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Br J Gen Pract. Feb 2012; 62(595): e127–e134.
Published online Jan 30, 2012. doi:  10.3399/bjgp12X625193
PMCID: PMC3268492
Primary-care based participatory rehabilitation: users’ views of a horticultural and arts project
Elizabeth A Barley, PhD, health psychologist, registered nurse and researcher
Section of Primary Care Mental Health, Institute of Psychiatry, King’s College London, London
Susan Robinson, PhD, sociologist, non-clinical primary care researcher; knowledge management & research officer
Lewisham Primary Care Trust, London
Jim Sikorski, MRCP, MRCGP, GP, honorary research fellow and chair of trustees
Sydenham Garden, London
Address for correspondence Elizabeth Barley, Health Services and Population Research Department, PO Box 28, Institute of Psychiatry, King’s College London, De Crespigny Park, London, SE5 8AF. E-mail: elizabeth.barley/at/iop.kcl.ac.uk
Received June 14, 2011; Revised August 18, 2011; Accepted October 3, 2011.
Background
Participation in horticulture and arts may improve wellbeing in those with mental and physical illness.
Aim
To conduct an in-depth exploration of the views and experience of participants of a primary-care-based horticultural and participatory arts rehabilitation project (Sydenham Garden).
Design and setting
Qualitative interview study of a primary-care-based horticultural and participatory arts rehabilitation project in South London.
Method
Semi-structured interviews were conducted with 16 participants (referred to as ‘coworkers’) of Sydenham Garden. Seven were female. Participants were aged between 38 and 91 years and had a range of severe mental and physical health problems; most had depression. The interviews were analysed using constant comparison and thematic analysis.
Results
Data were overwhelmingly positive concerning participation. Coworkers considered participation in the project to promote wellbeing by providing purposeful and enjoyable activity and interest, improving mood and self-perceptions, and providing an escape from life’s pressures. Being outdoors was considered therapeutic. The most-valued aspect of participation was the social contact derived as a result of it. Many of the coworkers who were interviewed developed transferable skills, including nationally recognised qualifications, which they valued highly.
Conclusion
Delivery of horticultural therapy and participatory arts is a feasible model for improving wellbeing in patients in primary care who have serious illness. Longer-term studies are needed to address what happens to people after leaving such projects.
Keywords: horticultural therapy, mental disorders, participatory arts, primary care, rehabilitation
Wellbeing is enhanced by connecting with and giving to others, learning new skills, being active, and taking notice of one’s environment.1 Activities such as social and therapeutic horticulture (STH) and participatory arts for patients with significant illness can provide opportunities for enhanced wellbeing.2-4
STH projects have been identified in a number of countries, including the UK, the US, and Sweden.5 The therapeutic aspect of the intervention may vary across settings; for instance, the American Horticultural Therapy Association defines horticultural therapy as:
The engagement of a person in gardening-related activities, facilitated by a trained therapist, to achieve specific treatment goals’.6
However, the less professionalised, more open approach of ‘therapeutic horticulture’ can be delivered by a variety of healthcare providers and is:
‘… a process that uses plant-related activities, through which participants strive to improve their wellbeing through active and passive involvement’.7
All STH involves group participation by people who are vulnerable; the activities are based around horticulture and take place in a formalised environment.8 Benefits of STH may include:
  • increased self-esteem and self-confidence;
  • development of horticultural, social, and work skills;
  • literacy and numeracy skills;
  • increased wellbeing;
  • the opportunity for social interaction; and
  • development of independence.2
Similarly, art therapy is ‘the use of art materials for self-expression and reflection in the presence of a trained art therapist’.9 However, simple participation in art activities, independent of an art therapist, may also be beneficial and has been suggested to increase self-esteem and emotional literacy, and reduce social isolation.4,10 Art can affect major determinants of health, including the physical environment, education and skills, employment, community cohesion, social exclusion, and access to services.11-14
Sydenham Garden is a primary-care-based STH and participatory arts rehabilitation project for people with significant mental and/or physical illness. Unlike its inspiration, the Blackthorn Trust,15 it does not have an underlying anthroposophical approach to therapeutic activities. Sydenham Garden’s approach is to facilitate meaningful creative activities, carried out as part of a community of coworkers, staff, and volunteers, to deliver significant therapeutic benefits. Users, known as coworkers, are referred by local professionals, such as GPs.
