Investigation of Horticultural Therapy as a Complementary Treatment for Posttraumatic Stress Disorder

Scholar: Dawn Ogle; McNair Faculty Mentor: Dr. Patricia Kyle

Biographical Narrative: Dawn Ogle is a senior at Southern Oregon University where she is attaining her baccalaureate of science degree in the field of psychology. Dawn is a current recipient of the Ford ReStart Scholarship and has maintained status on the Presidents Honor List since returning to school three years ago. Dawn is fascinated with personal growth and the healing process and expects to achieve a Master degree in Applied Psychology to pursue her dream of counseling. Her next goal is to attend a Ph.D. program to become a Counseling Psychologist. Dawn wants to utilize every educational opportunity available to her because she believes that through knowledge, comes power. She wants to use what power she has to help others learn to heal and grow. Dawn has a strong commitment to helping her community. Her most recent endeavor has been implementing a gardening group at a local womens shelter for domestic violence. She believes there is a strong correlation between noticing the beauty of the natural world and discovering the beauty of our inner selves. Abstract Horticultural therapy is a relatively new modality in the field of psychotherapy. This therapeutic technique utilizes the documented calming effects of nature while implementing activities that address the clients individual goals. Two major theories that explain the therapeutic benefits of nature on the human psyche are Ulrichs psycho-evolutionary theory (1991) and R. Kaplan and S. Kaplans (1995) attention restoration theory. Those suffering with Posttraumatic Stress Disorder (PTSD) need ways of stabilizing their overactive autonomic responses. Through a review of the literature and observations from a gardening group conducted by the researcher, this article investigates the viability of horticultural therapy as a complementary treatment for PTSD. Key Terms: Posttraumatic Stress Disorder, Restoration Response, Horticultural Therapy Posttraumatic Stress Disorder (PTSD) is a term that has become more prevalent in American vocabulary due to the thousands of war veterans returning home with this condition. Formerly known as shell shock, this anxiety disorder is brought on by a one time or prolonged exposure to traumatic events. PTSD has received a great deal of media attention recently as the number of cases increase in both veteran and civilian populations. Those with PTSD require therapeutic relief from the intense physical and psychological toll this disorder takes on the individual. Since nature and gardening have demonstrated a calming and restorative effect on humans (American Horticultural Therapy Association, 2008; Ulrich, 1986; Hartig, Mang, & Evans, 1991; Laumann, Garling, & Stormark, 2003) I will be focusing my research on the viability of horticultural therapy as a complementary treatment to the standard management of PTSD symptoms. I will also include personal observations gained through a gardening group I facilitated at a womens shelter for those escaping from domestic abuse, a population that frequently exhibits PTSD symptoms. Hearing the abuse histories of the women at the shelter and witnessing how these past incidents continue to affect their lives motivated me to research treatment options for PTSD symptomology.

Posttraumatic Stress Disorder Affected Populations According to the American Psychological Association (2008) most people will experience some type of traumatic event in their lifetime, while only 8% of those age 15 to 54 will be diagnosed with PTSD (Kessler, Sonnega, Bromet, Huges & Nelson, 1995). Women are twice as likely to be diagnosed with this disorder as men (Kessler et. al, 1995). The development of PTSD in an individual depends on several factors. Preexisting conditions such as genetics and psychological factors can play a role in the level of vulnerability a person has to this disorder (Keane & Barlow, 2002). Another factor can be social support and the individual coping styles utilized after the event (Zayfert and Becker, 2007). Diagnosed cases of PTSD in United States veteran populations grew by 50% between the years 2006 and 2007 (Anxiety Disorders Association of America [ADAA], 2008). Estimates of veterans with this disorder reach as high as 30% for veterans of the Vietnam War (National Center for PTSD [NCPTSD], 2008) and 19% for veterans of the Iraq and Afghanistan Wars (D. Sue, D.W. Sue, & S. Sue, 2006). PTSD is not limited solely to those who have experienced combat. Other traumatic events that are known to precipitate this disorder include car crashes, natural disasters, kidnapping, refugee status, sexual assault, and battered women syndrome (Sue et al., 2006). Those who experience human-caused traumas, especially when an individual feels powerless to control the situation, have a higher incidence of PTSD than those who encounter natural disasters (Sue et al., 2006). Survivors of sexual assault are the most at-risk population for this disorder (NCPTSD, 2008) and childhood sexual abuse is also a strong predictor of future PTSD symptoms (ADAA, 2008; Rodriguez, Ryan, Rowan, & Foy, 1996). Rates of symptomology have been shown to increase according to the severity and duration of the sexual abuse (Rodriguez, et. al., 1996). This is also the case for exposure to domestic violence (Griffing, Lewis, Chu, Sage, Madry, & Primm, 2006). These numbers indicate that mental health practitioners must become increasingly familiar with effective treatments for PTSD in order to reach these growing populations. The preponderance of the evidence within this paper suggests that horticultural therapy could be one of these effective treatment tools. Etiology and Symptomology The criteria for classification of a DSM-IV-TR diagnosis of PTSD must include the following symptoms: re-experiences of the event while waking or asleep, emotional numbing and avoidant behaviors, and increased autonomic arousal. Symptoms might include panic attacks, nightmares, flashbacks, irrational thoughts, hypersensitivity, and periods of disassociation from the outside world. Symptoms must also be ongoing for a period lasting longer than 4 weeks. These symptoms sometimes may not occur for months or years after the traumatic event (AllPsych, 2004; Sue et al., 2006). Anxiety Response Zayfert and Becker (2007) report that the recurring and persistent symptoms of PTSD are the product of maladaptive fear. This fear occurs as a response to triggers an individual remembers from the initial traumatic event (Zayfert &Becker, 2007). These triggers may include any type of sensory input such as sights, sounds, smells, tastes or tactile sensations (Sue et al., 2006). Symptoms can also be triggered by cognitive stimuli, such as thoughts or memories (Francati, Vermetten, & Bremner, 2007). The cycle from trigger to symptoms can be extremely taxing on an individuals biology, psychology and their social interactions.

