Note: the following article was originally written in Spanish, and can be viewed in Spanish here.
CASE STUDY: CAROLINA
By Cecilia Prigue & Karen Consuegra
FLORECER, Therapeutic Horticulture, Uruguay
Edited by Daniela Silva-Rodriguez Bonazzi
January 2023
Case study based on a horticultural therapy program offered to a teenager with ADHD for one month in a psycho-pedagogical Center in Uruguay. The program is offered by two horticultural therapists, trained at the Horticultural Therapy Institute in Peru, who run the “Florecer” program. The adolescent was part of a group that met twice a week, for 4 hours. The activities took place in the Center’s Garden.
Participant information:
Carolina is a 13-year-old Caucasian teenager, an only child. She lives with her parents close to the seaside. Her parents provide support and containment, help her with her needs and accompany her in her hobbies and interests. She has a high level of general culture and scientific knowledge. She has a great love for animals, especially cats. Her status is short and her complexion is fair. She has long, curly black hair and large, dark eyes. Physically she has a thick build but is not overweight.
Case history:
Carolina was referred to the horticultural therapy (HT) group at the psycho-pedagogical center where she attends during the summer vacation. The group has four other members, ages 10 to 18. Carolina joined the group a week after the start of the activities.
The first day Carolina was restless and agitated, talking without pause and in a high-pitched voice. Her movements were jerky and careless due to her high level of anxiety. Her presence made the group uncomfortable at first.
Carolina was respectful towards the horticultural therapists and the other members of the group. She has a great vocabulary, is smart and mature. Her interests include reading, drawing and music. She reported not having close friends and feeling harassed and “discriminated against”. She has a great need for acceptance, being a recurring theme in her conversation and in her tendency to be the center of attention.
Problem/symptoms/diagnosis:
Carolina is diagnosed with ADHD. Her behavior shows a severe degree of physical and mental restlessness; constant talking; high tone of voice; poor emotional regulation; distractibility and demanding behavior.
Paying attention or being silent irritates her, generates nervousness, agitated breathing, reddening of the face, body tremors, and self-injury. The impossibility to calm down leads to crying and frustration. She is very conscious of her condition.
Prognosis/expected results:
Carolina presents a complex picture of anxiety that hinders her social functioning and development. Expected results include: anxiety reduction symptoms and improvement of prosocial behavior in the horticultural therapy program.
Treatment plan:
Horticultural therapists prioritize the following GOALS for Carolina:
- Reduce anxiety symptoms
- Improve self-esteem
- Improve social interaction
Horticultural therapists felt that Carolina could benefit from group therapy because of the small number of participants.
Session 1: Activity: Container decoration
Carolina is introduced to the group and is well received. She is nervous and restless. To calm her down, the horticultural therapist invites her to touch vegetable seedlings and aromatic herbs to stimulate her tactile and olfactory senses. Carolina recognized several of the plants, which reduced her anxiety for a few minutes, allowing her to sit down and continue with the activity. She was then asked to decorate her container. At first, she refused, expressing she had “no patience”. To motivate her, she was shown containers decorated by the other participants. She agreed to decorate her container using only orange, her preferred color. She rushed through the activity, leaving unpainted areas. She was encouraged to complete the entire surface, motivating her to try other shades of orange, to which she agreed showing more commitment. She finished the activity feeling happy and proud. Everyone cheered her!
During the break, Carolina commented on having several garden snails in a container, which she cared for as pets, fed them, talked to them, took them out of the container to allow them to move around, and watch them closely. This motivated her and asked permission to take an unpainted container to adapt as a new home for her snails. The group decided to prepare an “ecosystem” inside the container. This activity served to improve Carolina’s self-esteem and acceptance by the other members of the group. She enjoyed searching and collecting materials with her classmates, making a special connection with Fanny, who was her same age. They gathered soil, green and dry leaves, stones, twigs, and moss. At the end of the activity, she excitedly ran to find her mother to show her the work she had done.
Session 2: Activity: Substrate preparation
Carolina arrived early and was excited to meet Fanny. They sat down together for the activity. Fanny is a girl with a learning disorder, calm and focused on the activities. Carolina expressed “feeling disgusted” to touch the soil with her hands, so she used a tool. Horticultural therapists talked about the importance and benefits of touching the soil with their hands. Fanny motivated Carolina to touch the soil; as she did so, she said “I can’t believe I’m doing this!”, with an amused tone. She carried out the activity, with many distractions and chatting. HTs constantly redirected her attention to the task. The other participants also guided her, spontaneously and respectfully. Carolina apologized, showing understanding and acceptance.
