xxx

All over the world there is an increasing interest in  research  results showing the impact of the  physical environment on people’s health and well-being. The  realization that good design, both indoors and  outdoors, not only generates functional efficiency but  also strengthens and improves health processes has  given rise to a new branch of architecture, called  Design and Health (Dilani, 2001). Knowledge and  awareness of how good design as well as bad design  may influence people’s well-being is increasing among  architects as well as among interior decorators and  landscape architects. An expression of design and  health in landscape architecture is to be found in the  movement around  healing gardens,  i.e. gardens that in  different ways may influence the visitor in a positive  way (Cooper Marcus & Barnes, 1999).  In Sweden today, the concept of healing has several  connotations, some quite concrete, others more  spiritual and mental. Generally speaking, however,  healing may be said to be a process that promotes  overall well-being (Cooper Marcus & Barnes, 1999).  In medical anthropology the individual’s personal,  subjective experience of recovery is also emphasized  (Janzen, 2002). It is in other words equally important  that the illness is cured in a purely medical respect and  that the individual experiences a personal feeling of  recovery. Is it, then, possible for a garden to be  anything else than healing? Is not the aspect of healing  woven into the very concept of  garden?  Myths all over  the world depict the garden as an enclosed and safe  place where one takes refuge to find shelter, comfort,  and relief from sorrow and pain (Prest, 1988;   Gunnarsson, 1992; Gerlach-Spriggs, Kaufman &  Warner, 1998; Lundquist, 2000). This, however, does  not apply to all types of gardens. There are instances of  modern gardens that have had a negative influence on  the visitor’s well-being (Cooper Marcus & Barnes,  1999). How is it possible for a garden to influence the  visitor negatively? To begin with, we should try to  define the concept of gardens.  The Garden as a Room  An important feature of the garden is that it should  be possible to experience it as a whole, marked off  from the surroundings. Through the ages the garden  has been defined as a piece of enclosed ground  (Gerlach-Spriggs et al., 1998; Lundquist, 2000). It is  therefore important how the border is shaped, since the  border may be regarded as the outer wall of the garden.  The wall, which may be a hedge, a wall, or a fence,  helps to delimit the garden from the surroundings and  may, if it is well designed, give the visitor a feeling of  being outside public life and of being safe. Inside the  walls are the rooms of the garden, several or just one.  These rooms have walls, floor, and ceiling; the floor,  for instance, may consist of grass or gravel, the ceiling  of heads of trees.  The Garden as a Manifestation of Life  Another important feature in a Western garden is  that it is built largely of living material. The living,  organic, growing, and constantly changing quality is  the foundation stone of the garden, designed to give the  visitor fundamental feelings of security, hope, and life.  Unfortunately, many created outdoor places have been  called gardens in spite of the fact that they have hardly  contained any living plant material at all. Trees, grass,  and flowers may be there but without dominating,  without being part of a composition, without being the  very core, or without being in focus. Instead, perhaps,  one finds a sculpture or that the rooms for the most part  consist of hard, angular elements in walls, floor, or  ceiling.  The Garden as Applied Art  A garden, particularly an institutional garden, may  be regarded as a very special form of applied art, able  to offer the visitor a rich variety of experiences since in  a garden all the senses of man are activated. To have a  complete idea of a garden one has to be in it – to feel  the irregularities of the ground under one’s feet, see  and rejoice at the tender blossoms of the witch hazel in  the middle of winter, smell the sweet odor of the rose,  hear the singing of the wind in the poplars, and feel the  wind in one’s hair. A garden that does not bring the  visitor a message of life, lust, and cyclic change, that  does not convey feelings of calm, safety, strength,  beauty or sensual stimulation – is it really a garden, or  does it fall outside the definition? We maintain that it  is in any case not a healing garden.  This article aims to summarize different research  disciplines’ theories on the healing influences of  healing gardens. Secondly, it discusses design  hypothesis based on the visitor’s needs and relation  with the garden.  