THE MODERN ASYLUM Andreas Lukita Haliman
THE MODERN ASYLUM A Discussion on the development of Asylums/Psychiatric Hospitals and how architecture can be used to develop the optimum Healing Environment
< Acknowledgements >
Firstly, I would like to express my sincere gratitude to my tutor, James A. Craig for the continuous support of my dissertation and related research, for his patience, motivation, and immense knowledge. His guidance helped me in all the time of research and writing of this dissertation. I would also like to thank my friend, Octorino Tjandra for proofreading and curating my dissertation. His support has helped me in the completion of this dissertation.
< Abstract >
“
Thesis Question: What is the future of psychiatric hospitals and how will the design of contemporary ‘healing environments’ have an impact on the recovery of patients?
” This research looks at the architecture and design of modern psychiatric units, considering how the architecture of UK asylums and psychiatric hospitals has developed throughout history, with a view to considering how architecture can be used to create the optimum healing environment. To achieve this, the research will explore how the history of mental health establishments in the UK has influenced the design of modern psychiatric hospitals, review the architecture of modern psychiatric hospitals in order to assess how these designs facilitate healing and establish a healing environment, and finally, it will assess the effect therapeutic innovations in the design of psychiatric hospitals have on the mental health of individuals undergoing treatment for mental health problems. It was found that revolutions in the treatment of mental illness, including the eighteenth and nineteenth century moral treatment and non-restraint movements led to the creation of asylum buildings with more space for communal activities within tranquil grounds. These innovations influenced modern psychiatric hospital design in regards to emphasis on communal living and the provision of gardens and courtyards. However, it was found that multisensory therapy, although beneficial for the treatment of mental illness, has, as of yet had little influence on the design of modern UK psychiatric units. This will be discussed in more detail in the dissertation.
CONTENTS
Introduction
Be ginning
1 7
Chapter I: A Histor y of Psychiatric Institutions 1.1 The York Retreat
11
1.2 Kew Lunatic Asylum
15
Chapter II:
19
T he Architecture of Psychiatric Hospitals
2.1 2.2 Chapter III:
NHS Modular Ward
22
Child and Adolescent Mental Health Unit, Cornwall
25
T he Healing Environment
27
3.1 ‘Snoezelen’ units
30
3.2 Afterwards
37
Chapter IV:
39
How this Research might be implimented
4.1 Hafan y Coed
41
4.2
46
Conclusion
Ending
Madlove: A Designer Asylum
51
List of Figures
53
List of Bibliography
55
INTRODUCTION
1
-
Be ginning -
This dissertation focuses on the architecture of the modern day asylum. The aim of this research is to discuss how the architecture of asylums/psychiatric hospitals in the United Kingdom (UK) has developed over the course of time and how architecture has been used to develop the perfect healing environment for patients. Of particular interest is the use of multi-sensory experience (the use of light and shadows, acoustics, tactile materials and so forth) to promote recovery. This topic is interesting and relevant as usually the architectural and institutional history of the asylum is discussed alongside the history of prisons and other restrictive institutions.1 However, discussing asylums in this context ignores the fact that the different treatments used to cure and mitigate mental health issues are present throughout the fabric of asylums and modern mental hospitals such as occupational therapy and other therapeutic innovations. In this dissertation there will be an exploration of the
1 Edginton, B., (1997). Moral
various approaches to architecture which are designed to facilitate
architecture: the influence of
rehabilitation and recovery from various mental disorders. Hence,
the York Retreat on the asylum
the main focus of this paper will be the importance of the healing
design. Health & Place, 3(2),
environment and the use of multi-sensory experience to encourage
pp.91-99.
healing among patients.
2
In the past, mental illness was stigmatised due to the difficulty encountered in managing it. This meant that the only options available for the treatment of mental illness were brutal management and isolation from the rest of the community involving institutionalisation, physical restraint and shock treatment. Proper institutional care for the insane was only properly implemented in the UK in the late eighteenth century as a result of the example of the physician William Tuke and the Quaker religious movement.2 However, physical restraint was often used and conditions in asylums remained appalling. Asylum care only began to improve in the nineteenth century when local authorities were encouraged to build public mental hospitals and supervise private ones. Mental hospitals were the main source of care for the mentally ill well into the twentieth century. This situation changed when the emphasis and purpose of mental health care adjusted in the western world from containing and controlling the mentally ill to encouraging healing in a therapeutic environment as a result of drug and psychiatric innovations. In 1930, the Mental Treatment Act led to the establishment of community psychiatric clinics to provide an alternative to hospitalisation and, in 1948, UK mental hospitals came under the authority of the National Health Service (NHS).3 These examples show that there was a growing realisation that mental health service users could benefit from gaining a degree of independence. However, the 2 Tulchinsky, T.H., & Vara-
abandonment of the old mental hospitals has been criticised on the
vikova, E.A., (2009). The new
basis that this change divides patients into ‘real’ and ‘pseudo’ users
public health, 2nd ed., London:
as community care has become more common.4 This indicates that
Elsevier.
therapeutic innovations could be of real use in terms of treating and curing mental illness rather than merely containing and con-
3 Ibid.
trolling those with mental health problems.
4 Crysikou, E., (2014). Architec-
ture for psychiatric environments and
increasingly common in recent years. During the latter half of
therapeutic spaces. Washington
the twentieth century, the asylum structure began to be perceived
D.C.: IOS Press.
as limiting recovery with the therapeutic communities offered by
A greater emphasis on therapeutic innovations has become
hospitals being seen as a preferable alternative.5 This has been the 5 Wilson, S., (2012). Thera-
case for healthcare provision in general. For example, Maggie’s
peutic communities in mental
Centres across the UK and the Commonwealth have been designed
hospitals. The International Jour-
to provide respite care for cancer patients in a pleasant and com-
nal of Therapeutic Communities 33
fortable atmosphere to aid the recovery process. The architecture
(1), pp.55-70.
of Maggie’s Centre’s facilitates the recovery process by creating an
3
of normalcy and domestic comfort. Maggie’s Centre’s achieve this
Fig. 1 Exterior of Maggie’s Centre,
by using features such as natural light, spaces, openness, intimacy,
Glasgow by Page/Park Architects
domesticity and views of nature to achieve this effectW. Charles 6
Jencks, the founder of the Maggie’s Centres, developed these care centres as a result of experiencing the architecture of cancer treatment units in hospitals. For Jencks, the institutionalised architecture of these units undermine the treatment of chronic illnesses such as cancer because it encourages patients to conform to the institutionalised hospital system and follow the advice of healthcare professionals rather than following their own instincts.7 Instead, hospitals encourage patients to be vulnerable, worsening illness, perhaps even slowing or preventing any chance of recovery. 6 Simon, J., Temple, N., &
Therapeutic innovations have also been a common feature
Tobe, R., Eds., (2016). Architec-
of mental health treatment from the mid-twentieth century on-
ture and justice: judicial meanings
wards. In fact, occupational therapy has been a feature of mental
in the public realm, Abingdon:
health treatment in the UK since the 1940s when engagement in
Routledge
‘soldierly activities’ was used to rehabilitate psychologically traumatised soldiers.8 In mental health, the introduction of the ther-
7 Ibid.
apeutic community means that patients should always be treated with respect, that both staff and users can benefit from therapeutic
8 Dickey, B., and Ware, N.C.,
innovations, and that therapeutic methods are an important means
(2008). Therapeutic communi-
of treating mental health issues. Hence, it is clear that modern
ties and mental health system
medicine favours programmes of therapeutic healing in a conduc-
reform. Psychiatric Rehabilitation
tive environment over the containment and institutionalisation of
Journal 32 (2), pp.105-109.
9
mental and physical illness. Furthermore, the example of the Maggie’s Centre’s shows that it is possible for a healing therapeutic envi-
9 Gale, J., Realpe, A., and
ronment that aids medical care to be created through architecture.
