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This is a post-print of an article
whose final form has been published in the Journal of Therapeutic Horticulture
2011, 21(1), copyright American Horticultural Therapy Association; the Journal
of Therapeutic Horticulture is available online at www.ahta.org
The use of Horticulture in the
Treatment of Post-Traumatic Stress Disorder in a Private Practice Setting
Howard Z. Lorber, LCSW
Abstract
More and more private practitioners in
psychotherapy are seeing those diagnosed with Post-Traumatic Stress Disorder
(PTSD) in their offices. The therapeutic use of horticulture is proposed as an
adjunctive method in the treatment of PTSD in a private practice setting. This
paper proposes combining the use of “nearby nature,” and hands-on
horticultural activities as a means of developing emotional safety, with the
desensitization and narrative restructuring of traumatic memories through the
use of Eye Movement Desensitization and Reprocessing (EMDR). The
cognitive/behavioral and physiological foundations of combining EMDR with
therapeutic horticultural activities as a modality of treatment are explored.
Introduction
In the United States, the profession of
horticultural therapy has developed as an organized discipline only within the
past 30 years. Yet the therapeutic use of plants for healing treatment is as old
as humanity. The remains of plant material is found in the graves of Neanderthal
and Cro-Magnon people dating back 40,000 years ago (Solecki, 1977),
archeological and anthropological study reveals deep botanical knowledge (for
healing as well as for poisoning) throughout all known peoples
(Brush, 1993),
and historical texts from ancient civilizations reveal the same sort of
knowledge (Brush, 1993).
In the Middle Ages, it was known that the central garth of the cloister, with
its garden of flowers, herbs, trees and fountain, was not only a place of
contemplation for the monks, but a soothing and tempering locus, giving refuge
and succor from the rigors of the daily round of prayers, labors, and constant
social presence (Landsberg, 2003).
The American Horticultural Therapy
Association states that horticultural therapy is "the engagement of a
person in gardening-related activities, facilitated by a trained therapist, to
achieve specific treatment goals (AHTA: 2009).” Yet horticultural therapy encompasses more than that
formalistic definition indicates. Presently, horticultural therapy methods are
being developed within the intersection of a broad array of therapeutic
practices: psychology, psychotherapy, social work, occupational therapy,
physical therapy, vocational rehabilitation, rehabilitation medicine,
therapeutic recreation, physiatry, and movement therapy, among others.
According to the AHTA website (2009),
horticultural therapists practice in:
·
Rehabilitation programs
·
Vocational and occupational
training
·
Psychiatric and mental health
clinics
·
Hospitals
·
Correctional facilities
·
Public and private schools
·
Nursing homes and senior centers
·
Community and botanic gardens
Generally, horticultural therapy is
practiced in facilities – whether as group or individual services – and has
not been shown in the literature as a method that can be adapted to private
practice work (Horticultural Therapy Institute, 2010). For the most part,
horticultural therapy private practice consists of individuals acting as
contractors and consultants to programs in the facilities listed above
(Horticultural Therapy Institute, 2010).
Of those who seek treatment for any mental
or behavioral health disorder – and only a fraction of those in need do so –
most seek help in outpatient settings (Moran,
2004). Most people first seek help from their primary care providers. Getting
from these front lines of care to the office of an out-patient therapy provider
is a short, but uncertain, step. When physicians do make referrals, they are
most often to private practitioners (Moran, 2004).
The
Emergence of PTSD and the Private Practice Setting
The formalized diagnosis of Post-Traumatic
Stress Disorder (PTSD) is fairly new (McKinney, 2003; McNally,
2006), though the symptomatology was described under different names –
for example, ‘soldier’s
heart,’ ‘shell shock,’ and ‘battle fatigue’ – since the mid-19th
century (McKinney, 2003). Developed first in response to the needs of
predominantly military sufferers, there has been a conceptual bias in treatment
philosophy toward institutional care (McKinney, 2003). However, those diagnosed
with PTSD include first responders (police, fire, and EMT personnel), accident
and disaster survivors, and witnesses. Of those who seek treatment, many will be
engaged in outpatient settings, either clinics or the offices of private
practitioners (Moran, 2004; Liebschutz, 2007; APA, 2010).
