by Afrouz Rahmati, Assoc. ASLA
The Healthcare and Therapeutic Design Professional Practice Network (PPN) is pleased to share a new installment in their ongoing Healthcare & Therapeutic Gardens Interview Series: a conversation with Dr. Garuth Chalfont.
Dr. Chalfont is a leading practitioner in the art and science of healing gardens, therapeutic spaces, and dementia gardens that incorporate the natural world into the healing process. He designs and builds engaging outdoor spaces in dementia care environments and leads hands-on training workshops to facilitate their active and enjoyable use by residents, staff, and families. In his research, he explores the benefits of the natural world for holistic health (mind, body, and soul), in particular how nature contributes to prevention of (and healing from) dementia.
What inspires you to do work in the therapeutic landscape?
When I first got into it, I felt that the healing qualities of nature were hugely undervalued and underused in landscape architecture and garden design. The emphasis was on visual qualities rather than a person’s lived experience of spending time outdoors and actually using the space. In care environments, that was predominantly the case. Over the years, I have witnessed and experienced positive changes in the mental and emotional health of a wide range of people through engagement with nature and the outdoors. There is an ethical imperative, that people have a birth-right to receive healing from nature and not be deprived of it.
Still, there is a huge lack of awareness in the health and care sectors of the basic therapeutic qualities of nature, for instance from natural energies of light, water, and earth which feed the body at a cellular level, and prevent or diminish inflammation, which is the main driver of most chronic diseases. I recently submitted a paper entitled “Light, Water and Earth—Towards a Bioenergetic Approach to Dementia” to a medical journal. After six months of peer review it was accepted for publication, and then at the last minute was rejected. This paper gives the science behind light, water, and earthing/grounding as it specifically relates to preventing and treating dementia. The paper presents a nature-based hypothesis for healthcare which will revolutionize and transform a healthcare environment into a true healing modality. (The search continues for an enlightened publisher…)
How would you describe your work environment?
I have a home office, and I spend time outdoors, often on site, where I sketch and design. I have hired others to help with CAD/SketchUp over the years, but I mostly work alone.
How did you come to do this kind of work, designing and researching therapeutic landscapes?
I started out as a gardener for residential customers in the US, where I discovered horticultural therapy and the power of gardens to heal. I designed my first site for adults with mental health challenges in the early 1990s (and recently donated a master plan for their new site in Virginia).
Alongside designs for mental health, I also had a gardening customer who was diagnosed with Alzheimer’s and went into nursing care. I began visiting him and found that conditions at the facility were horrible—residents seemed overmedicated, there was no personalization, rooms were shared, and even so, the place was expensive. There was no possibility of going outside at all, and no gardens to go to. My mother was also in a nursing home with dementia. By that time I was living back in the UK, so I would fly to South Carolina to visit her. We were born and grew up in England, where she was a keen gardener. When I visited her we would spend time outside along the coast (she loved the ocean). The nursing home had a very minimal garden.
Having done residential design/build in the states since the 1980s, I decided I would focus design efforts on improving care home settings. I did a PhD in Architecture at Sheffield University in the UK, so I could learn the language of architecture and communicate with architects and building commissioners. The important decisions that affect residents are made by architects. Landscape architects are rarely if ever brought in until it is almost too late. The building and parking is set in stone before planning permission, and the garden is whatever is left over, regardless of how realistic it is for the staff and residents to actually use these spaces.
I quickly got into some design work in the UK, and did my PhD research as well, spending months getting to know and understand people with dementia and their families and care staff living and working in these places. Design for Nature in Dementia Care was published in 2008, which provides comprehensive examples of the wide range of ways a person can connect to nature through indoor and outdoor activities, elements and environments. My PhD focused on the “edge space” between indoors and outdoors and how to enrich this for the benefit of residents and staff. Because this is where architecture and landscape architecture meet, there is little emphasis on developing this area (especially in care homes), as it is seen as not particularly part of the garden or the building. But it is highly relevant for people with dementia who are often uncomfortable going outside. So developing the edge space gives a person the comfort of indoors and the benefits of outdoors simultaneously.
What is your design process like?
Very much on-site investigation; discussion; meeting staff, residents, and managers; and observation. I focus on how the spaces can enable daily meaningful life. This requires a great deal of attention to the ‘care culture.’
If it is a new-build, a lot of my work is in educating and raising awareness about what is possible. I also would spend time in one of their existing homes. If it is an extension or remodeling, I spend time in the home or day center observing activity and having workshops with service users and staff about their aspirations, difficulties, limitations, and dreams.
In many of my projects I have been involved in the design and build, so I work with carpenters and landscapers I know and who have worked with me in the past, so they totally understand what I want to provide. I have them well-trained!
How do you market your firm?
Word of mouth, lectures about my projects, books and online materials, staying in touch with former clients, and networking with like-minded colleagues.
Do you do any post-occupancy research or evaluations of your projects?