Pedriali, E., Eds., (2008). Ther-
Thus, it should be possible to apply this principle to the example of
apeutic communities for psychosis.
modern psychiatric hospitals and care facilities.
Hove: Routledge.
4
5
The research will seek to achieve the following aims and objectives: •
To explore how the history of mental health establishments
in the UK has influenced the design of modern mental hospitals. •
To review the architecture of modern mental hospitals in
order to assess how these designs facilitate healing and establish a healing environment. •
To assess the effect therapeutic innovations in the design of
mental hospitals have on the mental health of individuals undergoing treatment for mental health problems.
In order to approach this topic appropriately there will be three parts in the research. The first part will focus on the history of mental health establishments, looking not only at the practices but also the architecture and the effects this may have had on patients. The next section will look at the architecture of mental hospitals, with a specific review of modern establishments, which are designed as bespoke buildings in order to provide a healing environment. The final part will discuss the various approaches to producing a healing environment and the paper will then conclude by drawing together the research covered in the paper.
Fig. 2 Interior of Maggie’s Centre Glasgow
6
CHAPTER ONE
7
-
A Histor y of Psychiatric Institutions -
In this section, there will be a discussion about the architecture and ethos behind the sanatorium throughout history. Hence, this discussion will aim to uncover the correlative effects of these different buildings and how the internal environments reflected the context of that time period. This section of the paper will also explore the
10 Tulchinsky, T.H., & Vara-
development of various research methods and practices, which
vikova, E.A., (2009). The new
allowed for the techniques, which have contributed towards ad-
public health, 2nd ed., London:
justing the environment in order to satisfy patientsâ&#x20AC;&#x2122; requirements.
Elsevier.
In the late eighteenth and early nineteenth century, while care of the insane had been standardised and institutionalised, the insane
11 Foucault, M., (1977). Disci-
were still subject to brutal treatment.10 When mental hospitals first
pline and punishment. New York:
became the standard treatment and solution to mental illness, the
Pantheon.
limited knowledge and research about various mental conditions meant that people with such issues would often be housed in the
12 Albrecht, G.L., Seelman,
same way as criminals.11 For example, in England 1837, visitors to
K.D., & Bury, M., Eds., (2001).
asylums reported that patients were confined to their rooms with-
Handbook of disability studies.
out clothing or heat, chained to the walls or their beds and were
London: SAGE.
routinely physically abused by staff.12
8
Such brutal treatment of the insane was commonplace until doctors specialising in mental health issues began to promote the benefits of ‘moral treatment’ of insanity and a ‘non-restraint’ approach towards the treatment of mental illness. Such approaches arose from the belief that society had a moral obligation to help the mentally ill. Also, these changes represented a more humane approach towards mental illness. Advocates of moral treatment promoted the theory that people develop mental illness because they succumb to external pressures and, as a result adopt faulty habits of living and become disengaged from normal life. To treat mental illness, a physician taking a moral approach promoted the idea that occupation could be used as a form of therapy as participation in everyday activities was thought to help to alleviate symptoms of mental illness. A moral approach to mental illness assumed that the mentally ill are capable of making decisions and can make the decision to recover or not.13 The ideal of moral treatment was closely connected to the non-restraint movement that emerged in the mid-nineteenth century.
The eminent alienist and asylum-proprietor John Conol-
ly (1794-1866) was instrumental in promoting the non-restraint movement in Britain. Controversially, Conolly put the non-restraint principle in practice at the large Middlesex Asylum after visiting a number of smaller asylums where non-restraint had been successfully implemented. Also, Conolly argued that it was therapeutic to abandon restraint in his book The Treatment of the Insane without Mechanical Restraint (1856). These new philosophies transformed 13 Kilelhofner, G., (2009). Con-
asylums into therapeutic institutions, which sought to achieve a
ceptual foundations of occupational
balance between institutional control and domestic tranquillity.
therapy practice, 4th Ed. Philadel-
Asylums were no longer prisons; instead they were transformed
phia: F.A. Davis Company.
into retreats located in rural settings. In the eighteenth century, the idea of environmental determinism, the theory that the environ-
14 Churchill, L., & Smith, D.,
ment could control behaviour, became popular. Thus, it was widely
Eds., (2015). Occupation: ruin,
believed that it was possible to transform and cure ‘unhealthy minds
repudiation, revolution—constructed
through asylum design’.14 Hence, by the nineteenth century thera-
space conceptualised. Abingdon:
peutic design was seen as a vital part of treating insanity.
Routledge. To the Right Fig. 3 Picture of a brutal treatment using tranquilizer chair for a patient at Westriding Pauper Lunatic Asylum taken in 1869
9
10
Fig. 4 The York Retreat (1796)
1.1
The York Retreat
It is clear that the new innovations in mental health care that became popular during the eighteenth and nineteenth centuries influenced asylum architecture. One considerable influence on 15 Edginton, B., (1997). Moral
the design of asylums during this period was the structure of the
architecture: the influence of
York Retreat, a small Yorkshire asylum built in 1796 by a Quaker,
the York Retreat on the asylum
William Tuke. What was significant about the York Retreat (Fig. 4)
design. Health & Place, 3(2),
was that it internalised moral treatment within its building design,
pp.91-99.
making it the primary inspiration for other subsequent asylums.15
11
The design of the York Retreat was influenced by the
movement for moral treatment in eighteenth century England.16 Furthermore, one of the implications of moral treatment of insanity was that an individual could only regain reason if they were treated in a building specifically designed to meet that purpose. This was because the physical structure of the asylum was thought to represent ‘a spatial [approach] designed for the cure of lunacy’.17 For this reason, William Tuke and other practitioners of moral treatment believed that the building in which the insane were treated was as important as drugs or other remedies when it came to treating individuals suffering from mental illness. According to Luther Bell, a leading American alienist:
“
An Asylum, or more properly a Hospital for the insane, may justly be considered an architectural contrivance as peculiar and characteristic to carry out its designs, as is any edifice for manufacturing purposes to meet its specific end. It is emphatically an instrument of treatment.18
16 Edginton, B., (1997). Moral architecture: the influence of the York Retreat on the asylum design. Health & Place, 3(2),
”
pp.91-99.
17 Scull, A., Ed., (1981). Madhouses, mad-doctors and madmen:
Tuke stressed a multitude of ways in which the asylum’s
physical structure and location contributed to its value as a therapeutic tool. Towards this end, Tuke emphasised the importance of designing institutions that were cheerful and aesthetically pleasing to inmates as it was felt that the insane were particularly sensitive to their surroundings.19 As such, the York Retreat aimed to reproduce an idealised form of tranquil family life and social norms. For this reason, Tuke made an effort to create a cheerful environment through providing good lighting, bright and homely furnishings, flowers and domestic animals.20 Tuke believed such features would encourage positive feelings and help patients to feel at home, facilitating recovery.
12
the social history of psychiatry in the Victorian era. Philadelphia: University of Pennsylvania Press. pp.10
18 Ibid.
19 Ibid.
20 Curtis, S., (2004). Health and inequality: geographical perspectives. London: SAGE.
Another important aspect of asylum design emphasised by Tuke was adequate separation and classification of inmates. This feature of the York Retreat is illustrated in a plan for the building presented in Fig. 5.
