Research Papers
Healing Grief Through Horticultural Therapy
Laura A. Cinq Mars, John Tristan, MS, HTR and Rob Zuckei; MA, LCSW
Journal of Therapeutic Horticulture, Vol. X, pp. 4-9. 1999.
Introduction
Issues surrounding grief and loss are often encountered in a variety of settings by professionals in the field of care-giving. Although one may assume that institutions with geriatric populations are more experienced in bereavement issues than most, every direct-care treatment provider will inevitably confront the needs of their patients and families affected by the experience of substantial losses, including death. Horticultural therapists working closely with populations at risk of loss, both physical and emotional, must be prepared to encounter bereavement issues and can benefit from a heightened awareness of the grief process and its ramifications.
Profound changes are set into motion with the occurrence of any illness. During hospitalization, patients and their families experience major disruptions in their daily routines, often including the loss of their community support system. While enduring physical and emotional pain they may be confronted with the implications of how the illness or injury will change their lives. Patients and their families rely on the caregivers in a hospital setting to help them cope with these highly stressful circumstances. In either long or short-term care facilities, the nature of illness or injury creates vulnerabilities for the patient which cannot help but impact the staff in charge of attending to their needs. Health-care professionals need to be concerned with what happens to their patients in order to be effective and compassionate. The circle of those affected by the significant losses or death of a patient often extends bey6nd the surviving family members to include those involved with direct-care treatment.
Now more than ever, the dead and dying are transferred into the hands of those that participate in and run the medical establishment. Presently, more than three quarters of Americans who die do so in the hospital. As rapid advances in technology increase the medical profession's capacity to prolong or save lives, death is often viewed as a failure (McCullough, 1996). Often then it is particularly difficult for the medical professionals who work to prevent death to effectively transition into the role of one who comforts when death occurs.
Health care professionals are required to take a prominent role in the life of a patient during hospitalization. Horticultural therapists engaged in ongoing program activities often are required to engage in close contact with patients during repeated sessions over many weeks or months. Significant emotional bonds may form so that when the death of a patient occurs the loss may be deeply felt. In whatever way the death of a patient affects the care providers, emotions of loss need expression. The mourning process must take place to restore one's equilibrium. In working through the pain of loss, one must be allowed the intensity of the sorrow experience as part of the process of adjusting. The healing process of accommodating loss forces growth that may translate into taking on new roles.
If the bereaved are unable to go through the mourning process then it may directly interfere with their receptivity to, or participation in any therapy program, even a therapeutic one. This is as true for any care-giving staff member as it is for the resident of a nursing home who is surrounded by eminent death. Significant losses take their toll on patients, families, and staff. As it is the intention of the medical establishment to adequately respond to illness, injury, and death, caregivers need to be provided with the tools of support to facilitate their own healing processes. Opportunities to identify and express feelings associated with loss enables those who grieve to adjust to new challenges in their lives. Sharing in a bereaved family's pain is a lesson in courage, determination, and love (Coolican, 1994). Ultimately, the caregiver's involvement is essential to ensure their continued effectiveness and professional viability.
Grief reactions
The grief reaction has profound effects, both in disrupting and in restructuring the lives of survivors. Grieving is a psycho-physiologic process that has been the subject of extensive investigation. Although its manifestations vary greatly with individual situations, grief is a shared human experience that transcends both personal and cultural boundaries (Reich & Rogers, 1988). Death is an unavoidable aspect of the human condition. The impact of grief is inevitably felt, and its effects are tangible.
A variety of symptoms are to be expected as indications of pain and despair experienced by those who have suffered deep loss. Although the condition of bereavement has been linked to severe complications with health, there are many distressing symptoms caused by the immensity of grief itself which are not indicative of illness complications. Normal physical responses to grief of-ten include disturbed eating and sleeping patterns, chest pains, a feeling of tightness in the throat, and other acute pains or aches. Cognitive responses often include anger, a preoccupation with the loss, inability to concentrate, irritability, confusion, a desire for escape, and a loss of meaning in things that formerly held one's interest or attention. The varied manifestations of grief influence the quality of life for any individual.
Unresolved grief
There are very real dangers involved with the postponement of the grieving process. Unresolved grief occurs when feelings relating to one's experience of loss are not coped with directly. Those feelings may eventually find release from the body in the form of both emotional and physical disease. The risk of such manifestations is minimized when the bereaved can obtain emotional support from helpers who are aware of the sympathy needs of mourners (Temes, 1977). The dangers of unresolved grief are not just imagined, nor are they a recent discovery. Charles Darwin's study on emotion asserted, '...he who remains passive when overwhelmed with grief loses his best chance of recovering elasticity of mind' (Darwin, 1872).
