Mental Health + Architecture Rethinking the Decentralized System of Community Mental Healthcare
Thesis Final Booklet Singapore University of Technology and Design Architecture & Sustainable Design | Masters in Architecture
Acknowledgements I would like to thank my thesis advisor, Assistant Professor Chong Keng Hua, for guiding me through the whole process, prompting me and questioning my initially unfocused direction. I would also like to thank my friends and people who have kindly helped out in my surveys and interviews, which are essential in my thesis. Lastly, I would also like to thank my family and you for your constant support and understanding throughout these arduous 8 months.
Abstract Stigma associated with mental illness is one of the main obstacles preventing early and successful treatment. It also prevents mentally ill people from gaining employment or moving on with life normally. From research studies as well as evidence-based campaigns held in different parts of the world, it has been proven that direct social contact is one of the most effective strategies to change attitudes and behaviours, therefore reducing stigma among those who interacted with mentally ill people . This thesis basically looks at how architecture can change one’s negative mindset towards a stigmatized social issue, in this case, mental health. To bring about direct social contact between people with mental illness and the members of the public, perhaps we need to rethink about the system of decentralized community mental healthcare in Singapore on how the centres should be re-interpreted. Currently, most of these centres are located within the HDB neighbourhood, usually in the void deck, behind closed doors. While there are many new extensive programs and support within these centres being developed for the recovery of mentally ill patients, a full recovery occurs when the individuals feel comfortable and secure enough to re-integrate back into the community to study, work or live with other people. Some of the programs in the centres includes vocational training and family events which allow them to interact with some members of the public. However, these members of the public are usually caregivers, staffs and volunteers who have sign up to help mentally ill patients. There still exist a great social distance between the mentally ill and other members of the public who, out of un-necessity and stigma, would not visit these centres. A new type of decentralised community mental healthcare system, which will be more integrated with the HDB neighbourhood community, can be a way to create opportunities for direct social contact and slowly break down the social barrier. Keywords: Stigma; mental illness, direct social contact; decentralized community mental healthcare; HDB neighbourhood
Chapter 1
Introduction
Thesis Statement Singapore has shown improvements in the provision of a progressive array of good quality treatment, programs, and support for people suffering from mental illness. Like many other countries, we moved from a centralised institutional model of healthcare to a decentralized, community-based model and looked at providing not just treatment but also support from various levels to people with mental illness, from community mental healthcare centre counsellors and volunteers to personalised caregivers at home for people who have difficulties stepping out of their house. To enable more people to gain more awareness and understanding towards mental illness, funding for education and training has also been provided by the government and other social enterprises to various specific groups of people in the community like teachers, employers, elderly caregivers. Even at the individual level, because of the prevalence of social media and youths being more open to discussions, more people from the millennial are
Chapter 1: Introduction
willing to step to share their experiences and talk about mental health, “making it less of a taboo” . However, the stigma of mental illness remains widespread and commonly held because it takes a long time to change people’s mindset and behaviour. “People tended to hold these negative beliefs regardless of their age, regardless of what knowledge they had of mental health problems, and regardless of whether they knew someone who had a mental health problem” (C.L., 2013). Apart from lack of understanding or knowledge towards mental illness , stigma has been a main cause in either deterring people to seek treatment, or impinging these people to have an early recover from their mental illness. According to research studies, direct social contact is determined to be one of the most effective ways to change people’s mindset towards mental illness. To provide a platform for social contact to occur, perhaps we should rethink how the system of community healthcare centres should
be designed since these centres are where some people with mental illness will go to, to participate in programs (besides treatment) and also located within the HDB area where most people in the community live in. Currently, majority of these community mental healthcare centres are located behind closed doors in the HDB neighbourhood, with little or no information outside the centres which may inform the public about mental illness. While these mental healthcare centres may provide effective programs and treatments for the patients inside, a more effective recovery occurs when the patients are able to go beyond the provided care and treatment, to re-integrate back into the community comfortably and interact with people like any other healthy individuals. This thesis will look at how we can redefine the design of the centres that encourage re-integration and interaction, which in turn aims to change more and more people’s attitudes and behaviour towards mental
illness and people suffering from it. As dealing with stigma is a long term process, this thesis outcome serves as a stepping stone for members of the public to change attitudes and behaviour towards the mentally ill, which will thus, aid in their recovery process and reduce stigma in the long run. In addition, it will also encourage other people who are still in the closet, to be less deterred to step forward and seek treatment in the near future.