PART I: Theories of the  Healing Influence of the Garden  Research about the impact of the physical  environment – indoors and outdoors – on people’s  health and well-being was formerly carried on in  isolation by different research disciplines, such as  medicine, environmental psychology, and in recent  years landscape architecture. Today a change can be  noticed. Collaboration transcending professions and  research boundaries takes place not just in Sweden but  also in several other parts of the world. An example of  this is the foundation of The International Academy for  Health and Design. This academy is multidisciplinary  and research-based. Its goal is to stimulate and develop  research on the interaction between culture, design,  and health (Dilani, 2001). As a result of the academy’s  2nd International Conference on Design and Health in  Stockholm in the summer of 2000 the book  Design &  Health – The Therapeutic Benefits of Design  was  published (Dilani, 2001). Several professional  categories are represented together in this book, active  in research as well as in practice, e.g. artists, designers,  architects, clinicians, psychologists, biologists,  landscape architects, administrators, doctors, and  nurses.  From a theoretical design and landscape  architectural point of view it is important to show that  one benefits from being in a garden environment while  also trying to find an answer to the questions of  how  and  why  one benefits. Are there better and worse  garden environments, and in that case, what is it that  constitutes the differences? For thousands of years  there have been ideas to the effect that man’s health  and well-being will be influenced in a positive way  by his spending time in natural surroundings, wild  nature as well as enclosed gardens (Knopf, 1987;  Gerlach-Spriggs et al., 1998; Cooper Marcus &   Barnes, 1999). Beneficial properties are attributed to  daylight, fresh air, and greenery. But it was not until  1984 that the first report about the measurable effects  of nature’s influence on health was published (Ulrich,  1984). This study was soon followed by others, now  forming the basis of the theories of landscape  architects (Verderber & Reuman, 1987; Kaplan &  Kaplan, 1989; Cimprich 1990, 1992; Ulrich et al.,  1991; Grahn, 1993; Küller & Küller, 1994). In this  article we have summarized and sorted the theories on  healing effects in gardens from different research areas  into three different schools:  The Healing Garden  School, The Horticultural Therapy School,  and  The  Cognitive School.  The Healing Garden School  According to this school the visitor’s health effects  are, above all, derived from the experiences of the  garden room as such, its design, and its contents. The  following three theories have been developed in the  disciplines of environmental psychology and  landscape architecture:  First theory.  The first theory claims that the health  effects are due to a restorative influence on emotional  centers in the limbic system of the brain, caused by the  environment – above all by nature-like surroundings  and wild nature. The theory regards man as a  biological individual, suited for a life close to nature.  In natural surroundings it is possible for man to react  and to trust his unconscious reflexes. Examples of  stimuli that generate reflexes that warn us or make us  extra cautious are darkness, precipices, snakes, and  blood. Other stimuli prompt reflexes that make us  relax, like a view over a lake framed by light or open  meadows. These quick reactions are based on innate,  memory-like functions that have had decisive  importance for man’s continued existence on earth.  (Coss, 1991). The city, on the other hand, is an  unnatural environment for man. In the city, man cannot  trust his reflexes but must make use of logical  thinking. Open, light, savannah-like natural areas have  been found to give the quickest restorative reactions  after stress, since they resemble man’s original home.  When you come to such surroundings, the body  unconsciously relaxes. If you are severely stressed, this  is more noticeable than when you otherwise feel well.  This theory has been tested successfully in laboratories  (Ulrich et al., 1991; Ulrich & Parsons, 1992; Ulrich,  Lundén & Eltinge, 1993; Parsons, Daniel & Tassinary,  1994).  Second theory.  According to the second theory, the  health effects are due to the restorative influence of  verdure on cognitive functions. The higher cognitive  functions require much energy and the brain may  easily be overstrained. This theory is based on the fact  that man has two different types of attention,  spontaneous attention and directed concentration.  Knowledge of these two different types of attention  goes back to the end of the 19th century (James, 1983).  One of these types is usually spoken of as  directed  attention.  It is governed by and at the same time part of  the mind – the higher cognitive parts – and its capacity  is limited. Directed attention is tired out in a relatively  short time and is very precious. We make use of it in  our daily work, when doing paperwork, when driving  through an unknown town, etc. With directed attention  we can focus on what has to be done at the same time  as we sort out all that is irrelevant.  