As a private psychotherapy practitioner in
New York City for over 25 years, the author has seen an increase in PTSD
referrals from zero cases in 1983 to 12% of caseload in 2010. These referrals
spiked in the years after the 9/11/2001 disaster, stabilizing to the current
level by 2006. This level seems to consistent with the current incidence in our
society (Liebschutz, 2007), but is increasing as more veterans of the current
wars are seeking help outside of the Veterans’ Administration facility setting
(APA, 2010). Over time, the author has worked in a variety of modalities –
psychodynamic, cognitive behavioral, psychoanalytic, psychocultural, narrative,
EMDR, horticultural therapy – in treating clients. In light, then, of a
demonstrated need and a growing number
of PTSD
referrals, it is important, if not crucial, that those in private practice develop
the tools necessary to best treat those coming to them.
The intent of this paper is to explore the
possibility of utilizing therapeutic horticulture methods adjunctively in the
treatment of PTSD in a private practice setting. PTSD sufferers often experience
anxiety, as well as intrusive memories of their traumas and triggering reminders
of those traumata. The therapeutic use of horticulture as discussed in this
paper can provide a calming ground for the exploration of traumatic memories. It
also provides a here-and-now tangible and tactile safe space within which the
past powerful events (Lorber, 2001) can be differentiated from the present.
Therapeutic
Horticulture for Stress Management and Stress Reduction
Involvement with nature – whether
experienced in the wilderness, or as “nearby nature” viewed passively
through a window – reduces stress and increases an overall sense of well-being
(Ulrich, 1984; R. Kaplan, 1992; S. Kaplan, 1992; Lewis, 1992; McDonald &
Bruce, 1992; Mattson, 1992; Relf, 1992; Ulrich & Parsons, 1992; Kaplan and
Kaplan, 1995). In fact, the “restorative experience” (R. Kaplan, 1992;
Kaplan & Kaplan, 1995) of involvement with the natural, green world has become a
foundation of the models developed by the above-referenced writers. Relf (Relf,
1992) and Mattson (Mattson, 1992) have worked to formalize horticultural therapy
and Ulrich and Parsons (Ulrich & Parsons, 1992) and the Kaplans (R. Kaplan,
1992; S. Kaplan, 1992; Kaplan and Kaplan, 1995) have focused on the more
psychological aspects of the human-environmental dynamic; each has attempted put
the involvement of people with their environment on a more rigorous, scientific
footing.
The salutary effects of viewing and
working with plants – the gardening or horticultural process – has been
known for centuries. Horticulture was used as an aid to recovery for the
mentally and emotionally challenged (e.g. Benjamin Rush, late 18th C;
Menninger Clinic, mid-20th C; Donald Natson, mid-20th C).
But it was not until Ulrich's (1984) seminal work, “A View Through a Window
May Influence Recovery From Surgery” was published, that the health-promoting
qualities of passive interaction with green spaces gained the attention of the
scientific community. Ulrich’s controlled comparison of the positive of
effects of simply having a window view of trees on post-operative gall bladder
surgery patients with a similar group having a view of a blank wall clearly
indicated that the plant-life view increased recovery rate and reduced pain and
stress (1984).
Within
six years of the publication of
Ulrich’s paper, a national colloquium, The
Role of Horticulture in Human Well-Being and Social Development: A National
Symposium (Relf: 1992), was held summarizing the research and knowledge
gained up to that point and indicating some of the direction future research was
to take. In that 1990 symposium, the theme of the restorative quality of the
individual's experience of plant life (R. Kaplan, 1992,
S. Kaplan, 1992, Kaplan & Kaplan, 1995) was developed. Despite Ulrich
and Parsons’ (1992) caveat that nature as experienced is more immediate and
emotional than cognitive, Kaplan & Kaplan indicate there are specific,
fast-acting neural components to the experience of nature:
“properties
of a scene such as texture as well as the size and location of the various
uniform areas are assumed to be the province of the ‘location system,’ an
ancient neural structure and processes visual information with great speed with
little need for inference.” (Kaplan & Kaplan, 1995, p. 54)
Following this view, emotional and
physical relief from stress and emotional and cognitive overburden is asserted
to be fundamental to the model from which horticultural therapy was developed.
