Abstract

In the United States there remains an effort for mental health services to provide holistic options that improve symptomatology while improving social belonging for people diagnosed with serious and persistent mental illnesses. Consequently, the mental healthcare delivery system appears to create community-situated users of services rather than people who are active members of their communities. This article reports on literature associated with the use of horticulture and gardening for mental health recovery and embraces the use of these services to generate enduring and genuine community integration outcomes through professional-community relationships. Conclusions are that mental health services should engage Nature-related programing to provide opportunities that enhance multiple aspects of health and well-being, increase constructive interpersonal relationships that lead to a more authentic social inclusion, and support the destigmatization of mental illnesses.

Throughout history mental health treatments have gone through radical changes that have resulted in the current system of service delivery. In the United States there continues to be many unmet needs for people recovering from severe mental illnesses (Wang, Lane, Olfson, Pincus, Wells, & Kessler, 2005) such as schizophrenia, bipolar, and depressive disorders. Multiple interventions have been employed that seek to fill the various gaps in services (Eisenberg, Kessler, Foster, Norlock, Calkins, & Delbanco, 1993; Jacobson & Curtis, 2000; Kessler, Soukup, Davis, Foster, Wilkey, Van Rompay, & Eisenberg, 2001). Reports by the Surgeon General, U.S. Department of Health and Human Services (1999) and the President's New Freedom Commission on Mental Health (2004) nevertheless emphasize the need for improved national mental health treatments and policies.

The concept of recovery is a set of guiding principles that have emerged as a significant policy model in the public mental health field (Jacobson & Curtis, 2000). Recovery is defined as, "[a] process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential" (The Substance Abuse and Mental Health Service Administration [SAMHSA], 2011). The use of Nature 1 in clinical mental health programming is a valid treatment option for recovery from mental distress. Interventions that employ Nature are specific, goal-directed actions that expose participants to the natural world in order to improve mental and physical health and well-being (Chalquist, 2009). Burls (2006) stresses that environmentally oriented interventions have the additional capacity to engage and authentically incorporate multiple dissimilar populations. Being commissioned in some capacity by multiple professions (Jackson, 2003) these types of services are neither common nor perceived as a readily accessible resource in the United States, especially for people living in urban geographies (Parr, 2007a).

Being exposed to natural settings can increase mood, facilitate positive affect change, and can improve a person's well-being (Moore, 1981; Ulrich, 1981; Ulrich, 1984; Ulrich, Simons, Losito, Fiorito, Miles, & Zelson, 1991). Where unpleasant scenes of the natural world result in reduced positive effects of physical activity, simply viewing pleasant rural and urban natural scenes can significantly improve self-esteem more than exercise alone (Pretty, Peacock, Sellens, & Griffin, 2005). Furthermore, after finding a high statistical significance in decreased symptomatology, Bishop (2010) suggests that photographs of the natural world can positively impact adults on a locked acute inpatient psychiatric unit. Actively participating in Nature has additionally been found to reduce mental distress, enhance self-confidence, improve physical health, and increase the sense of belonging for participants (Sempik, 2008; Sempik & Aldridge, 2006; Sempik, Aldridge & Becker, 2003; Stepney & Davis, 2004; Söderback, Söderstrom & Schälander, 2004).

Natural environments are currently being considered integral in built environments to fashion a more obtainable sense of Nature for people in urban settings (Evans, 2003). Although not widely utilized in the United States, several mental health agencies in the United Kingdom employ Nature-oriented services and continue to authenticate a wide rage of benefits (see Stepney and Davis, 2004) despite a general shortage of scientific documentation. Programs that seek to augment existing evidence-based research are warranted to validate the worth the natural environment for recovery from severe mental illnesses (Sempik & Aldridge, 2006; Sempik et al., 2003). Maller, Townsend, Pryor, Brown, and St. Leger (2002) do not, however, endorse waiting for complete knowledge to be obtained before implementing eco-oriented programming. Delaying the implementation of these services could ultimately prevent the restructuring and restoration processes of the lifestyles of participants (Maller et al., 2002). According to Burls (2006) and Sempik (2008), a multiple-disciplinary approach is encouraged. This method can promote the utilization of green spaces, expand health and wellness outcomes, and increase the amount of research in various professional fields "to bring together the different frameworks used in exploring the associations between nature and health to the specific field of social and therapeutic horticulture" (Sempik, 2008, p. 19, ¶ 3).