Sydenham Garden includes an area that is managed as a nature reserve and a garden where paid staff, volunteers, and coworkers grow vegetables, herbs, and flowers. Arts groups are held weekly in the garden. Produce is used by the coworkers or sold by them to the local community at fairs and from a weekly stall. Sydenham Garden is a user-centered service whose coworkers contribute to decision making. However, these coworkers are encouraged to move on to other opportunities after 12–18 months.
The aim of this study was to determine coworkers’ views of participation.
How this fits in
Social and therapeutic horticulture and participatory arts may be beneficial for people with mental illness. Most studies have been conducted in secondary care, but this study shows that patients in primary care who have a range of mental, physical, and social problems report benefit from participation in these activities.
Design
Two authors conducted semi-structured interviews with coworkers. A topic guide, based on the objectives of the project, was developed. The project objectives were devised based on literature review, clinical experience, and expectations of what could be achieved. The project mission statement can be viewed at the project’s website (http://www.sydenhamgarden.org.uk).
Open-ended questions were used to encourage fuller and more meaningful answers. Broad topics included those activities that were liked most and least, perceived benefits of participation, and the importance of being outdoors. All participating coworkers gave written informed consent.
Analysis
Interviews were digitally recorded and transcribed, and a thematic analysis conducted.16 Two authors independently applied open codes to three transcripts and agreed descriptive codes. These, together with new codes, were then applied to subsequent transcripts. Descriptive codes were collated into themes, guided by the topic guide, and a preliminary explanatory framework was devised. This was used as the basis for further coding.
Data for each theme were gathered and coded using NVivo 8 (QSR International). Disconfirming evidence and deviant cases were actively sought,17 and the robustness of themes tested by examining differences and similarities between coded data. Two authors agreed the coding.
The authors’ different backgrounds and level of involvement in Sydenham Garden were also considered.
Sixteen coworkers (of approximately 28 who were registered) agreed to be interviewed. They were aged between 38 and 91 years; seven were female. The diagnosis leading to referral was available for all but one; the majority had depression (Table 1). Those interviewed appear to be representative of those using the project overall. Self-reported duration of attendance was available for 12 interviewees: four had been attending for 2–4 years; two for 1–2 years; five for 3–12 months, and one for 6 weeks. Four participated in both STH and arts groups, seven participated only in gardening, and five only in art.
Table 1
Table 1
Reasons for referral
Interviews were numbered by transcription order. Quotations are identified by coworker interview number (CW1 to CW16), and were selected to illustrate the main points while reflecting views from a range of participants.
Joining and motivations
Several coworkers recalled initial apprehension:
I was a bit worried, but after a couple of weeks, I sort of settled in.’ (CW10)
I didn’t come for ages, until he (GP) sort of said “Well, I really think you should do”, so then I did.’ (CW2)
To help with this nervousness in attending, some coworkers reported being accompanied, initially, by a healthcare worker. Three coworkers reported being very positive about coming: one coworker (CW11) lived near the garden and wanted to be involved in its development; another (CW14) had seen the project featured on television and thought it would be relaxing; and a third (CW7) was actively seeking structured activity, which he believed would help him to cope with his bipolar disorder:
I knew, suffering from the depression the way I do, I needed structure in my week. Because, to me, structure is very important in managing my manic depression. And I love gardening, I love nature and wildlife, so it was an ideal project to get involved with.’ (CW7)
Only one coworker reported being obliged to come by members of his healthcare team:
I wasn’t 100% over happy about doing it. I felt like I was a bit obliged to do it, so I’m not happy about being obliged to do it, but as I done it, I’ve grown to like it a little bit.’ (CW9)
Motivations for attending were to ‘get out’ (of their homes) and to ‘meet people’:
I think [it’s] sort of a social thing, just, you know, getting out and just meeting people and erm, you know, becoming more, more normal.’ (CW3)
The chance to develop a new or existing interest was also often mentioned by participants, the feeling being that this would be beneficial for them:
I’ve always been passionate about gardening and it just seemed to be the ideal opportunity to do some of the courses that those … practical, organic gardening, erm, urban wildlife conservation.’ (CW2)
I, you know, do some sort of things like craft things … I’ve never been a gardener as such, although I would have liked to have been in a way, but … time has been taken up with other things. So that’s how that happened — initially it was the art and craft, then that of course led to being open to trying them both.’ (CW4)
One person (CW5), who had depression at the time of joining, said she wanted to get ‘bucked up a bit’.
