Urban Forestry & Urban Greening 11 (2012) 51–58

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Urban Forestry & Urban Greening

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Stress rehabilitation through garden therapy

A caregiver perspective on factors considered most essential to the recovery
process
Anna A. Adevi a,∗ , Mats Lieberg b
a
Swedish University of Agricultural Sciences, Department of Work Science, Economy and Environmental Psychology, Box 88, SE-230 53 Alnarp, Sweden
b
Swedish University of Agricultural Sciences, Department of Landscape Architecture, Box 58, SE-230 53 Alnarp, Sweden

a r t i c l e i n f o a b s t r a c t

Keywords: At the Alnarp Rehabilitation Garden in Sweden, people suffering from stress-related illness are reha-
Exhaustion disorder bilitated through garden therapy. Empirical data were collected through in-depth interviews and
Garden therapy focus-group interviews with the rehabilitation team. The present article is based on team members’
Stress recovery
understandings of significant factors to the stress recovery process. On-site observations were conducted
to achieve a broader comprehension of the empirical data. The article is based on the caregivers’ points of
view, as they are presumed to be close to the course of events occurring in the garden therapy programme
as a whole. The results reveal a generally complex picture of the rehabilitation form, but at the same time
indicate three factors that are of primary importance: (1) sensory impressions, (2) self-chosen places
in the garden, and (3) interactions between concrete and symbolic activities. The garden environment
tends to “prepare, receive and open up” the participants before and after therapeutic elements, which is
thought to be especially appropriate for this group. The results provide important knowledge about what
kinds of factors contribute to relief and recovery from stress-related ill-health in the context of stress
rehabilitation through garden therapy.
© 2011 Elsevier GmbH. All rights reserved.

Introduction stress symptoms (Ulrich, 1999), these positive effects on health

Nature’s role in health
Historically, people have always used nature as a powerful heal-
ing source and as a resource for recovery (Cooper Marcus and
Barnes, 1999; Jakobsson, 2009). Gardens, landscapes and spiritu-
ality have been interconnected since ancient times (Tuan, 1976).
Natural environments have been thought of as places that can bring
people closer to God or other beliefs or as places where one can get
in touch with their spiritual self (Janick, 1992; Rosenfield, 1992;
Van Zuylen, 1995). Since the mid-1980s, research has indicated
that gardens, parks and areas with natural greenery have bene-
ficial effects on human health, well-being and capacity (Wilson,
1984; Kaplan and Kaplan, 1989; Ulrich et al., 1991a). According
to Searles (1960), nature plays a significant role in promoting
mental health. Studies show that stays in natural environments
and gardens offer positive stimulation of emotional, cognitive and
physical functions (Ulrich, 1984; Kaplan and Kaplan, 1989). In
relation to mental fatigue (Kaplan and Kaplan, 1990) and acute
∗ Corresponding author. Tel.: +46 40415415.
E-mail address: anna.a.adevi@ltj.slu.se (A.A. Adevi).
achieved through stays in natural environments are called restora-
tive effects.
The organization for horticultural therapy in the United States
describes horticultural therapy as a process in which plants and
gardening activities are used to improve people’s body, mind and
spirit (AHTA, 2007). Horticultural therapy is primarily based on
behaviour that promotes recovery (Matsuo, 1992). In the field,
humans are seen as active beings that experience meaning in life
with the help of physical work. According to Kielhofner (2006),
humans control their life by choosing their activities, their path of
development, and how they will adapt to the surrounding world,
which in turn leads to an increased quality of life. Kondo (2002)
argues that places containing plants that promote calm may be
more effective than parks in their conventional forms. According
to him, such places are better able to instil a sense of unity with
the natural world. A supportive and health-promoting garden with
many green elements may help improve the quality of patient care
(Ulrich, 1992a).
Most people who are experiencing low psychological power and
energy do not wish to process new impressions; they first need
to sort impressions they are already familiar with (Grahn, 2005).
