SCHOOL OF THE ART INSTITUTE OF CHICAGO
MENTAL HEALTHCARE: CREATING SALUTOGENIC ENVIRONMENTS
MASTER OF ARCHITECTURE THESIS | DANIA MELENDEZ | SPRING 2019
TABLE OF CONTENTS INTRODUCTION A. CRISIS OF MENTAL HEALTH CARE B. STATEMENT OF PROBLEM C. COMMUNITY AS CULTURE D. SIGNIFICANCE OF STUDY E. LIMITATIONS AND CRITERIA F.
TERMINOLOGY
PRECEDENT STUDIES A. THE NATIONAL MEMORIAL FOR PEACE AND JUSTICE B. MATERNITY WAITING VILLAGE PROJECT TOMORROW A.
ORGANIZATIONAL PROGRAMMING
B.
FUNDS FOR MANAGEMENT
C.
DESIGN INTERVENTION
SITE A.
MACRO SCALE
BIBLIOGRAPHY
INTRODUCTION Crisis of Mental Health Care This thesis proposes to resolve the problems created by society’s low resourced mental healthcare system accessible to too few and present in unfit environments. Through this thesis I want to rethink new ways in which more people can have access to a public resource center that promotes awareness, provides means of prevention, and serves as a healing space for individual’s going through their recovery/coping stage. The function of the space will be designed for the community to implement a collaborative care model in an effort to combat the issue of suicide. The aim of study is to link a better understanding of a narrative space that affects a person’s behavior: physically and psychology to conduce a salutogenic environment. According to Aaron Antonovsky, the salutogenesis theory frames how a person interacts with their environment and finds mechanisms to cope with the changes happening in their everyday life. Thus, the theory acts as a constant learning process in which a strong sense of coherence impacts how we perceive our health. Sense of coherence is defined as one’s ability to comprehend the stressful situation and having the coping capacity to use available resources to help them progress in a healthier direction. The concept around “sense of coherence” constitutes three factors: comprehensibility, meaningfulness, and manageability - each reflecting on a person’s view of life and capacity to respond to stressful situations. Strengthening this
sense of coherence raises an opportunity for the theory to promote better ways of building health environments. Architecture can induce fundamental triggers, through spatial storytelling, that can affect one’s physical and psychological behavior. When we enter an unknown space for the first time we make preconceived judgments about our forthcoming experience based on the atmosphere we are first introduced to. This however does not mean it cannot be altered throughout our time in the space. Behavior is responsive to multiple variables, like our mood prior to entering the space, making us fluid to spatial perception. Two variables architecture does however have control over are the atmosphere and aesthetic experience. Atmosphere is defined as the measurement of an environment that contributes to our sensory perception of the space. Whereas, aesthetic experience drives how our state of mind: thoughts and feelings are stimulated and changed by our perception of the atmosphere; ultimately affecting our outlook of the space. Thus, the act of spatial storytelling becomes critical in salutogenic environments because it allows for the architecture to act as a healing mechanism that visitors perceive as comfortable, secure, and valuable. In the words of Peter Zumthor, “I enter a building, see a room, and- in a fraction of a second – have this feeling about it. This idea of aesthetic experience is the response that needs to be addressed in health environment to provide “sustainability” not just to the exterior of the building but also to the emotional experience happening inside the space. How a health center is presented can directly affect how a person perceives the quality of help they will receive. It is proven people make decisions based on an emotional level, therefore, if we can change what people see on an
emotional level, we can transcend the health outcomes. For example, Centers for Disease Control and Prevention is very different from Centers for Health Creation because intuitively one is focused on the problem while the other on the solution. Hence, optimal care can be better achieved by strengthening the relationship between the environment and its visitors. Suicidal risks are linked with an individual’s environment, sociological perspective, and biological traits. While there are several cofactors for suicidal behavior, the single most significant factor among teens is impulsive aggression. Impulsive aggression is the tendency to respond with hostility or aggression when faced with stress or frustration. However, architecture can counteract that behavior if it is strategically designed to create a therapeutic atmosphere that helps its visitors to heal during their path to recovery. By unveiling a new spatial experience, it can usher a sense of a fresh start which can be helpful to users needing to cope. Consistent treatment is critical for individuals wanting to recover, but where they receive their treatment becomes just as important. Salutogenesis addresses the feeling of reliability to its users but also serves as a holistic approach that challenges the architecture community to design fitted environments what will help with the healing process. As mentioned earlier, architecture can trigger our physical and psychological behavior, meaning it can affect our mental health by mitigating social isolation and stress -both factors that are currently being experienced in Montana in response to their socio-culture. With social norms modernizing, our living conditions and mental health are naturally evolving too. However, what have repeatedly failed