One of the unique and groundbreaking features of the
York Retreat was the division of space into areas for patients with different types of conditions and behaviours. For example, violently 21 Edginton, B., (1997). Moral
disturbed patients were separated from calmer, more easily man-
architecture: the influence of
aged individuals.21 Such separation meant that physical barriers
the York Retreat on the asylum
could be used to enforce the moral division among the patient
design. Health & Place, 3(2),
population and that treatment of different classes and classifications
pp.91-99.
of patients could be designed to match abilities and behaviour.22 It was thought that this kind of separation would encourage rational
22 Scull, A., Ed., (1981). Mad-
behaviour.23 This feature of the York Retreat is particularly interest-
houses, mad-doctors and madmen:
ing as such divisions continue to inform the therapeutic treatment
the social history of psychiatry in
of mental illness in the modern era.
the Victorian era. Philadelphia: University of Pennsylvania
Press. pp.10
multi-sensory experience for the Retreat, it can be argued that he
Although Tuke never mentioned about the use of
had, unconsciously or not, tried to incorporate this in his effort 23 Edginton, B., (1997). Moral
of creating a ‘homely’ environment in the Retreat. The ‘homely’
architecture: the influence of
environment he envisioned involves increasing the interactions of
the York Retreat on the asylum
the five senses through the availability of good lighting, furnishing,
design. Health & Place, 3(2),
flowers and domestic animals in the Retreat. It has been argued
pp.91-99.
that every senses, including vision, can be considered to be extensions of the sense of touch.24 In relation to this, he also argues that
24 Pallasmaa, J., (2012). The
anything that the stimulation caused by people’s sensations of touch
eyes of the skin - architecture and
is life-enhancing. Hence, the ‘homely’ environment that Tuke envi-
the senses, 2nd Ed. Chichester:
sioned, which encourages the involvement of the five senses, can be
John Wiley & Sons, pp.44-49
argued to create a life-enhancing environment for the patients.
From Top Right to Bottom
Fig. 5 Ground Plan of the York Retreat Fig. 6 a Common Room in the York Retreat features large windows and gives a ‘homely’ feeling
13
14
1.2
Kew Lunatic Asylum
Inevitably, moral treatment of insanity and the non-restraint movement began to inform hospital practices and change the therapeutic atmosphere of British asylums. This was because Conolly and other supporters of non-restraint and moral treatment of the insane argued that restraints in asylums should be replaced by constant visual observation of the insane by medical attendants.25 Thus, moral treatment and non-restraint necessitated a different sort of asylum design. Conolly outlined several features he believed modern asylums ought to have. He believed that patients should have access to open areas inside the building for recreation and that rooms should be set aside for various forms of occupational therapy.26 Also, he believed that asylums should be located on an appropriate site, that 25 Pietikainnen, P., (2015). Madness: a history. Abingdon: Routledge.
26 Ibid.
27 Ibid.
Below Fig. 7 Kew Lunatic Asylum, Victoria, Australia (1871)
the building arrangement should allow for natural sources of light and ventilation and that the asylum layout should be linear.27 Similarly, in On the Construction and Management of Hospitals for the Insane (1841), C.W.M. Jacobi argued that it was important that mental hospitals be located in areas of natural beauty and of mild climate. As Conolly and Jacobiâ&#x20AC;&#x2122;s writings on the subject suggest, nineteenth century alienists considered both location and design of asylums as conductive to recovery from mental illness.
An example of the productive model of lunatic asylum
promoted by Conolly was the Kew Lunatic Asylum, in Victoria, Australia completed in 1871 with a design that was modelled on the English approach (Fig. 7).
15
According to one of the architects that worked on the Kew Lunatic
Above
Asylum, Frederick Kawerau, the aim of the design was to re-social-
Fig. 8 Floor Layout of Kew Lunatic
ise residents, accommodate gender distinctions, and to encourage
Asylum
patients to participate in approved activities.28 Hence, the design of Kew Lunatic Asylum was intended to encourage the implementation of a â&#x20AC;&#x2DC;moral treatment regime,â&#x20AC;&#x2122; which would remove the habits that caused madness in the first place.
The separation between male and female patients at the
Kew Lunatic Asylum was emphasised by the presence of two separate wings for male and female patients demonstrated in Fig. 8, above. A similar configuration can be found in the design of Wakefield Asylum (1818), which also separated male and female patients. This separation came about as a result of the belief that men and women were intrinsically different thus separation of men and women was seen as necessary for implementing moral management of patients. Essentially, separating men and women was viewed as a vital means of controlling sexual passions. As well as this, separation of male and female patients had some bearing on the different therapeutic regimes each group participated in which each group being given gender-appropriate tasks.29 For example, while men did woodwork and gardening, women did cleaning, laundry and sewing as part of their occupational therapy. Hence, separation of male and female patients was a vital part of the therapeutic regime of the nineteenth century asylum.
16
28 Churchill, L., & Smith, D., Eds., (2015). Occupation: ruin, repudiation, revolutionâ&#x20AC;&#x201D;constructed space conceptualised. Abingdon: Routledge.
29 Scull, A.T., (1989). Social order/mental disorder: Anglo-American psychiatry in historical perspective. Berkeley: University of California Press.
17
Wakefield Asylum (Fig. 9) is shaped like an ‘H’ because this was
From Top Left to Bottom
deemed the most functional model for the asylum as it allowed for maximum social control. As well as ensuring that male and female
Fig. 9 Model of Kew Lunatic
patients remained separated, the ‘H’ design used for the Wakefield
Asylum (1818)
Asylum and Kew Lunatic Asylum, means that any attendant can
Fig. 10 Kew Lunatic Asylum
keep an eye on patients from all angles of observation. In accor-
(1818)
30
dance with Conolly’s theories on the treatment of insanity this allowed attendants to observe the insane rather than restrain them. However, modern psychiatric nurses do not approve of the ‘H’ design, believing it is an unsuitable environment for mobile patients. Furthermore, the ‘H’ design indicates that the asylum is still a place of imprisonment, which is deemed unacceptable today.31 In fact, contemporary accounts of Wakefield Asylum illustrate how the building’s function changed over time:
“
…In later years, the line of sight has been interrupted by the erection of glazed partitions, which subdivide each corridor into distinctly separate wards, so that you would have had to pass through several other wards on the way to the one you wanted. At Christmas this could be a delightful journey, as each ward would be decorated in its own fashion by the patients and staff. The long central corridor, barrel-vaulted like the rest of the hospital, seemed like a succession of Aladdin’s caves, each more fascinating and exotic than the one you were in and the journey developed from staging post to staging post, each new length of corridor a fresh unveiling - not at all what the architect had in mind.32
30 Roberts, A., (2016). Notes on asylum architecture. Retrieved 15 Nov 2016 from: http://studymore.org.uk/ asyarc.htm
31 Ibid.
”
Despite this, as Churchill & Smith explained, it is important to consider the design of asylums within the context in which they were built.33 For example, the Kew Lunatic Asylum was condemned as a failure in 1876, only five years after it was built because the Australian government failed to provide sufficient funding leading to overcrowding and staff shortages.34 For these reasons, moral treatment
32 Grainger, R., (1996). Asylum: memories of a local institution. Wakefield: Eastmoor Books.
33 Churchill, L., & Smith, D., Eds., (2015). Occupation: ruin, repudiation, revolution—constructed space conceptualised. Abingdon:
was never properly implemented at Kew Lunatic Asylum.
Routledge.
34 Willsmere, (2014). Kew
The legacy of nineteenth century asylum design then had
impact on mental health care well into twentieth century. From this research, it is clear that the design of the York Retreat and moral treatment of insanity has inspired modern therapeutic innovations intended to mitigate and cure mental illness.
18
Lunatic Asylum. Retrieved 16 Nov 2016 from: http://www. willsmere.net/styled-7/index. html
CHAPTER TWO
19
-
T he Architecture of Psychiatric Hospitals -
This section of the paper considers the approaches that have been undertaken in order to adapt certain establishments, with a view to enabling hospitals to more adequately accommodate people with various mental problems. The architecture and internal environment as two different but somehow linked aspects of the modern approach to building facilities will be discussed as will how research is developing new ways to better house mentally ill patients and how this can provide a better foundation for care. However, the impact of ward design on the outcomes of mental health patients remains unclear. A systematic review by Papoulias et al of the
35 Papoulias, C., Csipke, E.,
secondary literature on this topic found that no strong link existed
Rose, D., McKellar, S., &
between design of mental hospitals and psychiatric wards and clin-
Wykes, T., (2014). The psychi-
ical outcomes of patients. Despite this, he also found that private
atric ward as a therapeutic space:
spaces and a homely environment could improve patient well-being.
systematic review. The British
Thus, the following paragraphs will consider the architecture of
Journal of Psychiatry, 205(3),
modern psychiatric hospitals and its impact on the treatment of
pp.171-176.