People undergoing medical treatment often feel a certain psy-
chological vulnerability, which increases their sensitivity to new

1618-8667/$ – see front matter © 2011 Elsevier GmbH. All rights reserved.
doi:10.1016/j.ufug.2011.09.007
52 A.A. Adevi, M. Lieberg / Urban Forestry & Urban Greening 11 (2012) 51–58
Fig. 1. Illustrated plan of the Alnarp Rehabilitation Garden (illustration by Karin Sunde-Persson, 2010).
and habitual environments (Schroeder and Anderson, 1984; Ulrich
et al., 1991a; Ottosson and Grahn, 2008). “The Supporting Envi-
ronment Theory” (SET) argues that the more mentally fragile and
weak a person is, the more they need support from the surrounding
environment. SET includes ideas about the self’s communication
with the external environment (Grahn, 1991, 2005; Grahn et al.,
2010).
Stress-sensitive individuals will have more opportunities to
recover from stress if they are given the chance to manage a task
(Pariola, 2001), if the therapeutic value is perceived as meaningful.
Such individuals need to experience a balance between different
activities if they are to achieve a sense of well-being (Christiansen
and Baum, 1997). Cultivating plants in flowerpots is more effec-
tive at reducing negative feelings than is merely looking at plants
(Endo et al., 2001). During rehabilitation, humans are supported
by the plants in how they orient to reality and in their connection
with the surrounding world (Lewis, 1996). Plants may be important
to treatment if the focus of the therapeutic process is on how the
participants participate, how they perceive and become involved
with the plants using their five senses creating something with the
plants or taking care of them (Matsuo, 1992).
Knowledge gap
Although significant relationships between nature and stress
recovery have been identified in quantitative studies (Wilson,
1984; Kaplan and Kaplan, 1989), there is a knowledge gap in this
field of research when it comes to explaining the nature of such
relationships and why they exist (Magell and Viborg, 2005), espe-
cially when therapeutic elements are included. There seems to be a
great deal of research on the roles of caregivers within the health-
care sector in general, but a lack of research on the relatively new
rehabilitation form garden therapy. Because there has been lit-
tle research on garden therapy as a whole, it is natural that the
caregiver’s perspective in this context has also received limited
attention. The aim of the present article is to explore factors within
garden therapy that caregivers in the rehabilitation team under-
stand to be the most essential to successful stress-rehabilitation
and the recovery process.
Exhaustion disorders
Exhaustion disorder is characterized by extreme fatigue, cog-
nitive problems, and disrupted sleep. The condition is caused by
prolonged stress and may give rise to episodic cognitive problems,
tiredness, lack of empathy, aches and pains for years before the
onset of the illness. The course is often prolonged with residual
symptoms, mainly, enduring stress intolerance (Asberg et al., 2010).
The disease often stems from a strong stress reaction related to the
individual’s professional environment. It is also due to the limit-
lessness of work in contemporary society and the relationships at
home or during free time. Severe ill-health caused by stress con-
stitutes an existential crisis; a kind of life crisis (Maslach, 2001).
Today, exhaustion disorder is mainly treated using medications
such as anti-depressive psychopharmaceutical preparations and/or
different forms of therapy, such as psychotherapy.
Alnarp Rehabilitation Garden
The Alnarp Rehabilitation Garden has been constructed to inves-
tigate whether an environment offering separate garden and nature
elements can rehabilitate people afflicted by stress and exhaus-
tion disorders. The garden consists of a 2-ha area comprising
nature-like areas with restorative characteristics and traditional
cultivation areas with flowerbeds, where the focus is on more
demanding activities. The nature-like areas include small woods,
groves and meadows. The cultivation areas include paved sur-
faces, traditional cultivating rooms, forest-like garden rooms and
botanical rooms (Stigsdotter and Grahn, 2003). The garden is
ergonomically designed, providing opportunities for participants
to train their physical, sensory and cognitive functions (Abramsson
and Tenngart, 2003). Moreover, the distinctive features marking
a nature environment versus a garden environment need to be
clarified. In brief, nature stands for the wild, non-disciplined; for
a natural dynamic and “an unknown gardener”, while garden con-
tains the cultivated and ordered, with characteristics of something
designed by “a known gardener”. In the present text, the concept
nature is sometimes referred to using the word garden, because
garden therapy as it is practised at Alnarp mainly takes place in a
garden environment (Fig. 1).
