Evaluating the personal and group impacts of horticultural therapy for male service users presenting with learning disability and personality disorder within a medium secure NHS setting

Mark Christie (University of Cumbria), Michaela Thomson (NHS Calderstones)

Pioneering study within a medium secure environment

Used an emancipatory approach to investigate the effects of service user engagement in a horticultural intervention across a twelve month period

Service users were involved in all stages of the garden planning and design, and the ongoing development of the garden

“Our garden/ horticulture area has been four years in the planning” Challenges group identified: Agreement to buy the land Planning permission Bad weather Someone pinching the machinery! Seasonal delays – Christmas etc. Removing/re-deploying the tanks Different gas suppliers Delays waiting for the fencing /

subcontractors / security issues Removal of rubble

Able to grow our own fruit and vegetables Much better views! Able to use the products we produce Our own design for the layout Have a relaxation area Somewhere extra to walk More outside space Able to take part in the research Get fitter and get a sun tan! New knowledge of gardening Nature watching

More knowledge about how our bodies work Use of new equipment Using a heart rate monitor for the first time We’ll be published in an article It will be educational Our experiences can be used to help others in

the future

Male service users (n=11, mean age 38), from the medium secure unit agreed to be involved

Seven completed the full twelve month ‘intervention’ Individuals accessed the garden area up to three times a

week for two hours duration with supervision Researchers joined in activities alongside the service

users Garden was the new variable in terms of exercise activity

and proved to be the most popular leisure activity within the unit

ACTIVITY NUMBER OF SESSIONS AVAILABLE

NUMBER OF PARTICIPANTS INVOLVED

GARDENING 16 100

ELECTRONIC GAMES 5 20

LIBRARY 5 27

FOOTBALL 3 12

DVD 2 13

POOL 11 42

CRICKET 2 19

HENS 8 8

ARTS & CRAFTS 2 2

CARDS/BOARD GAMES 4 7

• Interpretative Phenomenological Analysis

• Purposive Sampling

• Coding & defining key themes

• 3 x Focus groups

• Recovery Star tool

• Reported incidents

• Heart rate monitoring

Exploring the personal

development and health impacts of

the intervention

Only 7 of the 11 service users completed the whole twelve months

Nature of the service: transfers in & out Only a small sample size for any statistical

analysis Lots of variables in play – high doses of

medication, unpredictability of personality disorders, transfers in and out affecting dynamics in the unit…

Three focus groups at or after ‘Speak Up’ sessions

One prior to the garden opening, then at 6 months and at 12 months

Aim: explore service users’ thoughts and feelings in respect of health outcomes and personal development factors linked to factors present in the Recovery Star tool

Developing Skills and Knowledge

Enjoyment of Varied Tasks

Being Productive

Health Improvement

Improved Relationships

with Staff & Peers

Emotional Control Stress Reduction Escape from

Routine/Being ‘Stuck’ Inside

Nurturing Plants

Occupational Performance

Outcomes

Motivation Regarding

Occupational Form

Beneficial influence of the Physical

Environment

“It’s been good...growing seedlings and then harvesting the garden. I’ve learnt lots about planting, weeding.” (Tim)

“(The garden)…calms you down a lot... just

because you are in the garden, in the

fresh air and you are doing something

worthwhile” (Neil)

“I like planting

stuff and growing stuff and doing things I haven’t

done before” (Gavin)

“It (the garden) chills you out in the sense that if you are stressed it can just release stress and makes you all laugh if you’ve been doing something mad and stupid and getting into bother for it.” (Matthew)

“…I don’t feel like the fencing is there when I am out in the garden, I feel that I am just coming to work. In my eyes the fencing is not there, in my eyes I am working for the council…It is that relaxing I feel that I am outside in the community!” (Tim)

“(It’s really great) growing our own vegetables... cabbage, rhubarbs – stuff like that and carrots, swedes. Anything like that, or any other vegetables... doing all the planting” (Paul)

