Green Therapy

The teens in the rehab program can’t have drugs, so they use the waterfall instead.

That’s how Lily Mank BSLA’15 explains the fact that when patients first visit the healing garden at the Rosecrance Griffin Williamson adolescent substance abuse facility in Rockford, Ill., they choose to sit near the cascading water.

“I think the drugs numb their emotions, and when they don’t have access to drugs, they become very raw, very sensitive to their thoughts,” says Mank. “They need the stimulation of the waterfall, the white noise, to quiet themselves down.

“They move away from the waterfall as they become more comfortable with their thoughts and more able to be balanced within themselves,” she says. “That’s a sign that they’re getting ready to leave the program.”

Mank doesn’t know if her explanation is right, but she plans to find out in her ongoing research of nature restoration.

The five-acre garden, designed by master Japanese landscape designer Hoichi Kurisu, is incorporated into every part of the highly successful 12-step addiction treatment program at the Rosecrance facility. It’s a powerful tool for clearing the minds of the 12- to 18-year-old patients.

It was also powerful for Mank. Since working in the garden as an intern in her junior year of the CALS landscape architecture program, she has made healing landscapes her career focus. She went on to do a senior thesis focused on improving nature access at a Wisconsin mental health hospital. She also earned a certificate in health care garden design at the Chicago Botanical Gardens and interned at Ziegler Design Associates, a company owned by Steve Ziegler BS’83 and Joan Werner-Ziegler BS’78, CALS alums who specialize in designing healing spaces.

Mank still thinks about the waterfall. How, exactly, she wonders, does spending time in the Rosecrance garden—or in any peaceful outdoor space—help settle an unsettled mind?

That’s a great question, says Sam Dennis. It’s right at the heart of what he studies as a professor and director of the Environmental Design Laboratory (EDL) in the CALS Department of Landscape Architecture (LA). While the LA department is best known for its work on environmental restoration—techniques people can use to heal damaged natural environments—Dennis and his team at the EDL flip that around. They’re finding ways to incorporate nature into human-made environments to restore the health of people. Dennis’s projects employ thoughtful outdoor design to help people eat better and get more exercise and to create safer, calmer and more cohesive neighborhoods.

Health-conscious design has always been on the department’s radar. In 1981, 10 years before the passage of the Americans with Disabilities Act, Steve Ziegler was encouraged to do his senior thesis on barrier-free design in elder care facilities. But today the topic is getting much more attention.

As one example, assistant professor Kristin Thorleifsdottir has been reworking the curriculum to make sure students get a good grounding in the burgeoning area of science that looks at connections between health and the built environment.

The native Icelander offers three classes on the topic, including a new sophomore-level design class in landscape architecture and a graduate seminar that attracts students from landscape architecture, interior architecture, urban and regional planning,health care and other disciplines. She touches on history—from the cities of the ancient Greeks to the urban squalor of the Industrial Revolution—but most of what she covers starts in the 1980s.

In a 1984 study, Texas A&M design professor Roger Ulrich found that postsurgical patients who had a view of trees from their hospital windows were released sooner, took less pain medication and experienced fewer complications than did patients who had a view of a blank wall.

“Ulrich’s study was the first that looked at health and design,” she says. “Since then there have been a lot more.” Those studies span diverse disciplines—urban planning, public health, pediatrics, psychology, gerontology, neurobiology, art, horticulture and forestry, to name a few—which means those who study the topic must learn several lexicons.

“The fields of public health and design speak very different languages,” Thorleifsdottir notes. “Design researchers tend to take a more qualitative approach—they look at how people experience the environment. Public health is very much into quantitative measures.”

Her own research focuses on health at the community level, including studies on neighborhood design and children’s outdoor physical activities. She’s embarking on two new studies, one of them on the quality of public city parks and the availability of settings for mental restoration, a collaborative project with research partners in Sweden and Serbia.

Sam Dennis has become pretty fluent in the language of public health. As part of UW–Madison’s campus-wide Obesity Prevention Initiative, his partners include researchers in nutritional sciences and family medicine. Body mass index (BMI) is a common research metric, and a recent study involved drawing blood. That project, a collaboration with the Madison-based nonprofit Community Groundworks, used a garden-based curriculum to teach young people to eat better.

