‘The planting puts new life into me’

In 2014 as a semi-retired person I applied to be a volunteer at Freedom from Torture (FFT), a human rights charity based in London but with branches all over the UK. I was appointed to work with a 'natural growth project' (NGP, a therapeutic gardening project) run for the treatment and benefit of people who have been severely tortured in many different parts of the world. 

These people have managed, usually with extraordinary bravery and courage and with enormous obstacles, to reach the UK and seek asylum. Unfortunately it is not immediately the promised land that they sometimes imagine. Once here they may be given often extremely poor accommodation and the accompanying £35 per week to live on. Accommodation is often dirty, noisy, and overcrowded. The slow processing of applications to remain in the UK by the Home Office means that these clients may wait several years to gain status in the UK. During this time, they are not allowed to work. These delays inevitably exacerbate and prolong mental health issues.

Most of the FFT clients are suffering severe Post Traumatic Stress Disorder, and have complex physical injuries and pain. They suffer depression, anxiety, poor sleep, have nightmares and flashbacks. Often they do not speak English. They can spend long hours alone and isolated in inadequate housing and may feel suicidal.

If accepted for help at FFT they have access to trauma therapy, legal and welfare services, medical assessments, and a number of activity groups. These include football, bread making, chess, choir, art, English classes, a writing group, and gardening. There is also a specialist pain clinic which offers medical assessment, physiotherapy and yoga.

Gardening and mental health

There is much written about the benefits of gardening to mental health, and I will just plant a few seeds here. Research issues – present in but not limited to this topic – include the feasibility of quantititave vs qualitiatative methodologies, types of projects, and the wide range of clients.

A meta analysis of research examining the effects of gardening including horticultural therapy on health was published by Soga et al. (2017). They examined control and treatment group studies plus 22 case studies, across the US, Europe, Asia, and the Middle East. A wide range of health outcomes were reported including reduction in depression, anxiety, BMI, and increases in life satisfaction, quality of life, and sense of community. The authors concluded that there is robust evidence for the positive effects of gardening on health.

David Buck's review (Kings Fund, 2016) on gardening and health cites Clatworthy et al. (2013), who note that horticultural activities featured in the early psychiatric institutions in Europe and the United States in the 1800s. The authors review the main theories that have been suggested to link gardening (and contact with natural environments more generally) with mental health; Attention Restoration, Stress Reduction, and Social Connections and Exercise.

Buck concedes that there have been no RCTs in this field, but the review has shown gardening-based interventions having 'a variety of benefits for people as an adjunct to existing treatment'. Some quantitative studies found 'significant reductions in symptoms of depression and anxiety, while qualitative studies found 'enhanced emotional wellbeing, improved social functioning, improved physical health and opportunities for vocational development'. The variation in the types of gardening intervention evaluated were, however, wide. Benefits were found during the interventions, but follow up evidence did not always show that this was maintained. Clatworthy and colleagues argue that 'a gardening-based mental health intervention may therefore be best conceptualised as a longer-term therapeutic option for the long haul, which can, over time, facilitate recovery and social inclusion among people experiencing mental health difficulties'. This of course has implications for resources.

Clatworthy et al. comment that well controlled trials are limited and we cannot yet clearly identify 'the active components of the interventions (i.e., what is it specifically about a gardening-based mental health intervention that makes it effective?)'. Nonetheless there is a plethora of green projects in the belief that these are helpful and beneficial to health.

Bragg and Atkins (2016) in a review of nature-based interventions argue that 'these could be part of a new solution for mental health care', but conclude that 'awareness and access to these interventions is challenging'.

Importantly, Buck concludes: 'it is important to recognise that the lack of RCTs in evidence is not something unique to green space or gardening – many accepted interventions in health and other policy fields are not based on RCT evidence. So while there is always room for stronger study designs, we have to ask the practical question: how much and what type and strength of evidence is 'enough' to guide action and policy?'

A recent book by Sue Stuart Smith (2020), who is a psychiatrist and psychotherapist, talks of the therapeutic benefits that gardening can offer to everyone including those with a variety of mental health difficulties including asylum seekers. She says: 'In this era of virtual worlds and fake facts, the garden brings us back to reality'.

