Critical Study by Rosie Cockcroft

The Role of Landscape Architecture in Improving Mental Health and Wellbeing

Rose Cockcroft School of Landscape, Architecture and Design Leeds Metropolitan University, 2011

Cover image (main): Author’s own, taken in Archbishop’s Park opposite St. Thomas’ Hospital, London. Cover images (top from left): Authors own, water fountain at St Thomas’ Hospital; Authors own, Millenium Gardens at St Thomas’ Hospital; Author’s own, evidence of pupil’s taking part in gardening at All Saints Primary School, Cockermouth, Cumbria; Authors own, Rosmarinus officinalis used in planting at All Saints Primary School to stimulate senses. 2

“He lay thinking for a while and then Mary saw his beautiful smile begin and gradually change his whole face. “I shall stop being queer,” he said, “if I go every day to the garden. There is Magic in there good Magic, you know, Mary. I am sure there is.” “So am I,” said Mary.” (The Secret Garden, Hodgson Burnett 1909, cited in Stigsdotter 2005, p.4)

Contents

Page 5

Acknowledgements

Introduction

Historical Evidence of Nature’s Role in Healing

Open Spaces within Hospitals

Opinions of Health Professionals

Patient Specific Gardens

Design Recommendations for a Healing Environment

Conclusion

References

List of Images

Appendices

Acknowledgements The author would like to thank the following people who have kindly helped with the research and production of this study:

Amanda Place, physiotherapist and allied health professional team leader Dr Anne Eldred, General Practioner Dr Timothy Johnson, General Practioner Rhona Clark, enhanced senior occupational therapist Gill Aitcheson, registered nurse at Hospice at Home Tony Green, architect at Green Design, Cockermouth, Cumbria Mrs N. Smallwood, headteacher, All Saints School Mrs H. Hobday, secretary, All Saints School Steve Heywood, tutor at Leeds Metropolitan University Andy Millard, tutor at Leeds Metropolitan University Tony Pomfret, planning manager, Copeland Borough Council

Introduction

s designers, landscape architects have the privilege of shaping the world in which we live and of enhancing the quality of life for the general public. There has been significant research to prove that natural environments have a positive effect on many aspects of people’s health, in contrast to urban settings, which can hinder recovery and sometimes even deteriorate health (Ulrich et. al. 1991). A recent inquiry from the National Trust has discovered that twenty-five percent of people living in the United Kingdom face some sort of mental illness within their lifetime, costing the nation £77 billion pounds per year (Morris 2010). In fact, in the current financial climate, the country should be leaning towards using good design of green environments to improve people’s health, rather than the greater expense of providing vast amounts of medication and building hospitals and other recovery centres. For example, Roger Ulrich (1984, cited in Ulrich 1991, pp.204) proved that patients that were simply lucky enough to have a view of trees through a window spent less time in hospital than those looking onto a brick wall and needed significantly lower strength and less expensive pain medication. Despite this body of evidence, we still find ourselves in a situation where the design of green space within healthcare environments is often introduced only at the very end of the design stage, rather than being integrated throughout. This study will investigate the relationship between designed outdoor spaces and people’s mental health and wellbeing and the extent to which landscape architects can influence this. It will focus on the designs of hospitals, care and recovery centres and specialist schools. It will approach this using both primary and secondary sources of research: • to explore existing evidence from history to the present day; • to evaluate the success of numerous case studies both in the UK and internationally; • to examine the differences that must be considered when approaching design of open space for specific groups of patients; • to undertake a number of questionnaires to health professionals to receive a different perspective and an informed view on the topic; • to draw conclusions from the collated evidence to produce a series of design guidelines to highlight what improvements could be made in the future.

Historical evidence of nature’s role in healing

here are numerous theories of why the presence of nature makes us feel more relaxed. One such theory dates as far back as the beginning of man and suggests that evolutionally, humans have always been exposed to natural settings and therefore the presence of life essentials such as water, wildlife and plant life are stimulating (Orians 1986, cited in Ulrich 1991). Other perspectives follow the belief that people tend to have more positive connotations towards more natural environments as opposed to urban settings, due to being exposed to Western culture and the way each are portrayed. For example, people are led to believe that a more rural setting has less impact on the environment and that urban areas tend to be more destructive; this is something that we have learned as opposed to instinct. Another aspect of this theory is that many westerners tend to choose rural settings to go on holiday, therefore they will associate this type of environment with enjoyment and feeling relieved from stresses and worries (Tuan, 1974, cited in Ulrich, 1991). In Europe, as long ago as the Middle Ages, courtyards and arcades were integrated into the designs of hospitals for the mentally ill. (Marcus and Barnes 1995) Evidence of its success in relieving stress and relaxing patients is illustrated in the following extract; “Within this enclosure many and various trees... The sick man sits upon the green lawn... he is secure, hidden, shaded from the heat of the day...; for the comfort of his pain, all kinds of grass are fragrant in his nostrils. The lovely green of herb and tree nourishes his eyes. ... The choir of painted birds caresses his ears ... the earth breathes with fruitfulness, and the invalid himself with eyes, ears and nostrils, drinks the delights of colors, songs, and perfumes.” (Warner 1995, cited in Marcus and Barnes, 1995) Despite the romantic nature of the language used here, this description of how the “sick man” reacts to contact with natural elements within a designed landscape echoes typical modern design theory on the relationships between nature and health. It highlights how stimulating the senses can distract from pain, stress and anxiety and create pleasing effects to the mind and body. Similar logic was used in 1865 by Frederick Law Olmsted in the justification for the design of Central Park in Manhattan, New York. He described the ways that people who worked in the city would benefit from relief of mental “fatigue” and that very little effort was needed by the mind to view nature and that is can “restore” it from the stress and concentration that is used in a working environment. Olmsted believed that when enjoying a view of elements of nature, “the attention is aroused and the mind occupied without purpose.” (Olmsted 1865, cited in Ulrich 1991) Another famous name to have identified the necessity of nature to healing is Florence Nightingale (1820-1910). She wrote with passion about how patients need direct sunlight for rapid recovery. In the present day we know that Vitamin D is a vital product of sunlight, just as evidence from experts such as Ulrich (1991) can provide scientific proof that there is a significant relationship between exposure to nature and healing. Such a link was identified by Florence Nightingale;

“Second only to fresh air... I should be inclined to rank light in importance for the sick. Direct sunlight, not only daylight, is necessary for speedy recovery. ... being able to see out of a window, instead of looking against a dead wall; the bright colours of flowers; the being able to read in bed by the light of the window close the bed head. It is generally said the effect is upon the mind. Perhaps so, but it is not less so upon the body on that account.” (Warner 1995, cited in Marcus and Barnes 1995) Even over a century ago, nurses were notably aware of the significant impact of the outdoors and the connection nature has on the body and mind, but in a technological age this seems to have been forgotten, as so many hospitals and care facilities seem to neglect the importance of green spaces.

Figure 1.