Improved wellbeing
Much data concerned the perceived benefits of attending. Only one coworker was less than enthusiastic; one difference between him and the other participants was that the staff at his hostel had made him feel ‘obliged’ to attend. Many aspects of wellbeing were discussed and coworkers expressed valuing not being judged or pressurised:
I can come here and do what I like. And there is no pressure, that’s the other thing. There is no standard to which you have to perform.’ (CW2)
You feel a sense of acceptance, people aren’t judging you … we don’t really know what different people’s situations are, but people, you know, are accepted whatever, and that’s lovely.’ (CW4)
Sydenham Garden also provided participants with a purpose, gave them something to look forward to, and offered a distraction from problems and an escape from life’s pressures:
It’s been really worthwhile coming along, and it’s like you’re doing something, keeping busy, rather than not keeping busy … it’s getting something to do, to look forward to in your mind…’ (CW6)
If I hadn’t come here, I just would have stayed in bed … To be able to come along and engage in some activities — that can help to get you out of it, sort of focus on something else rather than one sitting at home just being able to see what your problems are.’’ (CW4)
Instead of staying at home and watching another makeover programme or cookery programme, or, you know, just feeling sorry for myself or getting off my face on something, I can come here and do what I like … I don’t have to be bothered by my cats or my children or my phone ringing.’ (CW2)
Pleasure was found in aspects such as physical activity, brickwork, making tea, watering, crafts, helping at fairs, painting, and growing things, and garnered from a sense of achievement resulting from participation:
‘… to see the germination of seeds that one has helped to sow; to try out new things, learn new skills … with a sense of achievement at the finished result, no matter what it looks like!’ (CW4)
Participants’ moods also improved while working in the garden:
All three of us weren’t feeling very well, but we all stayed for the session and we got on and we did stuff, and we were all feeling a bit brighter at the end of it.’ (CW7)
However, one participant noted how hard it was to take good feelings home:
If you’re working with nice people, and the weather’s nice and you’re doing a job that you’re enjoying, then you have a nice day; you have a good session. And I try to take that feeling away with me, but, as I said before, that’s easier said than done.’ (CW7)
In spite of this, more lasting feelings of increased self-worth and self-confidence were also reported:
I’ve learnt that I actually do mean something to people and that’s something I was never aware of before deep into my illness and depression. I hadn’t thought that I mattered to anybody, but coming here, I do. I know that I do because if … I’m not here for a few sessions people actually get very concerned and I get phone calls and I get cards … it’s a lovely feeling.’ (CW2)
I feel more confident in myself because of those tests I’m taking and I’ve passed them, passed one. I can say “I’ve done it!”’ (CW8)
Dramatic lifestyle changes were also reported:
This is far better than a GP handing out diazepam and trimazepam [sic] to people. And since I’ve been here, I’ve not been on any antidepressants. I stopped taking them.’ (CW2)
I stopped taking benzodiazepine and I’ve stopped drinking … I found, with the drink, if I know I’ve got this to come to, I don’t want to drink the night before, because then I feel rubbish the day after. So when I was drinking, I would avoid drinking on the nights before the project. But now, I’ve knocked it on the head completely and that has made a difference, because the depressive episodes that I do still get … are a lot less severe.’ (CW7)
Relationships
Personal relationships and their benefits dominated most interviews. All interviewees, when asked what they liked best about Sydenham Garden, mentioned social contact. This could be with other coworkers, staff, or volunteers:
I mean one of the joys of coming up here is having someone to talk to. Make conversation, talk about this and that, or what I’m going to have for dinner or whatever.’ (CW15)
Two participants (CW5 and CW6) reported that staff, coworkers, and volunteers got on well together. Relationships were considered ‘caring’ and ‘encouraging’ respectively (CW3, CW8). There was no key worker system, as is common with other mental health services, and staff and coworkers were considered to have equitable relationships — as one participant commented:
…they [staff] don’t treat you like you’re nuts!’ (CW14)
A spirit of collaboration rather than hierarchical therapeutic roles is encouraged at Sydenham Garden; this may also explain why there was no overt discussion of personal therapeutic relationships between staff and coworkers.