“Rather than ask how much the students eat, the researchers took a blood sample. You could tell by levels of serum carotenoids in blood whether they were eating fruits and vegetables,” Dennis explains.

Dennis doesn’t wield the syringes. While his collaborators collect data on human health, he assesses how well the urban landscape supports it. He works with residents of underserved urban neighborhoods to identify features that either facilitate or impede physical activity, healthy eating and safety.

To collect the data, the EDL team has developed an innovative (and now widely replicated) tool that they dubbed “participatory photo mapping.” The researchers ask neighborhood residents—often kids—to photograph things that they see as barriers to healthy living, and then ask them to write stories explaining the photos.

“They tell the stories, then we geo-locate the stories and photos with GIS, so we can overlay their stories and images with, say, traffic data, or data about pedestrians and bicyclists getting hit by cars, or crime rates.”

Often the stories lead to simple fixes, such as repainting crosswalks, adding pedestrian signals or hiring a playground supervisor so that parents feel reassured about their kids using a local park.

But residents also point out problems that are pretty surprising—and tough to solve. Dennis recounts what Latino kids in South Madison had to say about a nearby city bike path.

“They say they’re not welcome there because the bike path is for white people—that you’ve got to be rich and have a special kind of bike,” Dennis says. “The literature says the presence of a bike trail significantly reduces the body mass index of everyone around it, but the kids aren’t using it because they don’t see it as their space. Instead, they ride on busy streets.”

“They’re very sensitive to where they feel welcome,” Dennis notes. “Mapping that is part of mapping their well-being.”

Stories like these are important, Dennis says, because they point to health problems that can’t be diagnosed by calculating body mass or drawing blood.

“Physiological things like body mass index are important, but so is our mental well-being,” Dennis says. “There’s a lot of research suggesting that chronic stress experienced by people with low incomes helps explains disparities in health across different environments. As environmental design researchers, we try to figure out the source of that stress and then see what we can do to reduce it through changes in the built environment.”

Spending time in a natural setting can relieve stress, but that’s not guaranteed. That was underscored by another of Dennis’ projects, a survey that looks at the benefits of natural outdoor classrooms at more than 200 early childhood care facilities across the U.S. and Canada.

Rapid staff turnover is a problem among early childhood care providers, due to low wages and very high stress. But according to the teachers surveyed, spending time in a green, natural environment during the workday helped compensate for the downsides.

“Their mental well-being is better supported when they can spend time in these natural settings,” Dennis says. He attributes this to a process known as attention restoration: We become mentally exhausted in situations where we have to make ourselves pay attention; our minds recover when doing things that are so inherently interesting that paying attention is effortless. Engaging with the natural world fits the latter category. But you really have to engage.

“The natural environment supports attention restoration if the teachers were using all of their senses to experience the natural environment in a loosely focused way, as opposed to the tight focus they give to their indoor lessons,” Dennis says. “It’s important that they aren’t ‘traffic cops’ or hypervigilant monitors like they typically are in a traditional playground setting—that they can engage with kids as they play in nature.”

Job stress is part of the job for caregivers at the UnityPoint Health–Meriter Child and Adolescent Psychiatric (CAP) Hospital, even though there’s plenty of nature nearby. The facility sits on a secluded wooded hilltop on the western edge of Madison. But while things outside are quiet and serene, inside a very different story plays out. The young patients who come here struggle with attention and impulsivity disorders, anxiety and depression—conditions that have made it hard to function in everyday life. Many, especially the teenagers, are at risk for suicide.

“We hear a lot of hard stories here,” says Karen Larson, the CAP program nurse manager. Mental illness in children can be as hard on families and staff as it is on the children, she points out.

Hospital staff members were excited when the program moved to this bucolic spot from its former downtown location in 2004. But they soon realized that there wasn’t a way to incorporate the green surroundings into the treatment of their emotionally fragile patients.