The other type of attention is quite spontaneous  and unconscious; it is located in the older parts of the  brain and is called soft fascination (It was earlier called  involuntary attention,  see Kaplan & Kaplan, 1989, but  is now known as  soft fascination,  see Kaplan, Kaplan  & Ryan, 1998). With this kind of attention we register  a sudden rustle in a bush or the glimmer of a stone. The  capacity of this kind of attention is practically  unlimited, as long as we do not have to sort out or sift  out our impressions. Nature contains fascinating things  that attract this spontaneous attention, where new  discoveries fascinate without tiring out, since  impressions in nature are contained in a larger whole  and therefore not in need of being sorted out and sifted  out by the directed attention of higher consciousness  centers. This theory has been tested several times with  positive results (Canin, 1991; Hartig, Mang & Evans,  1991; Cimprich, 1992; Gilker, 1992; Hartig, 1993;  Tennessen & Cimprich, 1995; Herzog & Gale, 1996;).  Third theory.  Finally, the third theory asserts the  health effects are due to the fact that the garden and  nature make demands that can softly balance the  person’s own ability and control. Perceptual and  cognitive functional obstacles cause accessibility  problems and handicap experiences in combination  with obstacles in the physical environmental  (Iwarsson, 1997). However, there is reason to talk  about the accessibility of the surroundings in relation  to mental functional obstacles or psychological states  of ill-health as well. A person stricken with a trauma  like grief or personal illness needs an environment as  well as relations that make less heavy demands.    Family and relatives demand more than unknown  people. Animals demand less than human beings and  are also more straightforward – they cannot lie or  burden anyone with guilt. Plants demand less than  animals; they can’t run away either or show  ingratitude. Rocks and water demand even less – they  are there all the time (Searles, 1960; Ottosson, 2001).  Generally speaking, nature makes fewer demands than  gardens, where you can build in more or less demands  in the design.  The Horticultural Therapy School  According to the theory belonging to this school  the health effects are primarily derived from the  activities in the garden room. A theory often put forth  among medical and horticultural therapeutic scientists  is that the health effects are due to the fact that work  in a garden is particularly obvious, meaningful,  and enjoyable (Relf, 1992; Simson & Straus, 1998).  Man is at heart an active creature, and activity is  healthful in itself. If he has a chance to use his  body and his mind in the pursuit of pleasurable  and meaningful occupations, he feels rewarded  (Kielhofner, 1997). This experience of being rewarded  is particularly apparent in connection with activities  and environments that generate so-called “flow  experiences.” In flow situations a harmonization  between the individual’s capacity and the challenge  is felt, and the demands and possibilities in  the environment give a feeling of well-being, total  commitment, and forgetfulness of time and self  (Csikszentmihalyi, 1990). Gardening can, in a simple  way, stimulate a great number of cognitive processes  and physical exercises, and, hypothetically,  self-rewarding flow-experiences as well.  The Cognitive School  The health effects are derived from the experiences  of the garden room as such as well as from the  activities in the garden room and the visitor’s  background and character. Researchers in  environmental psychology and landscape architecture  as well as in medicine and horticultural therapy often  mutually put forth the following theory: The health  effects are due to the fact that the garden or the wild  nature with its shapes, colors, odors, etc., plus the  activities that can be carried out there, can restore a  person to a more positive view of himself and his  capacities. Experiences and memories of meaningful  occupations or places during a person’s active years,  above all from his childhood and youth, give him a  conception of his identity. Such environments as   belong with his self are the ones he gives the  preference to. An environment that correspond with his  preferences and himself tells him that he is what he  feels he is – part of the world of meaning (Tornstam,  1986; Grahn, 1991; Perris, 1992; Havnesköld &  Risholm Motander, 1995). In this room it is also  possible for him to grow; it is a so-called  instorative  environment.  PART II: Designing for the Visitor  When designing a healing garden it is fundamental  to focus on the people the garden is indented for, but  one ought not to forget the basic theories. Some  hypotheses that might help, as a guide to the  construction of the healing garden’s design, will be  briefly presented below.  A Balance Between Just Being in the Garden  Experiencing It and Working with Gardening  The two schools of healing gardens and  horticultural therapy may be regarded as two poles on  a scale, where healing gardens deals with the passive  experience of the architecture of the garden room and  horticultural therapy with cultivation as an activity.  