35
mental illness.
20
For the first half of the twentieth century, mental health patients were languished in asylums that were just a little more than warehouses.36 However, all of this changed as a result of the adoption of new stances towards psychiatric care that had a major impact on how emotional and behavioural problems were handled by the medical establishment. Firstly, psychoanalysis was developed by Sigmund Freud who suggested that irrational behaviour often has hidden meaning. For this reason, therapy can be used to reveal the factors that had triggered this behaviour with a view to resolving it.37 Widespread adoption of psychoanalysis as an approach to mental illness meant that doctors now had to respect mental health patients and listen to what they were saying. The other new psychiatric care innovation introduced in the early twentieth century was democratisation. This was a model of community living where disturbed individuals would receive therapy and support to help them work through their mental health problems.38 Both these new forms of mental health treatment have informed the architecture of psychiatric hospitals built in the twentieth and twenty-first centuries.
36 Gale, J., Realpe, A., and Pedriali, E., Eds., (2008). Therapeutic communities for psychosis. Hove: Routledge.
37 Ibid.
38 Ibid.
39 Marberry, S. O., & Zagon, L., (1995). The power of colour: creating healthy interior spaces. Chichester: John Wiley & Sons.
40 Curtis, S., (2010). Space, place and mental health, Farnham: Ashgate.
41 Ibid.
The modern successor to eighteenth and nineteenth
century promoters of moral treatment was Austrian physician and scientist Hans Selye who found that stress can be caused by environmental factors. This finding lends itself to the suggestion that the right environment can successfully contribute to recovery from mental illness. Consequently, hospitals and medical establishments have made an effort to improve their environment to decrease stress levels and promote healing.39 Today, it is thought that a comfortable, protective and homely environment that also manages risk and controls patients is the best way of treating individuals who require residential care for psychiatric disorders. However, most mental hospitals in the UK dated back to the nineteenth and early twentieth century. Because of changes in how mental health problems are understood and treated these buildings are no longer fit for purpose and must either be upgraded or replaced with new facilities funded by the UK government under the Private Finance Initiative (PFI).40 It was felt that the previous generation of â&#x20AC;&#x2DC;modernâ&#x20AC;&#x2122; mental hospitals were more concerned with clinical functionality than with the wellbeing of patients. Instead, it has been argued that psychiatric hospitals need to be viewed as examples of civic architecture that have social and symbolic significance as well as clinical functions.41
21
2.1
NHS Modular Ward
Even though the twentieth century brought about positive innovations in mental health treatment, unfortunately the design of psychiatric hospitals still lags behind. In the UK, hospital, including psychiatric hospital design, is primarily the responsibility of the NHS. For reasons of economy, the NHS has opted for a modular design for hospital wards (see Figs. 11 and 12). This decision was
42 Leff, J., & Warner, R.,
undertaken under the assumption that a basic ward unit could be
(2006). Social inclusion of people
utilised for any branch of medicine with little modification re-
with mental illness. Cambridge:
quired.42 Consequently, any NHS ward can be used for disciplines
Cambridge University Press.
as diverse as surgery to maternity.
Below Fig. 11 NHS Modular Ward design
22
It has been argued that such thinking is inappropriate for acute psychiatric care as the bed performs a different function in mental health treatment than it does in other medical disciplines. This is because, for psychiatric patients, the bed is not the place of treatment; it is merely somewhere to sleep. Instead, treatment occurs in other areas of the ward where spaces are put aside for recreational and occupational activities, individual and group treatments, 43 Leff, J., & Warner, R., (2006). Social inclusion of people with mental illness. Cambridge: Cambridge University Press.
Below Fig. 12 NHS Modular Ward Design 3D Plan
and socialisation. Hence, it can be suggested that while the design requirements for fundamental elements of mental health treatment were understood by nineteenth century architects of psychiatric hospitals, the designers of modular NHS psychiatric wards have failed to pick up on the unique aspects of treatment of psychiatric disorders.43 As a result, many psychiatric admissions wards in general hospitals are cramped and claustrophobic. There is a lack of space for individual and group activities, and a lack of privacy for patients.
23
One solution to this problem could be to locate psychiatric administration units on the general hospital site but in a separate structure to the main building. One description of the ideal observes that:
“
The unit should be low-built, with no more than two floors, in order to reduce the danger to suicidal patients of jumping from a height. Ideally, there should be individual bedrooms in order to provide privacy and a place of refuge when the ward environment is very disturbed. Flexible spaces are reduced for a variety of activities and sufficient interview rooms are required for seeing patients and their relatives. There needs to be access to a secure garden that is screened from public gaze and provides sufficient space for assessed patients to walk about.44
44 Leff, J., & Warner, R., (2006). Social inclusion of people with mental illness. Cambridge: Cambridge University Press. pp.68.
”
45 Heyden, T., (2014). How patients might design a psychiatric hospital. BBC News. Retrieved 29 Nov 2016 from:
However, very few acute psychiatric assessment units in the UK
http://www.bbc.co.uk/news/
possess such features. Despite this, such features represent the
blogs-ouch-27206405
ideal psychiatric treatment environment for mental health patients according to recent studies on the subject. For example, James
46 Wood, V.J., Curtis, S.,
Leadbitter’s Madlove project to design a mental health ward found
Gesler, W., Spencer, I.H.,
that users and designers of psychiatric wards wanted these areas to
Close, H.J., Mason, J, & Reilly,
be not so clinical, to have specially-designed therapy rooms such
G., (2015). The impact of the
as a washable paint room, greenery and open spaces, areas where
design of the psychiatric in-
patients can act out safely, spaces for tranquil activities, and more
patient facility on perceptions
fluid boundaries between the hospital and the outside world.
of carer wellbeing. Designing
45
Similarly, when designing a new mental health unit in the north of
Buildings Wiki. Retrieved 29
England, it was found that users wanted greater accessibility to the
Nov 2016 from: https://www.
site for visitors, especially carers, ease of movement beyond hospi-
designingbuildings.co.uk/
tal grounds, a domestic setting for the hospital, with emphasis on
wiki/The_impact_of_the_de-
private space for patients, and spaces within the domestic design to
sign_of_the_psychiatric_inpa-
facilitate social interactions between patients. This evidence indi-
tient_facility_on_perceptions_
cates that the majority of psychiatric ward design in the UK fails to
of_carer_wellbeing
46
meet the expectations of service users.
24
2.2
Child and Adolescent Mental Health Unit, Cornwall
In fact, modern psychiatric design for independent, contained and specifically designed mental health units arguably reflects many of the principles first promoted by those in favour of moral treatment. This is because modern psychiatric facilities continue to segregate patients according to the mental health issues they have been diagnosed with and emphasise the importance of activity, domesticity and occupational therapy. One recent example of how these principles are reflected in architecture is the new design for the Child and Adolescent Mental Health Unit, Cornwall, designed by P.M. Devereux (2015). See Fig. 13 and 14.
The design for the proposed Child and Adolescent Mental
47 AFH, (2015). AFH design
Health Unit for Cornwall possess both shared and private spaces.
awards 2015â&#x20AC;&#x201D;shortlisted
For example, the building is divided into two 6-bed clusters and one
projects. Architecture for Health.
