Health blossoms in the garden

Case notes

Practitioner: Paula Gent.  

Field: Horticultural therapy.  

Location: London 

Client: Didier Dogley is a 28-year-old man with HIV who has a left-side hemiplegia, a brain injury that paralyses one side of the body. He also has a restricted field of vision and has difficulties in assimilating information. 

Case history: Originally from the Seychelles, Didier has lived in England for most of his life. Following late diagnosis of HIV, he spent some time as an in-patient at a specialised hospital. While there, he attended the garden project run by the horticultural therapy charity Thrive. He was part of a therapeutic group that attended once a week. It was felt that along with his hospital occupational therapy sessions, horticulture would be a good medium through which he could regain his manual dexterity. On discharge from hospital, Didier continued to attend the hospital as an outpatient, although he lives 12 miles away. Fortunately, the garden project had been granted funds from a foundation to carry out work with people with HIV. This allowed the project to continue to work with Didier. 

Dilemma: The offer of further therapy time in the garden project means travelling a long distance for Didier, which may reinforce his social as well as health dependence on the hospital and project. 

Risk factor: Didier might forget to take his required medication and there are also risks to working in a garden environment. 

Outcome: The development of Didier’s dexterity has been very impressive and he continues to attend the project.

Mention horticultural therapy and you might think of tree-hugging or some such other new age-related activity. And yet gardening and horticulture can enable people to increase their self-esteem and confidence, learn or relearn skills, and keep or improve their quality of life. Working gardens, such as the ones run by the horticultural therapy charity Thrive, provide a sensory environment in which it is not only plants that grow but service users, too.

Didier Dogley has HIV and a physical disability. He is able to live with the virus and has it under control, thanks to improved medication. He needs to take the correct amount of drugs at the same time every day, but finds this difficult.

As part of his hospital therapy, he began attending one of Thrive’s garden projects. It was believed that being involved with a working garden would help his confidence and improve his manual dexterity – both of which may help him ultimately to return to the workplace.

“The therapeutic group usually potter, but Didier was keen to do quite a lot,” says Paula Gent, who describes her role as providing “horticultural training in a therapeutic way”.

There were practical risks to consider. “We try and ensure that people working in the garden have had a tetanus injection. However, because tetanus is a live vaccine he is unable to have the injection,” says Gent.

So Didier wears protective gloves all the time, and is aware of the need to avoid cuts. If he does get a cut, he knows he needs to be checked by his GP.

“The other risks were his limited field of vision and weakened left arm. We try and keep this place as safe as possible, but obviously with his restricted vision there are branches he could walk into or things he could trip over. The weakness in his left arm could affect his use of tools and could make it dangerous if he loses his grip,” says Gent.

Didier originally proved reluctant to use his left hand. “We’d remind him about using his left hand and show him how to use cutting tools with it. This would also usefully help build up the muscles in the left arm. His first sessions concentrated on pruning big and small stuff, just to get him used to using two hands together,” says Gent.

“Each day he has to keep a diary but as Didier finds writing difficult we’ve a pictorial format from which to cut things out – such as pictures of the protective clothing and boots he has to wear,” says Gent, who at first would hold the paper for Didier to cut around the pictures. “Within five months we’ve seen a profound improvement in his dexterous skills. He is now able to cut the pictures out holding the paper with his weaker hand. He’s picking out and holding tiny seedlings, which is really delicate work.”

Although his dexterous skills are improving, Didier is still finding assimilating information difficult, Gent says. “At first, we needed to give him one-step-at-a-time instructions. With a two-step instruction such as ‘fill the pot and plant it’ he would get lost. So it’s ‘fill the pot’ first, do it, and then it’s ‘put the plant in’. But he is learning the job and can do some things together, but just needs prompts and reminders.”

She continues: “We also need to give him space to find his way of working. He may pick up a tool and look very clumsy and you think he’s going to drop it or cut himself, but he doesn’t. It’s like he is working out how it works – so you need to step back.”

This improved learning has also helped Didier to manage his medication safely. He now stores it next to the coffee jar in his flat so that each morning he is reminded to take it.

The project has brought Didier motivation and pleasure. “He enjoys it. It’s almost as if because he knows the garden, knows the ropes and knows where things are, that he’s developed a sense of ownership and acts like ‘this is my garden’. So, he helps the others and stays behind to help tidy up after the group has gone. He has a sense of doing something,” says Gent. She adds: “It’s so rewarding to work with someone whose prognosis is probably not good, but it’s lovely to see a smile on his face. I don’t think he relished being in hospital too much. He probably had enough insight to know that it wasn’t the best place to be and that it would be better to be outdoors.” A small but positive seed has been planted. And from little seeds…

Arguments for risk 

• The main risk is Didier forgetting to take his medication. The excitement of the garden might overwhelm his need to remember. However, routines in the garden have translated to routines at home – and he now takes his medication on time. 
• A further risk for Didier is that the project, although close to his hospital, is about an hour-and-a-half away from his flat. It is such a distance from the people and friends he knows at the hospital, and now at the project, that his isolation has increased since he became an outpatient. “He attends the hospital once a week, comes here twice a week, and does not do a lot else,” says Gent. However, he is able to travel the two-bus journey independently.  
• His garden work has given Didier a sense of purpose. Indeed, within two weeks of his attending the project, the hospital occupational therapist said that he had become much happier precisely because he was doing something.    

Arguments against risk 

• The garden therapy may have been valuable up to a point, but only when it was on the doorstep of the hospital. It was important that as an in-patient, he could get out occasionally – for some fresh air. However, because the hospital had no other form of external therapy, Didier agreed to attend the garden project and was exposed to the dangers of the garden.  
• He had never taken part in or showed enthusiasm for gardening so it could be argued that other, potentially safer, more controlled, forms of therapy might have worked also.  
• Now he is an outpatient, surely his case workers could be looking at alternatives that are nearer to home and in his local community. It is suggested that his isolation has increased since leaving hospital – while travelling a distance to take part in therapy may be breaking up the isolation, in reality it is adding to it – by preventing more locally based opportunities.

Independent comment

As a keen gardener, I can appreciate its therapeutic effects, and it looks as though Didier has vastly benefited from being part of this scheme, writes Lisa Knight. By building his knowledge and confidence, the project has managed to balance safety and freedom to explore and build his new skills.  

Whether the project is creating rather than building independence depends on Didier’s development plan and how keen he is to find employment. They could look at short-term one-to-one support that would help Didier expand his social networks, and explore links with back-to-work or employment-mentoring schemes. 

It is not clear how much Didier understands about his condition. Does he know the importance of drug timings and doses, and is he getting any specific treatment support? 

From an HIV perspective, being given a late diagnosis and learning to manage a treatment regimen is daunting. Managing treatments includes many of the outcomes in this study, such as building confidence and understanding and creating routine. People fare better on treatments when they understand the issues, feel positive about starting, and have access to appropriate support and information. 

This, in turn, enables them to develop strategies that fit into their lifestyle. Visual cues, such as placing the medication next to the coffee jar, are a good example of this.  

Lisa Knight is mentor co-ordinator, Living Well with HIV Mentoring Project, Terrence Higgins Trust (South).