Rehabiliteringscenter for krigsveteraner, Barrit, RHB // Critical Written Reflection

NURTURE ATURE AND

A rehabilitation centre

Critical Written Reflection Spring Semenster 2017 Michael Nykjaer Andersen Studio 2A Aarhus School Of Architecture

MANIFESTO In a time predominantly defined by concrete towers, prefabrication and efficiency, nature has been neglected, and with it, the nurture it brings We are self-imprisoned in a system which prioritize efficiency over comfort, where running the line and circumventing the rules have become standards to minimize costs Disavow the hypocrisy of the modern architectural notion of “form follows function� Form follows the individual.

Build in nature to nurture the individual.  

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Nature and Nurture A Rehabilitation centre

PREFACE Currently Denmark is participating in armed conflict in Afghanistan, Iraq and Syria, and has been present in the past, amongst other places, in Kosovo (1999), Afghanistan (2002) and Libya (2011)1.

Since 1990 more than 28.000 soldiers have been sent to war. Many of these soldiers have been deployed several times. A total of 42.000 times soldiers have been abroad for the past 27 years2.

If injured and thereby discharged, soldiers are sent home and the public healthcare system takes care of them.

Often, many of them return to a life and network that in many ways have moved on since they left. Furthermore, they are now living in a country, which is a strong contrast to those in which they fought. Such contrasts and rough encounters with multiple realities often strips them of the purpose they have spent years training for.

Repeatedly, this results in deep inner unrest and frustration, which is expressed through aggression and isolation from the surrounding world. It is of extreme importance that this behaviour is identified as fast as possible to make rehabilitation as effective as possible.

The process of rehabilitating a veteran begins with a screening at Svanemøllen Kasserne, where the initial psychological evaluation occurs. Depending on the conclusion, the system assigns a psychologist or psychiatrist if mental issues have arisen and if physical injuries are present, the veteran is also enrolled in a physical rehabilitation programme located at Rigshospitalet in Copenhagen.

Beyond this, the veteran is on his or her own, rebuilding their daily lives and routines. The only option they have, if times get tough and they need support and comfort, is going to a veteran’s home for temporary comfort and company.

Other than that they are left alone, living a life far away from the battlefield – a life that many have to rebuild on their own.

This critical written reflection investigates the possibilities of improving the return of our injured men and women of war. This is based on the meeting between Post Traumatic Stress Disorder (PTSD) and architecture in nature – giving basic knowledge about the condition, its parameters, the current process and how architecture can be an interacting and accelerating factor in the healing process.

1 likt.aspx 2

Danish Ministry of Defense (2012). Viden om Krig / Væbnet konflikt. Located March 23rd 2017 on http://www.fmn.dk/videnom/Pages/KrigvaebnetkonfJyllands Posten (2016). Danmark i krig. Located March 23rd 2017 on http://viden.jp.dk/undervisning/sites/danskereikrig/indsigt/danmarkikrig/

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Nature and Nurture A Rehabilitation centre

WHAT IS PTSD? “PTSD” or Post Traumatic Stress Disorder is a psychological disorder that may occur after a traumatic event so severe that it is experienced as being a threat to the victim’s life. Whether the event was life threatening or not is not significant, it is however how the victims perceive the situation, which influences the aftermath. The events normally range from natural disasters, military combat and torture all the way to sexual assault in adultor childhood.

The first part of the essay contains a description of PTSD in broad terms to get a better understanding of the condition. It is then followed by a specific focus regarding PTSD in veterans.

Traumatic events are experienced by 20-50% of the population worldwide during their lifetime, depending on the location. The chances of it manifesting as PTSD increases with the following factors3:

• • • • • • •

The The The The The The The

severity of the life-threatening situation amount of trauma the victim is exposed to less prepared the victim is for the incident stronger the feeling, of not being able to escape more introvert the victims personality is more prone the victim is to experiencing situations as traumatic amount of time it takes the victim to seek help

In most cases, the victim of a traumatic event returns to a normal life after a period. However, at the moment 1% of the general Danish population suffers from PTSD, where the percentage rises to 10% in soldiers and victims who have experienced combat. The highest percentage, 30%, is in people who have experienced rape4.

After a traumatic event, most people have some sort of reaction, such as grief, anxiety, a feeling of emptiness, anger or other emotional outbursts, which are all normal reactions after a traumatic experience. If these reactions, however, are still present after 30 days, they can evolve into PTSD5. Therefore, the first month is of crucial importance to the treatment of the condition.