A recent study done by the Institute of Medicine of the National Academy of Sciences found that bereavement is associated with measurable amounts of distress in everyone, but that the distress can range greatly in intensity and duration. A survivor's way of life is commonly disturbed for at least one year but it is not uncommon to find oneself affected for longer. An Academy of Sciences' report states that therapeutic intervention programs can help people move faster through the grieving process (Joyce, 1984). Support is essential for anyone who has suffered a loss. Often the bereaved feel as though they need to refrain from sharing their feelings of loss because it seems to make others uncomfortable to listen. Because strong emotions inherently seek expression it is crucial for the bereaved to be supported in their mourning process.
Cultural aspects of grief
In this modern culture we often lack the contexts for grieving. Bereavement rituals including the wake, funeral, and burial services provide brief opportunities for mourning. Based on our ideas and beliefs about death, the time appropriated for mourning is restricted in our culture as compared to others. In our culture there is a certain point of time when the bereaved are expected to stop feeling intense grief and stop talking about their loss. People experiencing grief are often expected to endure the majority of their suffering alone. In 1982, international grief researcher Professor Neck noted,
"It appears that the profiles of grief and mourning are shaped to a large extent by cultural determinants. The process of mourning can be assisted or impeded, and its benign outcome can be facilitated, hindered or distorted by the availability or nonavailability of grief-preventing and grief-relieving devices that cultures tend to prescribe" (Joyce, 1984: p.45).
Neki stresses the importance of preserving rituals, ceremonies, and other practices that have been traditionally introduced for working through and accommodating grief.
Mourning rituals
The extreme loneliness of the grief crisis can be essentially aided by the supportive structure of mourning rituals. Responding to the needs of the bereaved includes providing opportunity to articulate the meaning of the relationship of the deceased to the survivors. Marris (1974) suggests that mourning customs offer 'rites and gestures of remembrance to continue a relationship' with the deceased. Mourning rituals serve to 'attenuate the loss and help to incorporate the meaning of the relationship in the continuing stream of life' (Marris, 1974). Restoring the sense that what has been lost may continue to give meaning to the present and the future is crucial for the recovery of bereaved individuals. Multiple observances of the death through the use of mourning rituals allow the bereaved to participate in an action-oriented state of grief work rather than the passive-reflective process used in counseling procedures which do not foster mourning ritual acts.
Bolton and Camp (1989) documented the value of several post-funeral ritual acts in assisting the bereaved in grief work. Wilcox and Sutton (1977) reported that rituals help make sense of death and lend reality to the loss of a loved one (Shoemaker & Relf, 1990). Their definition of ritual in the context of mourning is 'a specific behavior or activity which gives symbolic expression to certain feelings and thoughts.' This premise holds that the active translation of mourning into ritualized actions facilitates the grieving process and constitutes an important element of recovery (Bolton & Camp, 1989). Moving on does not mean 'getting over' a relationship with the deceased, rather, resolution is figured in the ability to take one1s memories and use them to grow. Part of this growth can be demonstrated through ritual, in the creation of something meaningful to honor the memories of the bereaved.
The guidance of caring individuals helps to contradict the loneliness and despair of grief. Bereavement support groups are one form of support that many turn to for comfort. Bereavement groups are based on the philosophy that bereavement is a psychologically healthy state, and function to assist mourners in the process of grieving (Temes, 1977). Sometimes just having compassionate and accepting people present can reduce the intensity of grief. Group therapy can also provide an effective remedy in meeting the bereavement needs that our culture does not attend to.
Healing through horticultural activities
A variety of horticultural-based activities can be useful in clarifying feelings and expressing emotion. Plants and flowers have powerful symbolic meanings that vary with different cultures. Their usage in connection with death observance continues from ancient times. Trees and flowers, which people of Western culture associate with mourning ceremonies, commemorative rituals, and the transitory nature of life might include the following:
- Chrysanthemum speaks to fruitfulness and long life
- Cypress is a symbol of death and sorrow
- Evergreens symbolize immortality
- Ivy is associated with tenacity, faithfulness and constancy
- Lilies represent purity and resurrection
- Oak is regarded as symbolic of holy strength or eternity
- Roses signify the achievement of some kind of perfection
The uniqueness of the grieving ritual involving plan material is in its inherent connection with both life and death. The life cycle of the plant provides us with metaphorical framework for contextualizing death that is illustrative and meaningful. Live plant material can also bring innate feelings of peace and contentment as we appreciate its sensual beauty replete with scent, tactile and visual aesthetic. Using plant material in preparing arrangements as a therapeutic activity has also bee shown to be an incisive way to improve self-awareness facilitate communication, and resolve emotional problems (Sneh & Tristan, 1991).
