Therapeutic Landscapes: An Evidence-Based Approach to Designing Healing Gardens and Restorative Outdoor Spaces
About this book
Therapeutic Landscapes: An Evidence-Based Approach to Designing Healing Gardens and Restorative Outdoor Spaces, authored by Clare Cooper Marcus and Naomi A. Sachs and published by Wiley in 2014, is a landmark synthesis of research and design guidance for outdoor spaces in healthcare settings. Cooper Marcus, Professor Emerita of Architecture and Landscape Architecture at the University of California, Berkeley, and Sachs, founder of the Therapeutic Landscapes Network, spent years compiling post-occupancy evaluations, user surveys, literature reviews, and case studies to produce what has become an authoritative reference for the growing field of evidence-based healthcare landscape design.
The book's foundational premise is that outdoor gardens in healthcare facilities are not decorative amenities but therapeutic instruments with demonstrable effects on patient recovery, staff well-being, and visitor stress. This premise draws on two interlocking bodies of theoretical work. The first is Attention Restoration Theory (ART), developed by Rachel and Stephen Kaplan, which holds that natural environments — characterised by fascination, being-away, extent, and compatibility — allow the directed attention system to rest and recover from fatigue, restoring the capacity for sustained concentration.
The second is the Stress Recovery Theory (SRT) associated with Roger Ulrich, who demonstrated through both controlled experiments and clinical observational studies that exposure to natural settings triggers measurable physiological relaxation responses — reductions in cortisol, heart rate, blood pressure, and self-reported anxiety — that are distinct from and faster than responses to built urban environments. Ulrich's landmark 1984 study in the journal Science, showing that surgical patients whose hospital room windows overlooked a natural scene recovered faster, used less pain medication, and were discharged earlier than patients whose windows faced a brick wall, is a recurrent reference point throughout the book. Marcus and Sachs use this and subsequent research to argue that designed outdoor access in healthcare is not a luxury but a clinical resource that can reduce length of stay, lower pharmaceutical costs, and improve patient satisfaction scores.
A distinctive strength of the book is its patient-specific framework. Rather than proposing a single universal healing garden template, Marcus and Sachs organise their design recommendations around twelve distinct user groups: adult medical-surgical patients, paediatric patients, oncology patients, psychiatric patients, rehabilitation patients, patients with Alzheimer's and dementia, burn patients, hospice patients, women in labour and maternity wards, staff, family members and visitors, and children with disabilities. For each group, the authors synthesise the relevant clinical literature, identify the particular stressors and needs associated with that population, and translate these into specific spatial, material, sensory, and programmatic design guidelines.
Paediatric gardens, for instance, require age-appropriate play elements, clear sightlines for parental supervision, and spaces that allow ambulatory children to engage in physical activity without risk. Dementia gardens must be enclosed to prevent wandering, use non-toxic familiar plants, provide clear wayfinding cues, and offer sensory stimulation without confusion. Psychiatric gardens demand particular attention to safety, privacy, and the elimination of features that could be used for self-harm, while still providing genuine access to nature and a sense of agency for patients who may feel little control over other aspects of their hospitalisation.
The book addresses the full design process, from the earliest stages of site selection and programming through schematic design, construction documentation, and post-occupancy evaluation. Marcus and Sachs argue strongly for including future users — patients, families, and clinical staff — in participatory design processes, noting that designers who fail to consult actual end-users frequently misjudge the needs of populations with whom they have no lived experience. They also address the practical realities of healthcare design, including infection control requirements, maintenance considerations, wheelchair and mobility aid accessibility, and the budget pressures that frequently result in gardens being value-engineered out of projects.
Case studies drawn from hospitals in North America and Europe illustrate how the principles have been applied in diverse contexts — urban academic medical centres, suburban community hospitals, children's hospitals, hospice facilities, and psychiatric units. Post-occupancy evaluation findings from these examples provide both encouragement and caution: gardens that are well-designed, genuinely accessible, and actively programmed generate measurable benefits; gardens that are difficult to reach, poorly maintained, or designed without regard for actual user needs may sit unused. Therapeutic Landscapes closes by situating healing garden design within the broader movement toward salutogenic healthcare environments and making the case that the evidence base for outdoor nature access in hospitals is now robust enough to warrant incorporation into healthcare facility planning standards, building codes, and institutional procurement requirements.