An Evidence-based Approach to Therapeutic Landscapes

Therapeutic Landscapes: An Evidence-Based Approach to Designing Healing Gardens and Restorative Outdoor Spaces
by Clare Cooper Marcus, Honorary ASLA, and Naomi Sachs, ASLA, is more than an update of the milestone 1999 book, Healing Gardens: Therapeutic Benefits and Design Recommendations, by Marcus and Marni Barnes, ASLA. Compared to the earlier book, this book is more richly illustrated with color photographs, exemplary case studies, and practical design guidelines. This book also provides all the latest research on the benefits of exposure to nature.


Healthcare is currently undergoing tremendous change. Healthcare environments are increasingly offering gardens, with demonstrable benefits to patients, families, and staff.

Healthcare gardens have proliferated. Many healthcare grounds have evolved into functional spaces that provide intentionally restorative or therapeutic benefits. But not all gardens deliver as advertised. Some healthcare gardens featured in leading design magazines appear attractive in photographs, yet are missing elements and characteristics that optimize the health, safety, and welfare of the people that use them. Some gardens may actually be doing some harm, which is unacceptable in a medical setting.

Using the processes and guidelines presented in this book will improve garden design, enhance health care delivery, and boost economic return to healthcare facilities.

The book begins with a history of hospital outdoor space, provides a useful chapter covering research and theory, and follows with chapters on therapeutic gardens for specific medical populations such as: cancer patients, veterans, children, people with dementia, hospice care, and mental health facilities. These chapters present case studies of model gardens, supplemented with discerning analysis derived from post-occupancy evaluations of the design strengths and weaknesses. These evidence-based insights into which garden design approaches work or not in improving healthcare quality help make the case for including gardens in new construction or renovations to healthcare facilities.

The core of the book is Chapter 6: General Design Guidelines for Healthcare Facilities. Sachs and Marcus provide a checklist of both required and recommended guidelines for specific design elements, programming and site planning, along with general over-arching design considerations. Required guidelines are strongly supported by research or good practice, while recommended guidelines may have less evidence to support them or are less important when there are site constraints or programming conflicts. These guidelines will be enormously useful to ensure that a new garden provides maximum return on investment.

In another critical chapter, Teresia Hazen, Legacy Health Systems, outlines the participatory process used to create several successful gardens at Legacy Health in Portland, Oregon, a process that brings medical professionals, patients, family members, volunteers, and foundation directors together with designers to focus on the goals of a given therapeutic space. In the forward, professor Roger Ulrich notes that “an important theme running throughout the book, and expressly detailed in a chapter by Teresia Hazen, is that a participatory design process is vital to creating a successful therapeutic garden.”

In addition, there are useful chapters on planting design and maintenance, horticultural therapy, sustainability, and how to create the business case for healing gardens, including funding strategies, which can all aid advocates of therapeutic gardens.

While almost any garden provides a connection with natural elements, a garden design created on evidence-based principles — led by an informed designer and properly implemented — can facilitate stress reduction and improve health outcomes. Research has shown that exposure to natural environments enhances the ability to cope with and recover from stress, illness, and injury, and provides a host of social, psychological, and physiological benefits to humans.

This book beautifully illustrates how to implement the latest research to increase the quality and success of projects that provide access to nature.

Read the book.

This guest post is by Mark Epstein, ASLA, principal at Hafs Epstein Landscape Architecture in Seattle. Epstein was the long-time chair of the Healthcare and Therapeutic Garden Design Professional Practice Network at the American Society of Landscape Architects (ASLA). He is on the board of the Therapeutic Landscapes Network. 

Image credits: (1) Clare Cooper Marcus, (2) AECOM, (3) Clare Cooper Marcus, (4) Legacy Health / Wiley

2 thoughts on “An Evidence-based Approach to Therapeutic Landscapes

  1. Jane Rohde 11/28/2013 / 2:47 am

    Excellent resource that supports many efforts in improving the Design Guidelines for licensing of healthcare facilities; the Guidelines for Design and Construction of Hospitals and Outpatient Facilities and the Guidelines for Design and Construction of Residential Health, Care and Support Facilities developed by the Facility Guidelines Institute ( Note that the Environment of Care section for both sets can utilize this book as a resource for compliance.

  2. Dit is op My Feng Shui Garden herblogden reageerde:
    Written by my admired colleague Naomi Sachs. We share the vision that gardens and parks are healing spaces for everyone to enjoy. Build your garden in a way that you feel connected with nature, a space where you (be)long and (re)gain energy in your life.

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