Biological effects. When a trigger is encountered, the amygdala is activated and stress hormones flood the body. These heightened levels of hormones engage the fight, flight or freeze response, activating the bodys autonomic responses. In the past, this preconscious biological reaction was an essential component for the survival of the human species. It provided the rapid response necessary to escape the dangers of a natural environment. Today, this autonomic response can lead to dramatic reactions to otherwise innocuous cues for those with PTSD (Sue et al., 2006; Bisson, 2007; Francati, Vermetten, & Bremner, 2007). Studies conducted with neuroimaging technology suggest that those with PTSD have differences in brain activation levels when compared to those without the disorder. Research has shown an increase in brain activation in the amygdala, the area responsible for emotional reactions, and a decrease in the medial prefrontal cortex, an area known for its executive control of decisions. (Sue et. al., 2006 ; Francati, Vermetten, & Bremner, 2007; Bisson, 2007). This dynamic leaves those with PTSD in the position of trying to make sense of their overactive emotional responses without the full support of the part of their brain responsible for making discriminatory decisions. Other areas of the brain that have been found to be affected are the hippocampus, parahippocampus, orbital frontal cortex and the thalamus (Francati, Vermetten, & Bremner, 2007). Smaller hippocampus size has been linked to PTSD and lesions on this portion of the brain have been linked to more intense reactions to fear (Bisson, 2007). The hippocampus is responsible for memory and learning and has been shown to be especially sensitive to stress (Bremner, 2002). This deficit in hippocampal size has not been found in other anxiety disorders, but seems to be specific to PTSD (Bremner, 2002). Psychological effects. Evidence suggests that those with PTSD psychologically and emotionally link the trigger to the traumatic event through the process of classical conditioning (Zayfert & Becker, 2007). Because the trigger is then associated with the trauma, the sufferer typically uses avoidant behaviors to circumvent the triggers and the painful experiences they cause. Avoiding the trigger stimuli only strengthens the trigger/trauma link held by the individual and lessens the opportunity for extinction to occur (Sue et. al, 2006). Social effects. As the symptoms of PTSD progress, many with this disorder experience difficulties initiating and maintaining relationships. According to one study on Vietnam veterans, persisting PTSD symptoms were associated with worse family relationships, more smoking, less life satisfaction and happiness, more mental health service use, and more nonspecific health complaints at the 14-year follow-up. (Koenen, Stellman, Sommer, & Stellman, 2008, p. 49). Depression is another common comorbidity within this population (NCPTSD, 2008). This depression only exacerbates the situation and often leads to further social isolation. Substance abuse is also common among this population as sufferers try to cope with the stress they experience. Rates of drug and alcohol abuse are approximately double the rates for men and women with this disorder than rates in the general population (Kessler et. al, 1995). The impact these factors have on an individual can also put them at higher risk of suicide. Roughly 27% of those diagnosed with PTSD have attempted suicide at some time in their lives (Tull, 2007). These comorbidities point to the fact that this population needs more support dealing with the anxiety they are experiencing. Horticultural therapy could be one way to offer support to this population.