PTSD can be difficult to diagnose, as many of the initial symptoms may be mistaken for other illnesses such as depression, amnesia and stress, and are therefore often not initially linked to the traumatic event, especially if it has been years since the event.

The first symptoms usually arise within the first six months after the trauma occurred, but it may take several years before it evolves into full-blown PTSD. It progresses into a chronic state for about 30% of the victims, depending on the amount of professional intervention.

3 Psykiatrien I Region Midtjylland page 5. Located on May 17th 2017 on http://www.psykiatrien.rm.dk/siteassets/patient/information-om-psykiske-sygdomme/nar-du-er-voksen/ptsd/75969-pjece-om-ptsd-1_02_web.pdf 4 Sundhed.dk. Located on May 17th 2017 on https://www.sundhed.dk/borger/patienthaandbogen/psyke/sygdomme/oevrige-sygdomme/posttraumatisk-stressforstyrrelse 5 Psykiatrien I Region Midtjylland page 6. Located on May 17th 2017 on http://www.psykiatrien.rm.dk/siteassets/patient/information-om-psykiske-sygdomme/nar-du-er-voksen/ptsd/75969-pjece-om-ptsd-1_02_web.pdf

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Stimuli

Gatekeeper

Higher-order Thinking

Memory storage

SNS Fight or flight

ANS

PNS T. Immobility

Figure 1.

Map of process of making a memory Based on figure 1.1 page 5, �Posttraumatic understanding�

Matthew Finn, 2013.

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MAKING OF A MEMORY Before describing the symptoms of PTSD in more detail, it is necessary to have an understanding of how the brain creates memories, as it is within the brain’s memory function that the problem of PTSD arises.

In 2013, Matthew Finn, an Atlanta-based architect, made a report entitled “posttraumatic understanding6. His study, which was a collaboration with USMC veteran Clint McMahan, investigated how the soldiers’ mind works, what it is trained to do and how this affects the soldier if PTSD arises.

Finn defines the formation of a memory in four parts; I) the stimuli is recognized by the sensory organs, be it a smell, sound or visual component, II) the information is then passed through “The gatekeeper” – the part of the brain that assesses stimuli for further processing, III) the information undergoes “Higher-order thinking” where it is processed, connected to other information, categorized etc., and IV) the information is stored in the short- and longterm memory. This ensures the possibility to extract such memories and use its information later – what he calls an “associated memory".

The difference between the normal memory process, and the same process when under high stress, is optimization for faster handling of the given situation.

In this process, higher order thinking is removed, and all stimuli is handled by the autonomic nervous system (ANS) before going directly to storage, after which the ANS can activate one of two emergency systems to cope – the sympathetic nervous system (SNS) or the parasympathetic nervous system (PNS)7. - See figure 1.

If the SNS activates, it initiates the “Fight-or-flight” response – activating every single resource and system the body has in order to survive. If the gatekeeper “decides” that the “Fight-or-flight” response is not the correct approach, the PNS is activated. When this happens, the brain accepts the situation and determines that the best course of action is to wait it out. In this situation, the brain chooses to “simply submit to the conditions and wait. In this state a person is immobile, able to observe without feeling fear or pain, and time is perceived as moving more slowly.”8 The memories created in these situations, being devoid of processing by higher thinking, are instead stored as a “disassociated memory”. These are often fragmented and without connection to other memories, but are still kept in the forefront of the mind for the brain to refer to, if a similar stressful situation should arise again.9 The conclusion is that the problem with PTSD lies in the triggering event of these memories and its effect in the given situation. The triggers can be everything from sounds, smells or visual impressions, that the mind associates with an "under stress"-response.

6 ”Posttraumatic understanding” by Matthew Finn, 2013. Accessed on May 17th 2017 on http://www.perkinswill.com/sites/default/files/PosttraumaticUnderstanding_2013.pdf 7 Ibid., p.5 8 Ibid., p.5 9 Ibid., p.5

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SYMPTOMS PTSD is split into two different variants, simple and complicated PTSD, depending on the severity of the condition. The simple version is the first stage where PTSD-specific symptoms are introduced, whereas the complicated version occurs when the first stage is not treated properly or at all. This leads to a worsening of the present symptoms and adds additional mental and/or physical symptoms – for further information see report10.

