Emily Summers
Designing a space inspired by, rather than filled with, personality
AAD Dissertation Studio 16 2019–20
Extracts from Emily Summers, Designing a space inspired by, rather than filled with, personality
Dissertation Studio 16 Paths of Desire Tutor: Heidi Yeo
School of Art, Architecture and Design London Metropolitan University 2020
Introduction – The aim of this paper is to influence the future design of mental health inpatient units. With mental health disorders becoming increasingly recognised and discussed, the demand on the NHS and other private health care organisations is becoming unbearable. Those who are referred to these services can face an average waiting time of up to 61 days to get help with their mental health (House of Commons, 2020); this waiting period could be fatal for patients who need urgent care. In 2014 the Adult Psychiatric Morbidity survey, a study carried out every seven years to investigate adult mental health in England, found that statistically one in six adults struggle with poor mental health. Additionally, in 2017 a survey of Children and Young People’s Mental Health also found that children aged five to nineteen struggle with poor mental wellbeing. These alarming figures have influenced the investment of £13 billion in mental health services in 2019/20 (House of Commons, 2020). The majority of this investment will be spent on employing more phycologists and creating more appointment spaces; however, a percentage of this is likely to be spent on the upkeep of the environments that the therapies are offered in. This money will be more efficiently spent if the design decisions for these spaces are supported by evidence and knowledge. Currently, there are very few resources that offer this design guidance in a condensed and easily understandable manner which is why this paper is so important to our current society. In order to achieve a more effective conclusion this study will focus on a specific mental illness, as every type is complex and involves different treatment plans (The Centre for Health Design, 2018). This will allow the study to become a more thorough investigation researching into a more specific average user that will be using these environments. This paper will explore how interior design could enhance therapeutic environments for people suffering with eating disorders, as there are currently 1.24 million people in the UK who have been diagnosed with an eating disorder (Mental Health Foundation, 2019), emphasising its unmistakeable popularity. Additionally, this particular mental illness group has the highest mortality rate of any other mental illness, which stresses its importance (Mirasol, 2020). With the demand for beds growing all the time, the limited number of specialised units are under a lot of stress. Thus, it is entirely necessary that these units are run efficiently, safely and to the highest of standards. Could interior design in these environments help improve treatment for patients, potentially speed up their recovery, and result in shorter admissions, with faster bed turnovers so more patients can be helped? 6
Research into the historical context of mental health units, current therapeutic environments, and the use of Evidence Bases Design (EBD) will direct this study into producing a design proposal for Huntercombe Hospital Cotswold Spa and other specialised eating disorder units. Primary research will include a case study visit to Huntercombe Hospital Cotswold Spa to assess the current interiors of the hospital using an interior environment model. The hospital will also be hiring a videographer to film this visit, as it will later be used as promotional footage for the unit. When conducting any research within a mental health facility it is important that this is done ethically. A guidance document that explains how to respectfully conduct co-production within mental health services was used to ensure the visit was honourably carried out (National Collaborating Centre for Mental Health, 2019). Staff and patients chose not to be interviewed for confidentiality reasons but granted permission for any comments made during the visit to be written down in notes as long as anonymity was kept. For this reason, a sample release form was not required. The UK’s leading eating disorder charity, B-eat, are aware of this study and are interested in reading it after completion, as it could potentially be used to inspire any future design projects that they are involved in. This study was inspired by a personal experience where I was a patient in a mental health unit struggling with Anorexia. Six times a day the other patients and I had to enter a cold, dull dining room where the only attention to dÊcor was a feature wall covered with wallpaper that resembled a windows desktop background. I remember thinking that this room was one of the most important rooms in the hospital as it was where we all experienced the most anxiety and distress, yet it was probably the room that had been given the least amount of thought and attention in regards to its interior. I honestly believe that if this room were to be more comforting and inclusive, patients would feel more relaxed. This could essentially enable us to feel more courageous in terms of tackling our fears, which consequently could lead to quicker recovery. Ever since, I have become aware of my interest in the psychology of interior design and how much it can impact everything from moods, to health, and achievements. More broadly, poor mental health is becoming a huge national issue. Everyone needs to use their skills and knowledge to contribute to improving this crisis. As I cannot offer direct psychological advice to people struggling, I instead would like to use my passion for interior design to influence recovery to those with ill mental health and help those that are currently in the unfortunate position that I used to be in.