Three standardized literature searches were completed for the purposes of this article. 2 Results revealed a general lack of empirical data associated with Nature for recovery from severe psychiatric conditions and improved social integration outcomes. As suggested by Parr (2007b), explanations for this deficiency might include society's historical disposition of the natural environment, changes to the work ethos of Westernized cultures, or even the misuse of specific terminology in the related literature. The natural world may be so embedded within our social consciousness that it is overlooked and therefore not fully appreciated by providers of mental health services as a platform for successful recovery-oriented efforts (Sempik, Aldridge & Becker, 2003).

Supplemental sources were also consulted in order to gain a more complete understanding of the topic including references from reviewed papers, agency reports and publications, and various published books associated with the subject. Additional inferences were drawn from selective literature relating to the historical aspects, stigmatization of mental illness, and social belonging of the specified marginalized population. This author believes that these sources provide a significant compilation of the related material and produce an unbiased report.

Included in this article is a brief historical review of the changing philosophies related to Nature in psychiatric treatments followed by a description and explanation of the social and therapeutic contributions that Nature-related events provide. After summarizing the efficacy and feasibility of Nature in mental health programming a recapitulation of how Nature-related programming can support authentic social inclusion while reducing the stigmatization of mental illnesses concludes the article.

Changing Attitudes

Both social and scientific attitudes of the application of Nature in mental health recovery have changed throughout history. As described by Foucault (2009), shared "Reason" has supported multiple paradigm shifts regarding treatments of mental illness. Indeed, theocratic etiologies and the subsequent treatment responses for somatic and psychiatric maladies appear to have been increasingly replaced by more secular considerations. Throughout the seventeenth-century and eighteenth-century the increasingly accepted belief of the scientific community embraced the view that illnesses of the body and mind were caused by dysfunctions of the nervous system (Foucault, 2009). The specific etiology of "madness" was alleged to result from the corruption of the brain by "vapours" (sic) that blocked the vessels in the brain and permitted animal spirits to easily pass throughout the mind (Foucault, 2009). So called "heroic measures" such as bloodletting, purging, assorted burning and cauterizing techniques, and the extensive use of water-related treatments (Gamwell & Tomes, 1995) were often employed to treat and reportedly cure nervous maladies.

During the earlier part of the nineteenth-century societal attitudes began to adopt new criteria for the treatment of mental illnesses (Foucault, 2009). This move was due in part to an increased attention to Moral Treatment (Parr, 2007a) which embraced the social welfare and individual rights of people in asylums, including a greater attention to therapeutic relationships, sunlight, fresh air, and access to garden settings (Gerlach-Spriggs, Kaufman, & Warner Jr., 1998). Rather than prison-like facilities, over time psychiatric institutions began to reflect settings that promoted restoration in natural settings. The external, non-invasive characteristics of farms, gardens, and parks were commissioned as intrinsic characteristics of asylum treatment (Parr, 2007b). American asylums in particular began to integrate natural elements into the architecture of the buildings and through the allotment of land (ibid). Asylum architecture and landscaping, such as the designs attributed to Thomas Kirkbride (Tomes, 1994), provided patients "the promise of health premised in part on the passive absorption of the inherent healthy and rational properties of the moral and manicured asylum land" (Parr, 2007b, p. 541, ¶ 1).

Within such asylum environments, horticultural and domestic responsibilities were both common and equally obligatory elements of daily life. Patient-run farms and gardens were frequently built to afford patients an occupation, endorse the work ethic of the larger society, and provide the institutions with a greater level of sustainability (Sempik & Aldridge, 2006; Parr, 2007b). Patient duties included the planting, cultivation and harvesting of various crops, raising and slaughtering of livestock, laundering of clothes, cooking, cleaning, and other comparable activities (Gamwell & Tomes, 1995). Although labor was believed to afford patients a distraction from their symptoms, the therapeutic value of work was not documented and the obligation of the patients' efforts were not contested until nearly a century later (Sempik & Aldridge, 2006; Sempik et al., 2003).

