I recall a particular late morning in my garden, one of those late fall days when the sky is vivid blue and cloudless; the air holds the crispness of impending winter around the envelope of sunny warmth. The image still so vivid in my mind was a rose bud—still tight in its emergence with the petal tips deeply blushed with pink. With more warmth and sun, this bud was so full of potential to be a fragrant blossom. Yet the hint of frost on its green collar was the harbinger of another destiny, of unrealized fullness, a life cut short. This image was particularly powerful for me at that moment, as my student, our Fellow in Palliative Medicine, had been on the journey of a complicated twin pregnancy and had delivered just a few days earlier. One of her twins, Isabella, died within hours of the birth: such potential, beauty; such life unrealized, unable to blossom. That fragile rose bud crusted so lightly with frost gave expression to my grief, became of metaphor and a way of “making sense” of suffering.
My awakening to the power of the garden and gardening as instruments of healing occurred rather abruptly. Almost 75 percent of my grandparents had been raised on farms, so having “dirt on my hands” was hardwired into my very substance. Many early memories, particularly of my maternal grandmother, Beulah Matson, were nested in the garden. Grandmother Matson spent more of her adult life as a widow than married, raising three children on her own. Her garden was clearly her sanctuary. I can see her—standing close to 5’1” when she inhaled mightily, with her wide-brimmed crownless hat and well-worn gloves (which she frequently did not wear), gowned in culottes with an apron—in her garden. My engagement ring was willed to me by her—it almost wasn’t, as she accidentally planted it with the tulips one year. The day lilies in my garden (and before that, my mother’s garden) were those she hybridized—she did this as a novice, but also as a botanic explorer of sorts who loved plants. In my college years, my studies in biology and biochemistry at Purdue were heavy in botany; plants and green hideaways were always where I sought to be when I needed “sanctuary.” Any important papers I needed to write, including my applications to medical school and the personal statement for medical residency programs, were written in a garden. And yet, through this time, I was unaware of what drew me and of my inherent need to be among the sounds, smells, textures—the soothing and healing aesthetics of a garden.
It was not until I started my work with the dying that I discovered that the best way to process these journeys, to unpack what I had witnessed, to review the story of lives lost, was on my knees and with dirt on my hands. I could somehow make sense of death in the cycle of the garden, reclaim hope in the emergence of tender plants, grieve the losses with a trowel, shovel, and rake—feel my body alive and physically healthy. Perhaps this was a needed reassurance in witnessing so much illness and death. The epiphany—the connected meaning—occurred one day when I had gone to a funeral home to sign the death certificate of a woman named Dorothy, for me a needed observance if not ritual of closure. Dori had been my patient for several years, and I had been her physician in her diagnosis of lung cancer, easing its swift and breathtaking luge ride, and supporting her through her death. I recall her on the night she died, lying in bed, eyes closed, but with a soft smile and a whisper: “You know, Martha, I’m really going to miss you.” As I drove home from the funeral home that afternoon, I stopped at a nursery and bought a tree. And it hit me. A tree for Dori, a copper-roofed bird feeder for Barb, a rambling rose for Chester, the hydrangea for Kay . . . many of the losses, those rich with relationship and love, were memorialized in my garden through plants and garden fixtures. I shared this realization with a colleague as I drove home—the tree flapping through my sunroof—and his response to me was, “Well Martha, I’m glad you have a few acres of land—because given the work you do, you’re going to build an arboretum.”
Gardens and gardening are known to be powerful therapeutic modalities; horticulture therapy has been shown to help with pain, depression, and the agitation of dementia. Nature images in hospitals can decrease anxiety and improve pain control. But gardens and gardening are also modalities of healing.
What is healing? Medicine claims to be a healing profession, and modern medicine claims the ability to heal through its scientific approach. But in truth, medicine, particularly Western medicine, is more about “curing” than healing: defining and categorizing diseases and seeking to eradicate the “dis-ease” through interventions or treatments—chemical, mechanical, radiation, and otherwise. Thus, diagnosis and cure are the tenets of modern medicine, and the physician’s role has very much become the “curer of disease” rather than the “healer of the sick.” But this was not always so. The historic roots of Western medicine, of Plato, Aristotle, and Hippocrates (and likely some wise women with insufficient public relationships), were foundationally holistic. Plato said, “if one is to cure the ear, one must first cure the head and to cure the head, one must cure the body, but to cure the body, one must start by curing the soul—for if the part is to be well, the whole must be well.” This definition speaks of wholeness; the root meaning of healing literally means to make sound and whole. The root of this word is also the root of holy, meaning that which is spiritually pure. For centuries, there was a strong association between healing, wholeness, and spirituality. The splitting of medicine in the time of Descartes has led to a paradigm where modern medicine has no true model for what it means to be whole or healed, values the objective more than subjective, the quantitative more than qualitative, and certainly pays little attention to spirituality.