 A.A. Adevi, M. Lieberg / Urban Forestry & Urban Greening 11 (2012) 51–58
The rehabilitation programme
A letter of referral is written by a doctor for rehabilitation
through garden therapy; this often occurs after non-successful
attempts at other kinds of rehabilitation, medical treatments, dif-
ferent therapy forms, etc. Admission into garden therapy is limited
as there are so many eligible applicants (those who, according
to the insurance office, should be able to return to work follow-
ing recovery). During a twelve week period the participants are
rehabilitated four half-days per week. The basic objective of gar-
den therapy is to strengthen participants’ possibilities to return to
work with new knowledge about the tools and coping strategies
they can use in stressful situations. The rehabilitation is based on
daily routines and encounters with like-minded individuals who
are struggling with similar challenges, in close connection with
professional therapists who care for the individuals in an accepting,
calm and positive manner. The participants receive conversational
and picture therapy, physical therapy and relaxation, which take
place in close contact with nature and also include activities such as
traditional gardening and handicraft activities. The garden therapy
activities at Alnarp are divided into concrete, symbolic and self-
rewarding activities (Persson et al., 2001). The concrete activities
show visible and concrete results, which may be seen as a “finished
product”; one example is making pesto from fresh basil. Symbolic
activities are something the participant performs, at the same time
as he or she evaluates what is happening based on the associations
or memories that are triggered. One example is working with clay,
through which metaphorical values may emerge.
The participants go home each day, or to other housing they
have arranged, due to the large number of participants who live
in other parts of Sweden. What mainly distinguishes garden ther-
apeutic activities from other therapeutic activities is that activities
within garden therapy mainly occur outside. The senses and mus-
cles are activated when participants expose themselves to wind,
temperature, daylight, and increased physical activity (such as dig-
ging, crawling in flowerbeds, etc.). Because exhaustion disorder was
the mental illness most similar to the mental fatigue described by
Kaplan and Kaplan (1989), it was decided to rehabilitate people
with symptoms of exhaustion disorder at Alnarp. Approximately
80% of the participants in Alnarp are women.
The rehabilitation team
The rehabilitation team in Alnarp consists of five horticultural
therapists with different backgrounds and professional compe-
tence. Their main task is to treat or relieve participants’ symptoms,
as well as to facilitate participants’ increased understanding of
the needs of living things by using plants and nature as examples
and symbols. The role of the gardener is primarily to design and
care for the garden, which should provide opportunities to alter-
nate between contrast-rich and varying garden areas that affirm
both rest and activity. The primary role of the curative teacher is
to encourage within each individual the development of a healthy
core that can be reached. This is done by guiding the individual and
promoting involvement and participation in the entire spectrum
of being human: thoughts, feelings and volition. The occupational
therapist creates activities that present physical and psychologi-
cal challenges appropriate to the participant’s level of functioning.
Different forms of stress management are taught and practised.
The physical therapist’s point of departure is that the body is a
physical manifestation of who the individual actually is, but that
it simultaneously carries and shelters old learned thought and
behaviour patterns. Because exhaustion disorder is a kind of exis-
tential life crisis in which previous, ineffective thought patterns
need to be changed to more purposeful patterns, the role of the
psychotherapist is to help participants put their new experiences
53
into words in relation to how life functioned prior to ther-
apy.
The argument for focusing on the rehabilitation team members
in the present study is that they, as experienced staff, may possess
unique knowledge and competence. Within a rehabilitation con-
text, we prefer to refer to the rehabilitation team staff as caregivers,
given their closer connection with the participants, although a gar-
dener is not typically seen as a caregiver. Because they are working
in close connection with the participants each week, we are con-
vinced that they possess a special kind of knowledge of the recovery
process that is important to include in our research. (Another arti-
cle by the first author, focuses solely on the participants’ point of
view concerning important factors for the recovery process; yet to
be published.)
Methods
Research design
The study is based on in-depth interviews and focus-group
interviews with all members of the rehabilitation team – in total
five persons. The interviews were conducted during 2008–2009.
In addition, on site observations were conducted during 2009 and
2010 in order to achieve a broader comprehension of the inter-
view data. The caregivers interviewed have been involved in garden
therapy at Alnarp since the start in 2002 and have taken care of
approximately 120 participants (at the time of interviews) over
the years, with approximately 6–8 participants in each group. Two
interview guides were used that dealt with the following issues:
the situation of the participants and the interplay between partici-
pants and caregivers. The interview guides were broad in scope and
encouraged an open dialogue.