During the last five to ten years a closer association has  occurred between the schools, at least on an academic  level, but there is still a lot that separates them. Most  therapeutic gardens, of course, are about slight  differences on these themes, but too many gardens are  extreme variations. Many so-called gardens focusing  on horticultural therapy have rational cultivation beds  adjacent to care institutions. These cultivation beds,  often raised, are not planned or designed to be part of  the construction and composition of a garden room. On  the other hand, the cultivation beds may be planned so  that the cultivation functions well, the accessibility for  the patients is excellent, water is within easy reach,  convenient storehouses are nearby, etc. But there is  hardly a garden room as such.  On the other hand, landscape architects working  with healing gardens have sometimes also made things  far too simple and focused too much on the visual  aspects. A garden is not just to look at. One may enter  a garden and turn from being an observer into a visitor,  experiencing the four dimensions of the garden (three-  dimensional space and time) with all one’s senses. The  garden is unique in that it can activate all  the senses:  sight, hearing, smell, and taste, but also the  temperature sense, the muscular sense, and the sense of  touch are activated when, for instance, one puts one’s  hand on a stone warmed by the sun or the sense of  balance is exercised when one walks along an uneven  path. Many healing gardens suffer from functioning as  a point of observation without functioning as a place to  experience with one’s senses. The design may have a  vitality that can be experienced as interesting and  challenging, in particular to healthy observers, but  these challenges may be felt as heavy demands for a  person who is ill. Furthermore, experiences for other  senses than sight are lacking. Odors, sounds, and other  non-visual impressions are easily forgotten. The  gardens may also function badly for activities other  than passive observation.  The Visitor’s Mental Power  Earlier studies of how people function in parks and  gardens at the Department of Landscape Planning at  Alnarp (Grahn, 1989, 1991; Ottosson & Grahn, 1998)  have found that experiences of nature affect people  differently, largely depending on their life situation. A  person’s experience of nature will depend on how  much he is able to absorb from the environment and  how strong his mental power is. This may be illustrated  with the aid of a pyramid, where the need for  environments with few demands is big at the bottom of  the pyramid and smaller at the top as seen in Figure 1  (Grahn, 1991; Ottosson & Grahn, 1998).  At the bottom of the pyramid is the  directed  inwards involvement  level where mental power is very  weak. What physical activity can be undertaken tends  to be private, like walking, picking berries, or  collecting wood a short distance into the forest, and  disturbances are disliked (Ottosson, 2001). An   individual at this level is mentally active, sorting  impressions he carries with him, and not very willing  to be fed with new impressions that he has to sort out.  This individual wishes to think things over without  being disturbed. He is not alone but instead together  with himself.  On the next level in the pyramid are those who  have somewhat greater mental power. They begin to  take an interest in their social surroundings and like to  observe people around them, but they do not have the  strength to take active part in what they are doing.  They are content with  emotional participation  . They  manage to be a little friendlier and can talk a little with  neighbors; they are not as sullen and antisocial as the  individuals at the bottom of the pyramid.  Yet another step up in the pyramid  active  participation  is found. An example of this level is an  individual who is part of a group doing something  together. This individual possesses the mental power  of giving and sharing. Together with other people an  individual at this level can create things, such as  organizing a dinner or helping to plan and lay out a  flowerbed.  At the top of the pyramid is the  outgoing  involvement  level, where the mental power is very  strong and one is able to lead a group of people. Men  and women at this level can take initiative in starting  things and carrying them out. They are in charge of the  creative processes and make sure things get done. Only  individuals on this level are mentally strong enough to  completely follow through on their ideas and plans  without strong support from the surrounding group.  Visitors in a healing garden possess a varying  amount of mental power representing all the levels of  the pyramid. Therefore, a healing garden must be  designed to suit visitors of all levels of mental power.  The healing garden must be designed to create  different degrees of demand on the visitor. Specific  demands might include being together with other  people on one level and cultivation of a bed that  requires much care to survive on another level. There  should be areas or rooms where one can retire privately  but also rooms where one can be together with many  people at the same time.  