“The planting out (is best)…because you are handling plants that are delicate and they need care and things.” (Matthew)

“As the garden rep, you have to stick to the guidelines...like trying to be safe and considerate, wearing the correct clothing. Having a nice shower after, you feel rewarded, like you’ve earned it” (Neil)

“Sometimes if you’ve had a bit of a disagreement with the warden…(the) stress just goes away through the gardening” (Paul)

Fitter

The staff member supporting the men said that the garden had made a ‘massive difference’ to the dynamics of the ward area

He noted that the number of incidents had ‘dropped significantly’ and that the men ‘greatly valued’ the opportunity to be in the fresh air and working in the garden

Chickens had caused some ‘falling out’ – but resolved by setting a rota for egg collections

Sessions were ‘typically relaxed and happy times’ in which the men involved seemed to be ‘chilled’, getting on well together and happy to give and receive advice.

Chambers (2009) highlights the necessarily restrictive and highly structured clinical environment in which service users undergo treatment programmes

The relative freedom offered by the garden was mentioned several times by service users:

“…I can walk away from things more in the garden…I feel cramped in the building, but I feel fresh outside” (Neil)

“…it is that relaxing, I feel that I am outside in the community!” (Tim)

Sempik (2008) refers to Csikszentimihalyi’s ‘flow experience’, whereby individuals become so absorbed in activities that any negative thoughts/feelings are temporarily displaced or ‘screened out’

“(The garden)…calms you down a lot...just because you are in the garden, in the fresh air and you are doing something worthwhile and are getting something out of it” (Neil)

Importance of a programme of bespoke activities to target ‘deficits’ associated with personality disorder and intellectual disability (Withers et al 2012)

These activities can act as a ‘conduit’ through which positive, trusting relationships can be enhanced

Service users hinted at the power of the ‘plant-person relationship’ as a motivating factor, and its reciprocal effects:

“(I have)...enjoyed planting small seedlings and re-planting them in the garden and watching them grow” (Jake)

Where service users are empowered - as in this case – this is likely to add to their motivation to engage

Improved social networks can act as ‘buffers’ to stressors; and can be an important element in rehabilitation (Fieldhouse, 2003)

Group horticultural activity shown to reduce individual anxiety and depression, whilst enhancing social inclusion effects and access to employment networks (Stepney and Davis, 2000)

This study afforded opportunities for service users and staff to come together in more relaxed surroundings and undertake activities that the service users found liberating and fulfilling, and as a mechanism for improving relationships with others:

“Two of us work together on Tuesdays, and help each other, doing the same things. I’ll start and he’ll finish. We’ll start one thing and finish another. It works well” (Jake)

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Baseline Qtr Qtr 1 Qtr 2 Qtr 3 Qtr 4

Aggression incidents n=7

Using Interrupted Time Series Analysis, the following trend line became apparent; however statistical significance was not proven

Whilst the trends are present, the small cohort size means it is difficult to show any significant effect

For each individual RS factor, only one had statistical

significance (Relationships) whilst another was borderline (Managing Mental Health)

Larger sample sizes will help with quantitative data

analysis in future to assess significance

Heart rate was monitored every 5 minutes for 60 mins, including Rest HR and Recovery HR

In most cases, there were only limited occasions where HR reached ‘moderately intense’ levels to benefit cardiovascular health

But… every bit counts!

Useful insights regarding the health and personal development benefits of involvement

Mental and social health emphasised the most A clearly stated sense of achievement associated with

growing their own produce Clearly service users valued contributing to the garden’s

inception and ongoing development – empowerment, ownership, responsibilities to self & others

This appears to have transferred into their passion and enjoyment from undertaking the varied tasks in the garden

Difficulties in using other methodological approaches apparent

Case study approach perhaps the most useful way to highlight the benefits that accrue to individuals

Further research required within secure units to fully appreciate the benefits that might be obtained

Time for Questions to the presenters on either project, or on the overall nature of the research focus