Participants and procedures
The interview data are based on five semi-structured individ-
ual in-depth interviews with all the members of the rehabilitation
team (1 h with each person) and one focus-group interview (2 h
with the five persons in the group simultaneously). Interviews were
audio-recorded by the first author and a colleague. The reason for
conducting a focus-group interview in addition to the individual
interviews was mainly to emphasize the significance of interac-
tions and discussions between the rehabilitation team members
(Wilkinson, 1998; Bryman, 2008). We were interested in the care-
givers’ points of view on the main reasons for stress-recovery
through garden therapy. In the focus-group interview, the care-
givers were offered opportunities to probe each other’s reason for
holding a particular view. When listening to each other’s answers,
the caregivers were able to qualify or modify a view or voice agree-
ment with new ideas they may not have thought of without being
exposed to the impressions of others. The caregivers were given
opportunities to argue or challenge each other’s views. This allowed
us to study the ways in which the caregivers collectively discussed
the topic in question.
The on-site observations were conducted as participant obser-
vations (Bryman, 2008), where the first author practised as a garden
assistant during the summers of 2009 and 2010 for a period of 24
weeks (two rehabilitation periods of 12 weeks, four days a week,
4 h each morning); a total of 13 (5 + 8) persons participated. The
aim of the observations was to learn more about the therapeu-
tic environment and its actors from “within”, and in that way
to better understand and interpret the informants’ statements.
This approach is sometimes used in “micro-ethnographic” research
(Bryman, 2008, p. 403), where the possibility to stay in the envi-
ronment over a long time period is limited. The observations were
54 A.A. Adevi, M. Lieberg / Urban Forestry & Urban Greening 11 (2012) 51–58
made openly after consultation with the caregivers and partici-
pants, and the findings were documented as written field notes
at the end of the rehabilitation day. All interviews and observa-
tions were conducted at the Alnarp Rehabilitation Garden. The
interviews were transcribed by a person hired for that purpose.
Data analysis
The recorded material, as well as the field notes, were subjected
to qualitative data analyses. The method of inquiry for the study was
Grounded Theory (Glaser and Strauss, 1967). Grounded Theory is a
research method often used to explain human behaviour in certain
physical and social contexts. The method is most appropriate when
little is known about the field of research or when the predominant
theoretical perspective in the research field is unable to explain
what is going on (Bryman, 2008). The research process is inductive
in that data are coded and analysed as they are collected (Charmaz,
2003). Preliminary hypotheses about the emerging categories and
themes are deductively refined or confirmed in an iterative process,
through additional data collection (Denzin and Lincoln, 2005). In
this process, the researcher strives to develop explanatory and the-
oretical key concepts and to explain the relationships among them.
The goal is to develop a substantive theory. Themes were generated
through an iterative constant comparative process whereby data
collection, coding and analysis occurred concurrently. Open and
selective coding of the interview material was carried out. This pro-
cess is also called theoretical sampling (Denzin and Lincoln, 2005,
p. 185). Analysis through coding, categorizing and thematisation of
the textual material finally resulted in three key explanatory con-
cepts and delimited themes, which are presented in the Results
section.
Results
A complex picture of multiple activities emerges from the
results; each contributing to stress rehabilitation during garden
therapy. Among these activities, three stand out for being particu-
larly salient. These factors are presented here as different themes:
(1) sensory impressions, (2) self-chosen places in the garden and
(3) interactions between concrete and symbolic activities.
Theme 1: sensory impressions
The caregivers bear witness to how participants seek and find
a sense of belonging in nature’s order, which allows them to feel
they are part of something much greater than the immediate
environment. At the outset, participants make contact with this
new natural environment by acquainting themselves with it in an
unplanned and unconscious way.
What is really lovely is that they come to the conversation at a very
receptive stage . . . they are prepared on a physical level to open
up. . . . When one opens up and is so fragile it’s lovely to be touched
by great, friendly and soft sensory impressions. (Psychotherapist,
woman, 66 years)
The unpredictable occurrences of sensory stimulation and mem-
ory arousal are considered therapeutic effects in horticultural
therapy (Talbot et al., 1976; Lewis, 1996). The caregivers describe
this as when “locks are opened”; it tends to be easier to start the
healing process. It seems as if the garden environment, with its sen-
sory impressions, helps by offering the keys that are necessary to
open up the participant’s existential, emotional and physical sides.