The physician, professor, and a signer of the Declaration of Independence, Benjamin Rush has been celebrated as the "father" of therapeutic horticulture (Sempik, Aldridge, & Becker, 2003) after observing and documenting the benefits that horticultural and gardening work had on psychiatric outcomes (Parr, 2007b). While many of his methods of treatment were considered antiquated due to his continued employment of heroic measures (Sempik, 2008), Rush advocated for humane treatment of mental patients (Sempik et al., 2003) and published his treatise, Medical Inquires and Observations Upon the Diseases of the Mind in 1812. Although more detailed accounts can be obtained through Victorian-era asylum records on the benefits of working in Nature (Sempik, 2008), Rush briefly described that the occupational tasks allocated by the hospitals and asylums improved patients' recovery and re-entry into society:

It has been remarked, that the maniacs of the male sex in all hospitals, who assist in cutting wood, making fires, and digging in the garden, and the females who are employed in washing, ironing, and scrubbing the floors, often recover, while persons, who rank exempts them from performing such services, languish away their lives within the walls of the hospital (1812/1979, chapter 13, p. 226, ¶ 2).

Asylum work and patient vocations were increasingly established as therapeutic catalysts that improved patients' ability to recover and regain peace (Digby, 1985; Parr, 2007b). Furthermore, Nature work contributed to participants' capacity to establish a concept of time, the value of work, and appreciation for the societal values of the time (Söderback et al., 2004).

Rationales for mental health treatments shifted dramatically throughout the twentieth-century. The abundance of knowledge related to human biological and chemical processes eventually supported the use of psychopharmaceutical treatments to target individual dysfunctions and provided opportunities to treat people in communities rather than in institutional settings (Whitaker, 2010). As scientific knowledge and understanding of the human brain and body increased, psychiatric hospitals were forced to restructure and modernize (Gamwell & Tombes, 1995) and patient work at mental hospitals was increasingly being considered exploitative. The Community Mental Health Centers Construction Act of 1963 subsequently helped to solidify the process of deinstitutionalization. Patient run farms and gardens were eventually disbanded and the vast majority of inhabitants of state-run hospital systems were released to receive services in the community (Sempik & Aldridge, 2006; Söderback et al., 2004).

Rather than functioning with and in natural environments, many present day psychiatric interventions utilize clinical psychotherapeutic techniques and seek to treat dysfunctions within the human brain in more urban-oriented geographies, appearing to generate alternative forms of segregation and differencing within society (Parr, 2008). Although pharmacotherapeutic approaches are considered valid, they are not as holistic to recovery efforts as many wish them to be. It appears, however, that professional attentions are beginning to focus on other services to assist with recovery efforts. Although the use of Nature in mental health service provision and policy formation remains rather marginal, eco-therapeutic practices seem to be increasingly recognized and supported (Mind, 2007). While the majority of environmental issues appear to be related to building design and energy consumption, the social and therapeutic benefits that Nature provides must also be recognized in order to mutually improve individual, community, and societal capacities.

Social and Therapeutic Benefits

The initial intent of farming and garden work within institutional settings was primarily for the sustainability of the institution itself. However, as the therapeutic values of Nature became known throughout the psychiatric community the emphasis of programming shifted. Today there is a developing emphasis for mental health treatments and prevention to focus on implementing services throughout everyday community initiatives and spaces (Parr, 2008). In general, the primary concepts and values of mental health recovery-oriented practice are for personal growth rather than defined as a linear process. In a report on mental health by the U.S. Surgeon General, when compared to the medical model, recovery is considered to be, "a much wider spotlight on restoration of self-esteem and identity and on attaining meaningful roles in society" (U.S. Department of Health and Human Services, 1999, chapter 2). Nature-oriented services appear to directly express the characteristics of the recovery model and are a comprehensive resource for health and wellness while being adjunctive to traditional ideologies.

As a contemporary method for mental health treatment, Nature programming appears to enhance participants' overall quality of life. A study by Hefley (1973) has identified four categories of benefits associated with these specific interventions: intellectual, social, emotional, and physical:

  • Intellectual benefits: attainment of new skill sets; improved vocabulary and communication skills; arousal of curiosity; increased powers of observation; pre-vocational and vocational training; and multi-sensory stimulation
  • Social benefits: improved interaction within groups and with members outside of the group; and increased consideration of self and other individuals
  • Emotional benefits: increased self-confidence and self-esteem; opportunities for socially acceptable relief of aggressive drives; promotion of individual interest, satisfaction and creative drives; and increased hope and enthusiasm for the future
  • Physical benefits: development and improved fine and gross motor skills; maintenance of physical activity goals; increased outdoor activity and exercise; and enhanced knowledge of related fields of study (e.g. birds, insects, geology, etc.)