to evolve with us are the healthcare system and health environments. Thus, the challenge is to figure out design techniques that support the factors of salutogenic environments and reverse how we view mental health. Having followed the pathogenic model that focuses solely on disease prevention rather than health activation, we have surrounded ourselves with dull buildings that numb our senses and set us in autopilot. But think of the world we could live in if we viewed architecture as therapeutic. Our health momentum is constantly changing with our lifestyle, so how we manage life’s most stressful situations becomes important and the environments we choose to build. Studies by psychologist John Balling and ecologist John Folk have shown people have a greater sense of restoration and psychological well-being in higher density environments of wildlife. So in an effort to shift our healthcare environments into a simulating experience that triggers our senses, it will be necessary to rethink how a third place for visitors, that is not home or school but a place that is supported by the community, can lead to a better dialogue about mental health. It is important for teens to feel they are heard and understood; otherwise it can be difficult for someone to want to receive treatment. Therefore, improving the social-culture needs to be a community -based effort because suicide affects everyone. In conclusion, by focusing on the emotional and physical comfort; public resource centers can be rebranded with a new captivating architectural experience to encourage those in a vulnerable state to seek preventive care.
Spartanburg Area Mental Health Center, SC
Westpark Family Clinic, UT
Chicago Lakeshore Hospital, IL
Minnesota Mental Health Clinic, MN
Central Kansas Mental Health Center, KS
Richard Hall Community Mental Health Center, NJ
Statement of Problem For years mental health institutions developed a bad reputation for not providing proper treatment, leaving patients severely damaged under a failed system. The treatments given to patients during the opening of the first psychiatric hospital in 1773 were dangerous and inhumane- releasing unstable patients into the world after they were “cured�. According to author E. Fuller Torrey, the psychiatric hospitals were believed to be peaceful locations where patients could have a chance of recovering so they would not end up in jail. That was until the Community Mental Health Center Act of 1963 became a period of turnaround with the wanted reform for people living with mental distress to live in more natural community settings. That was until sweeping budget cuts led to a decline in mental health service in the 1980s. Twenty years later, the Supreme Court ruled mental health patients should have more access to community-based care. Coming to the conclusion institutions limit a person’s ability to interact with other people, to work, and to make a life for themselves. As a result, more people have become accepting of mental health centers and the perceived stigma associated with receiving help has declined. This change of public attitude is a highly contributing factor to the growing demand for mental health services in the United States. Unfortunately, policies in healthcare system have not made many changes since and have ignored the environmental impact mental health centers have on its users- leading us to be stuck with the dull buildings we have in the healthcare system.
On a macro level, the United States ranks number four in suicide rates with an average of 13.5 deaths per one-hundred thousand population, the highest level seen in decades. Today, youth suicide has become prevalent in rural and western areas and is the third leading cause of death for fifteen to twenty-four year olds. Making up 12.7 percent (5,723) of the 44,995 suicides reported in 2016. Where statistics show males are four times more prone to dying to suicide than females. What the statistics do not show however, are the 34,338 individuals left vulnerable to attempting it again. An agonizing thought family and friends have to deal with daily not knowing when the next attempt will be. For the past thirty years Montana has ranked in the top five states for suicide rates in the nation at twice the rate of the national average. Over the last ten years, sixty-five percent of the youth suicides were completed by firearms and research has shown that most suicides occurred after school hours and in the individual’s home. This crisis has left communities torn and families devastated. So what is it about Montana that has caused the suicide rates to spiral out of control? First it is important to understand Montana’s socioeconomic standing has one in five kids living below the federal poverty line. This puts kids at a disadvantage because their chance of receiving help from a psychiatrist is automatically reduced. Second, Montana’s geographic location is set at 6.7 people per square mile, a much lower density compared to the national average which is 88.7 people per square mile. This smaller level of social condition often takes communities longer to adapt to new ways and breakaway from old social and cultural norms, but through community connectivity, intervention is possible. Finally, there exists the lack of integrated psychiatric and behavioral healthcare into primary care.