It is presumably here the true recovery process begins. The more
mentally fragile and weak a person is, the more they need support
from the surrounding environment (Grahn, 1991, 2005). To be able
to “open up” for the participant is in line with SET principles.
This is what I see as the magic part.- . . . When they leave a session
with me I’ve hopefully managed to open them up to their inner-
most side, to their emotional core. Much would have been ruined if
we’d continued talking. . .. The garden is meeting them. . . . It’s here
that change is created and it’s a change that exists on the person’s
existential foundation. This is unbeatable . . .. (Physiotherapist,
woman, 58 years)
Frederickson and Anderson (1999) argue that the confrontation
with nature is inspired by thoughts concerning spiritual meaning
and eternal processes. This is supported by a caregiver in the current
study:
There is depth to the nature and the trees and the Earth that I did
not understand before . . . that it’s about existential questions, it’s
very clear that there’s something in this that goes deep that you can
get into contact with. That’s it. (Occupational therapist, woman,
60 years old)
Reflections, thoughts and ideas concerning existential charac-
teristics that are opened up seem easier to reach when one is
surrounded by sensory impressions. Any greater extent of contact
or socializing with other people on the part of participants is usu-
ally not desirable during the rehabilitation period. Simple, clear and
positive impressions are appreciated, as opposed to something or
someone who demands something in return.
The garden seems to help by approaching the participants’
feelings in a direct and immediate manner (i.e. Gardener, male,
38 years). “The amount of information and knowledge we obtain
depends on the variety and degree of contrast in the sensory data
that we receive and the extent to which we can differentiate them”
(Bell, 1999, p. 41).
It’s when you stop and gather around something and start to dis-
cuss and look at it that things start happening. It’s very difficult to
explain. Often, I feel like the garden and plants speak a language
without words, without letters or numbers. They speak directly,
so to speak. It takes a shortcut past the language, past something
and it goes sort of right into you. It goes directly to your emotions.
(Gardener, male, 38 years)
The sensory experiences establish a wordless “communication”
that to a great degree creates an extended emotional and existential
awareness, which in turn creates receptivity to rehabilitation. This
receptivity and sensitivity tends to greatly facilitate the remain-
ing rehabilitation work throughout the whole therapeutic process.
According to Matsuo (1992), it concerns how the participants relate
to the plants within the therapeutic process, and how they perceive
and become involved with the plants when using the senses. In the
view of the interviewed caregivers, this seems to be a matter of
how the participants open up and are receptive and, first within
that process, are able to relate to the plants and the garden.
Theme 2: self-chosen places in the garden
Humans often develop a feeling of belonging, identity, depen-
dence and a kind of ownership in relation to places that somehow
become “their place”, “the favourite place” or “the only place” for
a certain type of activity (Lieberg, 1995; Korpela et al., 2001). Place
attachment is understood as being an integrated part of human
identity (Stewart et al., 2004). Scopelliti and Tiberio (2010, p. 237)
define place attachment as “a complex construct that accounts for a
person’s affective bonds to place”. This attachment can help to form
and preserve the identity of an individual, group or culture (Low and
 A.A. Adevi, M. Lieberg / Urban Forestry & Urban Greening 11 (2012) 51–58
Altman, 1992). It can also serve as a defence against identity crises
in times of transition between developmental phases (Hay, 1998).
The second theme is related to place attachment and the effort
to explore the meaning of place. The theme is also connected to the
first as it involves sensory impressions from nature. Finding self-
chosen places in the garden based on one’s state of mind and needs,
not only before but especially after therapeutic sessions, tends to
contain an important dimension that allows participants’ healing
processes to begin. The participants are encouraged to explore
meaning of place and to find a place in the garden they feel attached
to. This, in turn, will improve their ability to find these sometimes
obscure places. People balance between various emotional states
in their daily life, and this is also true during a period of stress
rehabilitation. One exercise in the early phases of the stress reha-
bilitation programme focuses on finding such a place. Over time,
the places can be changed or maintained and the participants can
happily return to them. This could be, for example, the severely
pruned apple trees participants seek out to be able to endure the
fact that the trees’ “wings have been clipped”.