In Relf’s analysis (1992), it was considered to underlie the development of
the field at that point, and continues on today as the primary intellectual
underpinning for the various models of horticultural therapy (Schweitzer, et.
al., 2004; Wichrowski, 2006). Indeed, for the Kaplans, the perception of nature
is an inherently aesthetic process (S. Kaplan, 1992; Kaplan & Kaplan, 1995).
Their perspective of this aesthetic process is one in which viewers project
their sense of belonging in the scene, much in the same way viewers of a
figurative work of art find themselves in the world of the scene presented to
them. The experience of nature is "direct, immediate, and holistic.” In
fact, their research methodology of utilizing photos presupposes this underlying
approach. Nature is received, according to the Kaplans, as a given, a process
within which “one experiences no hint that one is going through a complex,
analytic process en route to one's judgment" (Kaplan & Kaplan, 1995,
p.136). Further, as Relf (2003) points out, our habituation to different
environments provides a familiar, expected gestalt from which we can locate
difference; difference being a source of physiological arousal. The habituation
to an expectable natural environment from which difference is recognized
provides a source of the ‘soothing’ quality of plant life. The physical
arousal through the recognition of difference intersects the formation of an
aesthetic experience and the regulation of physiological arousal.
The Kaplans’ model asserts that most
satisfactions of gardening are in the process of it rather than simply the
product, food, or flower. Sensorially, fascination
and mystery are the keys to
satisfaction. The sense of fascination is the drawing and holding of attention,
physically, cognitively, and emotionally (Kaplan & Kaplan, 1995). Mystery is
“the capacity to be drawn in, to be prompted to expect more than is merely
visible, to be quick to the challenge of…providing imaginal detail for
oneself.” (Kaplan & Kaplan, 1995, p.56) In this model, mystery and
fascination are properties of natural scenes that draw involuntary attention
and, as such, are innate (R. Kaplan, 1992; Kaplan & Kaplan, 1995) and
neurally based. As Ulrich and Parsons, building on the Kaplans’ model, state:
“viewing nature scenes dominated by vegetation…produce increases in positive
feelings; reduce negatively toned or stress-related feelings such as fear,
anger, or sadness; hold interest/attention effectively and hence may block or
reduce stressful thoughts; and elicit positive changes across physiological
systems” (Ulrich and Parsons 1992).
This complex of responses to nature seems
to be grounded in the perception of the scene as a whole, or gestalt, to which
one responds immediately and unconsciously. From evolutionary, ethological, and
cognitive/perceptual frames of reference, the experienced gestalt is the form or
ground against which one discerns danger or safety by the sensing of difference.
As R. Kaplan states: "properties of a scene such as texture as well as the
size and location of the various uniform areas are assumed to be the province of
the ‘location system’, an ancient neural structure, and processes visual
information with great speed and little need for inference" (Kaplan &
Kaplan, 1995, p. 54).
An emerging understanding of the neural
organization of cognition is that multiple areas of the brain encode a
combination of memory and action sequences. Perception and memory are
essentially integrated rather than merely linked (Saksida, 2009). The older
model is for “multiple memory systems” which each have specific functional
organization and output subserved by discreet brain ‘modules’ (Saksida,
2009). The memory of facts and events (declarative memory) is held to be
functionally and architecturally encoded in different brain regions than that of
skills and procedures (nondeclarative memory).
The new model integrates cognitive operation & memory. This allows us
to recognize the feedback between perception and memory. It gives a
neuropsysiological basis for the long-lasting effects of one’s history on
current perception. It also provides a similar basis for the modification of
cognitive states through the perception of current interactions. In the
therapeutic use of horticulture the modification of present “states of
being” (Woolf, 1976) through engagement with plant life is an outcome of the
integration of stored memories and action sequences (declarative and
nondeclarative operations) with the immediate (aesthetic) perception of
“nearby nature”. As such, this
modification through the therapeutic use of horticulture – the reduction of
stress and a renewed sense of safety – provides a means by which the client
can internalize a new mode of self-regulation.
The nexus of the activation of aesthetic
sensibility of nearby nature in states of being that are self-soothing, the
neural integration of memory and perception , the engendering of a sense of
safety within the human-plant encounter, and the internalization of
self-regulation of psycho-neuro-muscular states are a foundation for a
psycho-physical therapy utilizing horticultural activity as a component of the
treatment. This is especially important in the treatment of the outcomes of
powerful events (Lorber, 2001) when these powerful events become disregulative
of the psycho-neuro-muscular systems, or they are anaclitic[leah1] [HZL2] with past events
that resurface or intensify through their being restimulated.