Archbishop’s Park, opposite St. Thomas’ Hospital, London

Open spaces within hospitals

oger Ulrich (1991) carried out an investigation involving 120 participants who were all made to watch a stressful film, before being exposed to a second film of one of six different natural and urban landscapes. Several physiological variables were measured to assess the rate of stress recovery after watching the first film. This included heart rate, muscle tension, skin conductance and pulse transit time. The results were considered with verbal feedback which concluded that recovery was faster and more complete when the participants were shown the natural rather than urban environments. These findings support the theory that the stronger the presence of natural features in an environment, the less stressed people will feel which consequently will aid recovery within the landscapes of hospitals and other healthcare environments. St Thomas’ Hospital is situated in the heart of London, directly across the River Thames from the Houses of Parliament. A great asset to the hospital is its proximity to Archbishop Park, which provides a large green space with mature trees, exercise equipment and sports facilities, quiet seating areas, an impressive children’s playground and a wildlife area. Despite this great asset to the hospital, not all patients will be well enough to cross the busy road to this public park. Figure 2.

Sketch plan of St. Thomas’ Hospital, highlighting green spaces 9

Figure 3.

Main gardens at St. Thomas’ with water feature, lawns and underground car park.

Within the hospital grounds there are two separate areas of open space; the small Millennium Gardens and the main square with water feature. The main square is a more formal space and serves as a garden for the hospital as well as an area of public realm. This area is constructed over an underground car park which is unnoticeable from the garden itself and therefore is a clever use of space in this very competitive urban environment. The square has a clear focal point; a large modern water feature, which is set in the centre of a large square of lawn. This is a particularly impressive area and can be viewed by patients from the 12 stories of the hospital.

Figure 4. Seating and shrubs

There are a variety of seating opportunities; some provide more privacy than others giving patients and members of the public a sense of control and comfort. In warmer months the lawn area is used for sunbathing and relaxing, creating an open, friendly atmosphere which is refreshing away from the confined hospital environment. Research suggests that the sound and sight of water can have a significant impact on relieving stress (Cooper Marcus and Barnes, 1999). The water feature in the centre of the lawn acts as a focal point and helps people to identify with the gardens. It is contemporary and stylish and the noise also helps to mask the noise of the busy traffic of London. The material choices for the gardens give the impression that the area is dated, with pebble-dash surfaces and walls throughout and standard wooden benches. The planting is all within large beds around the perimeter of the square and consists of a variety of roses, grasses and shrubs. Overall there appeared to be little winter interest so the square of lawn seemed to dominate. Perhaps the areas and choices of planting could be updated to create a more sensory experience and provide colour and interest throughout the seasons.

Figure 5. Rosa common throughout, negative effect in winter months

Figure 6. Stunning view of water fountain in main square with backdrop of the Houses of Parliament

Figure 7.

Millennium Gardens. Fountain used as a focal point

Figure 8.

Poster at St. Thomas’ Hospital

The Millennium Gardens are a small addition to the hospital’s green space and offer a quiet, relaxing experience that appears to be mostly looked on to from inside the building itself, rather than for people to enjoy being outside. This is beneficial but could be improved if it were integrated better with the rest of the open spaces and people were encouraged to spend time in it. At present there are only two small benches in awkward positions where they do not look onto the gardens. The planting choices are definitely the most attractive of all the green spaces with a selection of grasses and perennials planted in blocks and drifts. These could perhaps be better organised to allow through views from the building better and to provide a greater variety in height and density but overall the planting looks modern and provides pleasant year-round interest. The small water feature is moderns and creates a focal point, as well as providing the calming sound of running water. Overall, authorities should be commended for providing good access to green space for both patients and the general public in a developed inner city area. This aids faster recuperation through reducing levels of stress from simply allowing people to be in contact with nature or the distraction of watching the world go by and providing an environment where patients can feel comfortable and supported by talking to family and friends. However, certain aspects could be improved to further reduce stress and encourage a positive mind set for patients and public. For example, the spaces should be clearly linked, as opposed to being two totally separate areas that are not easy to find. The planting choices and hard materials could be more contemporary and perhaps now is a perfect opportunity for the hospital to think about redeveloping parts of the outdoor space as they were advertising a “2020 Vision” on posters outside the hospital that unfortunately mentioned nothing about transforming the existing green space or making any additions to this. In contrast to the relatively large provision of green space at St Thomas’ Hospital, in proposals for the £90 million redevelopment of West Cumberland Hospital in Whitehaven, Cumbria, little thought has been put into the design of green space within the grounds of the hospital and consideration of this has been put aside until after the architecture and car parking has been organised. Given the amount of research into the impact of aesthetics and contact with natural elements can have on the mental health and wellbeing of patients and the impact of this on their recovery, it seems disappointing that the landscape design would not be considered at the very beginning of the design process to ensure harmony between each element of the landscape and built form. This would also be a great benefit to the health and wellbeing of staff and visitors to the hospital, both of which are likely to be suffering from high levels of stress. 11

As part of all planning applications a Design and Access Statement is required to be submitted by the design team to the Local Planning Authority. The purpose of the Statement is to demonstrate how the design team have worked through the design process and in particular how they have considered the following issues: land use, amount, layout, scale, landscaping, appearance, vehicular and transport links and inclusive access (CABE 2007). The Statement submitted to Copeland Borough Council for the proposal for West Cumberland Hospital, however, did not include any mention of landscape design (Gilling Dod Architects et. al. 2010). Planning permission was granted on 30th April 2010 for the redevelopment of the hospital(Copeland Borough Council 2010). However, the overall layout plan only indicated eight small areas of green space which were subject to certain planning conditions (Gilling Dod Architects 2010). Condition number seven of the planning permission states that: “No development shall take place until full details of both hard and soft landscape works have been submitted to and approved in writing by the Local Planning Authority. These works shall include hard surfacing, means of enclosure, finished levels or contours etc. Landscaping shall be carried out in accordance with the approved details. Reason To enhance the appearance of the development in the interest of visual amenities of the area and to ensure a satisfactory landscaping scheme.” (Copeland Borough Council 2010) The wording of this condition implies that the “landscaping” is purely just to improve the visual aspect of the site and does not emphasise the numerous other health benefits that a well designed outdoor landscape can have for such a large scale hospital. It also excludes instruction that a landscape architect should be commissioned to work with the design team from the start to ensure that all elements of the site complement each other and are in the optimum locations. The most qualified professional to provide “full details of both hard and soft landscape works” is a landscape architect as they have the broadest expertise of what materials, especially plants, will be the most beneficial to the users of the site. This is an indicator that a greater awareness of the benefits of green space needs to be improved within a number of disciplines, including landscape architects. The Design and Access Statement completely omits proposals for landscape design and this is an indication that the architect does not fully understand the benefit of green spaces to the health and wellbeing of patients and staff. The design team have missed a rare opportunity to create appropriate green spaces relating to speciality wards within the hospital.