Due to the definition of this semester’s project and the timespan in which my project is supposed to handle the patients (up to 4 months of treatment). I will therefore only briefly list stage 2 symptoms for a better understanding of the condition, but will not go into detail regarding the treatment of these.

Simple PTSD11 is defined by six primary symptoms: Intrusive memories and flashbacks The victim suddenly and involuntarily experiences a flashback to the incident due to an exterior impression, such as a smell, a sound or a visual impression related to the incident. This draws the thoughts back to the incident and introduces memorial imagery, which may induce anxiety, palpitations, choking sensations and dizziness. .

Increased vigilance and avoidance The victim experiences an increased vigilance to everything that might activate anxiety or distrust. The slightest sound can make the patient jumpy, leading to a low threshold regarding sounds and noise. The victim experiences a short temper and irritability, which in many cases leads to isolation from society and activities, as a securitymeasure to protect from negative feelings. This isolation may worsen the illness, as the opportunity for a meaningful life with a job and recreational activities is limited or completely terminated.

Insomnia and nightmares In many cases, the victim will have a hard time falling asleep, wake up multiple times when they finally do and often wake up very early. This is often accompanied by an excessive amount of thoughts and nightmares – often several each night. These interruptions leads to constant tiredness and the veteran being lethargic.

Memory and concentration issues Due to never being fully rested and the energy consumption of constantly being aware of their surroundings, many experience problems with memory and concentration, as the mind is using all its energy on “fight or flight” instead of rational chores. .

Personality changes Many victims experience changes in their personality. Anger and uncontrollable outbursts of anxiety and irritation can become detrimental to the relationship to people in their network, who finds it demotivating and inappropriate, creating distance and solitude.

Impaired emotional connectivity and interest Some experience a loss of interest in things that would normally be interesting, and an inability to show empathy, engagement, tenderness and love. The interest in other people and oneself is decreased or completely lost and they no longer experience any joy in otherwise joyful things. .

These are the six primary symptoms of PTSD, and will be the defining factors in the design of the semester.

The symptoms of stage 2 PTSD12 - complicated PTSD - include, but are not limited to depression, feeling of guilt, thoughts of death and suicide, dissociative interruptions and hallucinations, anxiety and obsessive-compulsive behaviour, amnesia, physical symptoms and substance abuse.

10 Psykiatrien I Region Midtjylland page 7. Located on May 17th 2017 http://www.psykiatrien.rm.dk/siteassets/patient/information-om-psykiske-sygdomme/ nar-du-er-voksen/ptsd/75969-pjece-om-ptsd-1_02_web.pdf 11 Ibid., p7 12 Ibid., p8

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Figure 2.

Subjects of current treatment methods Made by author

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TREATMENT When it comes to PTSD, there is no straightforward answer regarding the correct treatment and there is no easy fix for getting well. The only goal the current treatment aims for is to reduce the physical and psychological symptoms, and thereby improve the possibilities of a better quality of life and to create a good foundation for future treatment from the victim’s own doctor and social services13.

The current process for an injured veteran starts with a debriefing at Svanemøllen Kasserne. Here the specialized psychologists determine the state of the veterans mind and what treatment the veteran might need.

If the veteran is diagnosed with PTSD, he will be assigned a localized psychologist who handles the psychological part of the veteran’s recovery. For physical therapy, the veteran enters an intense course localized at Rigshospitalet in Copenhagen to recover from the physical injuries.14 In addition, several other professionals may be assigned if needed in each individual case.

The current practice thereby splits the treatment of the patient based on the professions15 of the healthcare persons instead of the needs of the patient - see figure 2.

This contributes to a stressful situation for the PTSD patient, thereby worsening the symptoms.

13 Ibid., p15 14 Mail correspondence on the 23rd of march 2017 with Kenneth Ernst Hilt, Leading physiotherapist, Military Physical Training Team 15 Psykiatrien I Region Midtjylland page 15. Located on May 17th 2017 http://www.psykiatrien.rm.dk/siteassets/patient/information-om-psykiske-sygdomme/nar-du-er-voksen/ptsd/75969-pjece-om-ptsd-1_02_web.pdf

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Figure 3 A Design Theory for Reducing Aggression in Psychiatric Facilities page 3 Figure by R. S. Ulrich, 2012

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ANGER AND AGGRESSION Due to the nature of PTSD, a common symptom is shortened temper and anger issues16. As mentioned earlier, uncontrollable outbreaks become part of the daily life and result in the veteran distancing him- or herself from the outside world. Anger is therefore of crucial importance regarding the design process.

