The term “healing garden” brings up a variety of images for most people. The understanding that gardens can support the healing process has gained widespread endorsement over the past decade. Experts who have published articles in research journals and who have written books on the subject claim that landscape-based therapeutic environments, defined as “healing gardens,” promote overall well-being for “users,” including patients, family members, and healthcare providers.

Design researcher Roger S. Ulrich, PhD, at Texas A&M University, has proven that the view to a green landscape can have dramatic positive effects on patients recovering from surgery. Clare Cooper Marcus, a design researcher at the University of California, Berkeley, and Marni Barnes coauthored a groundbreaking book in 1999 called Healing Gardens: Therapeutic Benefits and Design Recommendations. It was the first book to examine healthcare facility types and specific case studies of healing gardens.

The increased interest that such publications have demonstrated in landscape design for healthcare facilities has opened up incredible opportunities for landscape architects. However, the practice of merely listing and packaging healing-garden characteristics is disconcerting. Is a healing garden something magical that happens when the stars are aligned and a healing-garden designer waves his or her wand, or is it “mindful design”? Mindful design is a collaborative process in which owners, users, medical planners, architects, interior designers, artists, and landscape architects work as equal partners in creating an environment that is supportive and restorative.

Many design firms market the assembling of healing gardens as a specialty service, and some firms are sharing a Web site where clients can find healing-garden “specialists.” Various nurseries offer healing-garden products, as well as having healing-garden designers on staff who can personalize a healing garden for the private home. Thus, marketing has often made healing gardens a “product,” much like the Japanese Garden, the Kitchen Garden, the Labyrinth, or the Herb Garden.

In this context, a healing garden is presented as a space that has a specific formula for the placement of elements (like a prescription) that allows the healing to begin. It is usually a contained space, clearly differentiated, labeled-and sold to the highest bidder. Certainly no one actively involved in healthcare design believes in this approach, but the perception of a healing garden presented in this way is the result of our culture's reliance on easy answers and digestible sound bites.

In most cases, therefore, the term “healing garden” refers to a personal, scaled space that is contained and controlled, creating boundaries and limits to where the “healing” begins and ends. But why can't an entire campus, or even a community, be a healing environment? In the introduction to their book, Cooper Marcus and Barnes state, “By the late twentieth century, in many health care settings, ‘landscaping’ came to be seen as merely decoration used to offset the hospital building or perhaps to impress potential customers.” The larger campus landscape that encompasses the driveways, parking, and buildings is sometimes overlooked-and it is a missed opportunity. The landscape, on this scale, can be a meaningful and important part of the fabric of the campus, offering walking paths, courtyards, and an overall expression of the institution's belief in wellness.

In a personal communication, George Tingwald, MD, AIA, director of healthcare design at Skidmore Owings Merrill, shared another perspective on the notion of merely impressing or marketing to the potential user:

People assess “quality” by processing subtle clues: things they can understand easily, that reflect more complex processes. In the case of healthcare, the public cannot “see” the quality of the doctors, operating rooms, diagnostic procedures or therapies. How they assess these qualities is by judging what they do see and know, most strongly by visual first impressions. Showing an appreciation for living, breathing things and the ability to care for them and make them thrive, is one of the most powerful, visceral ways of displaying quality of service. The comfort of knowing that you are in capable, caring hands is the ultimate stress reducer.

Quality-based institutions and service industries, such as universities, museums, and resort hotels, have known and practiced this concept for years. It would only seem logical that this concept is applicable to healthcare. Why not make the entry sequence to a healthcare facility a healing experience? Could the concept of mindful design permeate the entire healthcare campus, including the full integration of all interior and exterior spaces? When is the last time you experienced a healing parking lot, a healing arrival court, a healing waiting room, or a healing cafeteria and dining terrace? The concept of mindful design, with thoughtful intention to create well-designed environments for all spaces, is missing from many healthcare campuses. If healthcare is committed to human-centered care and the healing of the whole person, then landscape and architecture must speak this language, as well.