PTSD
and Its Physical Correlates
Most theoretical models of human
involvement in powerful events assert that they are traumatic (Horrowitz, 1976) and
that the long-term consequence of trauma is, for many people (see McKinney
2003), post-traumatic stress disorder, as described in the Diagnostic and
Statistical Manual of the American Psychiatric Association (1994).
The fundament of stress disorder, whether
acute or post-traumatic is the physiological dysregulation of the individual
such that, in being overwhelmed, their emotional/cognitive response reduces
their capacity for clear thought, causes a regression to earlier defensive
states and strategies, and detaches the individual from a realistic sense of
being in the present (Porges and Lewis, 2009). Acute Stress Disorder, which
happens immediately in a powerful negative event, may become PTSD if the
reaction lasts more than six months or if the reactive processes return at some,
unspecified, future date (American Psychiatric Association, 1994). In PTSD, the
exacerbation manifests as “flashback memories,” residual guilt and shame,
dissociation/detachment from the present, acting out of emergent fantasies, and
a sense of inability to control these emergent states (Herman, 1992; American
Psychiatric Association, 1994; McFarlane, 1996; Van der Kolk, 1996; Van der Kolk
et. al. 1996; Ogden and Minton, 2000; Shapiro, 2001; Porges and Lewis, 2009).
Currently, the most bio-psychologically integrated theories of stress disorders
are found in Porges and Lewis (2009) and Van der Kolk (1996). They demonstrate
how the individual encounter of powerful events sets off a sequence of
consequences – neuro-physiological, endocrine, skeleto-muscular, and emotional
– that leads some susceptible individuals from stress response to stress
disorder and, and in some cases, to post-traumatic stress disorder.
Porges’ (2009) model of Polyvagal
Response is especially salient for adaptation to the therapeutic use of
horticulture. Porges describes how the sympathetic nervous system– that
part of the autonomic or involuntary nervous system that regulates the pulse,
blood pressure, muscle tone and ‘fight-or-flight’ response, among other
physiological conditions – is activated and responds to powerful events.
According to Porges, the reason for this response is an evolutionary adaptation
to the dangers inherent in the early environment within which animals,
especially mammals, developed. The sympathetic nervous system acts as a
thermostat for environmental response. In humans, because of the integration of
the memory and perceptual processes that environment can be internal, as well as
external. According to Porges’ model, the central axis of response to threat
or other environmental danger is the activation of the autonomic nervous system,
or, more specifically, the activation of the vagus nerve tracts. The vagus nerve
is a cranial nerve that goes from brainstem to abdomen, innervating the viscera,
heart, and lungs. When danger is
sensed, the brain/vagus nerve connection depresses some hormone production and
increases others. Anxiety is felt when a new environment or a difference in the
average expectable environment is sensed. In other words, when we distinguish a
difference from the expected environmental background, our sympathetic nervous
system is activated for directed attention and quick action. This process
changes the individual’s cognitive/emotional/behavioral responses to his or
her environment. For the individual to shift back from the activated, aroused
state of being to the normative, average state of being, he must have the
capacity to regulate or re-regulate his response to the world. In the shift from
Acute Stress to Post-Traumatic Stress, from localized to global stress disorder,
the individual’s capacity to re-regulate his autonomic response is distorted,
leading to PTSD (Herman, 1992).
While
trauma theorists generally focus on danger or life threats, a focus on
physiological adaptation is also necessary to differentiate safe environments.
This is precisely the thrust of Kaplan and Kaplan’s thesis in The
Experience of Nature (1995) and supports their view of restorative
environments. Human physiology is a bidirectional sensory motor system. The
periphery – all those parts of us that are not the brain – influences how
the brain works and the brain influences how the periphery works. It may be
considered that the perception of nearby nature acts to re-regulate the
autonomic nervous system, thus allowing the individual to engage more fully and
successfully with others and themselves (Herman, 1992).