Opinions of health professionals

ased on the success of projects that have used the collaboration of design and health experts, such as Alnarp’s Rehabilitation Garden in Sweden (see Patient Specific Gardens), a series of questionnaires have been completed by a small number of health professionals in Cumbria in order to build up alternative viewpoints on the relationship between landscape design and mental health and wellbeing. (See appendix for completed questionnaires.) The questionnaires were sent to a physiotherapist and allied health professional team leader, two general practitioners, an enhanced senior occupational therapist and a registered nurse at hospice at home. The aim of the questionnaires was to find out the awareness health professionals had of the relationship between health and design of outdoor spaces and to receive any additional information or evidence that could further support the theory. All professionals responded positively, stating that they recognised this relationship within their profession and many gave examples of patients groups that responded particularly well to being in an outdoor environment. Enhanced senior occupational therapist, Rhona Clark, described how she strongly encouraged her patients to spend time outdoors as it has, “a positive effect on mood and behaviour.” She explains that she has experience treating numerous mental health problems and states that the environment has a particularly noticeable effect on patients suffering with dementia and Alzheimer’s disease. “It can focus their mind on memories from the past - their short term memory is affected early on while their long term memory remains intact until later on. Happy memories of walks, picnics, time spent with friends/ family - it stimulates reminiscence and creates a very positive outcome. This in turn stimulates verbal communication and conversation, which unfortunately does deteriorate with this condition. “To smell the fresh air, touch trees/ flowers, look and listen to running water and feel the sun shining on their faces lifts their mood and stimulates their senses- smell, touch, hearing and vision.” This evidence is really useful in supporting the argument that design can have such a positive effect on the mental health and wellbeing of people. It also highlights the important characteristics of a healing environment, such as those features that will stimulate patients to reminisce and the importance of involving elements that stimulate the senses. Mrs Clark highlights the importance of verbal communication and conversational cues and this must be carefully considered when designing any environment, especially for this sort of patient group. “Within Day Hospital environments, where possible, garden areas have been created to provide such environments. Clients can talk about the weather, the seasons- time of year, see the summer flower/ autumn leaves, touch soil, plant flowers/bulbs. Birds and insects also become a topic of interest and conversation. “It can be seen as a type of Reality Orientation- reinforcing the time of day and time of year- nature and the seasons. This has a very positive effect on mood and wellbeing. A change in facial expression can be quite dramatic when a client is moved from indoors to an outdoor environment.”

Here, Mrs Clark shares experience in witnessing the changes in patients when they are exposed to outdoor environments. This is strong supporting evidence that shows what can be gained from consulting with health professionals. Seasonal change is easily achieved from creating a planting plan that contains plenty of variety and interest throughout the year, therefore providing conversational cues and a distraction from stress. Mrs Clark states that another method of stimulating the minds of patients is keeping them active and involved within the care of the garden, which also gives them a sense of ownership and pride; “involvement in small projects e.g. pruning flowers, vegetable growing which further stimulates memory, cognitive function, conversation, socialisation and therefore trying to maintain their level of function for a longer period.” Amanda Place, physiotherapist and allied health professional team leader also agrees that environment has a crucial role in affecting patients’ mood and recovery; “getting the environment correct for a client can have a hugely positive effect especially in dementia and Alzheimer’s space and how this is laid out is particularly important, also colours can have different effects on how calm the client is.” This useful feedback highlights the care that needs to be taken when selecting colours for a space. This suggests careful research and perhaps workshops with patient groups could be carried out to aid the understanding of the most calming colour combinations and which to avoid. Similar exercises could be carried out with other design elements such as textures, sounds, sense of enclosure to ensure that the spaces will aid healing and relaxation as much as possible. Mrs Place also goes on to say that she does recommend spending time in green spaces to patients and that she finds that it is particularly beneficial for; “clients with anxiety or depression, following head injury who may be tense and have an increase in muscle tone. Any activity which encourages relaxation can have positive effects and can improve the outcome of their rehab.” Gill Aitcheson is a registered nurse at Hospice at Home and works with patients who suffer from senile dementia, Alzheimer’s and depression. Again she states the importance of green space for the wellbeing of patients: “Only some of the patients I nurse are able to go outside but the majority can look out on green spaces. They find this very beneficial and it certainly lifts their mood and provides a good distraction.” It is really positive that simply being able to view green spaces from inside can have such an impact on patients and can be supported by Ulrich’s 1984 research (cited in Ulrich 1991, pp.204). Interestingly, the two GP’s who were questioned did not seem to recommend being in the outdoors purely for psychological reasoning but did, however, appreciate the benefit of exercise and both did recognise that aesthetics and other sensory qualities can improve mood and wellbeing. Dr Anne Eldred, General Practitioner, summarises that exercise in an open, rural environment can mentally have a far stronger impact on a person; “We are lucky in Cumbria to have lots of places to walk in beautiful surroundings which is good for the soul as well as the body and cannot be achieved in a gym.” 14

Dr Eldred later highlights the importance of careful consideration of layout and experience when designing outdoor spaces both in hospital or care settings and in the public realm; “When someone who has thought about the spaces available to provide ‘views’, seating, some greenery etc it makes such a huge difference rather than what we often see which is a few sad looking shrubs put in as an afterthought when all the building work is done. If the person to do this is a landscape architect, then yes, I do agree.” General Practitioner Partner, Dr Timothy Johnson also emphasises the benefits of exercise on mental health and general wellbeing and suggests that encouraging exercise through design would improve health and wellbeing; “The ability to be able to get outside into a pleasant environment – e.g. for walking/exercise will also have a positive effect. Exercise has been shown to be beneficial and to improve mood in depression so if this is encouraged by a particular planned space (e.g. walking/ running/ other physical activities such as tennis) then this could make a significant contribution... In general some places just look/ feel ‘depressing’ when you go to them for people who don’t have a mental health problem so I wonder how much more so they are to people who are already suffering from depression.” It is important to remember that a number of other factors, including exercise, contribute to improving mental health and wellbeing and that it would be naive to think that it is purely green spaces that can heal but that they can significantly contribute to improving mood and healing. “regular physical activity contributes to the prevention of more than 20 conditions including coronary heart disease, diabetes, certain types of cancer, mental ill-health and obesity.” (Department of Health 2005, cited in CABE 2009, p.4) Following Dr Johnson’s recommendations, therefore, it will be very beneficial to encourage physical activity through design. To conclude, Dr Johnson comments on how historically the importance of well designed green space was recognised in healing environments; “the old mental hospitals (which don’t exist anymore) were typically grand old places in the country with large pleasant gardens and were generally in very pleasant settings – it would be hard to imagine that this didn’t have a positive effect on mental health.” This statement highlights a common reaction to the relationship between health and wellbeing and landscape design; people know that being in a comfortable, green environment makes people feel better but lack the concrete evidence to support it. It is important that this is addressed, particularly to people who work in either design or health fields so that the two can work together to ensure positive, healing environments throughout the country. Despite providing a small number of questions to such a small group of professionals, the quality of useful information has been strong and emphasises the significant benefits that can be gained from working together with a range of health experts when developing a design specifically for a hospital or care environment. So much can be learnt from understanding the needs of both patients and staff to produce a more suitable and beneficial design. 15

Patient specific gardens

hen designing a garden or landscape for a hospital or care home it is fundamental that the conditions of the patients are thought about carefully (Marcus, n.d.). If the users of the space are of a single type of mental illness, then specific design frameworks should be considered in relation to their needs. Satisfactory research and knowledge of the condition of the main users should be carried out prior to the design and ideally the designer should work with health professionals and the patients themselves as much as possible, to create a garden that will benefit them most personally.