In the context of bereavement, flowers and plants continue to represent a thoughtful expression of concern for survivors because people associate the giving of flowers with the intentions of love, care, and concern. Re search in grief work has shown that flowers are associated with the emotional side of death and serve to provide noticeable comfort during a funeral and in other grieving rituals (Shoemaker & Relf, 1994). A 1990 survey of newly bereaved individuals showed that for many receiving sympathy flowers to help deal with grief was equally valuable to all other aspects associated with funerals. This survey also indicated that in addition to sympathy flower arrangements many people preferred to receive seeds, bulbs, or live plants as a living memorial to the deceased (Shoemaker & Elf, 1990).
A Model for Group Bereavement
An innovative example of horticultural activities used for facilitating grief work in a group setting was developed at the Baystate Medical Center in Springfield Massachusetts. Their experiential technique of flower arrangement in the context of a mourning ceremony focuses on close relations and dialogue to facilitate grief work.
Ceremonies are generally recognized as effective in helping people to release the private agony of grief and can have profound psychological effects that provide comfort (Neki, 1982). The foundational intention of the Baystate program was to allow the bereaved to experience therapeutic effects of plants in ritual beyond the funeral ceremony. Baystate's example of a post-funeral ritual encourages the expression of emotion using flow-em and plants as tangible elements of healing activities.
Baystate Medical Center's Pediatric Bereavement Counseling Program was developed to meet the emotional needs of families, staff, and the larger community when a child dies. An interdisciplinary team of social workers, pediatric specialists, and bereavement counselors supported families and staff prior to, and at the time of a death. Further services included bereavement counseling for relatives and friends specialized support groups, psycho-educational programs throughout the year, and individual parent follow-up by specially trained volunteers.
In 1990 the Pediatric Bereavement Counseling Pro-gram created a memorial gathering to collectively commemorate individual losses suffered. The annual event was designed by a planning committee consisting of bereaved parents, hospital staff, bereavement volunteers, and the bereavement program director. The list for invitations for this event included bereaved parents and family members who once participated in activities sponsored by the bereavement program, and all of those whose loved one(s) died at the Children's Hospital. Members of local support groups such as MADD (Mothers Against Drunk Driving), and Compassionate Friends of Bereaved Parents were also invited. During the four years of this program's existence, from 1990 to 1994, each memorial program drew over two hundred participants. The program schedule involved the reading of poems, performance of music, and featured a candlelight ceremony. At each gathering, when the names of the deceased were spoken at the time of candle lighting, both families and staff were encouraged to share a memory of each child they lost. Every year a bereaved parent served as a guest speaker to offer inspiration and comfort to others. Since families often find it difficult to return to the hospital because of painful memories associated with the site, the location for the gathering was planned away from the hospital grounds, at a local retreat center or an area college.
One goal of the memorial gathering was to reunite the surviving members of the families with the care-giving staff that once played a prominent role in lives of the deceased children. Professional caregivers can become disenfranchised if there is no avenue for the expression of their grief when a patient dies. To address this need of the staff, all were encouraged to take part in both the planning and presenting at the annual gathering. The attendance of the dedicated caregivers was noticeably appreciated by bereaved parents. Members of the care-giving consortium that contributed to each gathering included pediatric nurses, doctors, social workers, psychologists, child-life specialists, rehabilitation staff and bereavement volunteers.
The central feature of each annual commemoration was the collective activity of flower arranging. Each family arrived at the event with a cut flower to contribute to the floral arrangement created by the group. In years past, while talented high school musicians played Vivaldi in a string quartet, bereaved families were invited to step forward with their cut flowers and place them in the vases and bowls set on a platform. A bereaved parent experienced in flower arranging orchestrated the placement of each contribution. At the conclusion of the musical piece, the beautiful flowers had been transformed into a striking centerpiece that symbolically held the collective memories and emotions of the entire gathering. Following the ceremony, the containers full of flowers were set to decorate the serving tables in the reception area. At the conclusion of the eventful afternoon the flower arrangements were transferred to the Children's Hospital for decorating patient areas and nursing stations.
A large number of staff members were encouraged to participate in Baystate's annual gathering as a way of sharing their grief with the families and each other, tangibly reaffirming their compassion. Many staff members chose to offer additional help with another component of the memorial gathering called the Grieving, Caring, Growing Project.
Months prior to the event volunteers for the Growing Project were given seed packets, evergreen seedlings, or plant cuttings to propagate in colorful containers for establishing transplants. The activity of transplanting is a way of illustrating that one can recover from the damage inflicted by grief. Participants cared for the developing plants, assisted by designated staff members to manage any horticultural concerns. The new growth of the plant could be seen as an analogy for the steward1s compassion for the surviving family. Each fully-grown plant was then brought to the annual memorial gathering to be publicly displayed and ceremoniously presented as a gift to a bereaved family in attendance.