3-bed clusters. Each cluster has swing zones that allow beds to move
Retrieved 16 Nov 2016 from:
in a way, which means that more or fewer people can sleep in one
https://www.architectsfor-
room if required. Also, each cluster or group in the building has a
health.com/wp-content/
lounge, a quiet room and access to a courtyard garden.47
uploads/2015/06/CornwallCAMHs600
Each cluster is closed off from other clusters although each
cluster has access to a shared dining facility and activity room. 48 Ibid.
Classrooms are also provided for patients along with music and kitchen facilities and therapy rooms.48 These features allow patients
49 Ibid.
to have privacy if required as well as participate in group activities. Furthermore, the design allows for segregation by age group under the care of trained staff with staff facilities located at the centre of the building to ensure that staff can observe and access patients at
From Top Right to Bottom
Fig. 13 Design for Child and Adolescent Mental Health Unit, Cornwall (P.M. Devereux, 2015) Fig. 14 Axonometric Model
all times. Further shared space is provided in the form of gym and cafĂŠ. These facilities allow residents to meet family and friends in an appropriate space that echoes a social rather than a hospital or institutional environment.49 In other words, recent psychiatric hospital design is beginning to realise that the wishes of patients in terms of environment are an important aspect of treatment and, ultimately, recovery from mental illness.
25
26
CHAPTER THREE
27
-
The Healing Environment -
This chapter aims to explore use of multi-sensory experience such as light and shadows, acoustics and tactile materials for the recovery of mentally ill patients. This chapter will emphasise the importance of the healing environment and the use of the multi-sensory environment for recovery from mental illness. In this part, there will be an investigation into the ways, which an environment can be designed in such a way that it properly relaxes and calms the senses to offer a decent rehabilitative space. Generally, multisensory therapy takes place in a room either dedicated to or especially built for that activity. Therein, patients experience a range of tactile, visual auditory and olfactory stimuli designed to evoke feelings of comfort and safety.50 Essentially, the purpose of multisensory therapy is to allow patients to relax, explore and enjoy their surroundings with a view to making a full recovery. This is because a walk through a space with constant interaction of all sense modalities (in other words a multi-sensory experience) has healing and invigorating qualities.51 This section of the paper will look at aspects surrounding the layout of rooms, the objects within the different spaces, the use of natural light and the colours which patients are exposed to. There are many aspects to the external and internal aesthetic qualities of a building, which can result in having a positive and detrimental effect on patientsâ&#x20AC;&#x2122; wellbeing. This will be investigated through the use of a number of different texts in order to review the relevant literature on this subject.
28
50 Baillon, S., Van Diepenm E., & Prettyman, R., (2002). Multi-sensory therapy in psychiatric care. Advances in Psychiatric Treatment, 8, pp.444-452.
51 Pallasmaa, J., (2012). The eyes of the skin - architecture and the senses, 2nd Ed. Chichester: John Wiley & Sons, pp. 44-49.
A number of studies explore the role of the environment and space when treating psychiatric illness in modern times. For example, a 1970 study based on observations and measured on the Brief Psychiatric Rating Scale found that patients displayed less pathological behaviour after being moved to a more â&#x20AC;&#x2DC;physically attractiveâ&#x20AC;&#x2122; ward.52 Also, a recent Canadian study found that a positive correlation (+15 percent) existed between staying in east-facing rooms and faster recovery rates for major depression when compared with a control group.53 Furthermore, a similar finding was made by an Italian study into the east-facing room phenomena.54 However, these studies did not investigate whether other factors such as medication changes or environment might have also contributed to 52 Papoulias, C., Csipke, E.,
the recovery of patients involved in the Canadian and Italian stud-
Rose, D., McKellar, S., &
ies. As well as this, the creation of semi-private or domestic space
Wykes, T., (2014). The psy-
has been found to improve social interaction among psychiatric
chiatric ward as a therapeutic
patients. For example, a study by Holahan and colleagues report-
space: systematic review. The
ed that the creation of semi-private two-bay sleeping areas had a
British Journal of Psychiatry,
positive impact on social interactions between patients.55
205(3), pp.171-176.
53 Ibid.
In addition to that, a study that compared socialisation in
psychiatric hospital organised into wards versus single dormitories 54 Ibid.
by Ittelson and colleagues in 1970 found that increased socialisation occurred in the latter environment.56 Furthermore, a study that took
55 Ibid.
place in a New England psychiatric ward in 1987 following a renovation to add more home-like features reported increased social be-
56 Ibid.
haviour and a decreased in stereotypy among patients.57 Thus, these examples indicate that aspects of psychiatric ward environments
57 Ibid.
such as domestic settings and private areas have a positive effect on patients in terms of increased social interaction and a decrease in problematic behaviour.
29
Above Fig. 15 ‘Snoezelen’ Theraphy room
3.1
‘Snoezelen’ units
Multisensory therapy originated as a form of treatment for mental
58 Baillon, S., Van Diepenm
health problems in ‘snoezelen’ units in the Netherlands in the 1960s
E., & Prettyman, R., (2002).
and 1970s.58 The treatment was developed to provide a multisenso-
Multi-sensory therapy in psy-
ry experience that would promote and stimulate the senses and did
chiatric care. Advances in Psy-
not rely on verbal interaction. Instead, the individual may choose
chiatric Treatment, 8, pp.444-452.
specific aromas, sounds, colours, tastes and tactile experiences to help them relax. Also, ‘snoezelen’ units were large enough to permit
59 Abou-Saleh, Katona,
sufficient space for individual who like to wander. This measure can
C.L.E., & Kumar, A., Eds.,
avoid patients intruding on others’ personal space. Furthermore,
(2011). Principles and practice of
some snoezelen units promote stimulation of the senses by being
geriatric psychiatry, 3rd Ed. Chich-
connected to an outdoor area.59
ester: John Wiley & Sons.
30
Fig. 16 Sample layout of a Multi-sensory room
31
While multisensory therapy originated in the Netherlands to treat individuals with learning disabilities, in recent years it has been most often used to treat dementia patients, as it is believed that meaningful sensation can improve cognitive impairment.60 However, multisensory treatment may also be applied to the field of adult psychiatric treatment. Studies into the effectiveness of multisensory behavioural therapy have found that by undertaking single-blinded studies that patients who experienced such therapy experience a modest reduction in agitation and apathy compared to those who received standard psychiatric inpatient treatment.61 Thus, it is clear that multisensory behavioural therapy can be beneficial to the well-being and facilitate the recovery of psychiatric patients.
Multisensory environments have no uniform appearance
and contain a variety of equipment intended to suit the needs of the group of people benefitting from the room, whether they have learning disabilities, suffer from dementia or psychiatric illness. Generally, multisensory therapy rooms are painted white or in a pastel shade in order to create the optimum environment for projected light and windows are blacked-out in order to exclude light that cannot be used to enhance the multisensory experience.62 Seating and flooring provision depends on which individuals will be benefitting from the room.63 While seating may include specialised chairs, beds or beanbags, flooring may be textured or cushioned or even have lights and pressure-sensitive areas built within it.64 Fig. 16 (to the left) presents a sample layout for a multisensory room that might be located in a hospital, school or care home.
60 Johnstone, E.C., Owen, D.C., Lawrie, S.M., McIntosh, A.M., & Sharpe, M., Eds., (2010). Companion to psychiatric studies, 8th Ed. New York: Elsevier.
61 Abou-Saleh, Katona, C.L.E., & Kumar, A., Eds., (2011). Principles and practice of geriatric psychiatry, 3rd Ed. Chichester: John Wiley & Sons.
Multisensory rooms often contain a variety of equipment.
Such equipment includes a mirror-ball, coloured spotlights, fiber optic sprays or curtains, a projector, bubble-tubes (Fig. 17), a music system, interactive knobs and switches, an aromatherapy diffuser, and a variety of hand-held objects that provide patients with individual visual or tactile sensations (see Fig. 18). A multisensory environment can also take on different forms; i.e. it may be a ball pool, a specialised spa pool or even a soft-play area. It has also been observed that the majority of multisensory environments possess remote-control devices that allow patients to customise the equipment in the multisensory room independently.