Stress and its Influences on Other Aspects of Health Stress is a common condition affecting twenty-five percent of the population (NHS, 2010). Not only can it affect people’s performance, emotions and personality but it can lead to even more serious conditions such as depression, anxiety and hypertension (high blood pressure). Stress can also impair the body’s immune system making it more susceptible to illness (Landscape 2010). Consequently, reduced levels of stress can radically speed up recovery from other health problems, such as, patients’ recovery from serious operations and recuperation from both physical and mental illnesses. There is strong evidence from a large number of sources showing correlations between elements of nature within urban settings and levels of stress. “Studies have shown that muscle tension drops within three minutes of exposure to green spaces.” (Landscape 2010) Such evidence has led Natural England’s Strategic Health Adviser, Dr William Bird, to state that exposure to green spaces can actually help the body deal with treatments such as chemotherapy. Through a decrease in stress levels, patients are more likely to take part in physical activity, which in turn increases metabolism and allows the body to cope with the by-products of chemotherapy and other similar procedures. He reinforces the importance of landscape professionals being a key part of the design of hospitals from their inception to ensure that nature can be a part of the healing process. (Landscape 2010). The most effective method for creating a successful hospital or care environment is to encourage the collaboration of professionals across a number of fields. A fantastic example to illustrate the importance and success of this technique is the Rehabilitation Garden situated within the campus of the Swedish University of Agricultural Sciences in Alnarp. The therapy garden is for those who have been suffering from stress-related illnesses and burnout disease for a significant time (Stigsdotter and Grahn 2003, Ivarsson and Grahn 2009). The space was designed and implemented by a team of two landscape architects (Patrik Grahn and Ulrika Stigsdotter), a horticultural therapist, an occupational therapist and a physiotherapist. This guaranteed specialist knowledge from all angles, ensuring a thorough understanding of the illnesses was gained before the design phase (Marcus 2010). The garden serves a number of functions as part of a large project involving Figure 9. many people: 16

Sketch of traditional cultivation room, rehabilitation garden, Alnarp, Sweden

• “Offer different horticultural therapeutic treatment programs to people suffering from “burnout diseases” • Provide a setting for an interdisciplinary research program that will study how the garden functions for these people • Allow scientists to test different design hypotheses connected with the garden as well as different forms of horticultural therapy • Serve as an object of study for students” (Stigsdotter and Grahn 2003, p.39) It is impressive to see the ways this garden meets a number of goals and that it is being studied carefully to see what is successful and what needs to be improved, so that this theory and its results can then be applied to other gardens across the world. The garden is a fantastic resource for the university and will hopefully influence the young designers studying there to consider the effects of green space on health and wellbeing as they go on to design their own schemes. The garden covers two hectares of land which is divided up into different garden “rooms” each with a different character and varying levels of activity and demand on the patients (or participants, as they are called here.). The design for the “Welcoming Garden” was very difficult to get right as it was arguably the most important as the visitors enter the space. It had to make the users of the garden feel comfortable and safe and must be the least demanding area, so the planting here is very low maintenance. A sense of choice is given to the users as they enter into a social space, they can then choose to enter a sensory area with differences Figure 10. in microclimate, a water feature, fragrant plants and edible berries (Stigsdotter and Grahn 2003).

Sketch Plan of Rehabilitation Gardens, Alnarp, Sweden.

The garden provides two different approaches, giving the patients a choice in where they prefer to spend time. Certain areas that are more nature inspired and focus on relaxation, including many species of plants that can be found in surrounding Swedish landscapes. Others are cultivation areas, which focus on recovery through horticultural therapy as a form of building self confidence and also as a distraction from the pain of the illness (Stigsdotter and Grahn 2003). This provides areas that are more demanding than others, allowing the patients to build their mental strength on the path to recovery (Stigsdotter and Grahn 2003). It also allows for feedback as to which approach patients found had the most impact on their health and wellbeing, which can be a very useful resource for designers all over the world.

Alzheimer’s Disease Alzheimer’s disease affects around 465,000 people in the UK (Alzheimer’s Society 2010). The condition is a form of dementia and is a progressive disease, leading to the death of brain cells. The symptoms affect the memory, mood, confidence and personality and eventually sufferers will need support with many aspects of daily life. John Zeisel (1999, cited in Marcus and Barnes 1999) highlights that despite there being no cure for the disease at present, successful and carefully designed landscapes within care homes and hospitals can significantly reduce patients’ symptoms and help reduce stress for both relatives and staff. People suffering from dementia and Alzheimer’s will naturally benefit from design styles that trigger the memory and stimulate the mind and senses. This could be achieved through certain planting styles, everyday objects, smells, textures, colours and even tastes (Zeisel and Tyson, cited in Marcus and Barnes 1999). This suggests that gardens should provide planting that is familiar to the individual patients and that has personal meanings to them. The most effective method of achieving this is to involve the patients in the general care and maintenance of the garden, for example, planting seasonal fruits, or simply watering the plants, which can involve even the most critical patients. This is also a great way of doing some light exercise. One of the most beneficial design considerations is to encourage walking, as research shows that; “Maintaining physical activity levels helps to avoid cognitive decline in later life; as the World Health Organisation highlight, psychological and social hazards that often arise with age. “Mental illness, particularly depression, Alzheimer’s disease and feelings of loneliness and social exclusion, [are] lower amongst people who are physically active.”” (World Health Organisation 2002, cited in CABE 2009) It is therefore imperative when designing for this group of patients to encourage circular walks that are clear, easy to follow and allow for some light exercise. Creating destination or focal points along the pathways will encourage patients to wander around the space. It is the role of staff to ensure that patients make the most of these facilities and this will also benefit their own relaxation. Water can work well to create a relaxing background noise and can be an effective trigger for the memory. However, care has to be taken to ensure the water feature is totally safe by being not too deep and it is not in a place that patients could easily fall into. Careful consideration needs to be taken concerning access to and from the garden. Patients need to be able to find the garden easily through one access point, which is clearly visible from the garden itself. The garden needs to be easily monitored by staff in addition to being safe and secure to ensure patients cannot wander off the premises. Routes through the garden need to be stimulating, wheelchair accessible and clear so that patients can find their way back into the building.

Autism Autism is a disability which affects people differently, but includes difficulties with social communication, interaction and imagination. It is a lifelong, developmental disability which affects some people more than others (The National Autistic Society 2010). All Saints Primary School in Cockermouth, Cumbria, has a specialist autistic centre with approximately 16 pupils (Smallwood, N. Personal communication, 17 November 2010). Twenty-five percent of pupils within the school have special needs, which is a higher than average proportion and was therefore carefully considered when 18

designing for a new sensory garden in the summer of 2010. The design was inspired by research carried out by headteacher Mrs Smallwood and secretary Mrs Hobday on the work of a company called Magic Fountains (Smallwood, N. Personal communication, 17 November 2010). Magic Fountains (n.d.) design and construct interactive and sensory play equipment and one piece of equipment that caught the attention of the staff at All Saints school was the “sharing chair”. This is specially designed for autistic children, who struggle with eye contact as it allows two children to sit close together and have a conversation without looking at each other and therefore feeling more comfortable. The layout of the new garden, which previously Figure 11. was just an area of lawn with tarmac on a lower level, now has a main circular path that winds through the whole site and is totally wheelchair accessible. The path itself features a number of different surfaces with a range of textures which allow for the stimulation of the senses (See plan in appendix for more details). One benefit of the path is that is offers a choice of routes as it branches out into a trim trail area before joining the main path once again. This encourages pupils to become more independent and develop confidence. Other features include; a large wooden dragon which has sound recordings which are activated when a person steps in a certain area on the ground in front of it; touch activated plastic flowers that play recordings of music or animal noises; other plastic flowers that carry students voices to another flower across the playground and a storytelling chair built from reclaimed timber from a ship. An artist was commissioned to design and make a colourful mosaic illustrating a scene from a popular children’s story and involved many of the students in creating tiles for particular areas of the piece. This is a fantastic way to involve young children in the design of an area and gives them a sense of ownership to the space.

