Psychiatric services aim to help people with mental disorders improve their health and to facilitate their full integration and participation in society. Social integration has been defined as ‘a process, unfolding over time, through which (people with mental disorders) increasingly develop and exercise their capacities for connectedness and citizenship’ . For this process to succeed, people with mental disorders need social, moral and emotional competencies that underlie reciprocal interpersonal relationships, and the ability to assume responsibilities, similar to other members of society. Society can contribute to this process by providing opportunities where such competencies can be further developed and practiced .
Despite these theoretical insights, full integration and participation in society remain elusive goals for many people with chronic mental disorders. Challenges reside in the limited effectiveness of psychiatric, psychological and psychosocial interventions, and in the rejection of people with mental disorders by society.
In this paper, we discuss the involvement of farms in the provision of services for people with chronic mental disorders. Farms where agricultural production is combined with service provision are known as care farms. In Europe and USA, care farms represent a developing phenomenon. In the Netherlands, for example, the number of care farms has increased from 75 in 1998 to more than 1000 in 2009. Based on a limited, but potentially important literature, we argue that care farms serve as examples of socially embedded practices that have the potential to enhance processes of social inclusion and participation of people with chronic mental disorders.
To illustrate our argument, we use the case of one of the most prevalent and burdensome mental disorders, for which current treatment options may remain suboptimal, namely major depression. A high proportion of patients with major depression do not achieve symptom remission, possibly as a reflection of the heterogeneity of the depressive syndrome . Even when depressive symptoms remit, social and occupational functioning might remain impaired , making it difficult for some patients to resume normal roles in society. And finally, even when people with major depression live and work in the community, stigmatization and discrimination from family members, at the workplace, or in other social settings still act as barriers to a satisfying social life .
In this context, novel approaches that could potentially improve mental health outcomes and social inclusion remain relevant and of high priority. To date, the effectiveness of farm-based interventions for people with major depression was evaluated only by a limited number of studies. Two small-scale studies found that participants with treatment-resistant depressive disorder working with farm animals  or involved in farm-based horticulture  reported a significant decrease in the severity of depressive symptoms during the interventions. In addition, a randomized control trial with participants with schizophrenia showed a significant decrease in the severity of depressive symptoms for those involved in farm-based horticulture, compared to controls following standard vocational rehabilitation . Furthermore, participants in these studies reported improvements in social [5-7] and occupational roles [5, 7].
Although more research is needed, these findings suggest that care farms might offer a useful addition to the current possibilities for treatment of depressive symptoms and could support processes of social integration and participation. But what could explain these preliminary findings? Participants in the three studies described above were asked to reflect on their experiences with the farm environment. In their accounts, they referred to a diversity of elements, such as involvement in an ordinary working life, distraction from illness, ability to choose between tasks , positive appraisals from peers and farmers, feeling socially included  and being involved in pleasurable activities in nature [6, 7].
These three studies suggest that farm-based interventions might include a number of elements that are necessary for leading a fulfilling life in society. Indeed, care farms might provide a small-scale replica of normal socio-economic life. In the Netherlands, for example, many care farms are family-owned, provide services for relatively small groups of people and consider agricultural production as their main business. People with chronic mental disorders who have difficulties in (re)integrating in society might appreciate the meaningful, real-life work available on care farms, the diversity of tasks that engage attention and distract from problems, and the interactions with diverse social networks (peers, farm employees, customers and family members). Together, these elements seem to create an environment in which this group not only feels better and functions better, but also prospers. Indeed, positive experiences can be found in several qualitative studies conducted with participants on care farms , suggesting that they have clear ideas on what they consider helpful and useful.
This knowledge can serve as an important source of information for how current treatment options can be enriched through socially embedded practices, such as care farms. For example, people with chronic mental disorders can provide their views and reasoning on whether psychiatric treatments and care farms could be sequenced or provided simultaneously. This is consistent with recent research on the effect of combining mental health interventions or providing them in a stepwise approach. Further research could also investigate how the relation between care farms and psychiatric services can be conceptualized and institutionalized. These questions require the help of the different professions involved in service provision. Psychiatrists are already familiar with the use of farms from the old days of institutionalized mental health care, when the involvement of residential patients in agricultural work on farms or gardens was a common therapeutic practice. Contemporary farms differ from the farms and gardens of the previous age and provide new opportunities to their users. Research on how psychiatric services could best make use of these opportunities could also be relevant for farmers interested in professionalizing their services, without losing the authentic strength that made their farms attractive in the first place.
Farmers, professionals and people with mental disorders who work on this agenda might be confronted by many challenges, as their different perspectives, knowledge and values might seem difficult to combine. However, transdisciplinary research provides a robust methodology to support such a process and can be used to integrate the different types of knowledge in a transparent, reliable and valid manner  that can inform the agenda proposed above. In future, care farms might play a role in broadening the spectrum of services, improving mental health outcomes, and bridging the gap with society.