Treatments The Department of Veterans Affairs recently commissioned a review of the evidence regarding treatment modalities for PTSD. This rigorous investigation by the Institute of Medicines Committee on the Treatment of Posttraumatic Stress Disorder (IMCTPTSD) looked into both pharmacologic and psychologic methods (2008). The committee set strict criteria for this review and selected only randomized controlled trials. This narrowed the preliminary 2,771 published articles, to include only 37 on pharmacotherapies and 52 on psychotherapies, all of which met the criteria for level I evidence. On the objection of one of the committee members, pharmacotheries were shown to be inconclusive for efficacy on PTSD treatment. As pointed out by the reviewers, inconclusive evidence does not necessarily negate the effectiveness of a particular treatment, but simply a lack of standardized evidence. Given this, some drugs have proven useful for PTSD symptomology according to the National Center for Posttraumatic Stress Disorder (NCPTSD). These include benzodiazepines, which can decrease anxiety and promote sleep, antiadrenergics, which lessen arousal and aggression, and serotonin reuptake inhibitors (SSRIs), which can manage anxiety and depression (NCPTSD, 2008). According to the NCPTSD (2008) some psychotherapies have also had success in treating PTSD. These include cognitive behavioral therapy (CBT), eye movement desensitization and reprocessing therapy (EMDR), group or family therapy and brief psychodynamic therapy. The IMCTPTSD committee, on the other hand, reviewed the data on EMDR, cognitive restructuring therapy and coping skills training and found the evidence to be inconclusive. Along with these findings, the IMCTPTSD (2008) did find positive results for cognitive behavioral therapy which included the technique of exposure therapy within the category. Exposure therapy. Exposure therapy is a cognitive behavioral therapy (CBT) that utilizes behavior modification and cognitive restructuring (Zayfert & Becker, 2007). This theory is the most widely documented efficacious psychotherapy for treating PTSD. The theory behind this technique is that by exposing clients to the instigating memories, they will become habituated to the stimuli and the trauma will cease to exert the same power over their lives. This process of moving toward the pain can seem counter-intuitive to the client. Zayfert and Becker (2007) equate this process to the setting of a bone after a break: the pain has to get worse before it can get better. This healing process is often long and painful. Since the treatment itself can be such a powerful stressor on clients, finding ways to help them relax and recharge, in an environment that does not require a great deal of vigilance, can help this process a great deal. Going to nature is one of the ways humans have found solace for thousands of years and there are a few theories that try to explain this phenomenon. Human Response to Nature The Biophilia Hypothesis Much has been written about the love affair humans have with nature. Biophilia, or the love of life, is described as the innate tendency to focus on life and life-like processes (Wilson, 1984). The Biophilia Hypothesis, coined by Edward Wilson (1984) claims that humans need nature, not just for the purpose of sustenance or aesthetic value, but because nature is

rooted in human biology and evolutionary history. This hypothesis asserts that nature has impacted the human species on a deep psychological and physiological level and points to the thousands of years of intimate relationship between humans and nature as the cause of this effect (Kellert & Wilson, 1993). Archeology shows us that as early as the ancient cities of Mesopotamia, city dwellers have made efforts to incorporate nature into their lives (Ulrich & Parsons, 1992). Even people under the most severe conditions, such as those in Japanese Residents of block 26, Minidoka, Idaho, 1942 internment camps or soldiers in World War I, have Helphand, 2006, p. 197 persevered against great odds to create gardens for the peace of mind they provide (Helphand, 2006). There are now researchers from many academic disciplines investigating this human/nature connection and many have produced evidence that supports natures calming and restorative effect on the human psyche and physiology (Ulrich, 1983; Ulrich, 1984; Ulrich, 1986; Ulrich, Simons, Losito, Fiorito, Miles & Zelson, 1991; Hartig, Mang, Evans, 1991; Kaplan, S. 1995; Laumann, Garling, & Stormark, 2003; Parsons, Tassinary, Ulrich, Hebl, & Grossman-Alexander, 1979). In addition to the Biophilia Hypothesis, a few other theories have emerged that attempt to explain this relationship between humans Trench garden, WW I, 1916, and nature.
Helphand, 2006, p. 47

Theories on the Stress Reducing Effects of Nature Cultural. From a social science perspective, the values and beliefs a culture holds regarding nature can have an effect on the way an individual responds to exposure to natural environments. This cultural theory implies that a major part of an individuals relationship with nature comes from what he or she learns and incorporates from their cultural environment (Relf, 1998). One example is the commonly held dislike for cities and preference for greenery (Ulrich et al., 1991). Arousal/Overload. Another theory has to do with an individuals level of arousal. It suggests that when arousal is low, such as in a natural environment, recovery from stress is easier and more rapid (Relf, 1998). This arousal theory implies that arousal is caused by the complexity, intensity and movement within an environment (Ulrich et al., 1991, p. 205). Related to this premise are overload theories which maintain that highly complex environments, such as cities, take a large toll on an individuals processing ability. This sensory overload can have an effect on an individuals capability for stress recovery (Ulrich et al., 1991). Extended contact with highly complex and stressful environments is similar to what sufferers of PTSD go through after long term exposure to the high levels of stress produced by the disorder. Consequently, the addition of a highly complex environment might be counter-productive to PTSD symptomology.

