horticultural therapist, discuss the options for what people can do for the rest of the day. The community meeting usually finishes within an hour, and the members then get on with the activities they have chosen.

The group choose the activities from what is on offer, plus any other ideas that they come up with. So that everything is done in groups, we have an expectation that an activity does not take place unless at least three people are willing to do it. In summer, most of the activities are horticultural; in winter the popular options are cooking, art and craft work, administrative tasks, planning and research. Lunch is always a central part of the day where everybody comes together – in warm and dry weather this is usually outdoors; otherwise we eat in the yurt.

At about 3.30pm, half an hour before leaving time, we have the closing community meeting. This comprises of another go-round where everybody makes a brief comment about how they have found the day, and how they are feeling. For the last few minutes, we check that everybody is feeling safe to go home, and offer support if needed.

 

Initial research

wordle of initial research

Some introductory qualitative analysis of the programme and its impact on mental health service users has been undertaken. The thematic analysis identified the importance of the therapy taking place in a natural setting that was ‘not a clinical setting’, which was a ‘sanctuary’ which was ‘safe’, ‘lush and green’ and ‘non-stigmatised’. The variety of activities on offer, the importance of choice and the shared lunch were cited. Particular qualities that were valued were ‘togetherness’, ‘stillness’, ‘socialisation’, ‘catharsis’, ‘calm’ and ‘restful’ (Jones, Maurya & Haigh 2014).

 

Ethics and Principles

The permaculture ethics of ‘care for people, care for planet and fair shares’ closely fits with our underlying beliefs and values, and those of Growing Better Lives CIC. Care for people is our primary task: to provide therapy for people with long-standing and severe mental health problems. We use a model which is at the forefront of sustainable practice - how we care for the planet. The thoroughly democratic processes of therapeutic communities embody the idea of fairness and fair shares.

There are further developments of ecological principles we intend to pursue; sustainable construction of a therapy centre in partnership with a local animal sanctuary, and the growth of a transition town project based on therapeutic community principles and the idea of a ‘recovery college for all’.

Small-is-beautiful projects like this demonstrate that we can all be responsible for many aspects of our own mental health, through an interdependence that could be seen as an ‘ecology of human relationships’. By working with the NHS statutory providers, we can add a holistic, sustainable and compassionate dimension to the ‘bare minimum’ that the state provides – and do it in the same way that we will all need to live and think, if the human race survives our destructive actions on the Earth’s atmosphere, climate and soil.

 

References

Braastad, B.O., Gallis, C., Sempik, J., Senni, S. & van Elsen, T.  2010. COST Action 866 “Green Care In Agriculture”—A Multi-Disciplinary Scientific Network.

Bragg, R. 2014. Nature-based interventions for mental wellbeing and sustainable behaviour: the potential for green care in the UK, PhD Thesis, University of Essex.

Farmer, P. 2014. “Ecotherapy for mental health”, Journal of Holistic Healthcare, 11, 1

Haigh, R. & Lees, J. 2008. "Fusion TCs: Divergent histories, converging challenges", Therapeutic Communities, 29, 4, pp. 347-374.

Haigh, R. 2013. “The quintessence of a therapeutic environment”, Therapeutic Communities, 34, 1, pp. 6-15.

Haigh, R. 2014. “Industrialisation of therapy and the threat to our ethical integrity” Personality and Mental Health, 8, 4, pp. 251-253.

Jones, V., Maurya, S. & Haigh, R. 2014. "Growing Better Lives: Green Therapies for Personality Disorder (Poster)", British and Irish Group for the Study of Personality Disorder, Lincoln.

Natural England. 2016. “A review of nature-based interventions for mental health care” NECR204, Natural England, London

Tuke, S. 1813. Description of The Retreat, an institution near York, for Insane Persons of the Society of Friends, The Retreat, York.