“We started looking at the evidence about the impact of a natural environment on depression, anxiety and well-being, and what it could mean to our patients,” Larson says, “and we realized how much better it could be.”

With research in hand, the Child and Adolescent team contacted their employer’s philanthropic partners—the Meriter Foundation and Friends of Meriter—about raising funds to create a healing space for the patients. She emphasized that she wasn’t asking for landscaping.

“I compared it to purchasing an orthopedic tool that would allow somebody to have their hip replaced,” Larson recalls. “In psychiatry, one tool is the engagement of patients and staff in their environment. The more beautiful, less stressful and skillfully planned the environment, the better the tool.”

After a successful fundraising campaign, Meriter hired Ziegler Design Associates to create the healing garden. It was a good fit. The firm has worked extensively with caregiving facilities and has developed many creative outdoor spaces for youth for schools.

“It was a very special opportunity, to be able to bring healing into the landscape for kids and families and staff who needed it so badly,” says Steve Ziegler. “But it was also a complicated design challenge. A typical hospital healing garden wouldn’t work here.”

“In a psychiatric population, safety is a primary concern,” Larson says. “And a psychiatric population of minors is vulnerable on so many levels. We needed to make the space beautiful and usable and child-friendly and calming—and also safe and secure.”

This garden wouldn’t have secluded spots for quiet contemplation. There couldn’t be any trees big enough or grass tall enough to screen a staff member’s view of patients. No sharp edges, no loose objects that could be thrown (bricks were glued together). Joan Werner-Ziegler, the firm’s perennial plant specialist, researched plants for toxicity and potential reactions with medications. Steve Ziegler spent several days looking for nicely rounded boulders with serene colors.

“I stayed away from bright colors,” he says. “If you’re under psychological stress, abrupt changes can trigger a lot more emotion than they would in you or me. Our colors are wonderful, but not jarring. We chose pavements that didn’t reflect glare, because some drugs make patients’ eyes sensitive.”

They ended up with a space that’s compact enough for careful supervision while offering a variety of places to be or wander. There’s a “traditional” garden (to remind patients of home), a stepping garden with pathways through the plants, a grass garden, a prairie sensory garden and a separate garden for horticultural therapy.

You can tell the space works, says Larson, by watching the patients: “They just naturally settle. They settle into the chairs, they sit on the boulders, they sprawl on the ground, they kick balls around. They just settle into the space.”

More important, Larson adds, the garden helps get the kids talking.

“When you work with kids who are psychiatrically hospitalized, you’re trying to help them express their feelings,” she says. “If you just start asking questions, they are likely to shut down.

But if you go for a walk, they’re more likely to start talking. It’s true for all of us: If we’re feeling comfortable, we can talk about things that are really hard to talk about. And that’s what we have to do here.”

The healing garden also works wonders for the staff.

“When you work in a caregiving field, you give so much,” Larson says. “Your successes can be small and the challenges can be huge. You have to bring your best self every day. And then many of us go home to stressful lives. So if part of your workday can be restorative, it’s a wonderful gift.”

Meanwhile, Lily Mank is still intrigued by that waterfall. Now a CALS grad student, she’s teaming up with Sam Dennis and Kristin Thorleifsdottir on research to understand how all elements of a garden ease patients’ minds as they address their addiction issues.

Her goal is to help designers view healing gardens not just as a collection of streams, pathways, plantings and benches, but also in terms of how those features allow patients to interact with nature. At the waterfall, a patient may simultaneously be sensing rushing water, the breeze, the coolness of shade, light dappling through the leaves and fish moving in the nearby pool. There are many possible interactions with nature, she says, and they can combine in many ways to evoke different emotions.

“I’m trying to find out how different interactions with nature make patients feel. If I understand that, it can be another way to think about garden design,” she says.

And if patients have a better understanding about how their interactions with nature make them feel, they can use that to continue healing when they get back home.

“They won’t have access to a garden like the one at Rosecrance, but they can still seek out places that let them encounter nature in ways that make them feel calm,” Mank says. “A healing garden can be anywhere.”