For example, reduced levels of oxytocin are associated with the social
withdrawal encountered in people with PTSD (Herman 1992). Re-regulation of the
autonomic nervous system (and subsequently, increasing oxytocin levels) through,
in part, access to nearby nature, allows for the possibility of increased social
response and connection. When considering the Kaplans’ work (1995) there
appears to be a potential link between the capacities to re-regulate the aroused
autonomic nervous system, the aesthetic response to the natural environment, and
the importance of creating a safe social space. As well, recent research (Carr, 2007, Pekker, 2009) has found specific bacteria in the soil (Mycobacterium vaccae) that promotes both an enhancement of human immune response and the
production of calming/mood enhancing neuropeptides.
Collectively, these researches contribute to an emerging model
of treatment that, incorporating horticultural methods as an adjunct, may be
useful in treating clients with PTSD. Future evidence-based research will
strengthen and enhance our understanding of the linkage between physiological,
neurological, environmental and aesthetic states of individuals and will be an
important step in developing better clinical means of treating PTSD.
Utilizing
HT for PTSD Treatment in Private Practice
Many think of PTSD as mostly an outcome of
war or attack (9/11, assault, rape, etc.), yet other powerful life-events may
trigger PTSD. For example, upwards of 52% of those with orthopedic injury
experience PTSD (Brown, 2003). In treating PTSD often the narrative of the
powerful event is dissociated and fixed in an emotional and/or cognitive
‘distance’. The narrative, then, becomes an impediment to the treatment
process. Traditional psychotherapy, addressing the cognitive and emotional
elements of trauma, does not work with the profound neurological and
physiological changes that often present in people with PTSD (Levine 1997). The
use of a variety of hands on, experiential techniques in combination with
psychotherapy allows the therapeutic process to work around and beyond the
unassimilated, dissociated, and entrenched cognitive-behavioral and somatic
states associated with people with PTSD. The client can generate new actions,
and is enabled to deploy a new behavioral repertoire constructed in the
therapeutic frame (Gomez, 2009). At the same time, the treatment process, as a
talk-therapy, includes the important element of reshaping the individual’s
life narrative to assimilate and include the split-off sub-narrative of the
powerful event.
In her discussion of women's
autobiography, Benstock (1988) points out how the autobiographical writer
constructs a narrative of memories by choosing these memories to fulfill a
specific, aesthetic, meaningful intention. This construction provides an
imaginal structure that is meaningful to the author, intends to convey meaning
to the reader, and is fundamental to a process of telling the story. With
respect to any treatment process, this is how the construction is effected. In
the treatment process, the construction of a meaningful narrative between the
autobiographer and his or her audience (for this discussion, the therapist or
therapeutic group) is important, yet the therapeutic environment (the place),
provides an important, perhaps even crucial, part of the therapeutic process (Goffman,
1974).
In private practice, the treatment setting
can be controlled by the practitioner. Office settings, both consulting room and
waiting area, may be designed to provide access to ‘nearby nature’ through
the addition of live plants, water features, and art that is reflective of
nature. This can be done even if the practitioner is a part-time renter. Plants
and artwork need not be permanently affixed if office-mates or landlords object.
These features may elicit a client’s calm and trusting response, recognized as
both immediate and neurally based (Kaplan, R,
1992, Lewis, 1992, Kaplan & Kaplan, 1995). The environment thus has
the potential to provide the perceptual backdrop for the cognitive/emotive work
of the treatment process.
In treating PTSD, several treatment
modalities are seen as particularly useful: Cognitive/Behavioral Therapy (CBT),
Exposure Therapy (ET), and Eye Movement Desensitization and Reprocessing (EMDR)
(Hamblen 2010). Each treats the traumatized by methodically recalling the
traumatic event(s), distinguishing them from the here-and-now present, and
desensitizing the individual to the traumata. They differ in several respects.