When they’ve been with me they get in touch with their feelings,
thoughts, insights, and experiences; as I’ve understood it, there’s no
better way to help a person’s thoughts find a way out of the chaos
and make things manageable than allowing them to spend time in
nature and choose the way they’re attracted to it. (Physiotherapist,
female, 58 years)
The self-chosen places that attract participants are described as
places that “receive” their current mood. According to the care-
givers, reliance on the self-chosen places appears to create greater
confidence over time. In the beginning, the participants seek out
the garden areas nearby, and with time they venture into areas that
are farther away. Cimprich (1993), who looked at cancer patients,
argues that these patients improve their spiritual health (among
other things) by only passively perceiving nature. The activity of
sitting on a bench in a therapeutic garden is of great importance
in achieving contemplation and a meditative feeling (Messervey,
1995). Relf (1995) and Liu (1999) and others note how only passive
observation of floral and natural areas creates a general feeling of
personal well-being. A bench or a shed may be of importance if
a place in a therapeutic garden is to be perceived as contempla-
tive and meditative (Messervey, 1995). Searles (1960) argues that
nature plays an important role in mental health and Grahn (1989)
proposes that the need for familiar surroundings applies to out-
door places as well. Thus, there would seem to be some relation
between these notions and caregivers’ ideas about the importance
of enabling participants to continuously search for, find and use
self-chosen places in the garden environment. Signals from nature
shape creative processes and develop a feeling of ‘sense of place’
(Searles, 1960), which are important in the rehabilitation process.
The simplest relationships in crises are those that are the least com-
plicated and the least difficult for the individual to deal with. When
at their lowest level of mental strength, people derive the most help
from simple relationships such as those to water and stones; the
most demanding relationship is that to other people (Searles, 1960;
Ottosson and Grahn, 2008).
Well, just this idea of outside. being able to be outside. And that
there are different environments to visit and participants can seek
out the environment that speaks to them at the moment. (Curative
teacher, woman, 49 years)
Which place the participants experience as appropriate is highly
individual; one person might prefer to sit in a lawn chair under a
large tree, while someone else chooses to walk around in a specially
selected garden area. Sometimes there is a need to sit down on the
grass and pet the cat or start pulling weeds. Here Tuan’s (1977)
55
concept ‘fields of care’ may be useful. Fields of care refers to places in
the garden where participants have repeated contact and where the
physical environment can evoke affection in them. Such places have
often a deep meaning for participants, but may be insignificant to
others. The garden changes the starting point for therapy, conversa-
tions, activities, etc., by creating a sense of wholeness for the healing
process. In that sense the garden becomes an extension of the ther-
apist’s competence. The caregivers’ state that the self-chosen places
in the garden, with its constant changes, adapt in a non-threatening
way to the participants’ emotional needs at the moment; they
explain that the garden’s sublime message is perceived by the par-
ticipants as comforting. According to the caregivers, participants
often experience the places they are encouraged to seek out as espe-
cially welcoming. This has parallels with place attachment, in that
this is not only a place like many others, but a place felt to be mean-
ingful in the current situation. The self-chosen place seems to offer
an individual meaning that has an impact on the stress recovery
process as a whole. Kondo (2002) believes that garden environ-
ments that are conducive to peace and quiet are more “efficient”
than parks, because it is easier to experience harmony through the
great feeling of unity between man and nature. Taking inspiration
from Kondo and considering the caregivers’ understandings, a care-
fully structured therapeutic garden offering many opportunities to
find self-chosen places based on one’s current mood/needs may
serve even better to nurture a feeling of unity than a “common gar-
den” does. In other words, this feeling of unity ought to be very
central in the design of therapeutic gardens. Just as there is a wide
range of human emotional states, a therapeutic garden should con-
tain a range of opportunities to spend time in attractive areas for
sitting or reclining that encourage reflection, all embedded in an
environment that is as appropriate and well considered as possible.
Theme 3: interactions between symbolic and concrete activities
According to the caregivers, helping oneself in a more personal
way is a new approach to learning. Participants learn a new way to
take advantage of opportunities, different paths one can take and,
consequently, different decisions one can make. A newly acquired
pleasure and joy of life is often perceived through the natural envi-
ronment and the activities taking place there.