Figure 12.

Sketch of wooden dragon at entrance to sensory garden

“Sharing” chair, designed for children with autism at All Saint’s Primary School, Cockermouth, Cumbria

Another aspect of the design that the children were involved in was the planting, as the school’s gardening club along with architect Tony Green helped choose the plants for the design. A range of herbs had been planted, including Rosmarinus officinalis (rosemary) and Lavandula angustifolia (lavender), in addition to existing vegetable plots, Figure 13. Part of the mosaic made by all of which are a great way to educate children in commissioned artist and pupils at All Saints School 19

an outdoor environment and stimulate their senses. A small number of existing trees are located to the east and south of the site which provide a sense of enclosure and privacy, as well as areas of shade from the sun in the summer months. Although some carefully chosen planting exists, there could be small improvements within the design. The learning aspect of the space could be encouraged by including labelling of plants and perhaps some key properties. For example, prompts such as “Smell me” on the fragrant herbs would help children gain a greater benefit from the plants. If designed by a landscape architect, more attention could be given to the soft landscape which could provide a more natural Figure 14. experience and allow pupils to have greater contact with nature.

Textured surfaces and trim trail

Aside from this, the overall design has been a huge success and headteacher Mrs Smallwood explained that children were noticeably more focused after they had spent time outside in the new environment and she particularly liked the fact that the pupils were learning as they played. The area has also been used out of school hours by an adult disabled group and a nursery group, a great indicator of a flexible space that will benefit a number of audiences.

Figure 15.

Wooded area of sensory garden, providing sense of enclosure, shade and seasonal interest

Design recommendations for a healing environment

he purpose of this section is to assimilate all the useful information drawn from the findings of this study and present them as reference for landscape architects to use and consider when designing for any scheme. According to Cooper Marcus and Barnes (1995), recommendations for healing environments can be divided into three groups; A) “Locational, site planning and way finding B) Planting, seating, aesthetic and detail C) Policy regarding the provision and maintenance of gardens intended to be used for therapeutic benefit.” These guidelines are a useful method of breaking down the different factors that need to be considered when designing any landscape, but particularly those associated with health. “Locational, site planning and way finding” introduces the idea of a holistic approach to design, something that landscape architects are more than comfortable in doing therefore again emphasising the importance of ensuring a landscape architect is involved right from the beginning of the design process when considering the development of outdoor space. “A professional landscape architect needs to be on the design team from the start to assist with the determination of outdoor space location, orientation, function and ambience and to assess microclimates, accessibility and anticipated user groups.” (Cooper Marcus and Barnes 1995) As a part of site planning, it is important to provide a variety of spaces to suit different situations. For example, some people may prefer to sit and chat in groups while others may feel like sitting in a more private, enclosed space to reflect, relax and be alone. It is vitally important that the designer respects the sensitive needs of the user and provides spaces that feel safe and secluded. One factor that will seriously affect the feeling of calm created here is noise. Ulrich (2000) found that high levels of noise can make health professionals feel more stressed and make patients feel anxious and have trouble sleeping (cited in CABE 2009). Another variable affecting outdoor space is sunlight. Due to links to skin cancer and other illnesses from excessive exposure to harmful UV rays, care must be taken to provide sufficient areas of shade, especially when designing for children or for elderly. However, it is also important to consider that natural light has strong connections with people’s mood and wellbeing. “Exposure to natural light and its daily rhythm: Natural light has been found to be immensely beneficial as “a powerful regulator of the circadian system and [stimulating] increases productivity and health and safety of patients and care givers.” (Simenova 2004, cited in CABE 2009) It is therefore important when working with architects and interior designers that in addition to making sure that there are windows to allow views onto green space that they understand the importance of plenty of natural light to both patients and staff. Microclimates can affect the experience of a space considerably and so planning of location of seating and main social areas should aim to be sheltered from the elements to enhance comfort and a feeling of security. If 21

a patient is sat in a particularly exposed area that receives a lot of wind and rain then this will only add to their stress levels. Following feedback from the health professionals that responded to the questionnaires, providing opportunity for exercise is advisable as exercise is particularly effective in improving how people feel both emotionally and physically. It can help to reduce stress and releases endorphins which make people feel happier. This does not necessarily mean providing tennis courts and football pitches, but integrating interesting walks, promoting contribution with garden maintenance and creating destination points right around the site can encourage users to be more active. When designing for hospitals or care facilities, it is crucial that the landscape is easily accessible for all users, including those in wheelchairs, crutches, Zimmer frames or mobility scooters. Here detailing of surfaces must be carefully considered so that it is non-slip, but also is not so undulated that it is unpleasant to go over in wheelchair or mobility scooter.

Figure 16. Pleioblastus variegatus, used at Yawkley Centre for Care, Boston, USA

Another vital consideration is that the users are fully aware of the green spaces that are available to them. This can be done in a number of ways and does not have to include vast amounts of signage. Staff have a responsibility to ensure that the outdoor spaces are used as much as possible, whether that be as part of physiotherapy sessions with patients or as a meeting place for patients and visitors. It can also be achieved a degree of continuity that leads the user to the garden, through choice of planting or hard materials. It is important that the green space does not stop at a gate or barrier, but flows throughout the whole of the grounds giving a feeling of life and energy to what can be a stressful, emotional setting. Green spaces within health facilities must be situated close to the building, where it can be seen from the building itself so that those who are too ill or injured to go outside can still benefit from the healing properties of viewing nature. As designers, landscape architects have a responsibility to ensure that views to the gardens are clear and that circulation around the site is easily legible for those who may be easily confused in their more fragile state of mind (Cooper Marcus and Barnes 1995).

Figure 17. Ficus repens

Figure 18. Phyllostachys nigra

The next category of design guidelines set out by Cooper Marcus and Barnes (1995) is “Planting, seating, aesthetic and detail”. They describe the different design details that influence a change in mood and reduce stress, which in turn can aid recovery and calm in numerous other health problems. Cooper Marcus and Barnes (1995) explain that viewing plants that are unhealthy looking can have negative effects on wellbeing. Therefore it is crucial that a design that is to benefit health includes an abundance of healthy, lush, green plant life throughout the year, not just the spring and summer months. Trees are very useful in creating enclosure and a change in experience and designers should carefully consider the species of tree that will best suit the space. At Yawkey Centre for Cancer Care in Boston, Massachusetts, a healing garden has been designed using a plant palette that provides colour throughout the year using a rotation of plants that flower during different months (Carol R Johnson Associates Inc 2009). It also includes numerous evergreens, such as Phyllostachys nigra (black bamboo), Rhaphis excelsior (lady palm), Ficus repens (creeping fig), Tetrastigma nitens (grape ivy) and Pleioblastus 22