And yet many physicians find greater satisfaction in the biopsychosocial-spiritual model of care than the biomedical approach alone. An article that is foundational in my understanding of my role as a physician is “The Meaning of Healing: Transcending Suffering,” published in 2005 in the Annals of Family Medicine by Thomas Egnew. This study was a qualitative inquiry of in-depth, open-ended, semi-structured interviews with Drs. Eric Cassell, Carl Hammerschlag, Thomas Inui, Elisabeth Kubler-Ross, Cicely Saunders, Bernard Siegel, and G. Gayle Stephens—allopathic physicians chosen for their expertise in addressing the topic of healing. Their perceptions regarding the definition and mechanisms of healing were subjected to grounded theory analysis. Three themes emerged from this research, defining healing in terms of wholeness, narrative, and spirituality. Healing involves the restoration of wholeness: the physical, emotional, intellectual, social, and spiritual aspects of the human experience. Illness threatens or impacts wholeness by loss and isolation, disconnecting those who are ill from their roles, their loved ones, and their very sense of self. A sense of wholeness can be regained, even for the very ill and dying, through reconnection and reconciliation. Even as bodily illness progresses, healing can occur. Healing is, in essence, a reinterpretation of life in the midst of illness, and oft times, because of illness. Healing is an intensely personal, subjective experience involving a reconciliation of the meaning an individual ascribes to distressing events with his or her perception of wholeness.
Physicians can be instruments of healing when there is continuity and relationship—when the one who is ill and the one who provides care meet not just in a professional context, but in their humanity. This shared vulnerability creates safety and personal connection. In this relationship, the one who is ill can lay down their burdens and seek to make sense of their state of being—creating a new narrative that incorporates the illness and also, many times, the physician. The physician-healer must practice true compassion, that deep awareness of the suffering of another combined with the desire to relieve it. The physician-healer guides the patient in reworking their life narratives to generate meaning and to transcend their suffering. “Suffering ceases to be suffering in some way,” Victor Frankl wrote, “at the moment it finds a meaning.” Shared suffering (compassion means to suffer with) intertwines the life narratives of the one who is ill and the healer: the healer gently guides the reconstructing of identity, the reforming of purpose, and the revising of the life narrative towards discovered meaning so as to facilitate transcendence of suffering and healing. The physician cannot give or prescribe meaning and purpose, cannot always ease the anguish of suffering and loss, and certainly cannot cause transcendence; however, they can serve as catalysts in the process of healing by sensitively attending to this process and seeking to understand the nature of suffering. As Eric Cassell says, “The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick. Physicians’ failure to understand the nature of suffering can result in medical intervention that, though technically adequate, not only fails to relieve suffering but becomes a source of suffering itself.”
Modern medicine does very little to prepare the physician to relieve suffering, let alone facilitate healing. Cassell emphasizes that to experience wholeness is to be in relationship with oneself, one’s body, one’s culture, and significant others. Wholeness requires one to be amongst others and is experienced in connection with others. Continuity of care supports connection; trust and relationship are only possible with continuity. Yet healthcare has deteriorated such that physician-patient relationships are highly temporal and location defined; patients see multiple physicians who may or may not communicate effectively. Physicians are not trained to truly listen to their patients’ stories. Indeed, they may deliberately limit the narrative to facilitate diagnostic clarity and efficiency, and to avoid emotions or unpleasant feelings. Some physicians resist the role of being a guide or healer, as this role is uncomfortable if not inappropriately intimate. And yet to truly understand and to diagnose, which literally means to know fully, the physician must venture more deeply into connection and relationship. “The secret of care of the patient,” Egnew observes, “is caring for the patient by forging connexional relationships, grounding treatment choices in the person rather than the disease, maximizing function, and actively minimizing suffering, physicians strengthen patients with the goal of maintaining intactness and integrity. By helping patients transcend suffering, physicians surpass their curative roles to claim their heritage as healers and maintain the tradition of medicine as a healing profession.”
My training in the healing profession of medicine led me to the subspecialty of palliative medicine. This discipline of medicine is committed to easing the distress of illness, to providing treatments and interventions that facilitate symptom relief. Palliative medicine physicians are experts at symptom control, and they practice in the context of an interdisciplinary team to provide holistic care to patients and families. Medicare defines palliative care as “patient and family-centered care that optimizes quality of life by anticipating, preventing, and treating suffering. Palliative care throughout the continuum of illness involves addressing physical, intellectual, emotional, social, and spiritual needs and to facilitate patient autonomy, access to information, and choice.” This type of medical care is provided alongside and concurrently with other disciplines of medicine to promote healing, whether or not a cure is possible. Palliative care seeks to manage the experience of an illness, to promote the restoration of quality of life and function.
Horticulture therapy has the potential to be a powerful adjuvant in the care of the patient receiving palliative-care support. The engagement of the senses through the immersion in the aesthetics of nature, the therapeutic benefit of physical movement and activity, and the therapeutic guidance to promote reflection and find meaning in the circumstances of illness are among the many benefits. This therapeutic modality is not just for those who suffer from advanced disease, but for all of those who journey with them: the families and the professional caregivers. Suffering, either directly from illness and its impact or through compassion, requires a means and place to facilitate ease and healing. For me, this place is to be found—most effectively and powerfully—in the garden.
. V.E. Frankl, Man’s Search for Meaning: An Introduction to Logotherapy (New York, Pocket Books, 1963).
. E.J. Cassel, “The Nature of Suffering and the Goals of Medicine,” New England Journal of Medicine 306 (1982): 639-45.
. T. Egnew, “The Meaning Of Healing: Transcending Suffering,” Annals of Family Medicine 3 (2005): 255-62.
. Medicare Hospice Conditions of Participation, Final Rule, 73 Fed. Reg. 32204 (June 5, 2008).