Communication: Garden Rooms with Different  Characters  We communicate all the time with the world  around us, and not only with words. The environment  confronting us tells us how to behave, by instinct and  by conditioning. A healing garden must be able to  communicate with the visitor on many levels, through  sight, smell, hearing, etc. Professionals in the field of  architecture speak of the semiotics of buildings,  maintaining that people quickly learn to read what the  constructed environment has to say, for example, about  power, sanctity, and value (Morris, 1971; Rasmussen,  1986). Here, it is primarily a question of conditioned  behavior. C. G. Jung (1964), on the other hand,  maintains that we react by reflex to inherited symbols  – archetypes – that we can find when in a more or less  unconscious state, as in dreams. These archetypes  show us how to relate to the world around us. Recent  research by Ulrich (1984), Coss (1991), Öhman  (2001), and others shows that there are inborn reflexes  warning us of things like spiders, snakes, and great  heights. There may also be inborn attitudes towards  odors and sounds.  In a healing garden we should be able to build in a  lot of communication and attitudes. One type of  communication is about how we relate to demanding  surroundings; Harold Searles (1960) and Johan  Ottosson (2001) have earlier been referred to in this  context. At the bottom of the ladder of demands we  find stones and water, as on a shore. Higher up on the  ladder is wild nature, then a garden to cultivate. Still  higher on the ladder are domestic animals and at the to  are human beings. This theory suggests that some  visitors in a healing garden may find it difficult to start  by cultivating, particularly in a group. Table 1 gives  a brief presentation of the room characters  (Berggren-Bärring & Grahn, 1995a).  Earlier research at the Department of Landscape  Planning at Alnarp studied why certain parks are  frequently visited, whereas other parks hardly attract  anyone. The researchers came to the conclusion that  there are different park or garden rooms with different  characters (Grahn, 1991; Berggren-Bärring & Grahn,  1995a, 1995b; Grahn & Berggren-Bärring, 1995;  Hedfors & Grahn, 1998). Certain room characters are  more popular than others. A park where many of the  room characters are represented attracts more visitors  than a park with just one of these room characters. The  studies showed that there are eight main characters that  make up parks and gardens. These characters consist of  symbols manifesting themselves through many  different sensations via sight, hearing, locomotion, etc.  The characters communicate directly with the  visitor. The room characters  Serene, Space, Rich in  Species  and to some extent  Culture  appeal to many  people. It is of particular interest that they also appeal  to the most ill and vulnerable persons; those who strive  to find balance with themselves. The room characters  The Common  and  The Pleasure Garden  usually appeal  to those who are somewhat less stressed and  vulnerable, either those who wish to observe other  people carrying out activities or those who wish to  carry out the activities themselves.  The Festive  finally  appeals to some stressed persons but frightens others  (Grahn, 1991; Berggren-Bärring & Grahn, 1995a;  Grahn & Berggren-Bärring, 1995). Most of the room  characters require more natural areas with large masses  of growth such as tall trees and many kinds of plants.  The Accessibility to the Visitor  A healing garden, like all public parks and gardens,  should strive to be accessible to everybody, to be a  design for all  (Welch, 1995; Månsson, 1999). Design  for all is design of products, environments, and  services in such a way that they can be used by as  many people as possible, no matter what qualifications  or needs they may have. The idea is to make the garden  so flexible that it can be used exactly as it is without  any ugly post-construction additions or accessories. A  healing garden ought to be accessible irrespective of  people’s age or functional disorder. This is a high  objective and one that may be difficult to achieve  directly. A garden, however, is not finished when it is  laid out; it is a constantly ongoing and changeable  process. All the time one can change and improve the  design of the garden so that it better satisfies the needs  and wishes of the visitors.  Discussion  There are many gardens called healing gardens  both in Sweden and in other parts of the world.  