Natural Growth Project at FFT

'The planting puts new life into me. My heart has been planted with a lot of good' (Client, 2020)

The NGP at FFT has been running in varied forms for over 25 years. Different facilitators have brought different and varied ideas to the group. My predecessors were psychotherapists, and very creative people developing innovative ideas for working with this group. As a Clinical Psychologist – and perhaps one more open to a variety of therapeutic approaches than some having trained in a different era – I have had to adapt to a different way of working in this group. Measurements do not play a large part as clients can vary in mood from week to week. The group is time limited (two years) and clients do not leave when they are 'better'. I try to keep a balance between evidence-based practice and practice-based evidence.

Clive Critchley (2008) writes 'All struggle with the constant fear of being returned to the country they fled – an anomic experience in which clinical depression and anxiety are endemic. Given this, the small securities of a weekly and accepting group, the seasonal round of nature, and the contacts made with others in the same situation can become of both practical and therapeutic value.' He emphasises the need to 'be alert to non verbal moments' in this work.

The group is run by a psychological therapist (currently me) and a horticultural therapist, also a Clinical Psychology trainee who now replaces the volunteer role. It runs for two hours per week throughout the year. In the winter, there is inevitably less gardening and during this time we may do various cleaning jobs such as the greenhouse and tools, or offer art and craft tasks indoors. But from February through to November there is plenty of gardening peaking in the spring and summer months. The gardening is carried out for the first hour of the group and then there is a short break for tea, followed by an indoor therapy group. 

We have a maximum of ten clients, 2:1 male:female (which reflects the client group in FFT as a whole) although the groups tend to be smaller due to absences of clients from crises, depressive episodes, unavoidable other appointments. Clients' moods vary with many setbacks, some becoming suicidal. Safeguarding and risk are regularly assessed. However, we actively encourage clients to attend every week enhancing the beneficial potential. 

I telephone a client on the morning of the group as his attendance has been poor. He finds the journey from another part of London difficult. The client says he cannot come to the group because of pain from old torture injuries. I stress the importance of coming and meeting the others, how the group misses him. He arrives later and sits indoors saying his back is hurting. We give him a cup of tea and offer him a jacket to wear in the garden as he is inadequately dressed for the chilly weather. He is welcomed by the others and becomes interested in the tasks being done. He ends up pruning and tying back climbing plants, his back pain apparently gone.

Clients are from many different countries, including Sri Lanka, Egypt, Afghanistan, Syria, Uganda, Congo. The group language is English but we do have interpreters where necessary. Usually we have found that one interpreter in such a small group is enough, otherwise the pace and quality of discussion can be negatively affected.

Clients remain in the group for up to two years and many do not have leave to remain in the UK by then. A year is a minimum with such a project in order for the clients to see a full cycle of seasons in the garden. Many clients are very reluctant, and not ready to leave after two years. They have become close to other group members and enjoy the benefits of working outdoors and having the chance to talk about their experiences both past and current. However, the waiting list is such that we are obliged to move people on, sometimes to individual therapy, sometimes to other activities, sometimes to our Peer Support Group or to other agencies.

Some clients experience severe flashbacks and dissociation, which can become apparent in the group. These issues are not always amenable to meaningful help in the group setting, but we address these more generally through psychoeducation in grounding and stabilisation (Herman 2002). Clients can be very helpful in sharing their own creative solutions to, for example, nightmares. But what the group cannot easily address is severe individual trauma. Detailed accounts of torture in the group seldom happen and it may be necessary through individual therapy for some clients to overcome their personal trauma. Sometimes clients will seem to dissociate from the talking group content and we try to bring them back into focus. Others will find it hard to concentrate when others are speaking and get up to walk around the room. We try to discourage this and integrate them back into the group.

Majid could not settle in the group. We allowed him to go outside with the horticultural therapist, instead of sitting restlessly or pacing round the group to pick some flowers and leaves in the garden that he could take home.

An evaluation of the NGP in 2013 by Rebecca Horn (now Senior Research Fellow for the Institute of Global Health and Development in Edinburgh) identified three key therapeutic benefits: a positive change in energy and mood, an increased sense of agency, and increased sociability. We find that our clients benefit from the exercise afforded in the garden. Each client is informally assessed each week in collaboration with our Horticultural Therapist as to the sort of tasks that may best fit their mood. The tasks fulfil the role of distracting clients from their deep troubles arising from experiences of displacement and torture which haunt many in their daily lives. Some may prefer vigorous activity to release tension such as digging or mowing, others more gentle pursuits such as planting or harvesting, and others may like more mindful tasks such as watering. Where possible we work alongside or nearby to clients especially those who may tend to dissociate and be at risk from using tools,

Aamir experienced some fingers being cut off with bolt croppers when tortured. For this reason he was fearful of shears or secateurs and might dissociate when near them.