In 2012, Roger S. Ulrich published an extensive research paper describing violence in mental clinics. The key focus of the research was anger in relation to stress of the patient and ways in which design could minimize this stress.

The basis for the study was that 32,4% of patients in psychiatric facilities engaged in aggressive behaviour, based on 122 studies carried out in 11 countries., amassing a total of 224,4 violent incidents pr. 100 patients17.

The designresearch was based upon a concept of 10 different design factors present in different degrees in three mental institutions in Goteborg. The main research depended on a new institution that was built in 2006, which replaced an older institution from the 1940s-1970s, while the third institution functioned as a control hospital18.

The key premises were that the stress of the patient leads to violence, and by reducing stressful inputs through design, they would be able to lower aggression, and therefore the amount of violent incidents19 - see figure 3.

The key difference between his research and my project is that the stress came from involuntary hospitalization, where my project will see PTSD as the main stress factor – but design plays an equally important role in both studies, which I will describe further in the next section.

16 Psykiatrien I Region Midtjylland. Located on May 17th 2017 on http://www.psykiatrien.rm.dk/patient/information-om-psykiske-sygdomme/nar-du-er-voksen/PTSD/ 17 ”Towards a design theory for reducing aggression in psychiatric facilities” page 3 by Roger S. Ulrich, 2012. Accessed on May 17th 2017 on http://vbn.aau. dk/files/71203129/FINAL_pdf_UlrichBogren_Lundin_Toward_a_design_theory_for_reducing_aggression_Oct_2_.pdf 18 Ibid., p9 19 Ibid., p4

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The ten design factors mentioned above are elucidated below (for more information on the individual design features and sources see the report page 6 to page 920: 1. Single patient rooms Having one’s own bedroom and the opportunity to withdraw when needed was the most important design factor identified. Research shows that the number of people sharing bedrooms and bathrooms correlates with higher stress and lower privacy, perceived control, more disagreements with roommates, more illness complaints and social withdrawal as crowding induces stress and therefore probable aggression.

In my project, a private room will also give the patient space to reflect and give them the opportunity to withdraw completely behind locked doors if needed, as a base premise for the project is solitude in the private quarters, with a view framing the tranquillity of the forest, allowing for full detachment from the surroundings.

2. Smaller patient group size Research in non-psychiatric residential settings, such as dormitories and apartment buildings, found that smaller population sizes pr. unit (12-18 persons) are associated with a lower amount of crowding stress, a higher amount of helping behaviour and interpersonal contact than units of the same size, but with a larger number of residents. The smaller number of patients also makes it easier for personnel to be in control of each situation.

In the semesters project, this will be reflected in a maximum population of 16 patients at any given time. These will be split into smaller groups of 4 based on their progress, as part of the rehabilitation will be to be moved into more and more exposed conditions, ending in their living quarters being off-site. So even when all are present at the centre during the day, they still fall within the limits.

3. Movable seating in spacious common rooms The opportunity to control the space around one self and the distance to others induces a feeling of control for the patient. This allows for controlled interactions with others and reduces stress, as the patient can constantly regulate his or her own personal space.

In the project, this will be used within the boundaries of larger open spaces, placed at several locations throughout the centre, allowing for individuality and personal space within short distance at all times.

4. Noise reduction Noise reduction has been proven, in a non-psychiatric setting, to lower the blood pressure and lower the stress of the staff, perceived work demands and may help reduce burnouts.

In the setting of a centre for PTSD patients, a general noise reduction is also critical as noises can work as both general stress triggers and stimuli that may activate latent memories and incidents. This is especially critical within the private quarters as screaming may occur during frequent nightmares, which may scare others thereby creating a snowball effect.

I will therefore have to work with controlling sound within the private quarters through materiality and construction – allowing me to contain eventual audial outbreaks in the room in which they originate.

5. Nature window views Research have, in hospital settings, found that patients, recovering from surgery, who were situated in rooms with windows overlooking trees rather than e.g. a brick wall had better emotional well-being, fewer stress-related minor complications such as headaches, suffered less pain and had shorter stays.

Luckily, my project is placed in the outskirts of the woods of Barrit, and will therefore have ample chance to introduce nature views into the everyday of the patient through both panoramic and controlled views – depending on the situation. A main concept for the project have at all times been to frame nature based on the functions of the centre, so the private quarters will be facing the woods and the common spaces will be facing the lakes and beach.