The Grieving, Caring, Growing Project became a symbol of the hospital's commitment 'to keeping memories alive, and to honor each family1s grief journey.' Growing Project participants were presented with a certificate from the Children's Hospital to acknowledge their contribution and their efforts.
Nurturing new growth proved therapeutic for participants. Each plant became a living expression of genuine concern, as well as a medium for the non-verbal expression of a caregiver's grief. The therapeutic value of the Annual Memorial Gathering was enhanced by the use of plants and flowers. The Grieving, Caring, Growing Project enabled staff with the tools to both express and share their grief through the stewardship of plants. The gift of a potted plant represents a tangible way for families to understand that their children are fondly remembered.
As families face the life-long process of managing the repercussions of their child's death, they will benefit greatly from living gifts that speak to images of hope and growth. Similarly, collective flower arrangements are a collaborative and creative expression of deep longing and loss transformed into a gift of comfort and compassion for children and their caregivers still in the hospital. With their focus on accommodating the pain of death, the programs of Baystate Medical Center's Children's Hospital provided affirmation of life for those in the most need of it. Although the Baystate Medical Center's Pediatric Bereavement Program was discontinued in 1995, the therapeutic potential of such a program can still be considered highly valuable. Programs such as these demonstrate an ideal in caring responsiveness and serve to illustrate that from grief can come growth.
Conclusion
Horticultural therapy activities used to facilitate healing emotions can serve to transform the mourning process. Participation in a grieving ritual can offer a dimension of comfort at the same time that it encourages a crucial step towards the resolution of grief. Group interaction fosters a sense of mutual understanding that contradicts the isolating nature of grief. The opportunity for concrete acknowledgment of loss in the context of community support is important in every setting that confronts bereaved populations. The example of the Annual Memorial Gathering at the Baystate Medical Center utilized the activity of flower-arrangement to focus expression, share grief, and to facilitate a naturally supportive context. This annual community even and the Grieving, Caring, Growing Project illustrate how plants can be utilized in a collective bereavement process which serves to both engage professional caregivers and facilitate healing. These activities can be considered as a viable prototype for future programs in comparable settings.
References
- Bolton, C. & Camp, D.J. (1989). Post-funeral ritual in bereavement counseling and grief work. Journal of Gerontological Social Work, 13, 50.
- Coolican, M. (1994). After the loss: Offering families something more. Nursing, 24, 62.
- Darwin, C. (1872). The expression of emotions in man and animals. London: Murray.
- Joyce, C. (1984). A time for grieving. Psychology Today, 11,43.
- Manris, P. (1974). Loss and change. New York: Pantheon.
- McCullough, W.B. (1996). Witnessing death versus frowning death. Facing Death, Spiro, H, Cumen, M., & Wandel, L., eds. New Raven: Yale University Press.
- Neki, J.S. (1982). Grief. World Health, 11,23.
- Reich, P. & Rogers, M. (1988). On the health consequences of bereavement. New England Journal of Medicine, 319(8), 510.
- Shoemaker, C. & Relt, PD. (1990). Report on the role of flowers and plants in the bereavement process. Unpublished manuscript.
- Shoemaker, C. & Relt, PD. (1994). Attitudes of consumers and recently bereaved toward sympathy flowers. HortScience 29, 915.
- Sneh, N. & Tristan, J. (1991). Plant material arrangement in therapy. Journal of Therapeutic Horticulture 6,16-20.
- Temes, R. (1977). Living with an empty chair. Amherst: Mandala. Tolle, L. J. (1969). Floral art for religious events. New York: Hearthside.
About the authors
Laura A. Cinq Mars, BA, was certified as a Master Gardener in 1993 and earned her degree from Smith College in 1997. She gained experience in horticultural therapy program management working with individuals with psychiatric disabilities in Western Massachusetts. Ms. Cinq Mars is presently working for Sister Witness International, an organization of formerly institutionalized women, girls, and their allies. She continues her studies of how plants can be used to heal one's spirits as a student of Eliot Cowan, author of Plant Spirit Medicine.
John Tristan, MS, HTR, is director of the Durfee Conservatory at the University of Massachusetts. A registered horticultural therapist and instructor of horticulture with the Division of Continuing Education, Mr. Tristan has implemented many horticultural therapy activities and has received the Walker Community Service Award through the American Horticultural Therapy Association.
Rob Zucker, MA, LCSW, is a bereavement therapist, consult-ant, and educator, based in Western Massachusetts. As Director of Caring Communities Respond for the past three years, he has led seminars across the nation on topics ranging from parental, sibling, and childhood traumatic grief to the set-up of bereavement programs in hospitals, hospices, churches, and businesses. Mr. Zucker is editor of the Grief and Healing Newsletter and an associate/adjunct faculty member at Antioch New England Graduate School.