Nature-related programs are a significant resource to enhance the holistic person-centered recovery model of mental health services. By facilitating individualized development through educational, therapeutic, and leisure opportunities in community-oriented settings, participation in Nature builds multiple capacities and empowers individuals and their communities. The utilization of these services can help to generate hope while facilitating mutual respect and responsibility for the participants and society alike.

Sempik et al. (2003) employ the term social and therapeutic horticulture (STH) to indicate that events and activities described within are both clinically relevant to therapeutic interventions as well as a manner and a process for community integration. The authors highlight that activities that incorporate STH principles are neither inactive admiration of the land, nor do participants in such programs merely reflect upon natural landscapes. Rather, the distinct interconnected actions specifically produced within structured groups incorporate some manner of participant action, resulting in observable end products (Sempik et al., 2003). Although productivity is considered important for the welfare of the group and program, output is not necessarily intended to be the primary goal in STH and STH-like programs. Instead, these services seek to facilitate and regulate the daily routines, social opportunities, and work ethic ideals of the participants (Parr, 2007a). Moreover, while clinical psychotherapy is not typically directly expressed in STH practices, they appear to reflect many of the key components and techniques used in psychotherapeutic interventions (Sempik et al., 2003). Sempik and colleagues (2003) confirm that STH programs support the application of authentic, real-time interactions and circumstances in the community itself. Instead of participants being removed from society as portrayed in clinical environments (e.g. clinically driven groups or vis-à-vis with a practitioner) STH programs seek to exist in and with the community itself.

Several physical and behavioral health professions employ some level of STH into their practice (Sempik & Aldridge, 2006). For example, the professions of Occupational Therapy and Horticultural Therapy employ both active and passive therapeutic techniques within garden settings to enhance the general well-being of participants (Kim, 2003; Shapiro & Kaplan, 1998). These professionals assist participants with enhancing their social skills, self-esteem, and the use of leisure time in a non-threatening context (Smith, 1998) and seek to improve their quality of life (Perrins-Margalis, Rugletic, Schepis, Stepanski & Walsh, 2000). Through the application of specific activities in horticultural tasks, both occupational and horticultural therapists strive to meet individually defined goals within a clinical setting (Sempik et al., 2003; Sempik & Aldridge, 2006). These tasks focus on developing fine-motor and gross-motor proficiencies, improving mobility and cognitive skills, maintaining and increasing strength, and relieving tension (Kim, 2003). In addition to the interventions that improve physiology, working in garden settings can enhance self-awareness, increase the knowledge of available of coping skills (Neuberger, 2008), and improve emotional healing and personal restoration (Baker, 2009) while expanding participants' knowledge, interest, and willingness to continue services (Bishop, 2011a).

When comparing gardeners with non-gardeners Waliczek, Zajicek, and Lineberger (2005) find that people who participate in gardening activities report enhanced statistically significant perceptions of life satisfaction in addition to higher health and physical activity ratings. Specific at-risk and in-need populations have also reported benefits from utilizing STH and STH-like programming. Annerstedt and Währborg (2011) report that Nature assisted therapies are a significant resource for public health and conclude that significant outcomes have been established across the life span and throughout diverse diagnostic presentations. Examples include individuals diagnosed with severe and enduring mental illnesses (Parr, 2008), people suffering symptoms of Alzheimer's (Evans, 2003), physically disabled people (Rothert, 2007), people recovering from traumatic brain injuries, people diagnosed with intellectual disabilities (Relf & Dorn, 1995), individuals who are visually or hearing impaired, incarcerated populations, people recovering from trauma, and people with substance-related concerns (Kim, 2003). Sempik and Aldridge (2006) add that STH programs apply to inpatient and outpatient settings, individual and group approaches, and are appropriate for both short-term and long-term interventions.