20

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Ibid p6-p9

Nature and Nurture A Rehabilitation centre

6. Garden accessible to patients Garden access evidently creates a better feeling of well-being, reduces stress and gives a higher satisfaction with the quality of the given care.

As the project is places in the forest regions of the area, there is easy access to nature on all sides. Whether or not a defined garden will be available is yet to be determined, but there will be multiple access points into nature.

7. Nature art Studies show that a great majority of patients in a non-psychiatric setting responded better to and preferred representational nature art, whilst disliking abstract artwork and images displaying emotionally negative or challenging subject matter.

As a design feature of the architecture itself, I see nature art as being redundant as nature is just outside the windows on all sides of the project, and will therefore not be as prominent in my design decisions as some of the other design features.

8. Daylight exposure The author states no study has directly investigated the positive effect of different levels of daylight-exposure in accordance with aggression. However, several studies suggest that design, which provide higher exposure to natural light, reduces depression and shortens the time of the stay. In Alzheimer’s patients, it was found that higher amounts of sunlight resulted in lower agitation levels.

Due to sunlight’s natural effect on the wellbeing of people, as well as design feature 5 “Nature window views” a general theme will be large windows letting light and nature into as many rooms as possible, especially if it lowers agitation, and therefore anger.

9. Staff-stations close to patient activity area with large windows for good observation The placement of the staff-stations influences the accessibility of the staff to patients, and likely affects the staff-patient communications. This should contribute to a decrease in stress and violence, whereas problematic or inadequate communication has been proposed to have the opposite effect.

As the patients in the semesters project are not psychotic, but veterans with PTSD, the idea of the large observation windows seems redundant. However, the positioning close to common rooms to minimize the distance between patient and staff and thereby improve communication seems prudent.

10. Best practices As the author states these are not proven by empirical evidence, but seems plausible based on current design practices.

Way finding. Studies show that patients and visitors have found that difficult way finding elicits stress.

To make wayfinding easier the project will be based on long, straight hallways, that, when combined, create a circular motion, moving around the central lake to which there will be a constant view. This will create a constant overview, as you will always be able to see where you are going – either straight in front of you or through the windows.

Home-like characteristics. It is widely recommended to allow patients to create a feeling of home, when in for a longer stay, as this reduces stress and agitation.

Each of the patients will be given a personal space in which they are, except for a small amount of general furnishing, allowed to create the space they need to be comfortably at home. A large part of creating surplus mental energy is feeling at home and being able to relax.

Public spaces will, as mentioned in design feature 3 – “Movable seating in spacious common rooms”, also be furnished with movable furniture to further empower this feature.

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Figure 4.

Comparison of ward environments in three psychiatric hospitals with respect to stress-reducing environmental features in the Design Theory Figure by R. S. Ulrich, 2012

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PRELIMINARY RESULTS The different design options were categorized for the three hospitals - See figure 4.

The preliminary results of the use of the design options in the new hospital, was a decrease in chemical restraints by 21% per quarter and the number of physical restraints by 44%21.

This study clearly shows a positive effect of the design options on both stress and aggression by minimizing the amount of stress triggers. It is, however, mentioned in the discussion of the report, that it is impossible to specify which of the design options were stress reducing. It may be that certain ones were more prudent than others.

For the project I will use as many of the factors as possible to optimize the effect and they will be used in the manner described.

21

Ibid., p11

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“After years of active duty, it can become no less strange for a soldier to look for the subtle signs of a lurking IED on patrol than it is for a civilian to look both ways before crossing a street.

This altered state of awareness transcends merely looking for hazards, it is all-encompassing. A strange sound, a particular smell, or an expression on another person’s face could be the fraction-of-a-second early warning needed to survive. At any time, in the blink of an eye, a situation can become a fight for one’s life. With this understanding, it is no surprise that some men and women who have served struggle to adapt upon their return to civilian life.” (Finn, 2013)

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Nature and Nurture A Rehabilitation centre

UNDERSTANDING THE MIND OF A SOLDIER To determine how to design for PTSD patients we return to the report “Posttraumatic understanding” by Matthew Finn.

To better understand the constant thoughts going through the mind of a veteran, one must understand the thoughts of a soldier. The soldier spends years learning skills for improving the chances of survival. They are trained repeatedly to become second nature.