Whereas before more people felt ashamed and embarrassed about seeking mental healthcare because of the social stigma associated with it, today more youth than ever before is seeking help. However, a lack of health care reform continues to make budget cuts, turning away individuals needing mental health resources. This is because the cost associated with mental healthcare problems are less well known than the costs associated with the cost of physical health problems like cancer and diabetes. While it is recognized the value of human health is not a financial issue, calculating the costs of mental health problems for the national, regional, and local economy can be influential when making investments in mental health preventions and mental health services. So functioning under an insurance driven system makes it inevitable for people who experience mental health problems to face more stigmatic responses and discrimination in the healthcare system than those with physical health conditions. As a result, twenty-four hour crisis hotlines have been developed to reduce the number of suicides that happen annually all across the world. The idea behind receiving help anonymously is successful in gaining trust from its users; the problem with help lines is that they reach out to such a wide audience all over the world that the waiting time on the crisis line long and dreadful. The other problem with this method is the limitation it has with human contact. Listening to a voice over the phone or reading text messages only stimulates one sense which can be limiting to someone trying to receive help.
In contrast, the experience an architectural environment can bring is much more engaging. Architecture unfolds physical and psychological affects that can counteract the compulsive aggression that occurs in teen experiencing suicidal risks. Although not many studies have been done to understand the behavior that triggers one to have suicidal factors, it has been found that everyday stressors in our life affect our mental state of mind. Whereas suicide in adults is often correlated with depression, it is important to note the treatment of depression does not automatically translate into the prevention of suicidal behavior. Suicidal behavior in teens has been linked with compulsive aggression. Therefore, the period of adolescence is an important development stage where social, emotional, and cognitive processes are involved in the attempts to navigate the world around them.
Community as Culture The objective of architecture as therapy is to bring people’s experience into communal spaces in the neighborhoods. Currently the federal programs do not provide such shared spaces. These spaces would create space for the community to forefront its strengths and assets and to transform the obsolete health footprint in a living collective identity. In face of the lack of coordination between local, state, and federal governments contributing to mental healthcare, it is necessary to rethink how to better balance the supply and demand of communities needed to reduce the strain caused by a lack of healthcare reform. With more lives being lost to suicide throughout all ages, it is critical to train communities on the issue so they can provide available resources to a greater audience and be a voice for other communities. Hence, the architecture will be studied and analyzed as a transformative tool/set of strategies to design a public resource center where the younger community can receive support and a means to access appropriate care. It can also serve as a place to commemorate lost lives.
Significance of Study Sense of coherence is a stable entity that is developed during young adulthood. Although adolescence is a vulnerable time for the brain, the teen brain is resilient and most teens go on to become healthy adults. Hence, some changes in the brain during this important phase of development actually may help protect against long-term mental disorders like depression. Younger victims are mostly responding to interpersonal and legal difficulties so they react with impulsive aggression and with substance abuse. This suggests that the problem of impulsive aggression may be particularly significant in understanding youth suicide. Hence, if people are taught to deal with their life stressors during their adolescent years, it is likely they will be able to handle their mental health better during their adult years. The key here is the brain development that brain is undergoing during adolescent years. During this stage we begin to build a perception of the world around us, influencing how we choose to think and act. Hence, the interaction an individual has with the environment is important to improving physical and psychological behavior. So if an environment can be perceived as meaningful, manageable, and comprehensive, it can act as a perceptual mechanism that encourages individuals to feel it worthy of their investment. Dealing with fragile cases, perceiving meaningfulness probable becomes the most important because individuals visiting may already be feeling like their life is tenable.