In the United Kingdom people with mental health diagnoses are considered to be one of the largest groups that engage in Nature-related activities (Parr, 2008; Sempik, 2008; Sempik & Aldridge, 2006; Sempik et al., 2003). When compared to their non-marginalized counterparts, Burls (2004) reports that this particular group tends to have a higher degree of pronounced outcomes. Despite the lagging implementation of Nature for therapy in the United States, the mental health delivery system is nevertheless improving and numerous sources relating to Nature as a modality are becoming increasingly available (Relf, 2006). By applying STH programming throughout the multiple levels of psychiatric care in the United States, a significant continuity-of-care as well as an enduring consistency-of-care with improved community engagement for people with severe mental illnesses can be realized. Therefore, a higher level of meaningful recovery and community development is possible through the use of Nature in mental health programming.

Feasibility and Sustainability

Despite the reported beneficial impacts, data to support the efficacy of Nature-related programing is scattered (Parr, 2007b). In order to address the multitude of environmental and treatment concerns inherent in society today, further research is vital to advancing the use of Nature for recovery (Sempik & Aldridge, 2006; Sempik et al., 2003). There has been an increase of evidence supporting the positive role that the natural environment affords has seemingly been polarized into two areas of study (Sempik, 2008). The first focuses on the context in which therapeutic interventions are applied; the second examines the importance and meaning of natural surroundings and how each setting associates with humans. According to Sempik (2008) these areas of study should not be considered autonomous and this division should converge in order to obtain a broader understanding of the beneficial influences Nature provides.

To maximize the promotion of public health and to increase peoples' contact with the natural environment Maller, Townsend, Pryor, Brown and St. Leger (2006) declare that collaborative strategies between mental health professionals, primary care, human services, and the environmental management sectors are required. This author additionally supports the need to embrace a professional-community approach. Both professional and community stakeholders (including but not limited to farmers, private residents, community gardeners, and business owners) must develop a rapport and work together to form reciprocal relationships and develop the sense of community. Potentially amplify existing health promotion and prevention efforts while creating a foundation for the endorsement of environmental sustainability (Maller et al., 2006), joint partnerships can improve the likelihood of STH projects to become an inclusionary practice by the very experience of the progressive and connected occasions (Stepney & Davis, 2004). The creation of open alliances can increase the likelihood of program endurance while participants achieve a greater knowledge and understanding of one another, theoretically breaking down barriers that create separation. If, however, these associations are not equally engaged and STH programs function solely within an empirical mindset, Stepney and Davis (2004) foresee a lack of available opportunities, including a persistent diminished sense of social acceptance, reduced opportunities for vocational training, and decreased chances for gainful employment. Mutually supportive groups are therefore necessary to achieving a larger social support network and improve overall recovery efforts.

Financial practicality remains a central concern for organizational and programmatic strength. Multiple horticultural and gardening projects have nevertheless reported lower costs when compared to conventional therapies (Bishop, 2011b; Sempik & Aldridge, 2006). Data also suggests that smaller STH groups require less financial overhead to operate when compared to traditional clinical applications. Sempik and Aldridge (2006) note that STH projects with larger budgets typically support a greater clientele base and that budgetary increases may reflect project expansion with increased expenditures for additional services or staffing needs, not necessarily an increase in participant numbers (Sempik & Aldridge, 2006). Even so, many STH and STH-like programs seem to fiscally operate in reverse compared to traditional clinically based services.

Numerous resources are available that can potentially offer assistance to support STH programs. These supports may not necessarily be found within the social service sector and program directors may need to pursue additional sources of capital: community grants, public sponsorship, in-kind or private donations, fundraising campaigns, or even sales of production-related materials (for examples of funding sources utilized in the United Kingdom see Sempik & Aldridge, 2006). Out of 836 projects reviewed by Sempik and Aldridge (2006), over half represented garden or community garden projects. The authors note that more than half of the participants of these projects received funds from public sources and only ten percent were billed directly. Block grants were utilized in order for numerous programs to establish sites and to treat a specific number of participants. In many instances, and without a strain on program viability, many agencies reported accommodating additional participants who were not financially covered (Sempik & Aldridge, 2006). The authors therefore assert that Nature-related programs can (1) accommodate additional individuals without excessive, if any, financial burden; (2) maintain the same level of care with more direct attention to participants; and (3) retain the ability to successfully reach individual and programmatic goals.