CBT focuses on the thoughts and patterns of thoughts of the person with PTSD,
guiding them to recognize those thoughts and patterns, then to revise them to be
more manageable and realistic. CBT also facilitates the development of
strategies to cope with adverse emotional states such as guilt, shame, anger,
and fear (Hamblen 2010). ET focuses the specific memories of trauma,
incrementally re-exposing the individual to the trauma both in words and
behaviors that evoke those traumatic memories, thereby effecting desensitization
(Hamblen 2010). EMDR is, in effect, a blending of CBT and ET. The individual
focuses on specific incidents of trauma, shaped in dialogue with the therapist
as incremental, manageable memories. These memories are discussed in respect to
the individual’s self-views. The memories are then reprocessed (a kind of
imaginal exposure to traumata) in the context of the safety of the treatment
room. The experience of viewing the memories is recognized in the past, in
contrast to the here-and-now. The memories are, in both the development of the
incremental memory and in the eye movement processing, associated with other
like memories connected to the same self-view. All three models, then, can be
seen to provide a similar functional framework for treatment of PTSD. The use of
EMDR, with its technique of eye movement, generates neurological effects
analogous to the Rapid Eye Movement (REM) of dream states (Shapiro, 2001) In
this neurological process, the crossing & recrossing of impulses in the
optic chiasm entrains a cascade of neuro-electric, neuro-chemical and hormonal
effects that capacitates access to associative trains of memories. For PTSD
clients these trains of memories will contain the traumatic material (Shapiro,
2001). For the purposes of this paper I will focus on using EMDR, both for
brevity and because a discussion of EMDR can equally be applied to CBT and ET.
EMDR has only been in development
and use as a practice modality for 30 years but according to Hamblen (2010) it
is internationally recognized as one of the most effective models for treating
PTSD. The model, as developed by Shapiro (2001), is based on the
“state-dependent adaptive information” processes of the brain. By
state-dependency, Shapiro means a perceptually learned sub-network of
information containing affects and cognitions that are, because of their
powerful negative qualities, effectively encapsulated as received rather than
assimilated in the broader field of cognitions and affects. As such, trauma is
stored in memory in an unassimilated and fragmentary form, rather than being
regarded as ‘repressed’ as per the psychoanalytically derived models. The
technique of bilateral stimulation releases the state-dependent memory material
so it can be assimilated and restructured in a new narrative – a state of
being that is affectively and cognitively grounded in the present, rather than
having past states leak continually into the present.
To provide the context for the
therapeutic process of EMDR, a formal frame is developed that contains, aside
from the usual history-taking and diagnostic procedures, a set of questions that
establishes the most available current issue for the client and the most
available past memory that the client associates with that issue. For the
procedure to go forward an imaginal space is constructed with the client using
meditative and guided imagery techniques. Within this formal frame, a sense of
safety is generated for the unassimilated traumatic memories to be brought
forward and restructured in the current narrative space.
To
facilitate the development of safety in the formal frame of treatment,
horticultural activities can be utilized to great effect.
The therapeutic goal of the use of horticulture is to establish client
therapist rapport through real-time activity in common as well as providing the
stress reductive and mood enhancing neuro-endocrine and physiological effects of
the Mycobacterium vaccae contained in garden soil (Carr,
2007, Pekker, 2009).
A
sample treatment plan for this procedure is as follows:
Target
population: Physically abused Post
Traumatic Stress Disorder clients.
Activity treatment goals:
The goal is to establish client-therapist rapport in a real-time safe
space in a gardening context. More than a backdrop or décor, the gardening
activities join client & therapist in a common activity that generates a
safe, soothing atmosphere, provides a metaphor for change and a realistic sense
of control for the client.
1)
Activity #1: Introduction to
garden: elicitation of thoughts and feeling about being in the garden an
horticultural activities; beginning of real-time placement of self in the garden
space; tactile & kinesthetic experience of self through working with soil
and plants
2)
Activity #2: Visualization:
Elicitation of fantasy images of safer or more relaxed space; introduce tactile
and kinesthetic properties derived from real-time gardening activities;
elaborate safe-space images introducing actual gardening activities.
3)
Activity #3: Cognitive Reframing:
Eliciting fearful memories in context of elaborated real-time safe-space
visualizations already associated with tactile and kinesthetic experiences of
self in gardening activities; the real-time physical experience is meant to
provide a clear distinction so present & past experiences can be clearly
distinguished.
Completion time: Each
session with client is 1 hour; estimated duration of treatment 12 – 15 weeks.
Materials needed:
Table & chairs; outdoor
derived garden soil (cannot be sterilized soil; the Mycobacterium vaccae bacteria must be present); water & watering
can; 2 assorted herbs (e.g., basil, parsley, rosemary, thyme, etc.) 2 assorted visually colorful or interesting
plants (e.g., coleus, coral bells, lavender); broad, round scoop; 4 plastic 6”
pots & bases; plant labels & marker. This will be for every session.