“concrete activities . . . where you see a result from what we’re
doing, that can be important in the beginning for those who are
used to getting results. That they see the results of their work and
then use symbols and metaphors like nature and the garden. Well
there’s a lot of this, that we use in rehabilitation. . . . I am also
always thinking that they have a value because there is a certain
relaxation in doing something that is so clear and having such a
clear beginning and end to it. Then you may drop it or as I often see
further along in the rehabilitation, they take concrete assignments
with them because they are thinking now I’m going to do this from
A to B and then put it aside.” (Curative teacher, woman, 49 years)
The benefits of interactions seem to refer to a perceived inner
freedom and autonomy in combination with not being forced to
perform for someone else. This is something those suffering from
exhaustion disorder in particular seem to have a great need to gen-
uinely experience. The experience is that the interaction is achieved
through natural reflections made in an unconditional way. The abil-
ity to cope with a specific task is simultaneously blended with a
curiosity about further developing one’s metaphorical reflections.
The garden thus appears to offer support during painful symbolic
processing, where symbolic values help participants find the right
words to depict what is happening within them.
And there’s a quality, which of course is visible all the time when it’s
expressed. . . Your needs. are always followed up and that is how
56 A.A. Adevi, M. Lieberg / Urban Forestry & Urban Greening 11 (2012) 51–58

it is so that even in this concrete exercise there’s personal space.

And I think that’s very central. We never say ‘Forget yourself now
and concentrate on this plant here’. (Curative teacher, woman, 49
years) SELF
Because the participants are familiar with performing well, the
concrete tasks are of great importance. It is there they get “their
rewards” with which they feel familiar and comfortable. The con-
Life path
crete activities are deemed to be of great value, as there is a
special kind of rest to be found in doing something that has a clear
beginning and end. The importance of the need for interactions
between concrete and symbolic activities has its origin in the work Anonymity,
Knowledge
of Kielhofner (2006), who argues that how a person experiences recognition

and carries out a task depends on the dynamic interplay between

Sensory
the individual, task and environment; as soon as a person performs
impressions
an action, the result is an experience. The environment affects how Perceived
the activity is performed, offering an event in which people can characteristics

choose what to do, or signalling something that more or less forces Place
STRESS
a behaviour or action (Kielhofner, 1997). According to Christiansen attachment RECOVERY
and Baum (1997), a person needs to experience a balance between Self- Interactions Participants,
different activities in order to experience well-being. Within gar- chosen
h b
between caregivers
i
den therapy like that offered at Alnarp, this balance seems to occur places activities
often through the described interactions between activities.
“But maybe because of the symbolic exercise they’ve done they’re
discovering something completely different so . . . the concrete
activity has a value for the person . . . taking care of yourself maybe ENVIRON-
OTHERS
MENT
suddenly there is something to talk about when you’re caring for
Type of
the plant, and then you draw the parallel. How am I taking care of Atmosphere
inhabitants
myself? So even if the totally concrete elementary tasks are differ-
ent, you get different results depending on who is doing the task”
(Physiotherapist, woman, 49 years)
In the interviews, it is not clear whether one activity is dom-
inant; the main point is that the interactions can take place Fig. 2. Stress recovery model through garden therapy.
continuously and that participants get a sense of liberation from
being able to alternate between the concrete and the symbolic.
the place, its institutions and events. Fig. 2, illustrating a stress
However, the strength seems to be in the symbolic meaning the
recovery model through garden therapy, is inspired by Gustafson’s
participants are allowed to experience and relate to through this
model. The model includes information of significance in the form
interaction. Whenever the participants wish, they can let go of one
of separate factors when developing meanings of place, but par-
activity and directly find themselves back in another activity. In the
ticularly by looking between the poles, where interactions occur
interactions between concrete and symbolic garden-related activ-
between self–others, others–environment, environment–self, and
ities, it seems that the sense of freedom is significant for recovery,
self–others–environment.
which tends to reveal the meaningfulness of life itself. People expe-
The synergetic relationship between the three themes in Fig. 2
rience an activity as pleasurable when there is a balance between
is an attempt to conceptualize these themes, thereby presenting
challenge and skill (Csikszentmihalyi, 1996), and the unique ele-
the essence of a possible stress recovery model. The lowest com-
ment in the interactions between concrete and symbolic activities
mon denominator within the themes is the ability to continuously
is that the participants themselves “control” the balance in a non-
achieve a feeling of non-demanding freedom through the senses.