variegatus (dwarf white stripe bamboo). These plants will not just provide different shades of green throughout the year but also have interesting textures and forms which will appeal to the senses of the users. Different levels of planting have also been considered in terms of larger shrubs, plants in pots and ground cover planting; another important consideration for creating atmosphere and a more interesting experience. The design is contemporary with organic forms and a wide choice of seating situations for a relatively small space. (See appendix for more details.) Overall the designer has considered the needs of the patients well and produced a well designed space that should help to reduce stress in cancer patients, their carers and friends or relatives visiting. Care must be taken to avoid plants that are poisonous or irritants (Cooper Barnes and Marcus 1999). These plants, as well as the hard materials used, need to give the place a sense of identity and uniqueness that will help those suffering from the earlier stages of dementia or Alzheimer’s disease identify with the space and also create a stronger, more meaningful design that could connect with the place’s history, culture, geography, etc. Avoid soft or hard materials that are common choices for amenity landscapes as this will deter from the sense of escape from everyday life. Focal or destination points within the space will enhance a sense of place (Cooper Marcus and Barnes 1995), for example, the large sculptural water feature at St Thomas’ Hospital is a landmark and gives the gardens a sense of identity. Numerous sources that have been used throughout this study have recommended that distraction can be a great aid of recovery from mental illness and that this plays a huge part in the way that landscapes can make a significant difference in people’s wellbeing. One method of distraction from the pains or stresses of illness, for the patient, staff and visitors, is using both soft and hard materials to stimulate the senses. Fragrances, sounds, textures, sights and even taste can be used to improve the experience of a space through the use of water, light, colour, edible planting, paving surfaces, seating choices, encouraging wildlife and so on. During winter months when hours of daylight are limited, lighting is essential. Not only can interesting light designs make a place feel contemporary and exciting, but it is crucial in terms of safety and giving a feeling of security to the users. As designers, landscape architects should approach this in an enthusiastic yet sensitive way, ensuring that patients, staff and the general public feel calmed by the lighting choices and that they do not irritate or glare. Water features are known to have relaxing qualities, such as the sound of water distracting from the noises of urban life as can be seen at St Thomas’ Hospital in London and the aesthetics of watching water. However, several safety precautions must be taken by designers, especially when designing for an area where children, elderly or disabled people are likely to be using the space. Cooper Marcus and Barnes (1999) advise caution when designing water features so that, for example, patients with Alzheimer’s disease who are easily confused cannot trip into a water feature. Despite this concern, water features are extremely beneficial and should not be avoided completely due to health and safety concerns, but designed with care by raising them or enclosing them with perhaps a barrier of planting so that it is clear that it is not a part of the path. The third of Cooper Marcus and Barnes’ categories for recommendations; “Policy regarding the provision and maintenance of gardens intended to be used for therapeutic benefit,” refers to the people responsible for the space, whether that be local authority or hospital staff. Maintenance is crucial if a green space is to remain an aid to therapeutic healing, as a run-down, intimidating space with unhealthy, dying plants or litter strewn around will only add to the stress of the general public or somebody who is already suffering from ill health. Therefore it is imperative that policies are agreed with the group of people who intend to care for the garden prior to the design process starting. This requires a good relationship between the design team and the client.

Conclusion

his study has evaluated a large amount of research and evidence that prove the psychological benefits well designed green spaces can have on people, whether they are suffering from a mental illness, recovering from an operation or living a healthy life. This relationship is not a recent discovery and questions should be asked as to why so many public spaces with the aim of providing care for people seem to have neglected the opportunity for creating positive, healing landscapes that will consequentially reduce costs of medicines, staff and equipment. The questionnaires that were carried out emphasise how much can be learnt from both working with health professionals throughout the design process and researching the needs of specific patient groups. A greater understanding of the user group can only benefit the design of any environment, particularly when they are emotionally or physically fragile and have their sensitivity heightened. It is important, therefore, to respect and understand the differing needs and requirements that are needed when designing for specific patient groups and to apply this knowledge fully into the design, in a stylish rather than simply functional manner. A series of design recommendations have been produced to assimilate the useful information that has been found as a result of this study that can be used as a reference for landscape architects when designing spaces for health care environments. If more designers choose to follow these simple guidelines and consider the important effect that they could have on people’s health then perhaps in the recent future we will begin to see a decline in the percentage of people suffering from mental illnesses. The next few years are predicted to be particularly challenging times for landscape architects. Landscape design is all too often viewed by developers as an afterthought; as an addition once the construction phase has been completed. Consequently, with spending being reduced, it is an area vulnerable to cutbacks. This paper offers arguments to support the profession and highlights just how vital good design is to the health of a nation. Action to improve health through the provision of high quality green space is now more relevant than ever and must be started immediately. With an aging population in the UK, demands on the health service are rising (CABE 2009, p.4). However, the current financial climate in this country is making people look for cheaper alternatives. Improving and encouraging access to good quality green space across the country is a more feasible and cost effective method of preventing and treating mental illness than the expense of medication and highly qualified staff. If landscape architects, health professionals and local authorities can learn to work collaboratively there exists the potential to significantly improve the mental health and wellbeing of the population.

References A Room with a View, (2010) Landscape, Summer 2010, p.26 Alzheimer’s Society (2010) What is Alzheimer’s Disease? [Internet] Available from: <http://www.alzheimers. org.uk> [Accessed 5 December 2010] Burnett, F. H. (1909) The Secret Garden. Cited in: Stigsdotter, U. A. (2005) Landscape Architecture and Health: Evidence-based health-promoting design and planning. Doctoral Thesis, Swedish University of Agricultural Sciences, Alnarp. CABE (2007) Design and Access Statements How to write, read and use them. (n.d.) [Internet] Update 2, Commission for Architecture and the Built Environment. Available from: <http://www.cabe.org.uk/files/designand-access-statements.pdf> [Accessed 29th December 2010] CABE (2009) Future Health. The Commission for Architecture and the Built Environment. Carol R Johnson Associates Inc (2009) Design Development Sign Off. Boston, Massachusetts, USA. (See Appendix.) Copeland Borough Council (2010) Notice of Grant of Planning Permission. Copeland Borough Council. Department of Health (2005) Choosing Activity: a physical activity action plan. Cited in: CABE (2009) Future Health. The Commission for Architecture and the Built Environment. Department of Health & Neighbourhood Renewal Unit (2005) Creating Healthier Communities: a resource pack for local partnerships. Cited in: CABE (2009) Future Health. The Commission for Architecture and the Built Environment. Gilling Dod Architects (2010) Proposed Landscape Area Plan, Redevelopment of West Cumberland Hospital, 1:500. Chorley, Lancashire, Gilling Dod Architects. Gilling Dod Architects et. al. (2010) Planning Application for Refurbishment, Demolitions and Extensions to West Cumberland Hospital, Whitehaven. Design and Access Statement. Received by Copeland Borough Council 2nd February 2010. Iversson, C.T. and Grahn, P. (2010) Patients’ experiences and use of a therapeutic garden: from a designer’s perspective. Journal Forestier Suisse 161(3), p.p.104-113. Magic Fountains (n.d.) [Internet]. Available from: <http://www.magicfountains.co.uk> [Accessed 18th November 2010] Marcus, C. C. (2010) Landscape design: Patient-specific Healing Gardens [Internet], Available from: <http:// www.worldhealthdesign.com> [Accessed 31st October 2010]. Marcus, C. C. & Barnes, M (1995) Gardens in healthcare facilities: uses, therapeutic benefits, and design recommendations – 4. Historical overview of the provision of outdoor gardens in medical settings. Wayne Ruga. Marcus, C. C. and Barnes, M (1999) Healing Gardens: Acute Care General Hospitals: Case Studies and Design Guidelines. United States of America, John Wiley & Sons. 25