Attention Restoration Theory. One of the two major theories regarding natures restorative qualities is R. Kaplan and S. Kaplans (1995) theory on restorative environments. They make the distinction between stress or the preparation for an anticipated event that has been evaluated as being threatening or harmful and mental fatigue which is the worn-out state of mind that occurs when an intense amount of attention has been paid to something (1995, p. 178). Kaplan and Kaplan contend that reduction of mental fatigue is one of the main purposes of a restorative environment. Attention Restoration Theory (ART) centers around two types of attention, based on the amount of effort required for their use. Voluntary (or direct attention) takes a great deal of effort because not only must an individual apply effort to focus on something, but energy must be spent to block other incoming stimuli. Involuntary attention, on the other hand, is what happens naturally when an individual is interested in something. This takes much less mental effort and has been shown to provide an opportunity for the mind to replenish itself. Though attention plays a major role in restoration theory, Kaplan and Kaplan have also determined other key factors that are necessary for a restorative environment. According to attention restoration theory, the term fascination is equated to involuntary attention. Kaplan and Kaplan (1995) theorize that fascination, or a less-conscious focus of attention, is one of the four crucial elements necessary for a restorative environment to be effective. Another factor is being away, which the researchers identify as the physical or psychological act of being somewhere that is different from the usual context (Kaplan & Kaplan, 1995). Being away helps people separate from the stressfulness of their everyday lives. Extent is another factor. Kaplan & Kaplan (1995) deem this to be the amount of interconnectedness an individual can attain through his or her environment. They use the example of a wilderness experience, but extent is not limited by the distance of the physical location, it is the extent to which the individual feels a part of something larger than themselves. It can also include settings as small as a garden or activities such as going on a walk. The fourth element the researchers consider necessary for a restorative environment is the idea of compatibility (Kaplan & Kaplan, 1995). According to their theory, people will experience more restorative effects if they can find something within the environment that resonates with them. Each person has his or her own paradigm for relating to the environment. Utilizing a space or location that serves an individuals own particular purpose is important. Kaplan and Kaplans attention based model makes the assertion that modern day environments that are high in complexity, such as discussed in the arousal and overload theory, require a great deal of voluntary attention. They maintain that environments that meet the criteria of fascination, being away, extent and compatibility, for instance those found in nature, allow involuntary attention to come to the psychological forefront. Studies have shown that when this happens, a restorative response is more likely to occur (S. Kaplan, 1995; R. Kaplan and S. Kaplan, 1995; Hartig, Mang, & Evans, 1991; Laumann, Garling, & Stormark, 2003). Psycho-evolutionary Theory. The other most prominent theory on natures restorative effects has been formulated by Roger Ulrich. His psycho-evolutionary model contends that the human response to nature is preconscious and emotional. Ulrich and a growing number of researchers believe that the human response to nature is based on biological and psychologic advantages that have helped humans survive in a natural environment for thousands of years. Ulrich contends that these responses can encompass a wide range of affects depending on the situation. Responses could range from stress and avoidance behaviors, say in the case of an environmental threat, or restoration and approach behaviors, say in the case of finding food or in the need to restore a positive emotional state (Ulrich, et al.,1991, p. 208). Ulrich and colleagues maintain that humans are essentially hard-wired for biologically prepared learning. This type of learning is

one explanation for why nature based phobias, such as the fear of snakes and heights, are easier to develop and harder to extinguish than other more justifiable modern dangers, such as cars or guns (Ulrich, et al., 1991). This theory has gained a great deal of support over the years and is similar to the previously mentioned Biophilia Hypothesis in that these behaviors and reactions are rooted in human biology and evolutionary history. The same mechanisms of biologically prepared learning that cause the human affinity for nature are the same mechanisms that drive the symptomology of PTSD (hman, 1994; Zayfert & Becker, 2007). In the case of PTSD, the human physiology that once was essential for survival is now working overtime in a reaction loop of fear and frustration, heedless of the validity of the threat (Zayfert & Becker, 2007; Sue et al., 2006; Keane & Barlow, 2002; Bremner, 2002; Bisson, 2007). Evidence of Positive Response

Study 1.
In a highly cited study by Roger Ulrich (1984) patients recovering from surgery with a window view to a natural setting required less post-operative drugs, had less documented complaints filed on them by their nurses, and had hospital stays that were shorter in duration than those whose views looked out on a brick wall. For this study, Ulrich utilized hospital records from a ten year period and patients were randomly assigned to their rooms based on room availability. This study helped to launch Ulrichs investigations into human responses to nature and propelled him as a leading researcher in the fields of health care design, landscape architecture and urban planning based on the evidence from this and further studies.

Study 2.
In a 1991 study by Ulrich and colleagues, an examination was made into stress recovery rates based on exposure to natural or urban environments. Participants were first exposed to an extreme stressor: a work safety video depicting gruesome work related accidents. They then watched a video of either a natural or urban setting. Researchers used self-report surveys of emotional states and an electrocardiogram to determine recovery rates. Other physiologic measures used were: pulse transit time, skin conductance, and muscle tension. Ulrichs team found a positive change in emotional state and lower levels of physiological activity after exposure to the nature video (Ulrich, Simons, Losito, Fiorito, Miles & Zelson, 1991). This further substantiated Ulrichs hypothesis that natural environments are more restorative.