Methodology This thesis is a quest to understand how architecture can change people’s negative mindset towards mental illness. It is structured in the following way to gain an understanding about mental illness first, before we seek architectural solutions. Mental Illness - A Global Health Issue and Social Challenge This chapter serves as an introductory section to give readers a brief understanding on mental illness and stigma, and its criticality, as well as look at some of the stigma-reduction strategies that has already been implemented to see what we can learn from them. Rethinking the decentralised community mental healthcare system This chapter begins to look at the relationship between architecture and a social issue. Firstly, the thesis examines the current system of community mental healthcare in Singapore to understand
Chapter 1: Introduction
what is good and what may be lacking. Thereafter, it looks at the potential of a space/architecture being able to change a person’s mindset by studying some precedents. Designing for the differing needs This chapter identifies the differing needs of the stigmatized mentally ill and principles of designing spaces for them before illustrating different scenarios of the future that create possibilities of interaction to reduce stigma in the long run. Site Selection and Study In this chapter, the thesis starts to look at the application of the principles and concepts as highlighted in the previous chapter in a typical HDB neighbourhood in Singapore. Design Framework & Development
Throughout the paper, the thesis will be guided by the following design questions. 1. How does the way community mental healthcare centre in our HDB neighbourhood is being designed not aid in reducing stigma? 2. How can spaces be designed to change a person’s negative mindset towards a social issue? 3. What design guidelines are essential for different mentally ill people in Singapore? Besides literature reviews and other modes of research online, this thesis also uses other tools to gather data and learning points which are essential for justification of the design proposal at the end. Interviews/Surveys The interviews and surveys will serve as qualitative data to understand the general mindset of people in Singapore in their willingness towards interaction with people with mental illness. Interaction includes working or studying together,
socializing etc. This is necessary because many of the strategies being used to reduce stigma through promoting direct social contact are largely implemented in overseas like United Kingdom, Scotland and Australia. Those strategies have been effective to a certain extent but it might not be as effective when directly applied in Singapore due to the different social and cultural background. Precedents This thesis will be looking at projects relating urban design to improving mental health and how these projects may have promoted interaction between the public and people with mental illness. From these projects, lesson learnt can be evaluated and be applied in the context of Singapore. In total, this thesis addresses three precedents.
“Mental health matters, but the world has a long way to go to achieve it. Many unfortunate trends must be reversed – neglect of mental health services and care, and abuses of human rights and discrimination against people with mental disorders and psychological disabilities.� - Margaret Chan, Director-General, World Health Organization
Chapter 2
Mental Illness - A Global Health Issue and Social Challenge
2.1 Why Mental Illness? Mental illness is a critical global health issue. It has already affected at least 450 million people worldwide and it is projected to affect more people over the years. In fact, depression, one of the most common mental illnesses, is the leading cause of disability worldwide and a major contributor to the overall burden of diseases . This translates into an increasing strain on various levels such as families, governments and societies. In Singapore, it is no exception. Mental illness becomes a significant social challenge faced by many countries when many people who are suffering from mental illness are delaying or not seeking treatment because of reasons like stigma. This section gives a brief overview of how the world is affected by mental illness and some countries are coping with it.
Chapter 2: Mental Illness - A Global Health Issue and Social Challenge
2.1.1 Population of People with Mental Illness More getting affected Mental health has been a heavily stigmatized issue around the world even till today. However, as more and more people will be affected by at least one mental illness in their lifetime which leads to increasing strain on various levels as well as other implications like abuse of human rights to people with mental illness, mental health becomes something that we can no longer neglect.
Out of the 450 million people worldwide who are suffering from different forms of mental illness, 350 million of them suffer from
<
depression.
In Singapore, out of the 12% of population that will suffer at least 1 mental disorder in
78%
Depression
their lifetime, 170,000 suffer from depression.
<
Schizophrenia, depression, epliepsy, alcohol dependence and other mental, neurological and substance-use disorders make up 13% of the global disease burden, surpassing both cardiovascular disease and cancer.
Chapter 2: Mental Illness - A Global Health Issue and Social Challenge
31%
Depression
Younger Sufferers Amongst the increasing number of people that are suffering from mental illness at some point of time in their lives, many of them are actually youths and young adults. This is a worrying concern as these people are the key pillars of support for their own families, for the future growth of any society.
Around 20%
of the worldâ&#x20AC;&#x2122;s children and adolescents have mental disorders or problems.
Neuropsychiatric disorders are among the leading causes of worldwide disability in young people.
Globally, 75% of the people who will ever be diagnosed with mental disorder show signs at the age of 25.
No. of ppl with mental illness
50% already show signs at the age of 14.
In Singapore, youths faced the highest risk for depression, 8% between 18 to 34 suffered from Major Depressive Disorder (MDD).
of the youths aged
2.1.2 Key mental health-related issues Physical health problems leading to lower quality of life People suffering from mental illness tend to experience higher rates of disability and lower life expectancy. “Mental disorders often affect, and are affected by, other diseases such as cancer, cardiovascular disease and HIV infection/AIDS”. For example, “depression predisposes people to myocardial infarction and diabetes, both of which conversely increase the likelihood of depression”. (WHO)
“People with major depression and schizophrenia have a 40% to 60% greater chance of dying prematurely than the general population, owing to physical health problems that are often left unattended (such as cancers, cardiovascular diseases, diabetes and HIV infection) and suicide.”