32
62 Baillon, S., Van Diepenm E., & Prettyman, R., (2002). Multi-sensory therapy in psychiatric care. Advances in Psychiatric Treatment, 8, pp.444-452.
63 Ibid.
64 Ibid.
Fig. 17 Bubble tubes in a Multisensory room
33
Fig. 18 A Fiberoptic spray that can be held as it changes colour
34
In regards to the kinds of therapies illustrated in Figs. 16, 17, and 18, it has been said that:
“
Multi-sensory therapy provides stimulation, via the senses of touch, sight, hearing, smell and taste, and also vestibular and pro-prioceptive stimulation, as the patient moves about the room exploring the equipment. Its aim is to be a relaxing activity, designed ‘to create a feeling of safety, novelty and stimulation which is under the user’s control and in which there are no expectations for performance.65
”
The approach taken by the design of the ‘snoezelen’ units
can be considered to be an extension of the concept introduced by William Tuke’s York Retreat, built in 1796. As mentioned in the first chapter of this dissertation, Tuke took effort in providing really bright rooms (light), fully furnished with flowers (scent) and domes65 Baillon, S., Van Diepenm E., & Prettyman, R., (2002). Multi-sensory therapy in psychiatric care. Advances in Psychiatric Treatment, 8, pp.444-452.
tic animals (interactions). These aspects are then further developed with the help of modern technology to create the ‘snoezelen’ units, which as explained before, are fully customisable and encourage multi-sensory experience for the patients. From this example, it suggests that the use of multi-sensory experience to optimise healing of mentally ill patients has, unconsciously or not, been considered since 1796 by Tuke in his envisioned design of the York Retreat.
To the Right Fig. 19 People interacting in the ‘snoezelen’ unit
35
36
3.2 Afterwards The kinds of multisensory environments found in mental health setting differ in many ways to those found in care homes for individuals with dementia or learning disabilities. The organisation Star Wards notes that the kind of multisensory rooms found in psychiatric hospitals tend to fall under the category of sensory modulation rooms.66 This kind of sensory environment is best understood as a converted quiet room space on an acute or long-term care unit that has been designed to offer sensory support during periods where a crisis needs to be mitigated or prevented. However, psychiatric units may contain other kinds of sensory rooms that offer thera66 Star Wards, (2016). Sensory room: an umbrella term. Retrieved 29 Nov 2016 from:
peutic interventions intended for sensory support. Despite this, all these sensory spaces are intended to promote sensory modulation.67 Essentially, sensory integration rooms are used and created by
http://www.starwards.org.uk/
occupational therapists that use specific kinds of interventions and
67 Ibid.
fers somewhat from the ‘snoezelen’ approach, which is more geared
68 Ibid.
On the other hand, it appears that in some psychiatric wards a
69 Ibid.
as a form of multisensory therapy.69 Essentially, the kinds of multi-
70 Wood, V.J., Curtis, S., Gesler, W., Spencer, I.H., Close, H.J., Mason, J, & Reilly, G., (2015). The impact of the design of the psychiatric inpatient facility on perceptions of carer wellbeing. Designing Buildings Wiki. Retrieved 29 Nov 2016 from: https://www. designingbuildings.co.uk/ wiki/The_impact_of_the_design_of_the_psychiatric_inpatient_facility_on_perceptions_
equipment to implement sensory integration techniques.68 This diftowards the treatment of cognitive impairments than mental illness. mixture of ‘snoezelen’ and sensory modulation approaches are used sensory treatment implemented in psychiatric wards are utilised to benefit the specific patients under treatment and the setting they are being treated in.
Often, the kinds of multisensory space provided by psychi-
atric hospitals are more recreational than therapeutic. However, such spaces can also be beneficial for patients and their families. For example, when exploring a newly-built psychiatric facility in the north of England in comparison to its predecessor, Wood et al., found that organisation of space outside wards, bedrooms and treatment areas was important.70 This was because such spaces provided opportunities for domestic and social activities to take place within the hospital community. In the old hospital building, these spaces were used for visits to patients by friends and family to pro-
of_carer_wellbeing
vide opportunities for patients to talk with their visitors in private.
71 Ibid.
designed for private visits.71 Instead, these visits are placed in the
72 Ibid.
But when the new hospital was built, no rooms were specifically quiet rooms, which were not specifically designed for accepting visitors and were often used for other purposes.72 Visits and recreation also took place in the lounge area of the new hospital. However,
37
several participants in the study by Wood et al reported that the acoustics of these areas produced considerable ambient noise, which made visiting difficult.73
On the other hand, the enclosed garden created for the
new hospital created a comfortable area for patient recreation and for entertaining visitors. The domestic style of the garden made it a nice place to be in and to have normal, everyday conversations with visitors. By way of comparison, the gardens of the old hospital were described as ‘oppressive’ and resembling ‘a prison yard’.74 These examples suggest that patients, their visitors and carers have access to several different areas within the hospital and, that gardens and grounds can play an important role during treatment for psychiatric illness. Comparison between the old and the new hospital by Wood et al also found that spaces that offered opportunities for social
73 Wood, V.J., Curtis, S.,
gatherings were of upmost important as was a domestic environ-
Gesler, W., Spencer, I.H.,
ment. In regards to this example, the facilities of the old hospital
Close, H.J., Mason, J, & Reilly,
were found to be superior, offering a recreational hall where all pa-
G., (2015). The impact of the
tients could gather on an evening and take part in activities organ-
design of the psychiatric in-
ised by volunteers such as table tennis and pool. However, the new
patient facility on perceptions
hospital did not provide similar facilities. This indicates that psychi-
of carer wellbeing. Designing
atric hospitals need to provide more areas for patient socialisation
Buildings Wiki. Retrieved 29
as well as therapeutic treatment.
Nov 2016 from: https://www.
75
designingbuildings.co.uk/
There is evidence that suggests that the multisensory
wiki/The_impact_of_the_de-
approach to treating mental illness is still evolving. The findings of
sign_of_the_psychiatric_inpa-
the Madlove project indicate that patients are keen on benefitting
tient_facility_on_perceptions_
from multisensory treatment in more creative ways. For example,
of_carer_wellbeing
an anonymous sufferer of bipolar disorder wished to see a room ‘where I can explode with colour—whether it be paint or coloured
74 Ibid.
liquids’. This multisensory painting room would also be washable, 76
so basically a wet room where patients could explore their feelings
75 Ibid.
and emotions through paint and artwork. Participants in the Madlove project have also suggested that mental health patients might
76 Heyden, T., (2014). How
benefit from a thinking room with thought bubbles painted on the
patients might design a psy-
walls where they could record their thoughts. These proposals
chiatric hospital. BBC News.
touch on a little-discussed aspect of psychiatric treatment. It is im-
Retrieved 29 Nov 2016 from:
portant for patients to re-establish personal identity in an environ-
http://www.bbc.co.uk/news/
ment where it is often challenged or exterminated. Hence, it is clear
blogs-ouch-27206405
77
that psychiatric hospitals should ideally provide opportunities for a mixture of social and therapeutic activities in a domestic environment.
38
77 Ibid.
CHAPTER FOUR
39
-
How this Research might be implimented -
There will be an investigation in this section on an existing mental hospital in England, in this case the Hafan y Coed (‘Haven of Trees’) mental health unit attached to University Hospital Llandough, near Cardiff. An attempt/proposal to implement the result of the research on the existing building will be made, to provide a better ‘healing environment’ for the patients. An investigation into the ways of how the Madlove: A Designer Asylum is designed to provide a better ‘healing’ environment and how it can be linked with the research will then also be made.