Stepney and Davis (2004) further identify a significant connection between the vocational needs of participants and the stewardship of the environment. The want of normalization through human connection, job obtainment, and the willingness to promote ecological concerns by both program participants and the public alike, can provide a significant and timely link to the green agenda in the United States (Stepney & Davis, 2004). Facilitated by STH programs, groups can generate a greater potential for opportunity. Based on individual-community needs, people can also enhance the prospects of the group while maintaining the fiscal responsibilities of the programs. This attention to the sustainability of the group, the community, and the environment may collectively improve the availability of the local workforce, enrich the communities where the programs are situated, and potentially enhance the environment.

Stigmatization and Social Acceptance

The sense of belonging is a key aspect to social inclusion (Diamant & Waterhouse, 2010). According to Parr (2008) factors of community acceptance are often overlooked when structuring political concepts of social inclusion. Vulnerable and marginalized groups can subsequently experience a greater degree of separation from society when compared to the prevailing culture (Link & Phelan, 2001). In an attempt to adapt to their surroundings, some people with serious mental illnesses — if not overtly stigmatized by society — may attempt to internalize or conceal their perceived differences (Watson, Corrigan, Larson, & Sells, 2007). According to Link and Phelan (2001) experiences of interpersonal stigma and acts of self-stigmatization can endure through the fundamentals of a societal labeling system, stereotyping, separation from the unknown, loss of status, and discriminatory practices. The authors add that stigmatizing experiences can influence many of the choices people make and ultimately affect the general well-being and awareness of their inclusion in society (ibid).

Although self-stigmatization and label avoidance practices may temporarily relieve the rate of inequity for some, there remains a probability for increased levels of stress (Corrigan & Wassel, 2008). Stress has been documented as being drastically increased in Westernized societies (Grahn & Stigsdotter, 2004) and is widely recognized as having a direct association with symptom escalation. The escalation of stress, if not addressed, could result in further avoidance, missed opportunities, and could generate additional acts of exclusion, prejudice, or discrimination (Link & Phelan, 2001). This suggests that interventions that focus on responding to stigma directly should involve both identified vulnerable groups and the prevailing culture in order to reduce differencing, separation, and the to reduce levels of stress.

Grahn and Stigsdotter (2003) assert that proper landscape design has the potential to have a significant restorative property by reducing stress and facilitating positive health effects. Group gardening activities can additionally enable opportunities for increased competence and empowerment, link people to supportive resources in the community (Myers, 1998), and target the values, behaviors and attitudes of differentiation from both the marginalized and non-marginalized populations (Corrigan and Wassel, 2008). Studying the effectiveness of group gardening for an outpatient mental health service, Rappe, Koivunen, and Korpela (2010) conclude that group work is meaningful, increases social support and approval, contributes to both autonomy and working together, and ultimately promotes the development of a healthy community. Individuals and groups must therefore be equally engaged in order to create constructive results in the community. By acknowledging and confronting the interrelating characteristics of stigma from both sides, people can become increasingly more influenced by the outside forces of positive change (Link and Phelan, 2001). The productive modifications that are created from group work can ultimately result in both internal and social adjustments that erode numerous long-standing issues within society (Link & Phelan, 2001) and can be achieved through the meaningful occupation of horticultural work (Diamant & Waterhouse, 2010).

The perception of well-being and acceptance in society may also affect aspects of social inclusion. Presenting findings on the social functioning of people diagnosed with mental illnesses, Sempik et al. (2003) report that participants in Nature-related programs had increased interest, were more willing to participate in social functions, and improved their overall personal appearance and hygiene. Parr (2007a) has identified six major themes in a study involving the social inclusion of people diagnosed with serious mental illnesses. Analyzing data collected from various non-traditional mental health services that included gardening projects, the author concludes that participants benefit from and through the following themes:

  • Increase of positive emotions
  • Expand healthy relationships with peers and staff
  • Improve physical activity, fitness and well-being
  • Greater involvement and familiarity within the community
  • Exhibit skills that enable acceptance in the community
  • Enhance perceptions of being a part of the community

Through a reduction of the more socially overt and negative presentations or behaviors that tend to be hallmarks of serious mental illness (e.g. dishevelment, isolative behaviors, negative affects), communication and involvement in the community can improve. Additionally, participants in horticultural groups can experience a new identity through the reduction in stigma and increased support from the development of a broader social network (Fieldhouse, 2003). This suggests that a reduction of perceived difference will produce an appreciation of observed similarity and reduce the amount of stress related to the experience of dissimilarity.