Morris, H. (2010) National Trust to Probe People’s Connections with Natural Environment. Planning Resource, [Internet], 1 November 2010, Available from: <http://www.planningresource.co.uk/news/> [Accessed 1 November 2010] NHS (2010) Stress [Internet] Available from: <http://www.nhs.uk/conditions/stress/pages/introduction.aspx> [Accessed 30th October 2010] Olmsted, F. L. (1865) The Value and Care of Parks. Report to the Congress of the State of California. American Environment. pp.18-24. Cited in: Ulrich, R. S. et. al. (1991) Stress Recovery During Exposure to Natural and Urban Environments Journal of Environmental Psychology (11) pp.206. Orians , G. H. (1986) An Ecological and Evolutionary Approach to Landscape Aesthetics. Cited in: Ulrich, R. S. et. al. (1991) Stress Recovery During Exposure to Natural and Urban Environments. Journal of Environmental Psychology (11) pp.201-230. Penning-Rowsell & D. Lowenthal Eds. (n.d.) Meanings and Values in Landscape. London: Allen & Unwin, p.p3-25. Cited in: Ulrich, R, et al (1991) Stress Recovery during Exposure to Natural and Urban Environments. Journal of Environmental Psychology, 11, pp.201-230. Simenova, M. (2004) Health lighting for the Visual, Circadian and Perceptual Systems: Business Breifing: Hospital Engineering & Facilities Management, Report 3. Cited in: CABE (2009) Future Health. The Commission for Architecture and the Built Environment. Stigstdotter, U. A. And Grahn, P (2003) Experiencing a Garden: A Healing Garden for People Suffering from Burnout Diseases. Journal of Therapeutic Horticulture, XIV, p.p.39-48. The National Autistic Society (2010) About Autism [Internet]. Available from: <http://www.autism.org.uk> [Accessed 20th December 2010] Tuan, Y, F. (1974) Topophilia. Cited in: Ulrich, R, et al. (1991) Stress Recovery During Exposure to Natural and Urban Environments. Journal of Environmental Psychology, 11, pp.201-230. Ulrich, R. S. (2000) Effects of healthcare environmental design on medical outcomes, Design & Health: The Therapeutic benefits of Design. Cited in: CABE (2009) Future Health. The Commission for Architecture and the Built Environment. Ulrich, R. S. (1984). View through a window may influence recovery from surgery. Science, pp.224, 420421. Cited in: Ulrich, R et. al. (1991) Stress Recovery During Exposure to Natural and Urban Environments Journal of Environmental Psychology (11) pp.201-230. Ulrich, R. S. et. al. (1991) Stress Recovery During Exposure to Natural and Urban Environments. Journal of Environmental Psychology (11) pp.201-230. Warner, S. B. (1995) Restorative gardens: Recovering Some Human Wisdom for Modern Design. pp. 24 and pp.80. Cited in: Marcus, C & Barnes, M (1995) Gardens in Healthcare Facilities: Uses, Therapeutic Benefits, and Design Recommendations – 4. Historical Overview of the Provision of Outdoor Gardens in Medical Settings. Wayne Ruga. pp.7-8. World Health Organisation (2002) World Health Day. Cited in: CABE (2009) Future Health. The Commission for Architecture and the Built Environment. Zeisel, J and Tyson, M. M. (1999) Alzheimer’s Treatment Gardens. Cited in: Marcus, C. C. And Barnes, M. (1999) Healing Gardens: Therapeutic Benefits and Design Recommendations, John Wiley & Sons. 26

List of images Figure 1.

Authors own, Archbishop’s Park, opposite St. Thomas’ Hospital, London.

Figure 2.

Authors own, sketch plan of St. Thomas’ Hospital, highlighting green spaces.

Figure 3.

Authors own, Main gardens at St. Thomas’ with water feature, lawns and underground car park.

Figure 4.

Authors own, Seating and shrubs.

Figure 5.

Authors own, Rosa common throughout, negative effect in winter months.

Figure 6.

Authors own, Stunning view of water fountain in main square with backdrop of the Houses of Parlitment.

Figure 7.

Authors own, Millenium Gardens. Fountain used as a focal point.

Figure 8.

Authors own, Poster at St. Thomas’ Hospital.

Figure 9.

Authors own, Sketch of traditional cultivation room, rehabilitation garden, Alnarp, Sweden.

Figure 10.

Authors own, Sketch Plan of Rehabilitation Gardens, Alnarp, Sweden.

Figure 11.

Authors own, Sketch of wooden dragon at entrance to sensory garden.

Figure 12.

Authors own, “Sharing” chair, designed for children with autism at All Saint’s Primary School, Cockermouth, Cumbria.

Figure 13.

Authors own, Part of the mosaic made by commissioned artist and pupils at All Saints School.

Figure 14.

Authors own, Textured surfaces and trim trail.

Figure 15.

Authors own, Wooded area of sensory garden, providing sense of enclosure, shade and seasonal interest.

Figure 16.

Carol R Johnson Associates Inc (2009) Design Development Sign Off. Boston, Massachusetts, USA. (See Appendix.) Pleioblastus variegatus, used at Yawkley Centre for Care, Boston, USA.

Figure 17.

Carol R Johnson Associates Inc (2009) Design Development Sign Off. Boston, Massachusetts, USA. (See Appendix.)Ficus repens.

Figure 18.

Carol R Johnson Associates Inc (2009) Design Development Sign Off. Boston, Massachusetts, USA. (See Appendix.)Phyllostachys nigra.

Appendices

Critical Study: “The Role Landscape Architects have in Affecting Mental Health and Wellbeing” Rose Cockcroft, Leeds Metropolitan University. “Studies have shown that muscle tension drops within three minutes of exposure to green spaces” (Bird, 2010) “Presently there is no cure for Alzheimer’s disease. However, welldesigned environments, good planning and medical and social management can be used to reduce symptoms and ease the burdens on family members” (Zeisel et al., 1999)

Please answer questions as fully as possible. Thank you very much for your time. 1.

What is your name and job title? Timothy Johnson – GP Partner

In your profession, what type of mental illnesses do your patients suffer from? Everything! Most commonly Depression, Anxiety, Phobias, Dementias – less commonly Bipolar (Manic – depressive) illnesses, Obsessive Compulsive Disorders, Eating disorders, Schizophrenia. (Also people with drug related problems – paranoia/depression, and personality disorders.)

Do you agree that natural environments or elements of nature within a designed landscape can significantly improve mental health and wellbeing? I would agree that this would enhance a feeling of well being generally and that a positive environment is always going to be beneficial. For milder forms of depression and anxiety the aesthetic aspects of the environment may also be particularly beneficial. The ability to be able to get outside into a pleasant environment – e.g. for walking/exercise will also have a positive effect. Exercise has been shown to be beneficial and to improve mood in depression so if this is encouraged by a particular planned space (e.g. walking/running /other physical activities such as tennis) then this could make a significant contribution. In more serious mental disorders – e.g. severe depression/psychoses, I think other circumstances/relationships are more important but again the environment is likely to have an impact. In general some places just look/feel ‘depressing’ when you go to them for people who don’t have a mental health problem so I wonder how much more so they are to people who are already suffering from depression.