My Dementia Green Care Handbook of Therapeutic Design and Practice is an example of investigating if and how the design works. I did a research project in the home over 18 months to evaluate how well the garden spaces were serving those who I designed them for. The handbook is a guide for the creation of gardens and outdoor spaces for people with dementia, specifically about therapeutic use of these spaces for beneficial outcomes. It is aimed at managers, owners, and operators of care homes, nursing homes, and day care facilities. It will also be helpful to landscape architects, architects, commissioners of services for older people, and all those involved in the provision of dementia care services.
Over the 18 months following installation, I gathered data from care staff about time spent outdoors by every resident. On a daily basis they answered four simple questions: Did the resident go outside? For how long? On a scale of 1-5 how was their mood before going out, and upon coming back indoors? I collated the data and a masters student evaluated it. The paper was entitled “Exposure to nature gardens has time-dependent associations with mood improvements for people with mid- and late-stage dementia: Innovative practice.” We demonstrated that exposure to nature was associated with a beneficial change in patient mood, and this was true for relatively short duration exposures to nature (this was published in 2018).
The resident is my client; I don’t design for the owners—they only hire me and give me access to their residents. I also insist on being involved in training the care staff during the development of the design concept, so they are on-board with how the gardens will be used. So I won’t just go in and design something. I need commitment from the home that they are interested in truly providing an upgrade in daily life quality and experience for their residents, families, and staff, not just a pretty picture in the brochure.
I prefer to work with the owner/developer early on so I can affect the location of the gardens, entrances, views, and so on. I will give a presentation or workshop to the builders/developers in the early days all about how the environment can and should foster an active, meaningful daily life. I have only a few clients but they are long-standing and for some I have designed multiple gardens over time. In most sites I have gone back over time and spent days doing a bit of garden maintenance and encouraging staff in what needs to be done, meeting new residents, giving talks, etc. I am invited to their garden party event days, for instance.
How do you handle maintenance?
This is also addressed during the design stage—how much can staff handle, who will cut the grass, depending on the ability of the residents or day center users, how much can be managed as an activity and what will they need a maintenance contractor to do? It is an ongoing process of communication as the garden matures; it is also a letting go of any preciousness I may have had about how things would look over time. It’s heart-breaking to watch as new managers move in over time with their indoctrinated mindset of health and safety rather than enabling daily life.
Describe the challenges you see for the profession.
Professionally I have moved through music, garden design, geography, landscape architecture, architecture, and more recently, health research. About every 5-10 years I move on, as all professions present challenges for me because they commit to a certain mindset and worldview, a silo that is rarely progressive or evolving. I find this now in academia, where preventing and treating chronic long-term disease is taboo. Dominated as these institutions are by big pharma, my efforts to find grant funding to solve a disease that affects millions was constantly turned down, leading to the recent loss of my university position. This forced pause in my research has allowed me to reflect on my years of design work both in the UK and US.
I have maintained my ASLA connection over the years because I firmly believe that intelligent design can be transformative. ASLA has the potential to transform health through collaborative design, but not within the currently accepted framework of working for care providers, building commissioners, hospitals, and so on, where design is a shiny new version of a regulated, standardized approach to health. No matter how you tweak a dementia care home or how good the staff are, it is still about keeping people safely housed (and marginally happy) while they continue to decline.
Once I began my deep dive into the literature and I realized that dementia was treatable and people weren’t being told this (and that the care home sector and big pharma benefit financially from people with dementia and other long-term chronic diseases), I pivoted to how to keep people well and out of nursing homes. Hence, my current work focuses on dementia prevention and a multimodal non-pharmacological treatment approach. Recent papers include “A mixed methods systematic review of multimodal non-pharmacological interventions to improve cognition for people with dementia” and “Personalised Medicine for Dementia: Collaborative Research of Multimodal Non-pharmacological Treatment with the UK National Health Service.” (I’m training as a health coach to assist people with memory problems one-on-one, imparting nature-based treatment approaches—which are sorely lacking in conventional medicine!)
The challenge I see is that landscape architecture disempowers itself by disengaging from the synergistic, therapeutic, life-transforming abilities of nature-enhanced built environments. We do this by working for clients. On such projects our hands (and creativity) are tied. To remedy this, I imagine a design project we envision and own, not one based on regulatory frameworks and guidelines dictated by the care sector and governmental health authorities. Instead, it must be designed based on cutting-edge scientific findings from a wide range of fields—biology, neuroscience, physics, psychology, physiology, photobiomodulation, and so on. Once our profession considers itself to be a true healing modality, an alchemist (rather than merely the creators of spaces that someone else’s healthcare practice resides within), I believe we could transform health outcomes and the lives of millions—a challenge worth stepping into, perhaps.
This interview with Dr. Garuth Chalfont was conducted by Afrouz Rahmati, Assoc. ASLA, an officer for the ASLA Healthcare and Therapeutic Design Professional Practice Network (PPN).
Check out the ASLA Healthcare & Therapeutic Design PPN’s previous interviews from their ongoing Icons of Healthcare & Therapeutic Garden Design Interview Series: