This practice piece aims to review an occupational therapy led pilot programme – social farming as an intervention option in an adult community mental health setting in Ireland. It will also reflect on the practical implications of delivering the natural surroundings based programme through the COVID-19 pandemic and plans for the future development of such programmes in adult mental health services.
The Occupational Circumstances Assessment Interview Rating Scale (OCAIRS) was used to measure occupational participation (Forsyth, 2005). This was administered with participants’ pre and post their participation in the 10-week programme. An internal questionnaire was developed to further capture both the participant and farmer experiences of the social farming programme.
Whilst improvements were noted in a number of OCAIRS domains, it was difficult to identify small changes over a short period of time. The main domains of change were habits, roles, interests and personal causation. The success of the social farming placements was also reflected in the internal questionnaire. The pilot programme has resulted in the further development of the social farming programme and securing of funding for placements for five years.
It would be beneficial to consider other standardised assessments that assess quality of life and occupation for future placements. It is also beneficial to consider practical implications in delivering a social farming programme, particularly to those with barriers to transport. It is hoped this paper will contribute to the growing knowledge of social farming as a meaningful therapeutic intervention in mental health occupational therapy practice.
Deegan, D., Fingleton, E., McEvoy, J.J. and Quigley, K. (2023), "Nurturing mental health and well-being using ordinary farms", Irish Journal of Occupational Therapy, Vol. ahead-of-print No. ahead-of-print. https://doi.org/10.1108/IJOT-07-2022-0026
Emerald Publishing Limited
Copyright © 2022, Deirdre Deegan, Emma Fingleton, Joseph James McEvoy and Kate Quigley.
Published in Irish Journal of Occupational Therapy. Published by Emerald Publishing Limited. This article is published under the Creative Commons Attribution (CC BY 4.0) licence. Anyone may reproduce, distribute, translate and create derivative works of this article (for both commercial and non-commercial purposes), subject to full attribution to the original publication and authors. The full terms of this licence maybe seen at http://creativecommons.org/licences/by/4.0/legalcode
Introduction and background of social farming
“Social farming” (or “care farming”/“green care” as it is also known in the wider European context) is a term used to describe a therapeutic intervention which offers people the opportunity to engage in activities on a working farm, supporting them in forming social relationships and learning new skills in a non-clinical environment (Social Farming Ireland, 2019). Social farming provides a planned, outcome-focused, supported placement for people on a farm using the natural assets of the people, their place, the activities and the community to support a person to achieve their own chosen goals. Social farming also creates the opportunity to reconnect farmers with their local communities through the opening up of their farms as part of the social support system of the community. Social farming is based on three key elements: spending time with farmers and their families in the natural environment of the farm while engaging in meaningful activities which combines to deepen its impact to support recovery.
Social farming stems from a wider movement towards “green care” initiatives for health, which includes a range of therapeutic interventions involving farming and farm animals, horticulture and other contacts with nature such as wilderness therapy (Artz and Bitler Davis, 2017; Berget et al., 2008).
While most social farms in Ireland are small- to medium-sized holdings, they have backgrounds in a diverse range including forestry, equine and general livestock. Persons who have successfully engaged in social farming in Ireland include, for example, people with mental ill-health, persons with disabilities (physical, intellectual, sensory); young and older persons, people recovering from substance misuse and refugees. This practice piece will focus on the evaluation of an occupational therapy led pilot programme for clients of mental health services in County Kildare.
Social farming: a historical background
Historically, onsite psychiatric hospital gardens and farms provided an early form of horticultural therapy for inpatients throughout the 19th and early 20th century, stemming from the moral treatment movement and recognition of the therapeutic impact of working outdoors (Stucker et al., 2015; Hine et al., 2008). Although this type of treatment fell somewhat out of favour in the 1950s, modern research confirms that engagement with nature has proven positive benefits to human health including stress management (Parsons et al., 1998; Kuo, 2001), improvements in cognitive functioning (Wells, 2000; Taylor et al., 2006) and faster recovery from ill-health (Travis and McAuley, 1998; Cimprich and Ronis, 2003) as well as fostering a sense of belonging (Kingsley and Townsend, 2006; Moore et al., 2006). In addition, the outdoor environment and physical nature of the work on farms promotes natural exercise which has been shown to be an effective treatment for mild-to-moderate depression as well as reducing symptoms of anxiety (Herring et al., 2014; Craft and Perna, 2004; Paluska and Schwenk, 2000). The positive impacts of interactions with nature for mental health have been found to be significant and similar in effect to other well-studied contributors to positive mental health (Beyer et al., 2014).
By virtue of their emphasis on personal empowerment, participant autonomy and social connection, social farming and other green care initiatives map well onto current models of mental health recovery (Granerud and Eriksson, 2014). In addition, social farming presents a hybrid governance model in which public and community organisations work together with health-care providers to promote health and social inclusion (Borgi et al., 2019), which is in keeping with international recommendations such as the WHO’s most recent Mental Health Action Plan (2013–2020).
Despite the fact that social farming is often closely linked to occupational therapy practices such as horticultural therapy (Cutcliffe and Travale, 2016; Sempik, 2010) there is currently limited research focusing on social farming as an occupational therapy intervention for mental health. This being said, many of the participant outcomes discussed within qualitative research (Moroney, 2019) on the subject are of relevance to occupational therapy, including general occupational engagement in farming tasks, development of social roles and relationships, routine building and skills acquisition.
The occupational therapy led social farming pilot programme commenced in December 2020 with the objective of offering three 10-week placements over a 12-month period. Each placement block aimed to host three participants, totalling nine individual placements available. Social farming placements cost €80 per person per day. Costing for a 10-week (one day per week) three-person placement is €2,400. Three placements proposed over a 12-month period totalled a cost of €7,200. Additional transport costs of €2,000 were included in initial costings totally €9,200 for the pilot programme. Social farming Ireland committed to a contribution of €1,800 or a quarter of the initial pilot programme costs excluding transport in an attempt to support the commencement of the proposed pilot programme. Therefore, the final cost of the pilot programme to the Kildare West Wicklow Mental Health (KWWMH) service was €7,400 by year end.
The placements were open to all community mental health team (CMHT) service users across the KWWMH service with the occupational therapist on each team managing the screening, processing and submission of referrals to the social farming subcommittee. Noting the COVID-19 restrictions and guidelines at the time of commencement, social farming was an ideal programme to proceed while being able to encompass all public health guidelines safely. The physical environment of a farm with large open spaces and activities that could be done while maintaining two metre distances made this a particularly viable programme in the climate. The social farming subcommittee did make the decision in January 2021 to pause a placement for a period of four weeks when the COVID-19 positive numbers nationally were high and the vaccination programme was only in its infancy.
Throughout the year additional funding become available via social farming Ireland that allowed us to increase the capacity of placements offered, by year end the KWWMH service had offered 13 individual placements with 12 placements successfully completed. Three different farm types were used for placements, an equine and cattle farm, a forestry and sheep farm and a further sheep farm. Participants were placed on farms based on their interests, the geographical location of the farm, the availability of the farmers and the consideration of participants’ functional abilities and goals.
The diverse range of day-to-day activities involved in the running of a farm mean that clients have the opportunity to exercise choice as to which activities are most suited and enjoyable to them (Pedersen et al., 2015). Within almost all the qualitative studies considered, participants named flexibility to pursue activities of interest within the context of the farm and adaptability of tasks to suit individual needs, as well as the ability to explore roles outside of “patient” as being key to their enjoyment of the intervention (Ingeborg et al., 2016; Ellingsen-Dalskau et al., 2015; Iancu et al., 2013; Hassink, 2010).
Obstacles and overcoming barriers
COVID-19 presented as the greatest challenge when planning and implementing social farming placements. The safety of the participants and social farmers was of utmost importance. Direction was issued from Social Farming Ireland to assist in the facilitation of placements which adhered to strict public health guidance. This included the implementation of weekly COVID-19 screens within 24 h of attending the farm and ensuring that all participants were up to date with the public health measures, including mask wearing, hand washing and COVID-19 symptoms at the time of their placement. Individual plans were put in place in advance should a participant have become symptomatic while on the farm. One three-person placement was jeopardised as it was cancelled by the facilitating farm last minute due to concerns over COVID-19, however it was quickly rescheduled to a new location. No participant or farmer contracted COVID-19 during the placements.
Transport also presented as a challenge when planning placements. As the majority of farming sites are rural based, it meant that public transport options were limited. This had the potential to impact on one’s ability to engage in the placement as the majority of participants did not have access to their own transport. This was overcome by liaising with HSE transport, who were able to transport participants to the farms each week.
Feedback and outcomes
The Occupational Circumstances Assessment Interview Rating Scale (OCAIRS) was chosen as the outcome measure for the social farming pilot project. The OCAIRS was the assessment already being used as an outcome measure in the Sligo/Leitrim Mental Health Service’s well-established social farming programme since commencing in 2012. The OCAIRS is an interview focused tool providing a structure for gathering, analysing and reporting data on the extent and nature of an individual’s occupational participation (Forsyth, 2005). This was administered with participants pre and post their participation in the 10-week programme, and looks at roles, habits, personal causation, values, interests, skills, short-term goals, long-term goals, interpretation of past experiences, physical environment, social environment and readiness for change. Both pre and post OCAIRS were compared at the end of the programme to identify if any changes occurred following the 10-week placement. Whilst improvements were noted in a number of domains, it was difficult to identify small changes, particularly over a short period of time. The main domains of change were habits, roles, interests and personal causation. An in-house questionnaire was also developed by the social farming subcommittee to gather information that was not captured by the OCAIRS. Eleven participants completed the questionnaire, it was agreed within one of the CMHT’s that one participant would not be asked to complete it due to acute mental health needs at that time. Consent was obtained from each participant to use the information gathered from the questionnaire in writing a practice review paper. All participants identified that they enjoyed their social farming placement and would recommend it to others. Whilst the majority of participants felt that it was the right length of time, three felt that it should have been a longer duration. Working with animals, physical activity, developing routine, learning about forestry and socialising with other participants and the farmers were identified as favourite aspects of the social farming placement. This is consistent with the findings from the OCAIRS. Participants did not identify any aspects which they did not enjoy. The success of the placements was also reflected in the questionnaire when participants were asked about any lifestyle changes since completion of the placement. Three of the participants have gained employment since participating in the programme, two have commenced a training course and one is attending a social programme. Increased physical activity and developing routines were also identified as positive lifestyle changes since attending the programme. This is consistent with the research, and reiterates that the environment of a working farm can also help participants to develop a routine that they may previously have lacked, particularly for those who have left the structure of work or education due to mental ill health (Iancu et al., 2013).
The farmers themselves were asked to complete a four-question post-placement questionnaire also focusing on their experiences of the pilot programme, asking if they felt the participants were well matched to the placements, if the occupational therapist could do anything different/further to support the placement and if they had any further recommendations for future placements. The consensus was that all three farmers felt it was a mutually beneficial experience and that the participants were well matched to the farms and the farm activities. They felt well supported by the occupational therapy department and felt comfortable in the knowledge that the treating therapists and project lead were available and contactable if and when required. As regards recommendations, one farmer suggested they be better equipped to manage “suicidal ideation”, this may be best managed in contacting the occupational therapist to ensure any further assessment required in organised. Social farming Ireland may consider rolling out a training course for their farmers if the majority of farmers felt it would be helpful.
Implications for future practice
The success of the pilot programme led to a follow on business case proposing a five-year plan (2022–2027) to integrate social farming into the KWWMH Services. This would ensure social farming becomes a realistic and attainable treatment option for service users of all CMHTs. The costings slightly increased regarding transport to a proposed €2,800 annually totalling a cost of €10,000 per year or €50,000 over five years to implement three 10-week three-person placements per year, or 45 placements in total over the five years.
Relationships are now well established with social farming Ireland and the occupational therapy department within the KWWMH services. This has been aided by having a consistent senior occupational therapist as the project lead and the greater social farming subcommittee to support the roll out of each placement. The number and diversity of farms coming on stream within the area continues to increase and as they do the occupational therapists will visit potential sites, meet the farmers and have a clear picture of the range of activities available on each farm to ensure participants are matched appropriately. Activities in which participants are offered choice promote a sense of autonomy and therefore tend to be perceived as more meaningful, with engagement that comes from a place of internal motivation generally considered to be more satisfying than extrinsically motivated engagement, which can be felt as “pressurised” (Ellingsen-Dalskau et al., 2016). Such engagement in meaningful activities is a key determinant of mental health and the recovery process (Borgi et al., 2019).
The OCAIRS as an outcome measure will be re-considered due to the time constraints in administering such a lengthy interview pre and post placement. Notwithstanding the fact that the occupational therapists administering the OCAIRS felt that it was not sensitive enough to capture the smaller yet significant lifestyle changes that occurred for service users following participation in a social farming placement as the questions were broader and based on more macro concerns. Future assessment tools would be best served capturing qualitative data that highlights potential even small changes to daily routines and the development of social relationships.
As we embark on the implementation of our five-year social farming plan we note a slowdown in referrals to the subcommittee. This is particularly evident on CMHT’s that have a vacant occupational therapy post suggesting as predicted that the occupational therapist is a driving force and champion of social farming placements across the mental health service. The subcommittee will also consider in partnership with social farming Ireland and the farmers the possibility of an open farm day in which other disciplines from the CMHT’s including medical, nursing, psychology and social work are invited to experience a day in the life of a social farmer. This is hoped to generate more understanding of the potential of placements and broaden the net for referral sources.
Finally, we endeavour to develop a calendar at the beginning of each year outlining when and where the placements will occur over the next 12 months. This will help in offering stability to the farmer, knowing when the placements will happen and assist the subcommittee in matching referrals to the most suitable farm while allowing participants to plan for any upcoming placements.
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The authors would like to acknowledge the financial support made by Social Farming Ireland towards the initial pilot programme costs.