Introduction:
Greenery plays an important role in urban environments, it provides ecosystem services such as supporting biodiversity, reducing air and noise pollution, and regulating water resources. In addition, spending time in nature has been proven to benefit people’s physical and mental health. The development of the therapeutic gardens movement in Singapore is relatively young, with recent awareness to develop more user-specific gardens, especially in healthcare settings. Perhaps it is through the persistent efforts of green policies – from the transformation of Singapore as a Garden City to a City in Nature – that sowed the seeds for creating better landscapes for health. Early initiatives to encourage and promote a gardening culture in the community also set a precedent for the therapeutic garden movement. Launched in 2005, the Community in Bloom (CIB) Initiatives aim to promote gardening as a lifestyle choice and eventually became a national gardening movement. Since its inception, many positive outcomes have been observed, such as greater social cohesion between neighbours, teachers and students engaging in meaningful outdoor activities, and also retirees staying active through gardening [1].
In healthcare facilities, more garden spaces were introduced as it became evident that access to greenery and a natural environment is an important contributor to the healing process of patients. In 1984, Environmental Psychologist Roger S. Ulrich through his seminal research “View through a window may influence recovery from surgery” recorded findings that patients whose rooms looked out to natural settings recovered faster than those with windows facing brick walls[2]. This has a profound impact on subsequent studies on environmental psychology. The development of hospitals in the recent decade such as Khoo Teck Puat Hospital, Ng Teng Fong General Hospital, as well as the upcoming Woodlands Health Campus also embraced the permeation of greenery throughout their facilities, including designated rehabilitation green spaces for specific user groups like the elderly and dementia care, chronic health stroke rehabilitation. Other healthcare facilities such as Renci Nursing Home (Bukit Batok) and the Institute of Mental Hospital also benefited from incorporating purpose-built green spaces for their residents and staff to use and enjoy.
Photo 1:View of Khoo Teck Puat Hospital (Photo Credit: KTPH, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons)
Photo 2: View of Ng Teng Fong General Hospital. (Photo Credit: Joey Foo, CC BY-SA 4.0 <https://creativecommons.org/licenses/by-sa/4.0>, via Wikimedia Commons)
In 2015, the National Parks Board launched a plan to develop a network of therapeutic gardens across various parks in Singapore as part of the Action Plan for Successful Ageing report [3], in response to growing concerns on issues of a rapidly ageing population and increase in dementia cases in Singapore. Till date, six of such gardens were opened at HortPark, Tiong Bahru Park, Bishan-Ang Mo Kio Park, Choa Chu Kang Park, Punggol Waterway Park, and Telok Blangah Park. Although they are opened to anyone in the public to enjoy, these gardens were designed based on the needs of the elderly, including those with dementia [4].
Photo 3: View from entrance of Therapeutic Garden at Bishan-Ang Mo Kio Park, Singapore (Photo by author)
Photo 4:View of plantings and exercise area at Therapeutic Garden at Tiong Bahru Park, Singapore (Photo by author)
Defining the “therapeutic” in Therapeutic Garden (TG):
There is a disparity between what constitutes a “therapeutic garden” and the use of the word “therapeutic” to describe the qualities of a garden. As an adjective, it is commonly used to describe a garden or natural settings that provide a calming effect and mental relief. However, when used in the context of healthcare, it relates to the treatment of disease or disorders by remedial agents or methods. With this definition, it means that the target users are usually people who have certain medical needs, which require the garden to be specifically designed to treat or alleviate these conditions both physically and mentally. The users of the TG in the healthcare context the frail elderly, people with Alzheimer’s diseases and other dementias, people with cognitive impairment such as attention deficit hyperactivity disorder (ADHD), autism spectrum disorder (ASD), Down Syndrome, those with physical, mental and behavioural health conditions, as well as those requiring rehabilitation. In this sense, therapeutic gardens are designed to address the needs of specific users by encouraging and facilitating the healing process using plant-people interaction. It is healing because it promotes the restoration of health to the user. It is enabling because it provides a setting that makes rehabilitation possible and, practical and easy.
