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Case notes

Practitioner: Rosie Hollands

Field: Horticultural therapist and trainer with Thrive, the horticultural therapy charity.

Location: London.

Client: Sarah Temple, 32, has learning difficulties.

Case history: Sarah has features of autistic spectrum disorder. This causes, among other things, attention deficit, limited speech, poor eye contact and aversion to touch and noise. Sarah's behaviour can include verbal aggression which can escalate into physical aggression - mainly pushing and shoving. But this has further escalated into her damaging property and throwing objects, and becoming a risk to herself and those around her. Sarah's behaviour was a strong factor in the breakdown of her most recent day services placement. Subsequently, for about six months she had no day services. So, as Sarah had long shown an interest in gardening, she was referred to Thrive.

Dilemma: Sarah is missing out on meaningful daytime activities outside her community home. But would a placement in an open environment with all the risks that presents be appropriate for her?

Risk factor: Sarah's aggressive verbal and physical outbursts had been too risky for an enclosed, controlled social care environment. In the garden she would work with new staff and volunteers and be put into contact with the public and other service users.

Outcome: Sarah has settled in well to the project and has displayed little challenging behaviour. Plans are now in place to increase her time at the garden.

Although horticultural therapy is relatively new as a career option, the practice is as old as the hills. Gardening and horticulture can enable people to increase their self-esteem and build their confidence, learn basic skills and social skills, and maintain or improve their quality of life.

This is certainly the experience of Thrive, the horticultural therapy charity and its garden projects. These working gardens provide a sensory environment in which not only plants, flowers and vegetables can grow, but people too.

After the breakdown of her previous specialised learning difficulties day service, not least because of her challenging behaviour, Sarah Temple spent six months in her community home without a placement until an occupational therapist recommended a garden project in London.

"The working garden offers therapeutic and training placements for people with a range of special needs," says horticultural therapist and trainer Rosie Hollands. "For Sarah we were looking at enabling her to focus and stay with an activity, and begin to have a sense of belonging in a group - even though she finds it difficult to interact."

Hollands, an occupational therapist by background with a diploma in horticultural therapy, was concerned at the risks involved in accepting Sarah.

"I met the home manager after she and Sarah had visited the garden and went through the risk issues," says Hollands. "On the one hand we had a young woman without any meaningful activities in her life, but who was keen on gardening and who seemed to like being here. On the other we're based in a public park, which means we have the public - mainly women and children - walking through. And we have other service users who could be vulnerable or cause Sarah increased stress. So, there were a number of potential triggers and a big risk if Sarah's behaviours were to escalate."

It was agreed that Sarah, who has limited verbal communication, would only attend with a support worker from the home. As Sarah does not handle change easily this would ease the stress of a new environment and the worker would be able to spot signs of stress quickly and intervene as needed.

According to Hollands, Sarah finds it difficult if something does not happen as planned. Hollands says: "Although we have a structured working day - we start with a team meeting, have breaks, have a regular lunch time and end the day with a review and people filling in their individual diaries - we weren't sure whether it would be clear enough for Sarah to manage. It is a public space, it is a garden and things happen that are not planned. But so far it has had enough of a structure to hold her.

"I feel we have offered her the opportunity to engage in something she's interested in and to come to a work-type environment. She has a sense of getting up in the morning and going somewhere meaningful. And she goes home having achieved something."

Sarah has been filling pots with compost, planting bulbs, raking leaves, preparing vegetable beds for planting, watering and cleaning tools. "We give her a lot of one-to-one contact to reassure her that she's doing the task well and that she can be proud of what she's doing," says Hollands.

Indeed Sarah's pictorial diary, which comprises either drawings or cut-out pictures, is a proud record of her achievements. "If she's been planting daffodil bulbs, it's really nice to have a picture of daffodils in her diary so she can see what she's planted," says Hollands.

"At first Sarah found it difficult to make any eye contact and her interaction was minimal. Now when she leaves the project for the day she will give everybody a wave and smile - and there's a sense that she feels part of the group," says Hollands, who is positive about having taken the time to devise a risk management plan and see that pay off.

The calmness has reaped rewards. "It is a calm garden. We have some beautiful trees here. Sarah works near a eucalyptus tree - which has a very soothing sound. Naturally, there is lots of green which is a calm colour," says Hollands.

According to the home manager, since coming to the garden Sarah is more settled in general and better able to occupy herself. Funding is available for her to attend two days a week, which is the next step. "Interestingly," says Hollands, "one of our volunteers, who's been here since Sarah started, said the other day, 'I think she's come on amazingly'." She has, indeed, blossomed.

Arguments for risk

• The project took great care to consider all risk factors and agreed that action could be taken if necessary. Crucially, the use of a one-to-one support worker from the home helped Sarah to settle and could intervene early as stress triggers were observed. 
• Sarah's aggressive behaviour is often triggered by stress - the busy, active and often chaotic characteristics of traditional day services for people with learning difficulties worked against her. In a garden with its calm and sensory environment, despite its newness to her, Sarah could feel more at ease. 
• Being encouraged to be part of a group of other clients who are not only people with learning difficulties could also be beneficial for Sarah. 
• The project enabled Sarah to take responsibility. "Sarah finds it difficult to make choices but now we can say to her that she has the choice of two activities today, and she is now able to cope with that," says practitioner Rosie Hollands.   

Arguments against risk 

• Sarah's challenging behaviour was an important factor in the breakdown of her previous day service placement. And no other placement could be found that could meet her needs. Social care professionals with backgrounds and specialist training in working with people with learning difficulties found it difficult to meet Sarah's needs adequately.  What chance, then, would horticultural therapists and trainers, whose skills and work experience are more general, have in doing so? 
• Sarah has features of autistic spectrum disorder. This needs special understanding and management - not something you would expect to find on a gardening project. 
• A garden, although tranquil and sensory, is also a potentially dangerous environment. As well as poisonous and harmful plants, gardening tools can be sharp and dangerous. This is particularly worrying given Sarah's history of throwing objects around. 
• The garden is in a public park - the people using it could be putting themselves at risk without realising it.

Independent comment  

Think of a garden you enjoy being in, writes Kathryn Stone. Think of how you feel there. What can you touch, see, hear and feel? Now think of a day centre. Ask yourself the same questions. Are the answers the same? This is not some new age visualisation. This is the real world. 

Many people enjoy their day centres. But others find them impersonal, noisy places where there is little time for individual needs and aspirations. And creativity comes as an extra. This example shows what can happen if you put the person first and believe in their right to fulfilment, independence and dignity. 

It also shows what good can come of managing risks while thinking of different solutions to an otherwise impossible situation. Did anyone stop to think why Sarah was throwing objects around? Thrive did listen to her and understand. 

It is ironic that those who have all the "special understanding" of Sarah's condition failed to cope with her needs. All too often at Voice UK we hear of people being excluded from placements because their behaviour "presents challenges to the service". What this means is they are too much trouble. Nothing else is offered at all. 

There's no denying the risk in Sarah working in the garden. This has been managed in a way that supports Sarah not smothers her. She has become a person first and a "problem" way down the list. This is valuing people in practice. This is care for and about someone. This has made a difference.  Kathryn Stone is director of the learning difficulties charity Voice UK