40
4.1
Hafan y Coed
Hafan y Coed opened in March 2016 to replace the mental health 78 CVUHB, (2016). New
unit at nearby Whitchurch Hospital which closed in April 2016 and
mental health facility gives ser-
had served the community for 108 years.78 The Whitchurch Hospi-
vice users dignity and respect.
tal had fallen into disrepair and its facilities were not longer con-
Health in Wales. Retrieved from:
sidered to cater for the needs of psychiatric patients. The Hafan y
http://www.wales.nhs.uk/
Coed building cost £88 million to build and aimed to offer a ‘calm,
news/40767
warming and welcoming’ environment to patients. The brand new, purpose built facility is the first of its kind in Wales and aims
79 BBC, (2016). Hospital is
to provide service users with a modern, therapeutic environment
‘new face’ of mental health
considered conductive to recovery from mental illness. The chang-
in Cardiff and Vale. BBC
ing needs of the community are reflected in the design of Hafan y
News. Retrieved 29 Nov 2016
Coed. For example, the building has space for 134 patients who en-
from: http://www.bbc.co.uk/
joy en-suite rooms; on the other hand the Whitchurch Hospital had
news/uk-wales-south-east-
space for 2,000 patients.79 These changes reflect recent emphasis on
wales-35803350
the importance of care in the community and the fact that the new unit only deals with the most seriously ill patients, some of whom
80 CVUHB, (2016). New
require close monitoring.
mental health facility gives service users dignity and respect.
Health in Wales. Retrieved from:
that were not available at Whitchurch will give patients dignity,
http://www.wales.nhs.uk/
respect and privacy.80 Also, a discreet observation system has been
news/40767
placed in bedrooms allowing staff to monitor patients without
The individual en-suite bedrooms offered at Hafan y Coed
directly disturbing them, offering a sense of privacy. Other facili81 BBC, (2016). Hospital is
ties offered by the new mental health unit include ‘quiet’ areas, a
‘new face’ of mental health
gym, single sex sitting rooms, an outdoor sports pitch and a small
in Cardiff and Vale. BBC
cinema.81 Hafan y Coed also aims to offer patients the chance to
News. Retrieved 29 Nov 2016
recover in a tranquil, healing, and low-stress environment. In aid of
from: http://www.bbc.co.uk/
this, art work specially commissioned for the hospital with a nature
news/uk-wales-south-east-
theme decorate the walls and garden areas have been incorporated
wales-35803350
into the design, as shown in Fig. 20.
From Top Right to Bottom
Fig. 20 Garden area at Hafan y Coed Fig. 21 Exterior of Hayan y Coed
41
42
82 CVUHB, (2016). New
In terms of design, each ward at Hafan y Coed has its own outside
mental health facility gives ser-
space with a garden and courtyard area (refer to Fig. 22), allowing
vice users dignity and respect.
service users to enjoy the fresh air during their recovery. These
Health in Wales. Retrieved from:
kinds of additions allow patients to heal in a pleasant, stimulating
http://www.wales.nhs.uk/
environment. According to Dr. Annie Proctor, the clinical board
news/40767
director for mental health, the new facilities at Hafan y Coed reflect modern attitudes to mental illness:
83 Ibid.
“
This marks the modernisation of mental health services, the fact we’re doing everything we can to reduce stigma. It used to be about containment, hiding them, putting them away somewhere — but we understand so much more now so this is about concentrating on therapy, recovery and re-ablement.82
” According to Dr. Proctor, the success of the facility lies in allowing service users a degree of independence, access to therapeutic spaces and the creation of a stress-free environment.83
43
It was found that all too often, for reasons of economy, psychiatric units in the UK were designed in a modular ward fashion like normal wards.84 This design has been found to be unsuitable for mental health units as psychiatric patients are not confined to bed and require more facilities and stimulation to facilitate recovery. Hafan y Coed addresses this problem by being a purpose-built mental health unit, the first of its kind in Wales. The features found in the Hafan y Coed design are found in other modern psychiatric unit designs, such as the Child and Adolescent Mental Health Unit in Cornwall.85 As well as this, the Hafan y Coed design addresses several flaws found by Wood et al in the design for the new psychiatric unit they studied in the north of England. These flaws mainly concerned access to quiet rooms and communal areas and activities. By way of comparison, the Hafan y Coed mental health unit allows users access to quiet areas while also encouraging communal activities such as pool or socialisation in one of its single sex sitting rooms. However, it also possesses an area that are beneficial for the patients i.e. gardens and courtyards. Furthermore, several other studies have highlighted the value of gardens and communal areas on patient well-being in psychiatric units. As well as this, the commission of art work for Hafan y Coed hints at the staff encouraging creativity among patients, something that was cited as being of great importance by the Madlove project as mentioned in the previous chapter. For these reasons, in some ways the Hafan y Coed design represents the ideals of modern psychiatric hospital design and mental health care.
To the Left Fig. 22 A room in Hafan y Coed with garden view
44
84 Leff, J., & Warner, R., (2006). Social inclusion of people with mental illness. Cambridge: Cambridge University Press.
85 AFH, (2015). AFH design awards 2015â&#x20AC;&#x201D;shortlisted projects. Architecture for Health. Retrieved 16 Nov 2016 from: https://www.architectsforhealth.com/wp-content/ uploads/2015/06/CornwallCAMHs600
Above Fig. 23 Site model of Hafan Y Coed
However, there might be some flaws in the location and design of the Hafan y Coed mental health unit. The first problem is a matter of location. A research found that patients value therapeutic landscapes when undergoing treatment for mental health issues86, but Hafan y Coed is located in an urban centre and views from the unit are of the hospital and urban landscape. Such an environment has not been found to be conducive to recovery. On the other hand, this
86 Curtis, S., Gesler, W.,
aspect of the building is out of the control of the hospital authori-
Fabian, K., Francis, S., &
ties. Also, there is no evidence to suggest that Hafan y Coed offers
Priebe, S., (2007). Therapeutic
patients a less restrictive environment, which in some instances, has
landscapes in hospital design:
been found to encourage patient well-being. Another potential flaw
a qualitative assessment by
is that Hafan y Coed does not seem to provide service users with
staff and service users of the
multisensory therapy or spaces. This would be a beneficial addition
design of a new mental health
to the hospital and along with recreational rooms, gardens and
inpatient unit. Environment and
courtyard areas, would allow service users an additional opportuni-
Planning, 25, pp.591-610.
ty to relax and lower their stress levels, facilitating recovery.
45
4.2
Madlove: A Designer Asylum
Above Fig. 24 Site model of the Madlove
“
Asylum at the Wellcome Collection
It ain’t no bad thing to need a safe place to go mad. The problem is that a lot of psychiatric hospitals are more punishment than love… They need some Madlove…87
The Madlove: A Designer Asylum is an ongoing project lead by
”
87 Leadbitter, J. (2014). Mad-
two artists, James Leadbitter (aka the vacuum cleaner) and Hannah
love: A Designer Asylum. The
Hull, based on their experience on mental health, and their aspi-
vacuum cleaner. Retrieved from:
ration to experience mental agony and enlightenment in a positive
http://www.thevacuumclean-
space, to create a “safe place to go mad”. Hull and Leadbitter
er.co.uk/madloveasylum
88
recognises the need of incorporating multi-sensory experience into the design of the “perfect” asylum for mentally ill patients. This is
88 Heyden, T., (2014). How
shown in an illustration on how to re-design an asylum made by
patients might design a psy-
Rosemary Cunningham for the Madlove Exhibition in the Well-
chiatric hospital. BBC News.