Study 3.
Similar results were achieved in another study that measured restorative effects of nature. Researchers Hartig, Mang and Evans (1991) conducted one quasi-experiment involving a wilderness experience and one experiment involving the stressor of a proof reading exercise. Physiological measures of blood pressure, pulse and skin conductance were utilized in the experiment only, while self-reports and cognitive functioning measures were used in both studies. Both studies compared responses after exposure to natural and urban environments. Researchers found nature to have restorative effects in both studies.

Study 4.
A more recent study also incorporated proofreading as a stressor to measure recovery rates, but in addition, researchers administered an attention-orienting task. Rates were taken prior to and following exposure to a video of either a natural or urban setting. Cardiac inter-beat was the instrument used to monitor autonomic arousal. Researchers Laumann, Grling and Stormark (2003) were trying to discover if Kaplan and Kaplans attention restoration theory would be supported by the results of the attention-oriented measure. Their results did not verify

this hypothesis; however, they did find that the nature stimuli produced less autonomic arousal. This could be an important finding for those with PTSD, since overactive autonomic arousal is a major symptom of the disorder. Discussion of the Evidence I chose to review these studies out of the many on this subject because they incorporated physiologic measures to help support the nature-restoration theories that have relied so heavily on survey measures and inference. While not inclusive by any means, this research does give a window into the kind of studies being conducted on this subject. When considering the combined theories on the human response to nature, it is logical that problems might be experienced from the constant demand on voluntary attention required in todays complex society. Add to this the disconnection from the natural environment experienced by urban populations and it is not hard to understand how these factors could have an influential effect on human mental health. Impact of Dirt on Human Biology This disconnect from the natural world may also be responsible for affecting human biology in a completely different manner: through the human immune system and neurotransmitter networks. Researchers recently found that cancer patients injected with Mycobacterium vaccae (M. vaccae), a bacterium commonly found in soil, described greater life satisfaction levels and fewer symptoms of pain and nausea (Glausiusz, 2007). This same bacterium was also shown to provide relief of skin allergies. These findings prompted new studies by a team of researchers at the University of Bristol, England, to further investigate the effects of this bacterium on the brain and immune system. Evidence of Positive Response

Study 1.
One study applied M. vaccae directly to the lungs of mice and found that this produced increased levels of cytokine proteins within their lung tissue (Gasser, Lowery & Orchinik, 2006). According to Lowry, one of the leading researchers on the team, What we think happens is that the bacteria activate immune cells, which release chemicals called cytokines that act on receptors on the sensory nerves to increase their activity (Glausiusz, 2007, p. 1). A cytokine is the generic name for a group of chemicals that are beneficial for launching attacks against pathogens (Decker, 2006). This finding adds to a growing body of evidence linking exposure to soil to the strengthening of the immune system (Openshaw & Hewwitt, 2000). These results may seem unrelated to PTSD, but certainly having a stronger immune system could be a benefit to someone whose body is already taxed from the over-production of stress hormones.

Study 2.
Another study conducted by the same team looked at the effects on rat brains after an M. vaccae injection. Researchers discovered that the serotonin-producing neurons in the dorsal raphe nucleus region of the brain had higher activation levels than the control group (Gasser, Lowery, & Orchinik, 2006). This region of the brain is important for sending messages to the prefrontal cortex and the hippocampus, which engages mood regulation and cognitive functioning. These findings could be especially relevant to future investigations on PTSD because, as indicated, both the hippocampus and the prefrontal cortex are areas of interest to PTSD researchers.

In this same study, serotonin levels were also identified as being higher in the prefrontal cortex (Glausiusz, 2007; Gasser, Lowery, & Orchinik, 2006). One of the reasons that SSRIs have shown effectiveness for PTSD sufferers is because the drugs allow for the availability of greater quantities of the neurotransmitter serotonin (NCPTSD, 2007). Thus, the indications that this bacterium affects these levels could also have promising implications for those with PTSD.

