Green Therapies for Personality Disorder
Growing Better Lives is a community interest company that offers a Greencare intervention to patients diagnosed with personality disorder, or those without formal diagnosis but have long-term severe mental health conditions. These conditions affect all areas of life and people often suffer discrimination, stigmatisation and social isolation.
There is significant unmet treatment need and people who seek help often have poor experience of statutory services and expect rejection. They also seek relief in ways that result in unhelpful medicalization or involvement with the police or social services. Drop-out rates are high as people find it hard to complete challenging treatment and, because rehabilitative services are rare, many people who do manage to complete treatment find it hard to rebuild an ordinary life. A key objective of the intervention described here is to engage and stabilise individuals in a way that is not possible in NHS services, through using the principles of Greencare and enabling environments.
This preliminary research was designed to describe and explore various aspects of Greencare to produce a basis for future stages of research including examining areas of clinical benefit such as engagement, commitment and medication use.
THEMES AND NARRATIVES
Therapeutic benefits of Greencare
Therapeutic in its own right: Addressing issues that aren’t typically focused on in NHS services, Greencare aims to enhance social skills, allow people to re-connect and to build relationships by working together as a team. Service users felt that the Greencare environment may help people who have problems interacting with other people and allows people to avoid being isolated and not feel alone – yet at the same time providing both that space for people to be alone as well as to engage with others and feel part of a community.
“I suffer a lot obviously being social with people, this has made me come out a bit more to be honest, coming here”.
Alongside other therapy: One intended purpose of Greencare was to offer a space for clients to counter tense, anxious feelings experienced in therapy at hospital; it provides a balance and an alternative environment. Service users say it helps after difficult therapy sessions by allowing them to relax, calm down and to re-focus. Greencare is considered less intense and a chance to unwind after their therapy at Upton: as one member said:.
“I suppose you could liken it to an athlete, so when they’ve done their work-out they then do their stretches to come down and this is a bit like that”
For some, Greencare can act as a distraction from difficult therapy issues – yet for others, aspects of the activities will challenge their personal therapy issues (for example eating lunch together for someone with food issues).
Emotional state: There was complete agreement from services users that they generally felt better after a Greencare session, that it produced a positive effect on mood. Even before starting Greencare sessions, members voiced expectations that Greencare would have a positive impact on mood. Greencare was seen as offering a release from stressful and difficult emotions and enabled people to calm down and lower the agitation
The Environment
Being a natural environment: Greencare provides the physical and mental space that people wanted: there was overwhelming belief that the environment in which Greencare was conducted was very important. The site was associated with being natural and peaceful; a place of tranquillity
“I see it as mindfulness on a big scale; peace, quiet…somewhere to chill”
The horticultural aspects of the environment were appreciated, it was thought of as not ‘neat gardening’ (described as “organised, pruning roses, cutting grass”) but as wilder, a nature reserve. This outside environment is important even when the weather is bad and activities take place in the yurt.
“Here we’re in the open I think, we’re surrounded by the outside even though we’re in a room we’re still surrounded by the outside and I think that perhaps helps”
Not a clinical setting: Service users clearly appreciated being in a ‘non-hospital’ setting. They commented on a sense of the place belonging to them, away from the stigma associated with being in a mental health hospital. The setting was considered ‘non-judgemental’ again suggests being away from the stigmatisation of a hospital.
“Very different…like here is a hospital…corridors people come down all the time”
Greencare is able to take therapy away from a ‘clinical’ setting; the contrast in environment between Athena Therapy Centre and Greencare may complement each other – providing a balance, different settings for different purposes – and that transition seems very important to clients.
The Activities
The different activities: Varied activities are undertaken: gardening being the most prevalent or other outdoor work on the environmental centre site. The knowledge gained through these activities was appreciated and encouraged some people to do gardening at home: this enabled people to feel a sense of achievement. The use of animals in therapies is limited in the current Greencare session but something service users want and believe would be therapeutic. Other activities include cooking and craft work which were also enjoyed (particularly in bad weather!). In some aspects, the activities at Greencare present a chance for service users to rediscover enjoyable activities that they might have done as a child, thereby acting as positive reinforcement.
How activities are chosen: Service users are presented with a choice of three or four different activities to choose from (with the provision that at least three people take part in an activity): this choice is important to people although some struggle with having to choose and make a decision. Having the space and freedom to choose what to do is an important aspect of Greencare. Allowing choice enables everyone to be involved – even those who dislike horticulture enjoy the cooking and other activities.
Sharing lunch: For many service-users, particularly those that live alone, isolation and loneliness are problems. Being able to share food with others adds a new experience to their daily routine and provides the opportunity to be social and engage with other people. Generally people enjoyed the sharing of lunch at the start of Greencare and felt it enhanced their experience of socialising.
“sitting around the table having lunch, the social side of it that's really important to me, and I really enjoy that”
Travelling to the yurt: Most service users attend Greencare following sessions at Upton Park Hospital, a distance of just over five miles and taking approximately 15 minutes. The actual journey does not seem to be a problem to service users but there are often issues that arise around organising all the details of transport (using taxis, service user cars). For some people the distance from the hospital setting seems to contribute to the therapeutic environment of Greencare and they even identified the travel as part of therapy; finding it a positive aspect rather than a ‘hassle’. The ‘chance to regroup’ suggests the ‘break’ from the hospital setting is viewed as being able to physically leave any negativity experienced during therapy.
“Gives up a chance to re-group I think, the journey here and then the lunch gives you a chance to start again, a chance to re-group”
WHAT IS ‘GREENCARE’?
Greencare is an environment that aims to promote physical, mental, social and spiritual wellbeing through contact with nature and engaging as a community. It offers a range of activities and applies techniques from therapeutic horticulture, care farming, animal assisted therapy and other nature-based approaches which are the subject of investigation by researchers from different countries. Greencare is described and defined in a COST action report which sets it within the context of a number of theoretical and practical frameworks.
Based in a Mongolian-style yurt in the lush green wilderness of Iver Environmental Centre, Growing Better Lives holds weekly sessions for service users at various stages: pre-therapy stabilisation, preparation for therapy engagement, alongside intensive psychotherapy groups, and for step-down groups (leavers from intensive therapy). The weekly sessions involve:
Arriving in time for a simple lunch (provided by the project and often including home grown items)
Formal ‘check-in’: sitting in a circle, all members and staff give a brief update of how they have been feeling since the last group, and any other issues of particular significance.
Agreement of activities. Usually a range of different Greencare activities are available and members and staff participate in minimum-size groups of three.
Formal ‘check-out’: again in a circle, all members and staff say how they are now feeling.
CONCLUSIONS
These are preliminary findings based on a small number of group discussions with services users from different stages of the programme context. The experiences described generally validate the Greencare approach taken and service users acknowledge its therapeutic effect. The natural environment is as important to people as the types of activities undertaken and the community aspects of sharing lunch, working as a team, and general socialisation are all valued.
The programme is continually evolving and this information will help guide the development and set-up of additional groups. Further research developing potential outcome measures for Greencare and assessment/evaluation of individual activities is planned.