forced way. This should be done under the proper guidance of
This seems to have a decisive influence on the process of recovery
caregivers, however, to help participants “land” in the course of
from severe stress. In a setting and programme that promote use
events, with the caregiver sometimes putting into words what is
of the senses, the themes, summarized like this, seem to develop
happening. When participants allow themselves to pot one plant
the participants’ innate capacity for natural stress recovery. When
after another (concrete activity), they easily end up in a state Csik-
the factors (themes) are summarized, the model of stress recovery
szentmihalyi calls “flow” (Csikszentmihalyi, 1996). The symbolic
becomes clearer. It is within the relationship between the three
activity could be compared with what happens during moments of
poles that is needed to be discussed. Our revision of the model
soft fascination (Kaplan and Kaplan, 1989). Flow and soft fascina-
may act as an explanatory model regarding the complexity of fac-
tion both stand for something that is often soothing and pleasant,
tors that are involved in garden therapy. When the results are
and it is possible to drift off into them and rest from directed atten-
placed in Gustafson’s (2001) model, some characteristics may be
tion.
distinguished. In the context of garden therapy, the self–others
pole involves an intense interaction between all the characteris-
Discussion tics of life, path, emotion, activity, self-identification, and other
participants as well as the caregivers. The impact of being recog-
Gustafson (2001) has developed a three-pole model of mean- nized by and recognizing others, and sometimes the simultaneous
ings of place comprising the self, environment and others. The need to affirm feelings of anonymity, also plays a role in stress
self consists of an individual’s life path, emotions, self-identity recovery through garden therapy. Places such as the rehabilitation
and own activity. Other people have their own characteristics and garden are “attributed meaning through the perceived character-
behaviour. The environment comprises the physical features of istics, traits and behaviours of their inhabitants” (Gustafson, 2001,
 A.A. Adevi, M. Lieberg / Urban Forestry & Urban Greening 11 (2012) 51–58
p. 10). Our results are in accordance with this, as each of the factors
identified seems to influence the stress recovery process, with “sig-
nals” being sent from both the environment and others, to and from
the self. This goes in line with how place attachment is understood;
it can help to form and preserve an individual’s, group’s or culture’s
identity (Low and Altman, 1992). Environment–others includes
“atmosphere” as well as “type of inhabitant”, which are also sig-
nificantly involved during the recovery process. The environment
includes both humans and nature. Between environment–self,
opportunities are offered in accordance with how Gibson explains
affordances, i.e., action possibilities that are latent in the environ-
ment (Gibson, 1979). A system of synergetic parts is emerging, yet
these assumptions are not meant to diminish the strength of other
factors of importance to the recovery process, e.g., group dynamics.
The study provides one piece of the puzzle of what is occurring in
stress rehabilitation through garden therapy and in this, the recipe
for the steps towards lasting stress recovery may be hidden.
Conclusions
The present study supports previous research findings on the
importance of garden and nature on health. In addition to the com-
plex whole, this form of stress rehabilitation gives participants
different opportunities to have only the garden environment to
relate to in connection with therapeutic elements and activities.
The results show that a garden environment that they can feel safe
in, tends to “prepare, receive and open up” the participants to ther-
apy and activities in a way that seems particularly appropriate. The
change seen in the participants tends to provide opportunities for
thorough recovery from ill-health due to stress. Therapeutic ele-
ments in combination with nature and garden environments do not
seem to have previously attracted any serious attention within the
research field. This is an important gap in the literature because,
as our findings suggest, investigating a wider range of the treat-
ment spectrum reveals important interactive effects that promote
improved self-recovery in individuals suffering from stress related
ill-health. The results presented in this article are based on qualita-
tive data generated from a single case study, aiming at a deeper
understanding of the processes involved in stress rehabilitation
through garden therapy. Future research is encouraged to further
clarify and study the present findings in terms of the three factors
presented here as well as to take into account a wider range of
treatment activities and their effects. Until that time, other reha-
bilitation gardens in particular and rehabilitation centres in general
taking care of stress-related ill-health may be helped by our find-
ings.
Acknowledgements
The authors would like to thank the caregivers at Alnarp Reha-
bilitation Garden for their contributions. Thanks to Anna-Maria
Pálsdottír for helping with the interviews. Thanks to professor
Patrik Grahn and professor Eva Johansson for their helpful com-
ments on an earlier draft on this paper. Finally we would like to
thank Sensys Research School, Swedish University of Agricultural
Sciences for funding the project.
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