They are taught to constantly be aware of dangers, move in optimal patterns to cover all angles, to communicate specifically to avoid misunderstandings, to cover each other’s backs at all time and always go for the dominant position. These are the basic teachings and all of these are still in effect after a discharge.

As part of the research made together with USMC veteran Clint McMahan, Matthew Finn went through a two-day intense, immersive workshop on a training course. Here he systematically documented ingress into a pretend, unsecured location22 in pictures and descriptive text, and for one day, he was exposed to the pressure of the professional soldier.

He describes the situation as following: “After a day of thinking about the nightmare of entering a building filled with enemy combatants, I came as close as a civilian could come to understanding the stresses of urban warfare. I was completely helpless to lower my racing pulse or quiet my panting breaths. At that time, I got a glimpse of what it must feel like to experience code-switching; I was associating my present context with the memories of another situation”23 Based on his brief experience and his interviews with the veteran Clint McMahan, he defined the premises for his design direction, and defines that: “Given the opportunity to further this research, any design strategies developed should recognize the following principles: 1. PTSD symptoms may be triggered by anything.

2. Contemporary Psychotherapy: Identify the traumatic event(s) and trigger(s), and re-associate with present-day context through desensitization.”24

22 Posttraumatic understanding” Appendix C, Page 18 by Matthew Finn, 2013. Accessed on May 17th 2017 on http://www.perkinswill.com/sites/default/ files/PosttraumaticUnderstanding_2013.pdf 23 Ibid., p14 24 Ibid., p11

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RESULTS Finn quotes David Kirsh’s 1996 paper “Adapting the environment instead of oneself” that in the pursuit of “higher return on investment of our physical and mental resources a person can only improve their efficiency in one of three ways: 1. Adapt to the environment 2. Migrate to a new environment 3. Adapt the environment itself” He states that option 1 and 2 are quickly removed if seen in connection with PTSD as the disorder itself is a failure to adapt to the environment and option number 2 is removed due to it being impossible to migrate to a new environment without stress triggers, only leaving number 3 – adapting the environment to suit the veteran best.25 This is while still stating, “The built environment should not attempt to heal the sick. The goal is to provide a setting in which patients and providers can most effectively perform psychotherapy, to achieve a permanent and comprehensive resolution.”26 He further states: “The built environment may contribute to the healing of the psychological wounds of war in the following ways: 1. A high degree of cognitive congeniality reduces stress and effort exerted to navigate a building, allowing more cognitive resources to be available for undergoing psychotherapy.

2. Reducing complexity facilitates the veteran in identifying the trigger of their symptoms and with re-associating it with its present, safe, context”27 where cognitive congeniality expresses the cognitively hospitality of a space.

Finn concludes, based on the research, that the design of the building cannot be the healer of the problem, but only a purveyor of peace of mind. This in return frees up surplus mental energy for the veteran, making it available to be used into the psychological healing of the disorder.

25 26 27

Ibid., p9 Ibid., p11 Ibid., p12

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DESIGN THEORIES AND CONCLUSIONS Based on the stated research some conclusions can be drawn which can be incorporated into my design project. Based upon Finn’s findings I conclude the building itself cannot become a healer, but can only achieve the role of scenery in which the therapists can work.

The building itself will be a calming and nurturing surrounding in the key parts of the project such as common rooms, private quarters and therapeutic areas, which should help remove stress triggers and ease the job of the therapist.

This will be achieved by making the building be as far from a stressful situation as possible, as I will never be able to fully isolate the patients from impressions that might trigger the disorder, however I can “Adapt the environment itself” as Finn states.

In the private quarters, there will be a focus on the ability to create a temporary, but personal home for oneself, with clean white surfaces in the form of white walls and ceilings, creating a well-lit room. The living rooms will be deep rooms, with high ceilings and will open up towards the forest with large windows framing the woods and bringing in light to the back of the room, while the depth leaves the possibility to counter exposure.

The bedrooms will be small and easy to overview, but still with a large window framing the woods.

Due to the sound-sensitive nature of the rooms, floors will have carpets to limit ambient sounds and echo and to create a more homey feeling. On all sides, the walls will be thicker to accommodate for soundproofing for complete audial distancing from the surroundings.

Based on the concept of the “the dominant position” the private quarters will be raised from the ground to give a better view of the surroundings and to create a clear boundary between inside and out.