SIDEBAR—Healing With a Hoe

When Mike Maddox MS’00 signed on as Rock County’s UW–Extension horticulture agent in 2003, he thought gardening was about growing plants. Some tough-talking convicts convinced him otherwise.

Maddox was leading gardening workshops at Janesville’s Rotary Botanical Gardens when he got a call from the Rock County Jail asking if he could he teach some inmates. He figured he’d be working with some tough customers, and he was right—to start with.

“The first time these guys came out, they had this machismo attitude,” Maddox recalls. “They were too big and bad to be out there gardening. But after a few weeks, they were talking about how they used to work in the garden with their grandmas. And if they had kids, they were saying, ‘I need to get my kids out here doing this.’”

At the same time, Maddox was getting good news from the jail. On the days they’d been gardening, the prisoners were better behaved.

The experience was a career-changer for Maddox. It showed him that working with plants could be a powerful restorative tool, and he wanted to learn more. He got some formal training, first in Minnesota, and then in Colorado, where he earned a certificate in horticultural therapy. Now, as director of UW–Extension’s Master Gardener program, he trains 3,000 volunteers, and horticultural therapy is one of his favorite and most popular workshop topics. He’s also helping the Meriter Child and Adolescent Psychiatric Hospital staff incorporate horticultural therapy into their treatment program.

Maddox doesn’t usually lead horticultural therapy sessions himself, but he likes to keep his hand in it. So on Thursday mornings during the growing season, you’ll find him in a courtyard garden at the William S. Middleton Memorial Veterans Hospital in Madison. It features waist-level planting beds and wide walkways to accommodate the patients— many of them grizzled men leaning on canes or sitting in wheelchairs—who are busy planting and watering.

“It’s kind of a phenomenal process,” says Diane Neal, the hospital’s recreational therapist. “There is a positiveness that comes with being able to plant seeds and have them sprout. If the patients enjoy gardening and participate while they’re rehabbing, it raises their self-esteem and keeps them from being depressed.”

Nearby, Maddox is getting an earful. A U.S. Army veteran named August grew up on a Racine County truck farm, and he’s adamant that the VA garden is too small for corn. Maddox loves the give and take. He’s thrilled that August is so engaged.

“In this kind of a closed setting, where depression and isolation can be high and self-esteem can be low, you’ve got to create a spot where they can feel wanted and needed and purposeful,” he says.

It’s a lesson he learned from the jail inmates. “I thought it was going to be about growing carrots,” Maddox recalls. “No. It wound up being about growing individuals, just using carrots as the tool to do it.”

SIDEBAR—Why Nature Makes Us Feel Better 

The notion that nature can ease our minds is not new. It’s reflected in Japanese Zen gardens (an idea that goes back at least 10 centuries) and was espoused by writer Henry David Thoreau and by landscape architect Frederick Law Olmstead, who designed Central Park as an antidote to the stresses of urban life. But in the past 30 years or so, researchers have been digging into the science behind it.

A hardwired love of life. In 1984, Harvard biologist E.O. Wilson theorized that biophilia, our affinity for nature, is bred into us. He noted that the human race has been in close contact with nature for almost all of its 200,000-year history. Only in the past three centuries of industrialization have we separated ourselves from nature. Until then, a keen awareness of the natural environment was a trait that helped the fittest survive.

Restoring attention. A theory advanced in 1986 by University of Michigan psychologists Rachel and Stephen Kaplan holds that our most exhausting mental work is “directed attention”—when we have to force ourselves to concentrate. The way we recover is to give our minds over to things that are so fascinating that paying attention is effortless. The natural environment fits the bill because it’s immense in scale, full of fascinating things and usually removed from the places where we tax our minds.

Reducing rumination. Research published in 2015 by Gregory Bratman of Stanford University and others looks at how exposure to nature influences rumination— repetitive thought focused on negative aspects of the self—which is linked to depression and other mental illnesses. They found that a walk in a natural setting decreased self-reported rumination as well as neural activity in a part of the brain that’s associated with behavioral withdrawal linked to rumination. Walking in an urban setting had no such effect.