Empathy towards fellow coworkers was evident. One coworker (CW8) explained that you have to ‘take people as they are’ because ‘one day, I might do the same (upset them) to them’. Two people felt that seeing others who are in worse health put their own problems into perspective, and two coworkers maintained a friendship that extended outside of the garden project:
I help her, she helps me and she has, like, children. She comes to my house; I’ve been to her house. That’s an added dimension in my life that I wouldn’t have had if I hadn’t come to this project.’ (CW2)
For others, the garden was their only chance to socialise:
I was socially very isolated. I still am, in reality, because these sessions go very quickly when you’re enjoying yourself.’ (CW7)
Ownership
Ownership was discussed in terms of both the contribution participants felt they made and having a sense of ‘belonging’:
The salad that goes with the barbeque has actually been grown in the garden and picked and prepared by people here, you can’t beat it … It’s an “ownership”. Everybody’s taken ownership of the project.’ (CW2)
I treat it as my own garden in a way. I feel a sense of belonging and a sense of ownership towards the project.’ (CW7)
However, in people who have low self-esteem or confidence, claiming ownership can be difficult; some participants downplayed the contribution they had made:
I mean a little bit (of a contribution), not a great deal. I mean there are lots of jobs to be done here at the end of the day.’ (CW9)
… well there’s a lot more people in this garden, I’ll be honest, they’ve done a lot more work to what I’ve done.’ (CW12)
The coworkers’ sense of ownership was evident in that they had fundraising ideas and plans for the garden, such as building a ‘soak away’ for drainage. However, in a minority, the sense of ownership led to feelings of resentment when things did not go their way, such as: when their ideas had not been carried out; when, on one afternoon, men are excluded; or in tensions between groups over use of space:
It’s a women’s only group in the morning, which I felt a bit miffed about, because I felt it’s a community garden, I’m part of the community, why can’t I be here?’ (CW15)
‘‘Cause as soon as I put [suggest] something, I get pulled back ‘cause someone else has got it all.’ (CW8)
There is integration with art and craft and gardening but it doesn’t always quite work and, as somebody who hates any sort of conflict, who likes there to be complete harmony … I’ve wondered how it could be better integrated.’ (CW4)
Being outdoors
Both the gardening and the arts and crafts group members said they preferred to work outdoors; for the latter, however, this may depend on the season:
…’cause summer and spring’s lovely, but I’m not keen on mucky gardens in the winter!’ (CW13)
People talked about the project making them ‘feel better’ (CW5), ‘feel good’ (CW3), or as though they were ‘making a difference’ (CW11). The reasons given were that the garden was ‘peaceful’ (CW5), ‘an area of reflection’ (CW4), ‘relaxing’ (CW8, CW10), ‘therapeutic’ (CW8, CW6), and that it was possible to ‘see things growing’ (CW5), and feel in touch with nature (CW6, CW14). The garden was also considered ‘pretty’ (CW5), ‘a lovely setting for crafts’ (CW4), and, overall, an inspiration for art:
You just feel better, in yourself I think … Fresh air and I love flowers and plants and all that. I just feel better for it.’ (CW5)
When asked specifically about the nature reserve, responses were more mixed. Appreciation of the bird and pond life there was expressed. Two people (CW13, CW16) liked this area best:
The bit I like is the bit where it’s like the natural meadow, and you almost feel it’s like a little bit of very natural countryside. I like that bit most of all.’ (CW16)
However, five said they hardly ever visited the nature reserve area because they preferred the work in the garden and because there was nobody to talk to there:
Interviewer: ‘Is there a reason you don’t go [into the nature reserve]?