In practice do you ever advise patients to spend time in green spaces? If yes, what type of patients and to what extent does this affect their behaviour or recovery? Not specifically to spend time in green spaces but I do advise patients (particularly) those with depression to try and do some form of exercise e.g. cycling, swimming, going to the gym or walking.

Do you agree that if landscape architects were involved in the design of all hospital, care centre and public realm schemes that mental health and wellbeing could be significantly improved? I certainly think that it makes you feel better going to such places if they have been nicely designed and include aspects of landscaping – so yes, that would improve a feeling of well being. Whether it would significantly improve mental health is more difficult to say – the old mental hospitals (which don’t exist anymore) were typically grand old places in the country with large pleasant gardens and were generally in very pleasant settings – it would be hard to imagine that this didn’t have a positive effect on mental health.

Please answer questions as fully as possible. Thank you very much for your time. 1.

What is your name and job title? Mrs Rhona Clark, Enhanced Senior Occupational Therapist, based in Adult and Local Services.

In your profession, what type of mental illnesses do your patients suffer from? Depression, anxiety, agoraphobia, schizophrenia, drug/ alcohol abuse and dementia.

Do you agree that natural environments or elements of nature within a designed landscape can significantly improve mental health and wellbeing? I fully agree with the above. One of our main aims within the Council Plan is to improve the Health and Wellbeing of our clients We try to achieve this by giving people choice and control in the Services which we offer.

In practice do you ever advise patients to spend time in green spaces? If yes, what type of patients and to what extent does this affect their behaviour or recovery? Yes, I strongly encourage clients to get out of their homes to experience different environments especially outdoors as this does have a positive effect on mood and behaviour. Clients suffering from dementia clearly benefit from being outdoors. It can focus their mind on memories from the past - their short term memory is affected early on while their long term memory remains intact until later on. Happy memories of walks, picnics, time spent with friends/ family - it stimulates reminiscence and creates a very positive outcome. This in turn stimulates verbal communication and conversation, which unfortunately does deteriorate with this condition. To smell the fresh air, touch trees/ flowers, look and listen to running water and feel the sun shining on their faces lifts their mood and stimulates their senses- smell, touch, hearing and vision. Within Day Hospital environments, where possible, garden areas have been created to provide such environments. Clients can talk about the weather, the seasons- time of year, see the summer flower/ autumn leaves, touch soil, plant flowers/bulbs. Birds and insects also become a topic of interest and conversation. It can be seen as a type of Reality Orientation- reinforcing the time of day and time of year- nature and the seasons. This has a very positive effect on mood and wellbeing. A change in facial expression can be quite dramatic when a client is moved from indoors to an outdoor environment. This may lead to more involvement in small projects e.g. pruning flowers, vegetable growing which further stimulates memory, cognitive function, conversation, socialisation and therefore trying to maintain their level of function for a longer period. Outings/ trips can also be arranged for larger groups from Hospitals/ Day Services to experience these opportunities.

Do you agree that if landscape architects were involved in the design of all hospital, care centre and public realm schemes that mental health and wellbeing could be significantly improved? Yes I agree that landscape architects should be involved in the design of the above because it will add a very important aspect to such schemes and ultimately improve client’s health and wellbeing.

Please answer questions as fully as possible. Thank you very much for your time. 1.

What is your name and job title? Amanda Place Allied health Professional team lead (Physio)

In your profession, what type of mental illnesses do your patients suffer from? Dementia, Alzheimer’s, Anxiety and Depression

Do you agree that natural environments or elements of nature within a designed landscape can significantly improve mental health and wellbeing? Yes, getting the environment correct for a client can have a hugely positive effect especially in dementia and Alzheimer’s space and how this is laid out is particularly important, also colours can have different effects on how calm the client is.

In practice do you ever advise patients to spend time in green spaces? If yes, what type of patients and to what extent does this affect their behaviour or recovery? Yes, I would advise this for most of the above client group, but it can be very useful for clients with anxiety or depression, following head injury who may be tense and have an increase in muscle tone. Any activity which encourages relaxation can have positive effects and can improve the outcome of their rehab.

Do you agree that if landscape architects were involved in the design of all hospital, care centre and public realm schemes that mental health and wellbeing could be significantly improved? I agree that well designed open landscapes are extremely important for the wellbeing of both patients and carers, whether there is hard evidence to support this theory I do not know. In generally the better the client feels about themselves the more able they are to cope and self manage their condition.

Please answer questions as fully as possible. Thank you very much for your time. 1.

What is your name and job title? Anne Eldred General Practitioner

In your profession, what type of mental illnesses do your patients suffer from? The most common problems I deal with every day are anxiety and depression but as everyone is registered with a GP we also see some patients with more serious mental health problems. We are dealing with an increasingly elderly population so also see a lot of patients with dementia type problems 3. Do you agree that natural environments or elements of nature within a designed landscape can significantly improve mental health and wellbeing? Definitely. This is why I like living in Cumbria as I know from my own experience that a walk in the fells makes me feel much better 4. In practice do you ever advise patients to spend time in green spaces? If yes, what type of patients and to what extent does this affect their behaviour or recovery? I suggest exercise in the form of walking to a lot of patients for all sorts of problems including those struggling with weight and people with diabetes, a condition I have a special interest in. When people are anxious and/or depressed and are unable to work so have time, I do suggest getting out for regular exercise as a way of structuring their day. Many people seem to think that exercise means going to a gym. But walking is excellent exercise and can be combined with purposeful activity such as getting to work or shopping so doesn’t have to be an add-on activity at the end of a long day when it becomes a chore. We are lucky in Cumbria to have lots of places to walk in beautiful surroundings which is good for the soul as well as the body and cannot be achieved in a gym. I can’t say whether it affects recovery time as this is so variable between patients. Obviously frail elderly patients with dementia are not going to be able to get out walking, although it would be probably good for their carers. 5. Do you agree that if landscape architects were involved in the design of all hospital, care centre and public realm schemes that mental health and wellbeing could be significantly improved? When someone who has thought about the spaces available to provide ‘views’, seating, some greenery etc it makes such a huge difference rather than what we often see which is a few sad looking shrubs put in as an afterthought when all the building work is done. If the person to do this is a 33

landscape architect, then yes, I do agree.

Please answer questions as fully as possible. Thank you very much for your time. 1. What is your name and job title? Gill Aitcheson. Registered Nurse at Hospice at Home, West Cumbria. 2. In your profession, what type of mental illnesses do your patients suffer from? Senile Dementia, Alzheimer’s, Depression etc. 3. Do you agree that natural environments or elements of nature within a designed landscape can significantly improve mental health and wellbeing? Absolutely! 4. In practice do you ever advise patients to spend time in green spaces? If yes, what type of patients and to what extent does this affect their behaviour or recovery? Only some of the patients I nurse are able to go outside but the majority can look out on green spaces. They find this very beneficial and it certainly lifts their mood and provides a good distraction. 5. Do you agree that if landscape architects were involved in the design of all hospital, care centre and public realm schemes that mental health and wellbeing could be significantly improved? I do agree with this and feel landscape architects would approach this sympathetically and this in turn would have a positive impact on patients.

Back cover image: Author’s own, Platanus x hispanica (London Plane Tree), taken in Gardens at St Thomas’ Hospital.