The common rooms will be framing the water views – the ocean and the lakes – through large curtain walls – bringing in light, and the feeling of being in the midst of nature to even the middle of the space, while it will still be easy to overview.

As nature is just outside the windows, the walls and ceilings will still be white as a simple, calming surface in contrast to nature, and the floors will have carpets for sound reduction and the feeling of home.

There will be as little fixed casework in the rooms as possible, as the patients thrive by being able to create their own flexible spaces by moving around the furniture to accommodate any given situation, be it a small, private family visit, a larger party meeting for dinner or the need for being alone.

The therapeutic areas will generally open up to both the forest and the lakes, being centrally placed in the middle of both.

The psychologists office, being a place of contemplation and safety, will be well lit primarily through skylights, with only a few narrow, but tall windows to create cover and privacy at it is here the patients feel the most vulnerable, while still utilizing the tranquillity of the outside, through framed and calming views of the lake to the north. The dimensions of the room will be small to induce the feeling of intimacy and closeness, like the private quarters.

As the view towards nature is limited, at least one wall will be wooden or even green, which will be determined later, while the remaining walls and ceiling will be white. Floors will be wooden to stand in contrast to the private quarters.

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Nature and Nurture A Rehabilitation centre

The group therapy room will, as the therapist’s office, open up to the north, but through large panoramic windows to bring the lake into the room and create an open, but still secure space in which group sessions will take place.

The room will be spacious and will be able to open up towards the south, as part of the therapeutic process, increasing its size and the level of exposure, by utilizing the adjoining greenery, creating a through-lit situation in both spaces.

Walls and ceilings will be white, but due to the usage of the room, the floor will be lightly coloured vinyl – both to pull light further into the room when only open to the north, but also so it can be frequently cleaned.

The therapeutic pool area will facing the southern lake with large windows and a view all the way to the sea.

The wet nature of the room calls for tiling on the walls and floors, creating a recognizable and clear statement of the use of the room.

The room will be deep and will be featuring curtain walls on the sides to let in light to the far end of the room, and giving a view back into the forest canopies.

To keep the room from overheating the roof will overhang towards the south for shading.

The room will have a high ceiling to accommodate for the depth of the room and to allow for natural ventilation under the ceiling, to counter the hot air and heightened humidity from the heated pool.

The offices of the different professions need to accommodate the delicate nature of the sessions, allowing for privacy while still letting in light and nature through highly placed windows. Like the psychologists office it will be white walls and ceiling, with a wooden floor to better spread the light entering the room.

To counter the idea that the building in itself cannot be a healing factor of the mental illness, I will instead use it as a healing tool for the physical injuries. All stairways and ramps are incorporated as training facilities for the physical therapists, allowing them to plan routes through the flow of the building, revolving around the central lake – creating movement and progress throughout the building.

The hallways will also give the maximum amount of exposure, as they will mostly be through-lit with curtain walls on both sides to create the sensation of being one with the surrounding nature. The walkways will alternate between either be dug into the ground, creating a safe position or raised from the ground, creating a “dominant position” – a higher ground.

The hallways will lastly accommodate both the long and the broad view – to ease wayfinding and to give a constant overview of the patient’s current position.

This creates a high cognitive congeniality factor, by making a less complex building with a plethora of clean surfaces, to calm the eye and the mind, allowing for mental energy to be available for the treatment of PTSD.