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The relevance of design, in past and present – We shape ourselves, and are shaped in return, by the walls that contain us. Buildings affect how we sleep, work, socialise and even breathe. They can isolate and endanger us, but they can also heal us. We project our hopes and fears onto buildings, while they absorb our histories. (Sinclair, 2018) Man has always recognised the importance of architecture. To begin with our ancestors used architecture as a means of protection and shelter. This evolved into architecture that began to express culture and art through extraordinary structures. Ever since hundreds of architectural styles have been developed around the world recognisable by their decorative details and exterior aesthetics. Architecture, like any other art form, continually develops. The advancement of an architectural style is influenced by new materials, technology and human preferences. This time the focus is transitioning from less of an art form and more of a psychological study. Currently, a new architecture movement is developing and it’s one of the most important, fastest-growing trends in the building industry (Gold, 2019). ‘Wellness’ architecture can be defined as: The practice of architecture that relies on the art and science of designing built environments with socially conscious systems and materials to promote the harmonious balance between physical, emotional, cognitive and spiritual wellbeing while regenerating the natural environment. (Global Wellness Institute, 2019) This emerging focus on wellness architecture has stemmed from the overall increase in attention to health and wellbeing in general; from mindfulness, to being open and expressive about mental health, people are understanding the importance of self-care and wellness more thoroughly (Mazzotta, 2019). By most estimations, people currently spend more than 80% of their time indoors (Klepeis, 2001). Therefore, the quality of the environments that we live, work and socialise in need to be high as they can impact us significantly. A high-quality environment will consider elements such as ventilation, natural lighting, spatial adjacencies and practicality, as-well as aesthetic 8
attributes. Collectively, when designed well, these attributes can increase an individual’s general happiness. Although feeling happy and content is typically a result of a variety of factors, it has been proven many times that our physical environments do impact our success and emotions (Ricci, 2018). The wellness architectural movement has an enormous potential to advance peoples’ general quality of life, as well as benefiting those who receive healthcare in exceptional ways. The current architectural developments and triumphs celebrated today should be seen as the start of something extraordinary, especially as increasing numbers of architects, designers and phycologists are dedicating their careers into achieving ground-breaking innovations. However, less attention has been given to the importance of interior design and how fundamental the positive effects are off a of specifically designed interior environment. An example of how influential interior design can be is its potential use in psychoneuroimmunology (PNI). This is a term, devised by Robert Alder, refers to the interaction between the brain, nervous system, and immune system, and the role our emotions play in pathogenesis (the development of diseases) (Segerstrom, 2012). An interesting aspect of PNI is its focus on the five senses and their ability to influence emotions. Through the senses, people can learn to channel their energies into creative outlets that might allow them to view the world differently or develop feelings of self-worth and selfesteem. Emotional Conflicts, feelings of powerlessness, an inability to respect and love oneself can, overtime, alter body chemistry and lead to physiological damage of any organ system of the body. (Malkin, 1992, p.17). As the majority of the senses can be easily manipulated through interior design, the industry can be heavily involved in the development for controlling the onset of progressive diseases and mental health illnesses, such as dementia (The Dementia Centre, 2016). The interplay between interior design and human psychology is significant. Despite the importance just demonstrated, it is strange that it is not an outstanding part of interior design; however, developments are being made (Anderson, 2019). Due to the ignorance and stigma that surrounds the industry, sometimes the legitimacy of these developments can be overlooked. 9
However, in reality, an interior designer is responsible for the way in which a building affects our lives. It is a powerful and influential part of the way we function within an environment and anticipates our needs with a combination of atheistic and design knowledge. With interior design being so significant, are we currently using it at its highest potential? Taking into account the current strain on NHS Mental Health Services, can interior design be used to help tackle this problem by proposing design improvements established by evidence-based design? With interior design evolving all the time, and the current surge in interest into wellbeing and healthcare design, it is important to have a comprehensive understanding of previous design strategies and progression in the industry. As the aim for this dissertation is to produce guidelines to aid the improvements of mental health facilities, research has been undertaken on the history of mental health units to draw attention to any key developments that could inspire further advancement, as well as to inform on poor design decisions that have previously received negative criticism. The earliest recorded mental health institution in England is the infamous ‘Bethlem’ asylum founded in the 13th century. The hospital was made up of ‘cells’ for patients who were otherwise known as ‘lunatics’ (Historic England, 2019). Originally, the site was located in London, where Liverpool Street Station stands today, but was later moved to a grand looking building in Moorfields. The impressive exterior did not match the prison like interiors. (See fig.1&2).