CW1: No it’s, it’s just nobody’s there.’
Three older coworkers complained of a lack of accessibility because the paths were too rough.
Transferable skills
Many of the coworkers had learned new gardening, ecology, or craft skills. Five participated in taught courses; all enjoyed the learning aspect of this. Some coworkers used their new skills at home — for instance, one made Christmas cards and gifts — another had been inspired to tidy her own garden, and one man had developed an interest in photography:
Then I bought myself a camera and started taking photographs, which was good because it gave me something to do at home as well.’ (CW15)
For some time this coworker took on the role of project archivist.
Summary
Users of this primary-care-based STH and participatory arts rehabilitation project reported many benefits of participation. Despite some initial anxiety about attending, the coworkers felt a sense of ownership of the garden; they felt they contributed to it and belonged there. Some coworkers downplayed this, possibly due to existing feelings of reduced self-worth.
There was consensus that participation improved wellbeing by providing purposeful and pleasurable activity, an escape from problems, and improved mood and self-perceptions. The social contact the project provided was especially important to the coworkers.
The experience of being outdoors was also considered beneficial. Appreciation of nature was apparent and users appeared to link this with improvements in their mood. Having a reason for being outdoors, such as gardening, producing crafts, or socialising, was important — this was evidenced in participants’ comments as well as the fact that some of them were less likely to visit the nature reserve, where there is no work to do and no people to see.
Whether benefits experienced in the garden transferred to life away from it is difficult to determine. Although some coworkers reported applying new interests at home, one described having difficulties maintaining the improved mood experienced in the garden once at home; in addition, for some participants the garden was their only chance for social contact. Nevertheless, many had gained transferable skills and obtained nationally-recognised qualifications awarded by the Open College Network for courses undertaken at Sydenham Garden. In addition, two coworkers reported reductions in medication use and drinking since becoming involved in the project.
The views of those participating in STH, compared with arts activities, appeared consistent, but some individuals participated in both and it is not possible to determine from this study which is more beneficial. However, given the variation in views concerning being outdoors and in activity preferences, it appears that, by offering contrasting activities, the project may meet the needs of more people.
Strengths and limitations
Just over half of coworkers agreed to be interviewed. A policy of not pressurising coworkers to perform exists at Sydenham Garden; the data show that this is valued. In keeping with this philosophy, care was taken not to pressurise individuals when recruiting participants for the study. It is possible that those who refused had the highest levels of anxiety and depression but, as data about those who did not want to participate were not collected, it was not possible to test this.
Within this study design it is also not possible to test whether participants with more severe illness report different views. The possibility that those interviewed were more engaged in the project was considered; and duration of attendance may be used a proxy for engagement. In this study, some interviewees had been attending for several years and some only a few weeks; views did not appear to vary depending on duration of attendance.
The study did not measure objective changes in wellbeing or functioning; instead users’ accounts were elicited. Although these overwhelmingly indicated benefit, only a controlled trial can determine whether more benefit is gained than through usual care or other interventions. Nevertheless, qualitative work is important in informing the design, feasibility, and acceptability of such projects, as well as why they may work;4 it also helps in understanding users’ perspectives — an element that is often lost in trial design.
During the research period, the project capacity was growing slowly. Garden activities were run by two full-time horticulturalists and art and craft activities were run by a volunteer coordinator who had trained as an art teacher. Both garden and art and craft activities were assisted by volunteers who enabled small-group or one-to-one accompaniment of those coworkers who were less confident. Each session (lasting 2.5–3 hours) catered for a maximum of 10–12 coworkers and there were six garden and two art and craft sessions per week. The vulnerability of the client group led to considerable fluctuations in attendance from week to week, and sessions were not run at full capacity. It was not possible to assess whether the size of session groups had any effect on outcomes.