SIDEBAR—Tips for Creating Your Own Healing Garden 

Make it personal. Start by thinking about what it is that draws you into your yard, mentally and physically, advises landscape architect Steve Ziegler BS’83: “What’s healing for one person may not be healing for another.” For example, one of Ziegler’s clients likes to walk in the garden at night, so her garden features flowers and paving materials that reflect the moonlight. Another’s healing garden includes an attractive, custom-made clothesline, because she relishes the ritual of hanging out clothes. “That’s her Zen,” Ziegler says.

Mike Maddox MS’00, director of UW–Extension’s Master Gardener program, seconds that: “Don’t get caught up in magazine images of gardening or what’s on HGTV. Go with what’s fun. Work with plants you like and that have meaning to you.”

Make it lush. A rich diversity of plants leads to a diversity of animals—especially birds and insects—and a variety colors, aromas, textures and shapes. “You want to awaken all of your senses,” Ziegler says.

Create transitions. Moving from one area to another should be easy and inviting. That’s especially true for transitioning from your house to your garden. “You want it to be easy, not jarring,” Ziegler says. “If you have to walk out a south-facing door into the blazing sun, for instance, you might want to add a pergola that provides partial shade.”

Offer choices. We get stressed when we feel like we don’t have control over our daily lives. That’s huge for hospital patients—they can’t do much about their situation—and it’s true for the rest of us as well. A healing space can ease that by offering a choice of where to sit—in the sun or shade, in a secluded spot or a more social one—and of things to smell, feel, hear and look at.

Add a focal point. A well-composed photo draws your attention to a certain spot, and so can your sanctuary. It could be a water feature. Running water is therapeutic, and there’s a wonderful selection of easy-to-maintain fountains available, Ziegler says. A bench or gazebo can serve as a focal point as well as a place to sit. So can a tree or sculpture.

Take care of yourself. “If you want to garden, find tools that fit you well and learn about body mechanics and appropriate techniques for lifting, bending, cutting and pruning to make it easier on your body,” says Maddox. And pick tasks that are appropriate to your age and abilities. Pain is not therapeutic.

Class Act: Lily Mank

Lily Mank at Allen Centennial Gardens, UW-Madison

Lily Mank at Allen Centennial Gardens, UW-Madison

Some gardens are created to cultivate or showcase particular kinds of plants, others to grow food. But landscape architecture student Lily Mank is most interested in gardens designed to aid healing.

Last summer Mank had an opportunity to learn with a master: Hoichi Kurisu, an international leader in Japanese gardening who counts the Anderson Japanese Gardens in Rockford, Ill., among his works. Under his tutelage, Mank completed an internship there allowing her to participate in all aspects of garden maintenance and management— the first time the facility had ever offered one. She also worked at the nearby Rosecrance Griffin Williamson teen substance abuse rehabilitation center, which features a healing garden designed by Kurisu. The garden is an integral part of the facility’s treatment program.

“Seeing the benefits of the therapeutic garden firsthand was incredible,” she says. “It was probably my favorite experience.”

Mank, who holds a certificate in healthcare garden design from the Chicago Botanic Garden, wrapped up her internship with a report on therapeutic gardens. For her senior capstone project she’s taking what she’s learned to Rogers Memorial Hospital in Oconomowoc, which offers treatment for people with eating disorders, OCD and anxiety, depression and addiction.

When first-timers visit a Japanese-style therapeutic garden, one feature stands out: it’s primarily green. “A frequent comment is that there aren’t a lot of flowers, that everything is monochromatic green,” says Mank.

Yet most people feel the tranquility. It’s the special way that plants and other elements—paths, rocks, bodies of water, resting places—are brought together, and the emotions these landscapes evoke, Mank says.

A growing body of research about the benefits of therapeutic landscapes has changed how we look at healthcare, much of it stemming from a study decades ago showing that patients recovered from surgery faster and required less pain medication if they were placed in rooms with a view of nature, Mank says.

She hopes to hone her craft in the realm of therapeutic landscape architecture after she graduates in May.