Fig.1 – The exterior of Bethlem asylum, 1676.
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Fig.2 – The interior of Bethlem asylum after closure, 1930.
Bethlem, more commonly known by its nickname ‘Bedlam’, has been the inspiration for multiple horror films and plays, which dramatically emphasises the conditions these patients were imprisoned in (IMDB, 2005). Upon establishment in 1948, the NHS became responsible for over 100 asylums that were initially all run under different regulations and treatment plans (HSJ, 2008), Bethlem being one of them. Under a unified body it was discovered that the patients were subjected to inhumane containment, such as frequently being locked in padded cells or forced to wear straightjackets (Chadda, 2015). Therapy treatments were rudimentary and, most of the time, made no positive difference to the patient’s health. Brutal operations, such as lobotomies, were performed regularly in these environments. This procedure was developed in the 1930’s to help solve the problem of overcrowding within mental institutions, as there were not any effective forms of treatment available at the time. However, these operations had severely negative effects on patients’ personalities and resulted in the development of permanent cognitive disabilities (Live Science, 2014). As well as violent treatments the environmental conditions in these buildings were of an extremely poor standard. The NHS implemented immediate change after discovering this, which was later supported by the Prime Minister, Winston Churchill, and his conservative government. In 1954 they released the ‘Percy Commission’, which was a law set up to review the existing legislative framework that the institutions followed to detain their patients. The commission concluded in 1957 that: 11
“The law should be altered so that whenever possible suitable care may be provided for mentally disordered patients with no more restriction of liberty or legal formality than is applied to people who need care because of other types of illness, disability or social difficulty”. (The Percy Commission, 1957) This was followed by the 1959 Mental Health Act which was a big milestone in the development of mental health facilities and policies, which brings us to where we are today. The act’s main incentive was to eliminate the stigmatised difference between psychiatric hospitals and general hospitals, and to limit the growing numbers of institutionalised patients. People become institutionalised as a consequence of spending a long time locked up in mental hospitals or other remote institutions resulting in patients being unable to look after themselves. (Chow, Priebe, 2013). Churchill was a huge advocate for mental health and inspired the notion that buildings can affect the way we feel and operate. He argued that ‘We shape our buildings, and afterwards our buildings shape us’ (Churchill, 1943), and always believed that ‘To improve is to change; to be perfect is to change often’ (Churchill, 1925). Throughout the last 100 years, the knowledge and insight relating to mental health illness has developed immensely. In this modern-day, mental health facilities are run substantiality differently: every judgement and treatment decision made has to be supported by years of research and evidence before it can be practiced. There are also official guidelines for everything in regards to the running of a mental health facility. As well as a progression in the understanding of mental health conditions, there has also been huge progress into treatment options. Medication and therapeutic treatments, such as cognitive behavioural therapy (CBT), are proving increasingly successful, which plays a vast role in managing the overriding demand for mental health care in the UK (NHS, 2018). As of 31st May 2017, The Care Quality Commission, which is an independent regulator of health and adult social care in England, has rated 68% of NHS core services for specialised mental health units as good and 6% as outstanding. Among independent services, 72% of core services were rated as good and 3% as outstanding (CQC, 2017, p.7). This means 26% of NHS services and 25% of private services are running at an inspected level of ‘needs improvement’ or even ‘inadequate’. This report identified that the key areas of concern within these underperforming units were the much-needed 12
improvement for safety. It was also recognised that the physical environments of these facilities were not meeting the needs of today’s patients due to them being located in older poorly designed buildings (CQC, 2017). This evidence supports Dr Phil Moore’s statement within the ‘design guidance for psychiatric intensive care units” report. He states: “If we want to maximise recovery and safety, design in essential, design is informed by experience and evidence in exactly the same way that clinical care is. The two should act synergistically.” (Moore, 2017, p.6) Generalised mental health care design is no longer considered acceptable. The health care industry has only just begun to explore the potential that interior design has to impact treatment; not only to create comforting environments but to also contribute to recovery. Although the act of designing has always been – and always will be – a process of development and discovery, when dealing with healthcare environments the responsibility designers have to achieve effective and successful solutions is heightened. Evidence based design (EBD) can be used in these scenarios to meet these high standards. It allows designers to look beyond the limitations of their knowledge for reliable and statistical based information (Satterfield et al, 2009). EBD for therapeutic environments creates a bridge between research and design practice, combining the intelligence of architects, health care professionals, service users and designers to collectively produce successful environments. (See fig.3 )