From a neuroscience perspective, it is yet to be understood how a thought or emotion emerges from cells and its brain chemical process is developed, but what has been discovered is that the same nerve chemical and cell processes that create mood and imbalances of mood are involved in the perception of the world around us. It is understood that we construct an image of a place based on the information we receive through our five senses-all gathered to create our sense of a place. Thus, our perception of a place changes not only with our location, weather, and time of day but also with our mood and health. Our sense of where we are is continually being created and retreated in our brain depending on our current condition and our memories of what went on there. Studies have shown changes in the brain happen during early development and the environment plays a key role in the final product. Connections between neurons can be increased or decreased based on experience and even change the total number of neurons based on the experience and physical interaction with the environment. Although this structural plasticity continues throughout our life time, its greatest changes occur during our earlier development stages. In summary, the brain controls our behavior and genes control the structure of our brain, but the environment is what modules the function of genes and the structure of our brain. Thus, if architecture can affect our brain, it can change our behavior. Mental health is a cultural of behavioral and lifestyle, and involves the harmonizing emotions. Thus, individuals need a support system where they can learn to take control of their life otherwise it can be difficult for them to take control of their health. In recent years, the term
“salutogentic” has come to be used in the healthcare design industry making it more notable that architecture can be psychologically manipulative when it comes to patients feeling better or worse. “You find what you look for” is a notable expression that depicts the psychology behind how our emotions play a role in our experience and how a narrative space affects a person’s behavior through the brain and body. From an architectural perspective, the concept of aesthetic impact on health has been scientifically tested and has proven to the wellbeing of patients, especially those who are suffering from a balance between deterioration and recovery. Overall, salutogentic architecture has the capability to support and enhance people’s manageability, comprehensibility, meaningfulness; all factors that help a person through a natural process of recovery. The act of storytelling is crucial to the building of spaces that convey meaningful messages. Architecture can not only induce a sense of reliability, comprehensibility, and value to its visitors but also affect their mental health by mitigating social isolation and emotional distress through the quality of design that builds a level of trust and participation within the community. Health culture affects our perception of illnesses, beliefs about the causes of the behavior, approaches to health solutions, and where we choose to seek help. Thus, individuals need a support system where they can learn to take control of their life otherwise it can be difficult for them to take control of their health. Yet healthcare culture ignores the elephant in the room-by building dull buildings that fail to heal. Whereas, architecture activates our senses and expands design beyond
visible form, allowing individuals to embrace their senses and interaction with spaces. In conclusion, if design can activate our senses beyond visible form, why not evolve “a place for the ill� into healing spaces that are restorative to us just like nature and a place where we seek when we need to find joy? In the context of socio-culture and psychological change, we should care about emotional health in the same way we care about physical health and evolve to meet the demands of society.
Limitations and Criteria The growing perception about psychology in the general public is that more people will continue to seek help, increasing the demand for mental health. Assumptions and attitudes will change and different forms of seeking treatment will develop. The age group being studied will be living a different lifestyle from the group that is being analyzed with the resources and technology available today. The individual will actively use their reflective learning to get them into a better sense of health promoted by the resources made available to them. The act of reflective learning is being applied in the correct method and is progressively strengthening their sense of coherence. Because the process of building a sense of coherence is interdependent, there lies a chance some individuals might not find the resources useful because they do not perceive the environment to be comprehensive, manageable, nor meaningful. There are mixed opinions when it comes to memorializing the suicide of someone, because people fear it will encourage other teens to do the same if they are seeking to be remembered or make people feel responsible for what happened to them. Hence, this thesis does not suggest that someone’s suicide is justifiable. The intention of this thesis is to break the fear and stigmatized responses people have about mental health by creating a healing environment where people can share their experiences in a communal space.
Salutogenic architecture can be impactful when it comes to healthcare experiences. However, when it comes to living a poorly inclusive healthcare system where it is controlled by stakeholders who are more concerned with costs rather than with the capacity of aesthetic influence it can have on visitor’s health. Pathogenic healthcare models came to look the way they do because they value space efficiency and traditional finishes; essentially, leaving no room for innovative design. Controversially, people are often under the impression it is the schools’ responsibility to provide the support and resources for adolescents because it is the place they spend the majority of their time. Though this is true, schools have limited funds and with their current budget, they do not have the sufficient economic funds to cover these types of costs. In addition, the academic time frame the schools work on do not allow enough time for students to receive mental health services without cutting time out of other classes and activities. So unless school days are longer, this solution is not likely to be effective on adolescents. Ergo, although schools hold the right audience, it would be difficult to implement the proper services. The other concerning issue is the low level of trust the students would have as a result of fearing they will be bullied. For these reasons, the better solution would be to accommodate a community space that adolescents feel safe visiting when they are feeling vulnerable and alone.