In her book Human Spaces: Life-Enhancing Designs for Healing, Working, and Living, designer Barbara Crisp defines the concept of a life-enhancing environment as a place built or created to support and sustain the well-being of a particular occupant of time, place, and culture, where the person as a whole, both inner and outer, is engaged in the experience. Referring to built works, the book describes life-enhancing environments as total environments that reconnect mind and body, fostering a sense of place and time and true well-being. Crisp offers a set of contrasts that speak to the nature of life-enhancing design:

  • Body-centered vs image/object-centered

  • Multisensory vs single sense

  • Natural vs synthetic

  • Emphasizing sense of place vs homogeneity

  • Valuing duration (nature's seasons) vs immediacy (the “wow” factor)

  • Collaborative vs ego-centered

Crisp states, “Our environments can and should be seen as agents for transformation, providing what is needed to balance the human spirit-support, nourishment, and peace of mind.” She sees life-enhancing design as a mindful process that is all- encompassing. This carefully designed choreography of spaces, she says, works on many levels to comfort, soothe, and support the activities of the users. Crisp goes on to say that “design's power can only be realized when it is fully recognized and appreciated from the beginning and not as a device to clean things up after the fact. The landscape must influence the architecture and vice versa to appropriately balance and capture the spirit of place.”

Does this concept of creating a mindful landscape design that is supportive and inclusive cost more? Are these spaces more difficult to maintain and operate? Is it problematic to have meaningful design dialogues between the design professionals and users, including patients, families, healthcare providers, and owners? The answer to all of these questions is no. A thoughtful design process costs the same as one that operates in a vacuum and offers no innovation or important breakthroughs. It is not more difficult to maintain a carefully designed landscape environment, and the best projects are always ones in which the collaborators are treated as equal partners in the design process.

World-renowned architect Louis I. Kahn believed that buildings and landscapes were designed to honor those who inhabited them. He saw the activities of his clients as incredibly important, and therefore he spent an immense amount of time getting inside the heads of those people. In the end, he always met the needs of his clients and gave them something they never dreamed they could have. By spending hundreds of hours getting to know how they lived and worked, he was able to challenge tradition and bring innovation to the process. At the Salk Institute near San Diego, for example, Kahn broke from tradition and created a living laboratory that offered the greatest flexibility of function, while creating a humane, day-lit environment for the scientists who worked there.

While we seem to be making big strides in the mindful design of landscapes for healthcare facilities, we have, in fact, barely scratched the surface. Inclusive or holistic design that incorporates a team of collaborators in a comprehensive design process will make a strong impact on the final product. A healing garden should not become a “kit of healing parts”-the landscape equivalent of Hamburger Helper. We need to work harder to understand the full potential of the health center landscape as one that integrates the interior and exterior. This collaborative process described as mindful design, which is universal and does not exclude, can foster and support a healing campus landscape. HD

James Burnett is a principal of The Office of James Burnett, located in Del Mar, California, and Houston, Texas. The firm has collaborated on the design of numerous healthcare campuses across the country. Current commissions include ER1, a major trauma center in Washington, D.C.; Scripps Center for Integrative Medicine and the Salk Institute, both in La Jolla, California; and new replacement healthcare campuses for Intermountain Health Care in Salt Lake City, Utah, and Kaiser Permanente in Santa Clara, California.

For further information, phone (713) 529-9919, visit http://www.officeofjamesburnett.com, or e-mail jburnett@officeofjamesburnett.com.

Bibliography

  1. Cooper Marcus C, Barnes M. Healing Gardens: Therapeutic Benefits and Design Recommendations. New York:John Wiley & Sons, 1999.
  2. Crisp B. Human Spaces: Life-Enhancing Designs for Healing, Working, and Living. Gloucester Mass.:Rockport Publishers, Inc., 1998.

Healthcare Design 2003 May;3(2):20-23