Study 3.
The last study by Lowrys team (2006) measured the length of time it took for mice to go from active swimming to passive floating when placed in a tub of water. Mice injected with M. vaccae paddled, on average, twice as long as the control group. Previously conducted studies had shown antidepressants to have the same effect on these swimming patterns of mice as the bacterium demonstrated (Glausiusz, 2007). This research might have implications with regards to coping in stressful situations, a common problem for those with an over activated amygdala, such as in the case of PTSD. Discussion of the evidence. Since M. vaccae can either be taken in through ingestion or inhalation, humans have only to eat vegetables, drink water, or walk in the woods to get a dose of this helpful bacterium (Glausiusz, 2007). This could also have implications when considering the effect of gardening on a persons mood and outlook. The Biophilia Hypothesis, restoration theories and these recent studies with bacterium lead to interesting questions with regards to human relationship to nature. How strong is the connection between the evolutionary biology of human beings and the way they are responding to nature? Today, roughly 70% of Americans live in an urban environment, 40% of those in regions of one million or more (U.S. Department of State's Bureau of International Information Programs, n.d.). How is this new urbanization affecting the mental health of those who live in the city, and specifically, those with PTSD? Does this bacterium have anything to do with the enjoyment reported by those who garden? More empirical evidence needs to be gathered in these areas, but a growing body of research now points to nature as having a positive effect on humans (Parsons, Tassinary, Ulrich, Hebl, & Grossman-Alexander, 1979; Ulrich, 1983; Ulrich, 1984; Ulrich, 1986; Ulrich, Simons, Losito, Fiorito, Miles & Zelson, 1991; Hartig, Mang, Evans, 1991; Kaplan, 1995; R. Kaplan and S. Kaplan, 1995; Laumann, Garling, & Stormark, 2003; Gasser, Lowery, & Orchinik, 2006). Horticultural Therapy Brief History Horticultural Therapy (HT) is an idea that has been around for a long time, with the first historical record of horticulture as treatment dating back to physician records of ancient Egypt (Davis, 1989). Davis goes on to report that a U. S. professor, named Benjamin Rush, discovered in 1798 that mentally ill patients who worked on farms experienced a decrease in symptoms. According to Davis, by 1817, the Friends Hospital in Philadelphia had incorporated garden design and activities to help with the convalescence of their patients. Following World War II, many veterans benefited from the addition of horticulture to hospital rehabilitation programs (Davis, 1989). By 1973, the National Center for Therapy and Rehabilitation through Horticulture was formed, which later became the American Horticultural Therapy Association (AHTA). Today, this organization works for the promotion of HT through research, networking, education, and the setting of national standards for training and terminology and in the field.

Current Methodology Definition. A common misconception about Horticultural Therapy is that any garden activity qualifies as therapy. While the passive exposure to nature has been shown to be beneficial, horticultural therapy is related more to recreational therapy in its methodology and practice. Similar to art or music therapy, HT is generally an adjunct therapy to other more traditional medical or psychologic treatments. This means that an HT specialist generally works as a member of an interdisciplinary team within an established healthcare, educational or vocational setting (Haller, 1998, 2006). Like other types of recreational therapies, it entails carefully designed activities tailored to meet the clients individual needs, level of functioning and personal goals (AHTA, 2008; Haller, 1998, 2006; Shapiro & M. Kaplan, 1998). Needs are determined through an initial assessment and sessions are designed by including activities that address treatment issues and incorporate the clients own personal gardening interests as much as possible (Haller, 2006). Treatment issues could be cognitive, physical, emotional or social. Treatment plans generally address the problem, the HT goal, a short term objective, a long-term objective and the procedure to make this happen (Sieradzki, 2006). It is recommended that treatment plans be specific, measurable, action-oriented, realistic, and time based (Sieradzki, 2006, p. 97). A horticultural therapist utilizes gardening and related activities to engage the client in an interactive way. Activities are generally season specific, such as propagation and planting in the spring, care and weeding in the summer, and harvesting in the fall. When weather does not permit, indoor activities are utilized, such as floral design and nature crafts, planting terrariums or cultivating house plants. When activities are planned so that they build on the previous week, it can foster a sense of continuity and growth for the client. It can also be helpful to revisit projects to track client progress. Sessions preferably take place on at least a weekly basis. HT can be done on an individual level, working one-on-one with the client or in a group setting. When conducting HT groups, the needs of each individual are closely monitored to ensure the desired outcome, as is the case when working with groups utilizing other modalities. One of the main things to remember about HT is that the healing is in the process, not necessarily the product of the activity (Catlin, 2006). Effective Factors Horticultural Therapy can effect positive change for a client in a variety of ways. The most basic routes are through passive and direct means (Relf, 1981,1998). Passive refers to the restorative qualities nature imparts simply by exposure, as indicated in the previous studies. Direct means refers to the benefits gained through the actual therapeutic activity. Diane Relf (1981) a leading expert in the field of HT, has identified several factors of direct involvement that are beneficial to the client in an HT milieu. I will illustrate these elements with examples from a gardening group I recently implemented and facilitated at a womens shelter for domestic abuse. This group was not an actual HT group, so benefits were gained primarily through passive means. This first gardening group was a pilot project to investigate whether the women might enjoy gardening activities and to test the waters for possible inclusion of HT techniques and further research.
Garden at Dunn House Womens Shelter Ogle, 2008