During the break, Carolina shared her school experiences, about the discrimination she suffered from her classmates, the feeling of loneliness, not having friends because they all “ran away“. She commented that her teachers had no patience for her. Carolina was very aware of her difficulties. She was listened to with respect by the group, others also exchanged experiences, and Fanny was especially sympathetic to Carolina.
Session 3: Activity: Seedling transplant
The HT demonstrated the step-by-step, emphasizing careful and slow movements because of the fragility of the seedling. Carolina paid attention to the indications but expressed that she was not able to manipulate the seedling delicately because her movements were clumsy. She became nervous, her body trembled but was supported by the HT who gave her confidence and encouragement to do so. She managed to be silent and concentrated during the transplanting task. Upon completing the task and seeing her transplant in the container, she felt very proud of her accomplishment. This activity fostered Carolina’s commitment to care for another living being. From that day on, Carolina began the session watering and observing the plants, as well as sharing some curious facts about plants with her classmates.
Session 4: Activity: Working with succulents.
The work with succulent plants attracted Carolina’s attention; she expressed her liking for the textures and shapes of this group of plants. Horticultural therapists took advantage of the activity to use the metaphor of resilience, the strength gained in adverse situations. Carolina worked together with Fanny, they chose the same succulents, planted them in the same way in their pots, and decided that it was a symbol of their friendship. Carolina’s bond with the group improved significantly, and with Fanny, a very special one began to develop. Breaks became more meaningful as the group’s confidence grew. Carolina sang her songs and talked about her song writing skills.
Session 5: Activity: Kokedama
Carolina was very enthusiastic from the beginning, being able to follow instructions with a better degree of attention. She enjoyed the preparation of the soil ball, showing no aversion to touching the soil. The step of wrapping the soil ball with the cotton thread represented a challenge that activated nervousness and limiting thoughts since it required her concentration and smooth and controlled manual movements, to which Carolina showed frustration expressing with irritation “not being able to do”. The HT sat next to her and patiently guided her through the procedure. Carolina managed to wrap her kokedama, again overcoming her moment of irritation. She felt proud of her accomplishment and happy to be able to give away something made with her hands.
Session 6: Activity: Dreamcatcher
This new activity activated Carolina because it required her to weave a cotton thread around branches. Anxiety symptoms appeared and escalated into a severe crisis that prevented her from maintaining attention. This situation triggered crying and a lot of frustration. The HT sat next to her and proposed to start the dreamcatcher together, so that she could mimic the HT’s movements to get the weaving orderly. At this, Carolina’s breathing became agitated and strong, her face reddened and she began to pinch her hands, scratch her legs and sway abruptly in the chair. The HT in a calm tone of voice, suggested a pause, and guided her to deep breaths that helped her calm down and come out of her state. The group also gave her encouragement to overcome the situation.
The HT modified the proposal, asking her to observe the movements of her hands, repeating the words: “up, down”. Repeating the words aloud served to calm Carolina down, and she was able to finish the last turns of the weaving herself.
Carolina was able to identify an emotional self-regulation strategy. At the end of the session, Carolina hugged the HT, thanked her, and ran away.
Session 7: Presentation of the work done to the families.
Carolina participated with great enthusiasm in watering and tidying up the plants and the space. She arrived to the session with drawings for Fanny and her song notebook. During the break, Carolina sang a song full of suffering and feeling, and another song that conveyed positive feelings. At the end, her group mates applauded her effusively.
Carolina’s parents appreciated and recognized the impact of horticultural therapy on Carolina: the joy with which she attended and returned home.
Results:
Carolina was successful in participating and performing nature-based activities 80% of the time. Horticultural therapy goals were met. Carolina was able to identify gardening activities that worked in regulating her crises. She was able to express her feelings to therapists and peers. Negative thoughts and narratives decreased significantly from the time of arrival. She acquired new skills such as transplanting and caring for plants. Experienced with the group a sense of belonging, inclusion and acceptance.
Conclusion:
The horticultural therapy program was effective in addressing the goals set, achieving:
- Anxiety reduction
- Increased self-esteem
- Acquisition of social skills
- Acquisition of vocational skills
REFERENCES:
- Williams, F. (2017) – The Nature Fix. Why Nature makes us Happier, Healthier and more Creative, Editorial W. W Norton & Company, New York / London.
- Louv, R. (2005) – Last Child in The Woods. Saving Our Children from Nature- Deficit Disorder, Editorial Algonquin Books of Chapel Hill, United States.
- Sequeira, A. (2019) – HIERBAS. Medicinales y Aromáticas Usadas en Uruguay, Ediciones de la Plaza, Uruguay.
- Sequeira, A. (2020) – HUERTA. Calendario Ilustrado, Ediciones de la Plaza, Uruguay.