come Collection (2016) that considers stimulation of imagination
Retrieved 29 Nov 2016 from:
and creating a sensory palette as aspects that need consideration to
http://www.bbc.co.uk/news/
design the asylum for the Madlove project. (see Fig. 25)
blogs-ouch-27206405
46
89 Hohenadel, K., (2015),
The design of the Madlove: A Designer Asylum involves the input
This is what a psychiatric
from more than 300 patients, psychiatrists, architects and designers
ward designed by patients
that Leadbitter and Hull had gathered for the project (Hohenadel,
looks like. Slate. Retrieved 23
2015).89 Some examples of the inputs from mentally ill patients
January 2017 from: http://
that they envisioned will create the “perfect” environment for them
www.slate.com/blogs/
includes big windows, white walls covered with plants, a washable
the_eye/2015/03/19/mad-
paint room, more greenery and a larger space for dance, music and
love_a_designer_asylum_
sports (Heyden, 2014).90 All of these inputs are elements that can
from_james_leadbitter_the_
stimulate the involvement of all the senses in the sensory palette,
vacuum_cleaner_is_a.html
thus allowing a multi-sensory experience. The inputs are also all things that the patients desire, because they are things that make
90 Heyden, T., (2014). How
them feel more comfortable. This would then lead to the reduction
patients might design a psy-
in distress and aggression amongst the patients. This can be prov-
chiatric hospital. BBC News.
en by a research by Huckshorn demonstrates the reduction in the
Retrieved 29 Nov 2016 from:
use of restraint and seclusion for the patients by creating an envi-
http://www.bbc.co.uk/news/
ronment that decreases incidence of distress and aggression, thus
blogs-ouch-27206405
allowing better recovery.91 Hence, by incorporating these inputs in the asylum design, a better environment for recovery is created.
91 Huckshorn K. A., (2004).
Reducing seclusion and
restraint use in mental health
a larger scale version of the ‘snoezelen’ units that was explained in
settings: Core strategies for
the previous chapter. The use of the input system and then incor-
prevention. Journal of Psychoso-
porating these inputs into the design means that the asylum is some-
cial Nursing 42(9), pp.22–33
how ‘customisable’ by the patients, they get to see, smell, hear, feel
The whole complex of the asylum can be considered to be
and do what they want. This concept of customising means that the asylum uses similar concept as the ‘snoezelen’ units, which allows a Below
multi-sensory experience, but at a much larger scale.
Fig. 25 Illustration on how to redesign an Asylum by Rosemary Cunningham
47
Below Fig. 26 A Sketch by Michael Duckett during a workshop in Newcastle, England, asking for ideas about what the ideal asylum would look like
48
Fig. 27 Illustration by Rosemary Cunningham
49
50
CONCLUSION
51
-
Ending -
This paper aims to draw together the various perspectives and research to provide a definitive account of how the architecture of a building can impact the treatment of mental health patients. Throughout history, mental hospitals have generally focused on containing and controlling the mentally ill rather than treating them. However, this all changed in the late eighteenth and early nineteenth century when moral treatment and the non-restraint movement gained credibility in Britain and Western Europe. Following this shift in thinking, the emphasis of asylum design changed from containment to creating spaces that encouraged communal activities which could be closely supervised by staff. It was also considered important to locate asylums in tranquil, rural environments as a means of encouraging and promoting recovery.
This history is reflected in the design of modern psychiatric units in the
sense that these institutions continue to place great value on providing patients with communal areas and access to nature in the form of gardens and courtyard areas. The review of the architecture of modern psychiatric hospitals found that these designs use a variety of means to establish a healing environment including private sleeping areas, communal areas, activity areas, and access to attractive gardens and grounds. It has been found that therapeutic innovations such as communal activities and access to gardens have a positive effect on patient well-being. However, it has also been found that multisensory environments have not been used as much as might be beneficial in the field of psychiatric care as these innovations tend to be viewed as more beneficial to dementia patients and those with learning disabilities. Despite this, there is evidence that suggests that such innovations could be of great benefit to psychiatric patients in residential care.
52
LIST OF FIGURES
53
Fig. 1 http://pagepark.co.uk/projects/maggies-centre-glasgow [ Accessed on 24 January 2017] Fig. 2 http://pagepark.co.uk/projects/maggies-centre-glasgow [ Accessed on 24 January 2017] Fig. 3 http://www.dailymail.co.uk/news/article-3000407/Portraits-asylum-Harrowing-19th-century-photos-patients-notorious-institution-kept-SHACKLES-visibly-distressed.html [ Accessed on 24 January 2017] Fig. 4 http://archive.oneandother.com/articles/31-days-of-history-our-psychiatric-secret/ [ Accessed on 24 January 2017] Fig. 5 http://www.wakefieldasylum.co.uk/wp-content/uploads/galleries/post-670/full/ Ground%20Plan%20The%20Retreat%20sm.jpg [ Accessed on 24 January 2017] Fig. 6 http://www.theretreatyork.org.uk/timeline.html [ Accessed on 24 January 2017] Fig. 7 http://www.willsmere.net/styled-7/index.html [ Accessed on 24 January 2017] Fig. 8 http://www.asap.unimelb.edu.au/pubs/articles/asa97/KEWA.htm [ Accessed on 24 January 2017] Fig. 9 http://studymore.org.uk/asyarc.htm [ Accessed on 24 January 2017] Fig. 10 http://www.bshs.org.uk/travel-guide/west-riding-lunatic-asylum-wakefield [ Accessed on 24 January 2017] Fig. 11 http://trovex.com/case-studies/st-marys-ward-luton-dunstable-hospital/ [ Accessed on 24 January 2017] Fig. 12 http://www.elliottuk.com/modular-volumetric-buildings/healthcare-rental-buildings [ Accessed on 24 January 2017] Fig. 13 https://www.architectsforhealth.com/design-awards/2015-winners/2015-design-awards-shortlisted/ [ Accessed on 24 January 2017] Fig. 14 http://www.pmdevereux.com/Projects/Healthcare/Cornwall-CAMHS-Unit.aspx [ Accessed on 24 January 2017] Fig. 15 http://www.rompa.com/multi-sensory-environments-rooms [ Accessed on 24 January 2017] Fig. 16 http://m4.wyanokecdn.com/eb97946cfbabd14d0cbcd0ee3601e2ce.jpg [ Accessed on 24 January 2017] Fig. 17 http://apt.rcpsych.org/content/8/6/444 [ Accessed on 24 January 2017] Fig. 18 http://apt.rcpsych.org/content/8/6/444 [ Accessed on 24 January 2017] Fig. 19 http://www.japantimes.co.jp/news/2016/05/17/national/dutch-therapy-people-learning-disabilities-gains-foothold-japan/ [ Accessed on 24 January 2017] Fig. 20 http://www.walesonline.co.uk/news/health/new-88m-hospital-set-transform-11047467 [ Accessed on 24 January 2017] Fig. 21 http://www.cardiffandvaleuhb.wales.nhs.uk/hafan-y-coed [ Accessed on 24 January 2017] Fig. 22 https://www.tripadvisor.co.uk/LocationPhotoDirectLink-g1041931-d8272594-i135207845 -Hafan_y_Coed-Abercraf_Powys_Wales.html [ Accessed on 24 January 2017] Fig. 23 http://www.southwalesargus.co.uk/news/11486589.Health_board_creates__lsquo_haven_ rsquo__for_mental_health_care/ [ Accessed on 24 January 2017] Fig. 24 http://www.illustrationetc.co.uk/#/wellcome-collection-1/ [ Accessed on 24 January 2017] Fig. 25 http://www.illustrationetc.co.uk/#/wellcome-collection-1/ [ Accessed on 24 January 2017] Fig. 26 http://www.slate.com/blogs/the_eye/2015/03/19/madlove_a_designer_asylum_from_ james_leadbitter_the_vacuum_cleaner_is_a.html [ Accessed on 24 January 2017] Fig. 27 http://www.illustrationetc.co.uk/#/wellcome-collection-1/ [ Accessed on 24 January 2017] 54
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T hank You -