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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



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.


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.




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.




American Horticultural Therapy Association 2009 History [Electronic version] Retrieved October 2010 from http://www.ahta.org/content.cfm/id/history

American Psychiatric Association (1994) Diagnostic and Statistical Manual of Mental Disorders, 4th Ed.; Washington, DC: AMA

 American Psychological Association (2010) The Critical Need for Military and Civilian Mental Health Professionals Trained to Treat Post Traumatic Stress Disorder and Traumatic Brain Injury.  [Electronic version] Retrieved October 2010 from http://www.apa.org/about/gr/issues/military/critical-need.aspx Posted 2010,

Benstock, S., Ed.: 1988 The Private Self.  Chapel Hill, NC: University Of North Carolina Press.

Brown, AJ (2003) Most Orthopaedic Trauma Patients Experience Post-Traumatic Stress Disorder. [Electronic version]  Retrieved 02/15/2003, from http://www.medscape.com/viewarticle/448963 

Brush, Stephen B.  (1993) Indigenous Knowledge of Biological Resources and Intellectual Property Rights: The Role of Anthropology. American Anthropologist:  95 (3), 653–671

Carr, M (2007) How Gardening Could Cure Depression. Cosmos Magazine. [Electronic version] Retrieved 03/13/2011, from http://www.cosmosmagazine.com/news/1154/how-gardening-could-cure-depression

Catlin, P. (2006) Activity Planning. in R.Haller, and C. Kramer (Eds.) Horticultural Therapy Methods (pp 33 – 57). NY: Haworth Press,

Davis, S. (2003) Development of the Profession of Horticultural Therapy. In S. P. Simpson and M. C. Straus (Eds.) Horticulture as Therapy. (pp 3-18). New York: Food Products Press,

Goffman, E. (1974) Frame Analysis NY: Harper and Row

Gomez, A. (2009) EMDR for Children and Adolescents.  Talk presented at Binder-Britt EMDR Workshops 4/3-4/09, Stamford, CT

Hales, M. (2000) Monastic Gardens New York: Stewart, Tabori and Chang

Haller, R. 2006a The Framework. In R.Haller and C. Kramer (Eds.) Horticultural Therapy Methods. ( pp 1-22) NY: Haworth Press

Haller, R. 2006b Goals and Treatment Planning: The Process in R.Haller, and C. Kramer (Eds.) Horticultural Therapy Methods NY: Haworth Press pp 23-37

Haller, R and C. Kramer (Eds.) (2006) Horticultural Therapy Methods. NY: Haworth Press

Herman, J (1992) Trauma and Recovery. New York: Basic Books

Hofer, M.A. (1994) Hidden Regulators in Attachment, Separation, and Loss. Monographs of the Society for Research in Child Development.  59:192-207.

Horticultural Therapy Institute (2010) Career Choices webpage [Electronic version].  Retrieved January 2010 from http://www.htinstitute.org/careerchoices.htm http://www.htinstitute.org

Horrowitz, M (1976) Stress Response Syndromes. New York: Jason Aronson.

Janick, J (1992)   Horticulture and Human Culture. In D.Relf (Ed.) The Role of Horticulture in Human Well-Being and Social Development: A National Symposium. (pp 19-27) `1, OR: Timber Press

Kaplan, R. (1992) The Psychological Benefits of Nearby Nature.  In D.Relf (Ed.) The Role of Horticulture in Human Well-Being and Social Development: A National Symposium. (pp 125 -133). Portland, OR: Timber Press 

Kaplan, S. (1992)   The Restorative Environment: Nature and Human Experience In D.Relf (Ed.)  The Role of Horticulture in Human Well-Being and Social Development: A National Symposium. (pp 134-142). Portland, OR: Timber Press

Kaplan, R and S.Kaplan (1995) The Experience of Nature.  A Psychological Perspective Ann Arbor, Michigan: Ulrich's Bookstore

Landsberg, S. (2003) The Medieval Garden Toronto, University of Toronto Press

Lewis, C.A. (1992)   Effects of Plants and Gardening in Creating Interpersonal and Community Well-Being. In D.Relf (Ed.) The Role of Horticulture in Human Well-Being and Social Development: A National Symposium. (pp 55-65).  Portland, OR: Timber Press

Levine, P (1997) Waking the Tiger. Berkeley, CA: North Atlantic Books

Liebschutz, J, R.Saitz, Brower, V. Keane, C.Lloyd-Travaglini, T.Averbuch, and J.Samet (2007) PTSD in Urban Primary Care: High Prevalence and Low Physician Recognition. Journal of General Internal Medicine. 22(6): 719–726.

Lorber, Howard Z. (2001) Powerful Events [Electronic version] Retrieved October 2010 from www.allbluescounseling.com/writings/powerful_events 

Marcus, G.E. and M.M.J.Fischer (1986) Anthropology as Cultural Critique. London and New York: Oxford University Press

Mattson, R.H. 1992 Prescribing Health Benefits Through Horticultural Activities. In  D.Relf (Ed.)  The Role of Horticulture in Human Well-Being and Social Development: A National Symposium (pp 161-168). Portland, OR: Timber Press

McDonald, B.G. and A.J.Bruce (1992) Can You Have a Merry Christmas Without a Tree? In  D.Relf (Ed.)  The Role of Horticulture in Human Well-Being and Social Development: A National Symposium. (pp 38-42). Portland, OR: Timber Press

McFarlane, A. C. (1996). Resilience, vulnerability, and the course of posttraumatic reactions. In B. Van der Kolk, A. C.McFarlane, and L.Weisaeth (Eds.) Traumatic stress: The Effects of Overwhelming Experience on Mind, Body, and Society.  (pp. 214-241). New York: Guilford.