Relfs seven effective factors of direct involvement in horticultural therapy. 1. Integration of biological and psychological factors One woman, recently single after years of marriage, was struggling to fulfill the physical needs of herself and her daughter. While at the shelter she took on much of the responsibility for the care of the garden, including the planting, watering and weeding. After witnessing the productivity of her work, she gained a concrete example of the productivity she was capable of in her own life. According to Rice (1993), Caring for plants provides physical confirmation of our ability to care for life (In Haller 2006, p. 19). 2. Mastery of the Environment Most of the women at the shelter are interacting with the court system for restraining orders and custody hearings. While gardening, one woman expressed to me how frustrating it is to have so little control in these legal situations. As an activity that day, I let her decide what type of seeds to plant in which locations in order to give her the feeling of affecting some control over her environment. Mastery over the environment may be one reason that populations such as soldiers or the homeless, chose to garden even under dire circumstances. 3. Work Substitute Many women at the shelter are in a temporary limbo between U.S. soldiers growing corn in Iraq 2004 relationships, homes and jobs. Helphand, 2006, p. 244 Participating in gardening activities gave them a way they could feel productive. This especially seemed to be the case when harvesting and preparing the vegetables they had grown for the other residents at the shelter. 4. Responsibility Residents were responsible for maintaining a watering schedule for the garden. I noticed that the residents who took on that responsibility seemed to gain more enjoyment from the garden and had a stronger sense of ownership. Two girls in particular seemed to feel great pride in their watering duties and took on the watering of other trees and bushes that had been neglected by the sprinkler system.
Homeless garden, Lower East Side, New York, 1992 Helphand, 2006, p. 222

5. Creativity Experiencing crisis does not afford much time for creativity. Decisions about the design and grouping of the plants initiated lively discussions within my group. Once, when making hanging baskets, I neglected to bring wire and the group seemed to have more fun coming up with ways to hang the baskets than in the actual planting. We eventually used colorful pipe cleaners and string. 6. Frustration Tolerance Most of the families at the shelter are functioning at a high level of frustration from loss of home, jobs, schools and friends. For the children at the shelter, it was frustrating to wait for the

strawberries to ripen. This took a great deal of patience on their part. We also had some ongoing insect problems that were challenging to deal with. 7. Intense Concentration One statement I heard repeatedly from the women was that when they were busy focusing on the garden, they stopped thinking about their problems. One woman even equated gardening to a meditation. This effect of nature is what Kaplan and Kaplan (1989) call an opportunity for reflection because it allows for the individual to focus on something larger than themselves. I noticed this quality often within my group, whether they were busy working or simply sitting and observing the garden. In conclusion of my group observations, I also want to report that a great deal of sharing took place between members. As the group evolved, I noticed more of a support group atmosphere than a simple recreational group. Many also expressed that it was nice to get away from their daily concerns, which relates to Kaplan & Kaplans (1995) theory of extent. Settings HT programs are useful in many different capacities: vocational, long or short term psychiatric care, rehabilitation, schools, community gardens, elder care, veteran administrations, developmentally disabled training and incarceration (AHTA, 2008; Haller, 1989, 2006). Programs can be adapted to almost any population or setting. The garden we set up at the shelter, for example, consisted of two long raised beds for easier access to those with disabilities. Efficacy of Horticultural Therapy on Various Populations My search for evidence of the efficacy of HT for the treatment of PTSD did not reveal any empirical data connecting the two. I did, however, find studies conducted on other populations that point to HT as a viable and effective therapy.

Study 1& 2
One population mentioned in the literature as possibly benefiting from HT is those incarcerated due to violations of the law. One quasiexperimental study by Richards and Kafami (1999) suggests that participants in an HT program at a penal institution experienced significant improvement in their rate of vulnerability to addiction due to their six month HT program. Since those with PTSD are at higher risk for substance abuse, this could have important implications for those with the disorder. Another gardening program was instituted at a long-term detention facility for juvenile offenders. This 2004 pilot program did not offer specific HT programming, but simply provided the inmates the opportunity to garden. Even without the therapy aspect, administrators found a 25% reduction in disruptive incidents after the creation of the garden (Sandel, 2004). This reduction of incidents could also have implications for PTSD since the disorder has been linked to hyper-responsivity to emotional cues.

Study 3 & 4
In a 2005 study, researchers investigated the effectiveness of HT for the treatment of elder populations suffering from dementia. With this study, researchers Gogliotti and Jarrott (2005) hoped to add to previous evidence of higher engagement and affect levels with HT activities than standard activities within adult day service (ADS). Data was gathered from four ADS facilities using observations, demographic information and the Mini-Mental Status Exam. Results indicate considerably greater positive reactions to HT activities when compared to standard ADS activities (Gogliotti & Jarrott, 2005).

In a separate study on patients with Alzheimers disease, researchers, Mooney and Nicell (1992) discovered that in the five care facilities they studied, those with gardens had a 19% lower rate of violent incidents than those without gardens. These findings could have implications for others who experience high levels of frustration and aggression, such as those with PTSD.