Proficiencies in designing Therapeutic Gardens :
For landscape architects involved in the design and development of landscapes for health, including therapeutic gardens, they need to be well-versed in 3 areas namely, environmental psychology, evidence-based design (EBD), and participatory design (PD).
Environmental psychology is a multidisciplinary study of how people relate to their surrounding and how it influences our behaviour. When applied to the design of Therapeutic Gardens, two theories are highly relevant. Firstly, the Attention Restoration Theory (ART) by Rachel and Stephen Kaplan. ART explains that a person has several states of attention, both (directed) voluntary or involuntary. Prolonged direct attention on specific tasks could cause direct attention fatigue due to the limits of one’s brain capacity to focus on a particular task. Through redirecting one’s attention to a more effortless brain functioning by being in a natural environment or plant-dominated spaces, one can recover from this mental fatigue and restore direct attention capacity. Secondly, the Stress Reduction (SRT) by Roger S. Ulrich. Here, Roger proposed that the well-being of people can improve tremendously by being in a natural environment or plant-dominated space such as gardens[1]. Simply looking at plants and hearing the sound of flowing water can significantly bring positive outcomes to physical and mental health.
According to the Centre for Health Design, a non-profit organisation based in California, USA, evidence-based design (EBD) is the “process for basing decisions about the built environment on credible research to achieve the best possible outcomes”[2]. While EBD is primarily utilised in the design of healthcare infrastructure, adopting it in the design of landscapes such as therapeutic gardens has also been shown to be effective. In recent years, there has been an increasing body of research documenting quantitative and qualitative benefits received by various target users of the Therapeutic Gardens. Backed by research, design decision making becomes more objective. Design Audit Tools and Post Occupancy Evaluation are also good assessment resources that can increase the credibility of any design processes in the development of therapeutic gardens.
The participatory design process involves active participation from all project stakeholders in the design process to ensure the outcome meets their needs and requirements. This is an important part of designing therapeutic gardens as it brings together all stakeholders, including facility administrators (the client), healthcare professionals such as doctors, nurses and therapists who work directly with the patients and residents to clarify design objectives, discuss possible programming and facilities, which in turn instil a sense of community and ownership to the project. The designer acts as a facilitator in guiding the engagement process, backed by evidence-based studies. In most cases, certain stages of the process might revert back to the do-what-the-client-wants situation, however, it is up to the capability of the designer to give an informed recommendation to the client (and other relevant stakeholders) on the best possible solution.
Conclusion:
Therapeutic gardens are increasingly seen as an integral component of any healthcare facilities. The demand for it will continue to increase as more people, especially policymakers and management of healthcare facilities begin to see the importance of incorporating purpose-built green spaces to improve the wellbeing of its patients and staff. A good therapeutic garden design requires the landscape architect’s understanding of principles derived from environmental psychology and incorporating design processes rooted in evidence-based design and participatory design approach. In addition, just as the design of each therapeutic garden is unique to its site condition, so is every user group with their needs and requirements and only by taking the effort to understand the users can meaningful and effective gardens be created.
Tham Xin Kai is co-founder of Hortherapeutics, a social enterprise that focuses on providing research, design and programming service in the field of therapeutic garden design and therapeutic horticulture. He is currently taking the Certificate in Horticultural Therapy from the University of Florida, which is an accredited program by the American Horticultural Therapy Association.
[1] Singapore. National Library Board, & National Parks Board. (2014). Community in bloom: My community, our gardens.
[2] Ulrich, R. (1984). View through a window may influence recovery from surgery. Science, 224(4647), 420-421. https://doi.org/10.1126/science.6143402
[3] Ministry of Health, Singapore. (2016). I feel young in my Singapore: Action plan for successful ageing.
[4] Therapeutic gardens. (n.d.). National Parks Board. https://www.nparks.gov.sg/gardens-parks-and-nature/therapeutic-gardens
[5] Ulrich, R.S., Simons, R.F., Losito, B.D., Fiorito, E., Miles, M.A., and Zelson, M. (1991). Stress recovery during exposure to natural and urban environments. Journal of Environmental Psychology, 11(3), pp. 201-230.
[6] About EBD. (n.d.). chd | The Center for Health Design. https://www.healthdesign.org/certification-outreach/edac/about-ebd