McKinney, Kelly (2003) Beyond Care and Control: Therapeutic Interventions for Survivors of Torture and Refugee Trauma Unpublished Doctoral Dissertation, Graduate Faculty in Anthropology, City University of New York, New York

McNally, R.J. (2006) The Expanding Empire of Posttraumatic Stress Disorder. [Electronic version] Retrieved 26 April 2006 from http://www.medscape.com/viewarticle/528984?src=mp

Moran, M. (2004) Many More People Seeking MH Treatment Since 1980s.  Psychiatric News  39(19): 15

Natson, D. and A.Burlingame (1960) Therapy Through Horticulture. NY: Macmillan

Ogden, P, and K.Minton (2000) Sensorimotor Psychotherapy: One Method for Processing Traumatic Memory [Electronic version] retrieved January 2010 from http://www.fsu.edu/~trauma/v6i3/v6i3a3.html

National Institutes for Mental Health (2009) Post-Traumatic Stress Disorder [Electronic version] Retrieved January 2010 from http://nimh.nih.gov/health/publications/post-traumatic-stress-disorder-ptsd/nimh_ptsd_booklet.pdf  

Pekker, M .(2009) Therapeutic Gardening Against Clinical Depression. Retrieved March 2011 from


 Porges, S.W. and G.F.Lewis (2009) The polyvagal hypothesis: common mechanisms mediating autonomic regulation, vocalizations and listening. Handbook of Behavioral Neuroscience, 19: 255-264
Relf, D. (Ed.) (1992) The Role of Horticulture in Human Well-Being and Social Development: A National Symposium Portland, OR: Timber Press

Relf, D. (2003) People-Plant Relationship. In S.P.Simpson, and M.C.Straus (Eds.) Horticulture as Therapy. (pp 21- 42).  New York: Food Products Press.

Romano, M. (2006) Trauma Now Nation's Costliest Medical Problem [electronic version] Retrieved January 2006 from http://www.aast.org/Membership/catc_details.aspx?id=1226  

Saksida, L. (2009) Remembering Outside the Box. Science 325: 40-41

Shapiro, F. (2001) Eye Movement Desensitization and Reprocessing 2nd Ed. NY: The Guilford Press

Schacht, T. (2006) Making Psychotherapy Work in Primary Care Medicine. American Family Physician 73(1):34-37

Schweitzer, M., L.Gilpin, S.Frampton (2004) Healing Spaces: Elements of Environmental Design. The Make an Impact of Health. Journal of Alternative and Complementary Medicine. 10 (supplement 1): S71-S83

Shear, M.C., A.Zuckoff, and E.Frank (2001) The Syndrome of Traumatic Grief  [Electronic version] Retrieved 4 Aug 2004 from  http://www.cnsspectrums.com/article.php3?id=56 Simpson, S.P. and M.C.Straus (Eds.) (2003) Horticulture as Therapy. New York: Food Products Press

Solecki, R.S. (1977) The Implications Of The Shanidar Cave Neanderthal Flower Burial.  Annals of the New York Academy of Sciences July: 114–124

Ulrich, R 1984 A View Through a Window May Influence Recovery from Surgery. Science 224: 420-421

Ulrich, R.S., and R.Parsons (1992) Influences of Passive Experiences with Plants on Individual Well-Being and Health. In  D.Relf (Ed.) The Role of Horticulture in Human Well-Being and Social Development: A National Symposium. (pp 93 –105). Portland, OR: Timber Press

Van der Kolk, B.A. (1996) The body keeps the score; Approaches to the psychobiology of posttraumatic stress disorder. In  B.Van der Kolk, A.C.McFarlane, and L.Weisaeth (Eds.) Traumatic stress: The Effects of Overwhelming Experience on Mind, Body, and Society. New York: Guilford. (pp. 214-241).

Van der Kolk, B., A.C.McFarlane, and L.Weisaeth (Eds.) (1996) Traumatic stress: The Effects of Overwhelming Experience on Mind, Body, and Society.  New York: Guilford.

Hamblen, J (2010) Treatment of PTSD.  [Electronic version] Retrieved March 2010 from http://www.ptsd.va.gov/public/pages/handouts-pdf/handout_TreatmentforPTSD.pdf    

Vinson, D.C.,  V.Arelli (2006) State Anger and the Risk of Injury: A Case-Control and Case-Crossover Study. Annals of Family Medicine 4: 63-68

Woolf, Virginia (1976) Moments of Being. J.Schulkind (Ed.)  New York: Harcourt, Brace, Jovanovich. 

Wirchrowski, M. (2006) Skills and Theories to Inform Horticultural Therapy Practice. Journal of Therapeutic Horticulture XVII: 49-54