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Bibliography Architects, T. A. (2017, 05 17). ADULT: POST-TRAUMATIC STRESS DISORDER (PTSD). Retrieved from The American Society of Landscape Architects: https://www.asla.org/ContentDetail.aspx?id=39553 Danmark, P. i. (2017, 05 01). Hvad er PTSD? Retrieved from PTSD i Danmark: http://ptsdidanmark.dk/hvad-er-ptsd Finn, M. (2013). Posttraumatic Understanding. Atlanta: Perkins+Will. Retrieved 05 17, 2017, from http://www.perkinswill.com/sites/default/files/ PosttraumaticUnderstanding_2013.pdf Finn, M. (2014, 05 29). Designing for Health: Post-traumatic Understanding. Retrieved from Contract Magazine: http://www. contractdesign. com/projects/healthcare/Designing-for-Health-11028.shtml Forsvarsministeriet. (2017, 05 17). Krig/væbnet konflikt . Retrieved from Forsvarsministeriet: http://www.fmn.dk/videnom/Pag- es/Krigvaebnetkonflikt.aspx jp.dk, V. (2017, 05 17). Danmark i krig. Retrieved from Viden.jp.dk: http://viden.jp.dk/undervisning/sites/danskereikrig/indsigt/danmarkikrig/ Jørgensen, P. (2017). Fra indlagt til udskrevet. Psykiatrien i Region Midjylland. Retrieved 05 17, 2017, from http://ipaper.ipa- percms.dk/RM/ PsykiatriogSocial/psykinfo/Udskrivningsguide/Fraindlagttiludskrevet/ Kirsh, D. (1996). Adapting the environment instead of oneself. Retrieved 05 18, 2017, from http://adrenaline.ucsd.edu/Kirsh/ Articles/Adaptive/ adapting_env_00.pdf Midtjylland, P. i. (2017, 05 17). Psykiatrien i Region Midtjylland. Retrieved from PTSD : http://www.psykiatrien.rm.dk/patient/information-om-psykiske-sygdomme/nar-du-er-voksen/PTSD/ Netpsykiater. (2017, 05 17). PTSD - POSTTRAUMATISK BELASTNINGSREAKTION. Retrieved from Netpsykiater.dk: http://www. netpsykiater.dk/ Htmsgd/PTSD.htm Pedersen, L. N. (2017, 05 17). De fysisk sårede. Retrieved from Viden.jp.dk: http://viden.jp.dk/undervisning/sites/danskereikrig/artikler/defysisksaarede/default.asp?cid=151031 Rodiek, S. &. (2013, 02 20). Multidisciplinary effort produces veteran treatment center designs. Retrieved from Archone: http://one.arch.tamu. edu/news/2013/2/20/rodiek-lee-studio/ Taubenheim, T. (2013, 08 02). Architecture Versus PTSD. Retrieved from aegraphics.com: https://aegraphics.com/architec- ture-versus-ptsd/ Ulrich, R. S. (2012). Toward a design theory for reducing aggression in psychiatric facilities. Chalmers, Gothenburg: ARCH12: Architecture / Research / Care / Health. Retrieved 05 17, 2017, from http://vbn.aau.dk/files/71203129/FINAL_pdf_Ulrich- Bogren_Lundin_Toward_a_design_theory_for_reducing_aggression_Oct_2_.pdf Ulrich, R. S. (2013, January 11). Designing for Calm. Retrieved 05 17, 2017, from New York Times: http://www.nytimes. com/2013/01/13/ opinion/sunday/building-a-space-for-calm.html Veterans' Affairs, N. D. (2017, 05 17). What is PTSD (Posttraumatic Stress Disorder)? Retrieved from Post Traumatic Stress Dis- sorder: http://www. ptsd.ne.gov/what-is-ptsd.html Videbech, P. (2017, 05 17). Lægehåndbogen - Post traumatisk stressforstyrrelse. Retrieved from Sundhed.dk: https://www.sundhed.dk/sundhedsfaglig/laegehaandbogen/psykiatri/tilstande-og-sygdomme/oevrige-sygdomme/posttraumatisk-stress- lidelse/ Videbech, P. (2017, 05 17). Posttraumatisk Stressforstyrrelse. Retrieved from Sundhed.dk: https://www.sundhed.dk/borger/patienthaandbogen/ psyke/sygdomme/oevrige-sygdomme/posttraumatisk-stressforstyrrelse/ Aargaard, J. &. (2017, 05 17). PTSD hos voksne - Sygdommen, behandling og forebyggelse. Retrieved 05 17, 2017, from Psy- kiatrien i Region Midtjylland:

http://www.psykiatrien.rm.dk/siteassets/patient/information-om-psykiske-sygdomme/nar-du-er-

ptsd-1_02_web.pdf

voksen/ptsd/75969-pjece-om-

Image references Cover image Ideogram - Made by Author, Michael Nykjær Andersen

Figure references Figure 1.

Map of process of making a memory Based on figure 1.1 page 5, ”Posttraumatic understanding”, Matthew Finn, 2013.

Figure 2.

Subjects of current treatment methods Made by author Figure 3 A Design Theory for Reducing Aggression in Psychiatric Facilities page 3 Figure by R. S. Ulrich, 2012 Figure 4.

Comparison of ward environments in three psychiatric hospitals with respect to stress-reducing environmental features in the Design Theory Figure by R. S. Ulrich, 2012