Credible Research and evidence
Ecological context – cultural, historical, social and physical environments
Design Decision Making Client and population needs
Designers expertise
Fig.3 – EBD concept model (Adapted from Satterfield, et al, 2009)
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Reflection upon existing facilities, case studies and data is a fundamental stage within EBD as it encourages designers to learn from mistakes and progress faster. Dr. Diana C. Anderson uses EBD within her practice; however, interestingly she plays the role of both the architect and the doctor. She is qualified in both professions and has branded herself as a ‘Dochitecht’. Dr. Anderson combines educational and expert experience, in both medicine and design, in order to create environments that benefits both patients and the medical professionals who work in them. “Effective patient encounters do not happen by chance—the impact of design should be realised” (Anderson, 2019). Interestingly, long before EBD was established, Florence Nightingale conducted a study that resembles EBD. Nightingale produced a paper listing four major defects of the building designs that disrupted the general operation of hospitals. By acting upon each issue, a healing environment was created that had a positive effect on the recovery of her patients, ultimately limiting mortality’s (Nightingale, 1863). A current recognised healing environment that uses interiors to enhance the patients experience are hospices. The modern concept of a hospice includes palliative care for the incurably ill, taking place in therapeutic environments that are uplifting and supportive for both the patient and their families. The clearest current illustration of the phenomenon are the Maggie’s Centres. Initiated by Charles and Maggie Jencks, they are retreats that are neither quite medical nor domestic, but a hybrid space of wellbeing accentuated by ambitious architecture. The concept is based on the legacy of Maggie Jencks who through her own battle with cancer, developed an understanding for the importance of the environment for someone suffering with one of the most difficult physical and psychological states that humans can encounter. She recognised the need for a welcoming, reassuring space, as well as a place for privacy, where someone can take in information and cope with the drastically life altering illness at their own pace. The architecture and interiors of the Maggie’s Centre buildings is often theatrical and unexpected, allowing those with cancer and their families to experience the positive power that design is capable of. “Every Maggie’s centre is a unique place that fits perfectly into its surroundings – a home from home that’s designed to feel nothing like a hospital” (Maggies, 2019). Healing of this extent requires so much more than just medicinal practice. Although every Maggie’s Centre is built with the same architectural requirements written by Maggie herself, who composed a leaflet ‘A view from the
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front line’ when she was ill, listing how the centres should be approached and organised (Jencks, 1995), each building has been designed by a different architect and not a single one resembles another. Architects Roger Stirk Harbour + Partners were behind the design of Maggie’s West London that opened in 2008. The bright orange surrounding walls protect the hospice from the hectic hustle of London so that patients can look out from the open planned building at the expertly designed courtyards and gardens without any distractions. A biophilic design has been created by the excessive use of natural materials internally as well as elaborate glass walls to provide views of the garden (See fig.4&5). These design elements have been proven to reduce stress and increase the sense of being home (Channon, 2018, p.54). The centre has been recognised for its outstanding design globally and has won prestigious awards, such as the RIBA Stirling Prize in 2009 (Maggies, 2020).
Fig.4&5 – Interior and Exterior of Maggie’s West London, 2008.
All sensory elements are considered within these designs to achieve ultimate tranquillity despite the difficult circumstances that the users are in. Could this environmental consideration and concept be reflected to enhance the treatment of mental health therapy? Or more specifically, treatment centres for eating disorders?
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‌ School of Art, Architecture and Design London Metropolitan University 2020
liveness.org.uk