A two-level plan has been proposed and necessitated by Link and Phelan (2001) for the reduction of stigma. As previously explained, the first level identifies a need for programs that confront stigmatizing characteristics to become comprehensive in their approach by incorporating both the marginalized and non-marginalized populations. The second level calls for programs to adhere to the foundations upon which the stigma is based upon for the marginalized group while maintaining attraction to the parent society. The dominant group can then be directed to the unequal power disparity as well as the similarities that exist between each group to increase their understanding of the marginalized population (Link & Phelan, 2001). This second tier in particular suggests that Nature-related projects should have a broad programming initiative that appeals to dissimilar groups in order to reduce disparity and increase the experience of connection in the community.

Nature is a significant resource for both personal and community enrichment. The natural environment can additionally attract multiple populations and improve public perceptions of difference to accommodate the connection and understanding of others. If STH programming options become more widely established in mental health recovery efforts in the United States there can be a decrease of societal separation to improve the sense of belonging and generate authentic community belonging and inclusion. These positive changes can therefore begin to positively influence and alter public perceptions, reducing the stigmatization of mental illnesses.

Conclusion

As is often the case with many socially relevant themes throughout history, multiple philosophic transformations have occurred in the United States regarding the origins of and treatments for mental illnesses. Although there is optimism about the changing perceptions of mental illness there are also barriers that prevent the acceptance of people diagnosed with serious mental illnesses. There remains a strong public perception that mental illness is associated with violence and danger (Link, Phelan, Bresnanhan, Stueve, & Pescosolido, 1999). Yet, "mental illness is now conceived of as something less alien and less extreme than it was in 1950" (Phelan, Link, Stueve, and Pescosolido, 2000, p. 200, ¶ 3). The current evolutionary interpretation of mental health treatment has nevertheless allocated the need for improved services and enabling community involvement by people who utilize mental health services.

The model of recovery has become a significant conceptual framework that seeks to provide self-directed choice and lasting positive outcomes for people diagnosed with serious and persistent mental illnesses. Even so, shards of the past remain in social consciousness that generate perceptions of difference and social separation for this particular group of people. Endorsed social estrangement can lead to symptom escalation and further exclusion, creating a community-situated population rather than people who are truly community-integrated. It is therefore essential to implement programs that attract and involve diverse groups of people while providing direct phenomenological experiences to promote overall quality of life for everyone.

Nature-related services are adjunctive to both contemporary and conventional ideologies and can be utilized to advance the promotion of global health to profit individuals, communities, and society alike (Dustin, Bricker, & Schwab, 2010). Mental health programs that engage Nature can help to normalize differences, increase the perception of belonging, and change public perceptions of mental illnesses. Horticulture and gardening services can contribute to recovery-oriented efforts by enabling positive changes in symptomatology and overall perceptions while progressing the access to genuine social inclusionary practices. In addition to enhancing physical and mental wellness, STH services can enable interpersonal exchanges, understanding, and lead to constructive societal and environmental changes (Annerstedt, 2009; Okvat & Zautra, 2011). This article additionally supports the practice of engaging multiple professional, provider, and community stakeholders in order enhance knowledge and to provide access a more real-world, real-time application of community.

Nature is power-full, yet often overlooked as a mental health treatment option in the United States. Participation in Nature provides multiple systemic benefits and can stimulate authentic social integration. Social and therapeutic horticultural programs are fiscally responsible and socially generative services that have a great potential to create a more persistent continuity of care. The mental healthcare delivery system in the United States should embrace the opportunities that Nature provides so that people may be enabled to experience an improved quality of life and connection. The use of Nature must therefore be implemented within all levels of the mental healthcare delivery system in the United States in order to enrich the lives of people, progressively develop society, and further advance humanity.

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Benjamin P. Bishop MSW, LSW has been developing and applying a model of social integration related to the concepts reviewed in this article. He is currently working to implement its characteristic throughout multiple levels of psychiatric care and improve the sense of community in the Pittsburgh, PA area.

Endnotes

  1. For this article Nature refers to elements of the natural world, especially those of and related to plants (Kingdom Plantae).
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  2. PsychINFO, MEDLINE, and JSTOR online databases for the years 1970 through 2011 using terms that should be common in articles related to the subject: severe mental illness, integration, horticulture, gardening, and therapy.
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Copyright (c) 2013 Benjamin P. Bishop



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