Study 5
I did identify many veterans administrations throughout the U.S. and abroad that incorporate gardening in their rehabilitation activities, but was unable to locate any reliable studies conducted on the efficacy of HT for veterans with PTSD. I did, however, locate one horticultural therapist working with survivors of sexual assault. While not as significant in terms of empirical data as the previously mentioned studies, this pilot project demonstrates a promising direction for future research in terms of working with women with the disorder. ChristeneTashjian, a horticultural therapist working within the framework of the Orange County Rape Crisis Center (OCRCC) in Chapel Hill, North Carolina implemented and facilitated an eight week support group for survivors of sexual assault. As previously indicated, this population is at highest risk for the development of PTSD. According to my telephone interview with Tashjian (personal communication, July 7, 2008) all of the six women in the group demonstrated some symptoms of the disorder. The two-hour sessions consisted of an HT activity planned around a daily topic, followed by discussion. An example session she relayed to me was on the topic of fear. First, the women talked about their fear and what it meant to them. They then took turns imagining what they were afraid of as a branch on a plant, clipped off the branch and put it in the compost. This is a prime example of Relfs previously described integration of biological and psychological factors that is a key element in the effectiveness of HT (1981, p. 148). The physical act of pruning represented the psychologic process of releasing the thoughts and feelings that were no longer useful in their lives Tashjian used a Likert scale survey instrument before and after each session as well as at the completion of the program. Tashjian believes that the deeply emotional content of the groups may have confounded the post group surveys. Findings from the surveys taken at the completion of the program were overwhelmingly positive. These positive results have lead to the continuation of the program and further financial support by the OCRCC (Tashjian, 2007). Continued Research Weaknesses and future directions. Because HT is such a relatively new field of therapy, there is still some confusion about the terminology. In my research I ran across many terms such as garden therapy, healing gardens, therapeutic gardens and sanctuary gardens, which all have slightly different meanings from horticultural therapy. The American Horticultural Therapy Association has done a great deal in the clarification of these terms, but worldwide definitions still vary somewhat. Evidence that supports the restoration response to nature and the benefits of HT remains small, but is growing thanks to an interdisciplinary approach to the research. Some of the disciplines involved in this investigation include environmental psychology, neurology, microbiology, and healthcare and landscape design. The demand for evidence based practice within the third-party payment system mandates substantiation of the horticultural therapys effectiveness. Today, there is still a great need for empirical evidence from randomized controlled studies in order for HT to gain further acceptance by the medical community. As with other mentally ill populations, there are many difficulties conducting experiments with those experiencing PTSD due to the seriousness of the disorder.

Conclusion As previously indicated, cognitive behavioral therapy, including exposure therapy, has the most documented efficacy in the treatment of PTSD. In order for this technique to be effective, the practitioner must step outside the traditional role of providing calming support and into the role of guide, leading the client into dark emotional territory (Zayfert & Becker, 2007). This process can be arduous and can cause stress to both client and practitioner. Horticultural therapy could be an effective complimentary treatment to CBT in three major ways. First, the passive exposure to nature could provide restorative effects to clients after the stress created by CBT. Olmsted, a landscape architect in 1865, stated that when looking at nature The attention is aroused and the mind occupied without purpose. (Ulrich, et al., 1991). This relates to Kaplan and Kaplans (1995) attention restoration theory in that, while involuntary attention is focused on nature, the mind has an opportunity to restore itself. Exposure to nature, through the use of HT, could give comfort to those with PTSD who are undergoing distressing cognitive behavioral therapy through the passive means of natures restorative qualities. Secondly, HT activities can be designed to address the same client issues as CBT. According to Relf (1981) In the therapist-client relationship, the plant world may be used to establish a nonverbal relationship to open communications on subjects that the patient finds extremely threatening, or to face and deal with subjects with which the patient may not be consciously aware are disturbing in nature (p. 147). In traditional therapy, the focus is on the client and the client/therapist relationship. In an HT milieu, the gardening activities are designed to confront the same issues as traditional therapy, but with the added benefit of providing the client the opportunity to focus on something outside of his or her self. Gardening and a natural environment provides a safe and non-threatening atmosphere for the healing to take place. Finally, throughout history human physiology has reacted to the natural environment out of necessity for survival. The same preconscious physiological response mechanisms that are calmed by nature (Laumann, Grling & Stormark, 2003; Ulrich, et al., 1991; Hartig, Mang & Evans, 1991) are the same mechanisms that are activated by PTSD symptomology (hman, 1994; Zayfert & Becker, 2007). I suggest that humankinds affinity with nature be accessed through a therapy that utilizes a natural environment in its design. I believe horticultural therapy is a highly underutilized modality, and in the case of PTSD, has encouraging prospects as a successful addition to cognitive behavioral therapy. As indicated in this review of the literature, HT has demonstrated effectiveness in lowering vulnerability to drug use, decreasing disruptive and violent incidents and increasing levels of affect and engagement (Richards & Kafami,1999; Sandel, 2004; Gogliotti & Jarrott,2005; Mooney & Nicell,1992). Comparison between the needs of those with Posttraumatic Stress Disorder and the benefits of horticultural therapy point to an efficacious fit. From my own observations, gardening has shown to be a great stress reliever and has also imparted a sense of personal accomplishment to the women involved. Next summer, I would like to expand on my loosely formed gardening group to include more HT activities. Following Tashjians (2007) model, I would like to include surveys as an instrument to measure the affect of the gardening group on the women at the shelter. Long term, I would like to focus future research on populations with a formal diagnosis of PTSD and incorporate physiologic measures to establish a research link between HT and PTSD.

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