Saad was in an angry mood following multiple stresses in his asylum accommodation with noise and drug dealing late at night. He was sleep deprived. He was given a task of tidying the lawn edges with an edging tool, but it was rapidly observed that he was doing this too sharply and vigorously. After some discussion he felt calmer and was able to moderate his actions.

As Mary Raphaely observes (2003): inner turmoil can be expressed in over-watering a plant or brutally cutting back a shrub. The work demands constant vigilance and attention, or key pointers to an internal landscape can be lost.

The sensory benefits are of great importance. The garden is full of smells and textures. It is a calm space where there is no need for talking unless the client wishes to. Clients are able to see the results of their work, things that they have planted growing, some from their own cultures. For example, one client showed us how to plant potatoes in Afghan style, others choose to grow herbs from their own countries. Conversations often emerge about their own countries through this. Sometimes items are planted in memory of loved ones. Produce is taken home where possible. And sometimes clients cook soups for the group using the produce.

There is increase in trust between group members who may enrol very timidly but gradually be able to confide in other group members. It derives from the confidence they gain in the garden and the talking part of the group, meeting others whose stories and experiences they hear, becoming part of the group family. Their physical health can improve too through gentle or more vigorous exercise in the garden, getting out into the sunlight after often spending days in their small rooms. This can help to improve their appetites and also sleep.

A client was diabetic and overweight. She valued the opportunity to be able to use her body in the gardening process alongside others as exercising alone was not easy for her.

Increased sociability and feeling cared for is a very important outcome of the group. 'We are like a family' said one group member. They learn about each other's stories and the daily battles they face with housing, legal situations, interminable Home Office delays, nightmares, and flashbacks. They offer comparisons with their own experiences and how to manage them. This inevitably brings the members closer together. One female member who is older than the young men in the group has become something of a maternal figure.

A client reveals in the group that his anger about his situation makes him want to hit people and things. Another shares that she used to feel like that, threw crockery around, but has turned her energy into cleaning the house she is living in.

A client says he has been stung by an insect in the garden and drops out of the gardening sitting on a bench nursing his arm and looking in pain. This young man, a former child soldier, left his country alone at age 14 to escape here. I talked to him then went to find some insect sting relief cream. I asked him to put it on his arm. He wanted me to do it for him. The pain soon abated and I felt that it was his deep need to be parented that had been momentarily met.

The tasks fulfil the role of distracting clients from their deep troubles arising from experiences of displacement and torture which haunt many in their daily lives.

Themes of group – the talking therapy

'The fundamental precept of the NGP is to use nature as a metaphor for life, and a way of healing and reaching the soul. The cycles of life, death and rebirth are evident in the sowing of seeds, the growth, harvesting, and dying back which nature provides' (Raphaely, 2003).

We sit in a circle drinking tea for this part of the afternoon. Sometimes in the warm summer months we hold this part of the group outdoors, although the distractions are greater and focus can be lost.  Clients are physically more relaxed by this part of the afternoon having done some gardening work. The clients are asked how their week has been. Some of them will have told us things during the gardening and are encouraged if relevant to share with the group, especially where problems have arisen. The group themes frequently recurring refer to the practical difficulties of living as an asylum seeker. Housing, finance, and uncertainty as to whether the clients' futures will ever change are of deep and recurring concern. PTSD symptoms are frequently acknowledged and discussed. Different cultures arise and there are often discussions about political situations, customs and the food in their own countries. Sometimes clients will bring food they have made for us to sample.

Some clients have families they are separated from, parents, children, siblings. These family members may be in very dangerous situations in their countries. Some they are in touch with often with difficulty, others are missing. Others may be dead. A recurring theme that arises with those with children from whom they are separated is the terrible grief about not seeing their children grow up, and how to be a parent.

'Refugees are generally dominated by one feeling – a painful and traumatic sense of loss which is experienced both outwardly and inwardly… the combining of these losses produces a deep sense of alienation' (Grut, 2003).  

A client regularly telephones his wife and children who are in a camp in another part of the world. He has also lost children who were killed. His case is taking more than ten years. He despairs as to how his role as a father seems so minimal. I encourage him of the importance of his contact, that the children still know they have a father and how important that is.