Pre-session preparation:
Client history & assessment; have plants and planting materials ready to
hand. Discuss with client being in the garden or (in colder months) handling
plant materials & soil. Have
slightly more soil than needed for potting in a plastic tub; have plant material
(seedling plugs) individually separated from flats but still in cell-packs.
Placement of tools and
materials: Have plants, tools & materials at the sides of table or in cart
near table.
Step-by-step instructions:
1)
Introduce garden & gardening activity:
a.
Discuss gardening activity with client.
b.
Ask client which plants they would like to start potting.
c.
Discuss potting procedure.
i.
Plant selection
ii.
Pot retrieval
iii.
Fill pot with ¾ - 1” soil
iv.
Remove plant from cell-pack
v.
Place plant to be potted in center of pot
vi.
Fill soil around plant to just above soil of plant plug
vii.
Gently press soil around plant
viii.
Put pot in base
ix.
Water until about 1/10 inch of water appears around base of pot.
x.
Discuss, throughout gardening process the feel of the soil making pt
aware of their movements and sensations
2)
Visualization:
a.
Elicit imaginal safer-space through discussion with client
b.
Develop with client slow-breathing rhythm.
c.
While client is doing slow breathing ask them to think of & describe
safer space.
d.
As client is describing safer space, ask them to think about the
sensations, movements and emotions that were felt during gardening activity.
e.
Ask client to describe those sensations, movements and emotions.
f.
Ask client to imagine those sensations, movements and emotions within
their safer space.
g.
Ask client to continue rhythmic breathing and hold image & sensations
of safer space.
3)
Cognitive Reframing:
a.
While client is in safer-space image that is interwoven with the
sensations, movements and emotions of the gardening activity, remind pt they are
in the garden space with the therapist.
b.
Ask client to describe an image of the last time they had a fearful
memory of the incident/incidents that traumatized (or hurt, or frightened) them.
c.
Ask client to look at the image from their safer garden context.
d.
Begin EMDR procedure as described in Shapiro (2001)
e.
Discuss memories, negative self-thoughts, wished-for positive
self-thoughts, emotions and physical sensations connected with the memories.
f.
Ask client to distinguish memories, negative self-thoughts, emotions and
physical sensations connected to memory from sensations, movements and emotions
generated though gardening activity and within safer-space image.
g.
Utilize further EMDR processing to install (establish the cognitive field
of) the processed memories and current emotional states,
h.
Return to rhythmic breathing and visualization process to help client
focus on and maintain the distinction between past and present states.
4)
Repeat progressively each session, modifying horticultural activity from
planting to tending, ensuring soil contact for each session.
Conclusion
The collective goal of psychotherapeutic
talk therapy and EMDR/desensitization treatments with clients with PTSD is to
engender a more complete, more emotionally flexible narrative. The integration
of therapeutic horticulture in the treatment process as described in the sample
treatment plan above may help facilitate a grounding of the sense of
self-in-the-environment. This exemplifies the Kaplans’ aesthetic and cognitive
model of response of nearby nature. In a well-designed private
practice setting the client encounters “nearby nature” in the office and,
through working with that learned actual and imaginal experience of plants, is
empowered to restructure their own narrative space. As an integral part of the treatment plan, the client is
encouraged to encounter natural settings and work with plant materials in and
out of the office setting, in imaginal and actual forms. In so doing the client
may generate a reformulated gestalt that opens up the narrative space. This
space is now no longer the privileged component, as in the talk therapy model,
but it is integrated into a frame of physical actions, a newly established
rhythm within physical and social environment – a new, grounded and safe
gestalt against which – as a figure to a ground – the painful affects and
states of being can be engaged and discharged.
Further empirical study is required to establish the extent and
ramifications of this treatment process.
Integrating the therapeutic use of
horticulture with visualization and EMDR allows deconstruction of past
experience, construction of new experience, and reconstruction of the narrative
reflective of behavioral sequencing. The introduction of plants and gardening as
a focus, then installing via EMDR as metaphor of change and as a calming
activity, described in the sample treatment plan allows an integration of
therapeutic horticultural practices and EMDR.
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