Terminology Reinforcer - Anything that increase the likelihood for a behavior to happen again. Energy Aesthetic- lets us know our surrounding are alive and can help us thrive. Hedonic Adaptation - The observed tendency of humans to quickly return to a relatively stable level of happiness despite major positive or negative events or life changes. Color Psychology As a social culture in the United States, we have been led to believe that monochromatic and simple designs are “adult like” and “professional”leading to the impression colors are “kid like”. Studies however have shown colors can actually improve our overall mood and psychological behavior. Colors carry characteristics that we subconsciously associate with moods or auras based off of the social culture we developed over the years. Color activates our senses and becomes part of our aesthetic experience of a space.
Aesthetics of Joy Is a shared common experience of the physical world studied by designer Ingrid Fetell Lee who discovered that certain elements--like patterns, round shapes, bright colors, abundance, feeling of lightness and symmetry are universally joyful. Concluding designing more joyful spaces can actually change how we feel and act.
Aesthetic Experience The concept our state of mind: thoughts and feelings stimulate the way we perceive a space; and the atmosphere: the measure of an environment; contributes to our sensory perception of the space.
MASS DESIGN GROUP
PRECEDENT STUDIES “Health culture� in the United States needs to bridge preventive care with the quality of life in order to create a fundamentally new and effective health system that embodies more people. In the example of Montana, there is a social culture that accepts suicides and needs to find of mean of reducing the availability of lethal weapons and instead find more ways of accessing mental healthcare. As a community very few resources exist in the state and there is a great need to build safer and more supportive environments. The social affiliations within community member that have a history of violence and substance abuse needs to be restored to a community that has a sense of connection to people, to the community, to the public resource center; but most importantly a sense of entitlement and control over their lives.
The National Memorial for Peace On a six-acre site of Montgomery, Alabama sits the national lynching memorial that is a sacred space for truth-telling and reflection about racial terror in America. The structure contains the names of over 4000 lynching victims engraved on columns hanging from the ceiling. By reconfiguring old elements in new ways, the memorial fades the outside world and transports you to a time of racial terror. This memorial space at first glance creates an emotional experience of our country’s remorse but simultaneously embraces the truth and inspires reflection and change. It also creates a space for people to come together, work together, hope together, and heal together.
MASS DESIGN GROUP
Maternity Waiting Village Malawi has one of the highest infant and maternal death rates in the world because many women live in rural area where medical providers are hard to reach. By building a birthing center the village was able to attract more women in their final weeks of pregnancy to live within close proximity of medical professionals and transforming a waiting experience into an empowering experience by fostering a sense of community.
PROJECT TOMORROW Organizational Programming The mission is to reduce the number of suicides and suicide attempts through collaborative efforts that promote awareness and prevention. The initiative was rebranded in 2016 through a collaborative campaign effort that advertises crisis text lines/hotlines and community resources in Montana. Under this model, Project Tomorrow has educated hundreds of community members on how to identify suicide warning signs and use safe intervention strategies. Since initiated, Missoula has trained 4,000 residents in QPR Training, Question-Persuade-Response. This safe talk training is accessible to all interested, with the goal of contacting as many people as possible and informing them about available resources. Together, leadership groups in Missoula are uniting to show Montana suicide does not need to be a one way effort.
Funds for Management
Design Intervention
SITE Missoula County Population: 117,441 (2017) Deaths: 349 Age Adjusted Rate: 16.5
Connection to the City
Connection to Nature
Land Region There is a generational culture of acceptance of suicide as a viable option to resolve feelings of hopelessness and when one feels they are a burden to others. There is an ongoing stigma towards seeking mental health services and concerns of maintaining confidentiality in small communities inhibit individuals from seeking needed treatment. Montana has a high availability of lethal means that increase the risks of impulsive suicidal behaviors.
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Rosston, Karl. Suicide in Montana Facts, Figures, and Formulas for Prevention . Montana Department of Public Health & Human Services, 2018, pp. 1–14, Suicide in Montana Facts, Figures, and Formulas for Prevention . Sternberg, Esther M. Healing Spaces: the Science of Place and Well-Being. Belknap, 1020. Sternberg, Esther M. The Balance within: the Science Connecting Health and Emotions. Freeman, 2001. “Suicide.” National Institute of Mental Health, U.S. Department of Health and Human Services, May 2018, www.nimh.nih.gov/health/statistics/suicide.shtml. “The Perception of Color in Architecture.” TMD STUDIO LTD, 20 Aug. 2017, medium.com/studiotmd/the-perception-of-color-in-architecturecf360676776c.