Morad grieves deeply about not seeing his children grow up. His case is taking several years to process. We acknowledge the terrible grief but also that he is still alive and able to speak to them on the telephone and that this would probably not be the case had he not escaped.

Sabir has lost touch with his parents and cannot trace them. He remembers holding his little brother's hand shortly before he left eight years ago. Now he does not know if they are alive or dead.

Where possible we use gardening metaphors in the group. These include metaphors of life and death, renewal and change, decay, and healing. The cycle of life for example creating roots, the need for bulbs to have a cold period in the ground in order to grow well, the production of flowers, vegetables, fruit, plants and trees withstanding various weather conditions are common metaphors. 

The work can encourage focus for some clients as they gradually relax and become engaged in various projects. I have seen clients who appeared to have learning difficulties initially flourish and become much more articulate over time as their confidence increased 

Rolland was almost unintelligible when I met him. He seemed to find following instructions very difficult. Over two years he became a well-respected group member who worked hard and enjoyed the gardening. His confidence increased and he became very positive about his life. His articulation and expression of ideas were unrecognisable in their sophistication from when he first started.

Most of our clients are religious and their beliefs can be very sustaining. For example the prophet Mohammed, who spent dark times in the desert, is often cited as an example. The group is multicultural, yet everyone is respectful of the differing beliefs. 

Ending each group can be difficult. Topics can become very intense and painful during the discussions. I see it as important for the group leader to attempt to end on a message of hope. This means being vigilant with time keeping so that clients are finishing what they are saying a little before the end. Sometimes we can summarise using a theme from the group. Each group has a moment of hope or humour, and it can be possible to pick up on that to end. At other times we may pick future events to talk about, such as the next tasks in the garden. Some clients find it hard to leave and will try to see the therapist individually. These requests are often hard to resist but always clients are encouraged to bring material to share with the group.

A focus outside their thoughts

Our group encourages clients to do an activity which helps them to focus outside the thoughts that plague them daily about their past and fuelled by an uncertain future. They are occupied with physical tasks and able to see constant change in the garden setting. They gain or revisit practical skills. They can share with other clients their hopes and fears. They make important friendships across class, religion, and race boundaries, brought together by the common experience of fleeing their own countries and the experience of torture. 

- Jennifer Walters [email protected]

'My greatest thanks go to Clive Critchley (d 2018) horticultural therapist at FFT from 2002–2018 for teaching me so much about this work. And to Caroline Roemmely, Psychotherapist, who mentored me in my work as a volunteer. From both them and the clients I have learned so much. Big thanks also to Robin Ewart Biggs, former clinical Director of FFT, who took over the role of gardening therapist with enthusiasm and skill when there was a sudden gap, and to Rebecca Smith our current horticultural therapist who brings great knowledge, calm and sensitivity to clients.'

A note from Freedom From Torture: 'Freedom from torture has 5 centres across the UK. We have now introduced a new clinical model and deliver evidence based trauma focused therapies to clients who have PTSD, and offer a range of other therapeutic approaches where clients have other preferences. The gardening group described is offered as part of the stabilisation phase of treatment, and will reconvene when the public health situation allows.'

References

Buck, D. (2016). Gardens and Health: Implications for Policy and Practice. Kings Fund Report

Bragg, R., Atkins, G. (2016). A review of nature based interventions for mental health care – Natural England Commissioned Report 204. London: Natural England.

Clatworthy, J., Hinds, J.M., Camic, P. (2013). Gardening as a mental health intervention: a review. Mental Health Review Journal Vol 18 no4 pp 214-5

Critchley, C. (2008). Horticultural Therapy with Survivors of Torture . Growthpoint Issue 114

Grut, J. (2003). The Healing Fields in Therapeutic Communities Vol 24 No3

Herman, J. (2002). Recovery from Psychological Trauma in Psychiatry and Clinical Neurosciences January 2002

Raphaely, M. (2013). Touching the Soul; Grounding Victims of Torture. Paper presented at Group Analytic Society Conference, Bologna, 2002.

Soga, M., Gaston, K.J., Yamaura (2016). Gardening is beneficial for health: A meta -analysis. Preventive Medicine Reports Nov 14;5:92-99. eCollection 2017 Mar.

Stuart-Smith Sue (2020.) The Well Gardened Mind: Rediscovering Nature in the modern World. William Collins.