A proportion of those interviewed had been attending the project for 2–4 years. Sydenham Garden is an evolving scheme and the possibility that coworkers may develop a dependence on this community has been noted; as such, the project now accepts new coworkers on the understanding that their placement will last for a period of 12–18 months.
Comparison with existing literature
Although the majority of referrals to the project are from GPs and community mental health teams, some also come from other voluntary agencies; these individuals are commonly considered as having an intractable condition and they are often viewed, by those who refer them, as limited in their ability to undertake new activities, despite conventional treatments.
Social Functioning Scale scores18 were available for a subset of 20 coworkers (including the 16 who were interviewed for this study) attending the project at the time of this evaluation; these scores indicate considerable unmet need and isolation (median Social Functioning Scale total score: 101.6, range 77.4 to 117.6). These, together with other quantitative data relating to Sydenham Garden coworkers, are available on the Sydenham Garden website (http://www.sydenhamgarden.org.uk/news/28/66/Research-shows-Sydenham-Garden-s-impact); results support the current qualitative findings of poor social functioning in this group.
Overall, according to the Social Functioning Scale scores, the coworkers referred to Sydenham Garden are comparable to those with enduring psychosis who participated in an earlier feasibility study of a primary-care-based care management and occupational therapy intervention.19 In that study, social functioning was seen to improve at 12 months following intervention, although a lack of a control group means it is not certain that the improvement can be attributed to the intervention.
Two coworkers reported friendships extending outside the project; this is an expected result for any group of diverse people gathered together to participate in a programme and tallies with findings from a time-banking project20 with similar aims. Engagement with the wider community was not mentioned even though coworkers at Sydenham Garden engage with the local community at annual fairs and at a weekly stall. This observation is supported by findings of a review of studies regarding the effect of participation in art on mental health,4 which found greater effect on empowerment than on social inclusion.
The current finding that participants perceived benefits from being outdoors is supported by evidence from trial findings that individuals with a range of mental health problems reported greater mental health benefits after exercising outdoors, compared with exercising indoors.21
Implications for practice and research
Funding for the period of this research came entirely from charitable trusts and the UK Lottery Fund; no grants were received from health or social care agencies. Although Sydenham Garden activities were additional to normal current provision, it is interesting that local commissioners were reluctant to fund them: a survey undertaken in 200422 found the mean cost of an individual client placement (£53.68) in 836 projects providing STH activities compared favourably with NHS trust day-care costs of approximately £54 per day (two sessions) for people with mental health problems. During the study period, coworkers were able to attend two sessions per week. As a result of this variation in attendance, and because there was a lack of routine while monitoring data during the research period, it was not possible to provide a reliable estimate of cost per coworker or cost per session.
This study has shown that delivery of STH and participatory arts is a feasible model for improving wellbeing in patients in primary care who have serious illness. People with serious health and social problems perceive a range of benefits of participation, including the obtainment of nationally recognised qualifications and other transferable skills. Practitioners in primary care may consider referral to STH and participatory arts projects as a potentially beneficial intervention for those with mental health problems and other long-term conditions; however, longer-term studies are needed to address what happens to people after leaving such projects.4
Acknowledgments
The authors would like to thank the staff and volunteers of Sydenham Garden who facilitated this study and, of course, the coworkers for giving their time and opinions.
Notes
Funding
This study was funded by the Maudsley Charity (Ref LG231), the UK Department of Health via Lewisham Research Unit, and Natural England. All funding was specifically for the evaluation.
Ethical approval
Full ethical approval for the study was obtained from Lewisham Research Ethics Committee (ref no 07/Q0701/27).
Provenance
Freely submitted; externally peer reviewed.
Competing interests
Elizabeth Barley and Susan Robinson report no potential conflict of interest. Jim Sikorski is chair of trustees for Sydenham Garden.
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