Alarmingly many of them do not answer to the  traditional definition of a Western garden. A lot of  these gardens are entirely focused either on the  activity, which in most cases is horticultural therapy, or  on a more isolated design concept that has very little to  do with the visitor and his or her needs. The impact of  the garden room on the visitor and how he or she  experiences the room with its seclusion, security,  sunlight, odors, beauty, and history, has not been  considered. This may be the beginning of a dangerous  trend. A garden is a piece of nature, marked off from its  surroundings, with floor, walls, and ceiling. Unlike  architecture, a garden room can offer not only three-  dimensional experiences of space but also the fourth  dimension of time. A garden is about perception as  well as activity and they are both needed. Our own  earlier research results and those of other researchers  have convinced us that people are unconsciously  influenced by the environment they spend time in,  since the physical surroundings are their reality  (Grahn, 1989, 1991; Kaplan & Kaplan, 1989; Coss,  1991; Ottosson & Grahn, 1998; Ulrich, 1999;  Ottosson, 2001). Our relationship to our physical  surroundings depends on how we perceive it with our  senses and how we emotionally and intellectually  consider those perceptions. If we only focus on the   activity or on a trendy design concept, we will miss the  impact of nature and architecture on people’s well-  being.  To work with the creation of gardens, it may be  necessary to think about a garden as a phenomenon.  There is a relation, today unspoken, between the visitor  and the garden; they are interdependent. The visitor  and the garden become a fusion of nature and culture.  The needs of the individual visitor vary, which leads to  notions of different phenomena and values in the  garden, depending on what one is looking for. If the  visitor enters a garden with many room characters, he  or she will have a better chance to find what he or she  is looking for. Thus, it gives the individual the  opportunity to lose himself in thoughts and activities  that he finds both amusing, interesting, and healing.  The garden is a phenomenon that is several thousands  years old, and it may have been regarded as a healthful  place to be in from the very beginning (Prest, 1988;  Gunnarsson, 1992; Gerlach-Spriggs et al., 1998). This  has led to the use of gardens in medical care and  treatment for a very long period of time. Ideas of  connections between health and garden can be traced  back to the Middle Ages, the Roman Empire, and as far  back as the Persian Empire (Prest, 1988; Gerlach-  Spriggs et al., 1998; Stigsdotter, 1999). We know for  certain that the medieval monks thought that their  hospitals ought to be built in areas of great natural  beauty in order that the rehabilitation should function  well (Gerlach-Spriggs et al., 1998). Modern scientists  can explain this with semiotics, inborn reflexes, and  restorative experiences.  But why not listen to the old myths that tell us that  man and garden originally belong together? Here we  find the Garden of Eden, the Paradiszia of the Persians,  and the Arcadia of ancient Greece. In the myths, man  and garden belong together in the future as well, in the  heavenly paradise and in Elysium. What is it in this  perspective that takes man to the garden? Why do we  find through the millennia similar descriptions of  beautiful enclosed gardens in myths all over the world?  What is it in the myths that draw people to the  gardens? Perhaps it can be described as a yearning for  devotion and beauty, or for a place without sin. If you  are at the bottom of the pyramid of mental power, the  unconscious urge that takes you to the garden perhaps  can be described precisely as a yearning. This yearning  for a place where you can forget yourself and melt into  the surroundings so that you become a rather  insignificant part of something bigger perhaps can be  described as devout. This urge appears to be stronger  the more difficult your own situation.  Conclusion  Today many different professions and research  disciplines have several theories concerning the  healing garden’s healing effects on the visitors. We  have divided the theories into three different schools:  1. The Healing Garden School, where the health  effects are, above all, derived from the  experiences of the garden room as such, and its  design and contents  2. The Horticultural Therapy School, where the  health effects are primarily derived from the  activities in the garden room  3. The Cognitive School, where the health effects  are derived from the experiences of the garden  room as such, as well as from the activities in  the garden room  We believe that the healing garden is about  perception as well as activity. However, it is crucial to  find the balance between just being in the garden  experiencing it and working with gardening. To do that  the designer needs to have knowledge about the group  of people the garden is intended for, and be aware of  their levels of mental power. A healing garden must be  able to communicate with the visitor in a supportive  and positive way. Depending on the visitor’s stress  level, the garden should consist of different rooms with  different characters;  Serene, Wild, Rich in Species,  Space, The Common, The Pleasure Garden, Festive,  and  Culture.  Finally, a healing garden, like all public  parks and gardens, should strive to be accessible to  everybody.