In the United States, people with severe mental illness die 25 years earlier than the general population. In Denmark, the life expectancy gap has shown to be as
high as 18.7 years with certain disorders.
In Singapore, 51% of those with mental disorder have a chronic medical condition.
+ “Globally, mental health conditions account for 37% of healthy life years lost from Non- Communicable Diseases.”
Chapter 2: Mental Illness - A Global Health Issue and Social Challenge
Suicide & economic losses Having a mental illness can often lead to suicidal thoughts and suicide due to the suffering. On a larger scale, the implications of suicides and untreated mental illness have translated to a huge economic costs for the society.
â&#x20AC;&#x153;Suicide is among the 3 leading causes of death among those ages 15-44 years in some countries, and the 2nd leading cause of death in the 10-24 years age group.â&#x20AC;?
< <90%
In the last 45 years, suicide rates has increased by 60% worldwide. Each year, an estimated of 800,000 people died by suicide. Out of all these cases, more than 90% are committed by people who are
About $2.5 trillion estimated global economic costs of mental illness every year and this amount will increase to $6.0 trillion in 2030. More than heart disease, more than cancer, diabetes and respiratory diseases combined.
Nearly $100 billion estimated economic costs of untreated mental illness in U.S. which includes unemployment, unnecessary disability etc.
diagnosed with a mental disorder.
In Singapore, most of the 401 cases of suicide that were reported in 2009 are due to people not seeking treatment for mental illness on time.
2.1.3 Key challenges in dealing with mental health-related issues Delaying or Unwillingness to seek treatment - slower recovery Amongst the increasing number of people that are suffering from mental illness at some point of time in their lives, many of them are actually youths and young adults. This is a worrying concern as these people are the key pillars of support for their own families, for the future growth of any society.
50% of the respondents do
67%
not want anyone to know if they are suffering from a mental illness
Percentage of people globally who never seek help for their mental disorder.
In Singapore, only 25% of the people seek help for their mental disorder
These people believe that people with mental illness â&#x20AC;&#x153;can get better if they want toâ&#x20AC;?
Average of 10 years of delay across all types of disorders for people around the world with mental illness who seek treatment/help In Singapore, it takes an average of 4 and 13 years of delay for people who seek help for depression and alcohol abuse respectively.
Chapter 2: Mental Illness - A Global Health Issue and Social Challenge
Unemployment due to fear and discrimination Due to stigma and a lack of awareness about mental illness, many employers will rather choose to employ a handicapped than someone recovering from mental illness.
Mental and psychosocial disabilities are associated with rates of unemployment as high as 90%.
Loss of 6 working days as a result of lost
70%
in productivity due to mental illness and about 10 days where work quality is compromised per person
In Singapore, an estimated 70% of the 60,000 people with mental illness are unemployed, either because they fear of returning to the workforce or got rejected employment.
The rate of unemployment among people with mental illness is twice
as high as those who donâ&#x20AC;&#x2122;t.
2.2 Why Focus on Stigma of Mental Illness? From the earlier section, we understand the criticality of mental illness by the number of affected people and the issues caused by mental illness. Instead of just a health concern, mental health is also a social challenge. Usually, in developed countries like Singapore, people delay or do not seek treatment because of two main reasons: lack of awareness & knowledge towards identifying a mental illness and the stigma of mental illness. Over the years, the government and various parties have been putting a lot more effort to educate the public about mental illness, on the causes, symptoms, how to reach for help etc. and to provide a more extensive network of care and support for those who want to get well. However, many are still not willing to seek treatment because of stigma. Fear of judgement, discrimination, loss of human rights, loss of employment etc. are pulling them away from seeking treatment. This in turn create a vicious cycle where people potentially develop physical health problems because of untreated mental illness, commit suicide, greater economic costs etc.
Chapter 2: Mental Illness - A Global Health Issue and Social Challenge
Mental illness is nothing to be ashamed of, but stigma and bias shame us all. - Bill Clinton
Stigma as several inter-related elements Cultural beliefs that link the label and the labeled person to negative stereotypes
Labeled people categorized that create a clear distinction between ‘us’ and ‘them’
Unequal access to social, economic and political power
About Stigma During the ancient Greek times, ‘stigma was the act of branding someone to illustrate their social undesirability and to humiliate and shame them’ (Open the Doors, 2005). Today, stigma has been defined as an overarching concept that consist of three elements: problems of knowledge, problem of behaviour and problem of attitudes (Thornicraft, 2007). This definition of stigma considers the environment in which people live and structural imbalances that are crucial to the process of stigmatising. (OAM & Morgan, 2013). It is a complex social process encompassing different parts interconnecting or mutually reinforcing one another that exclude people with mental illness. Generally, people with mental illness are seen as having less social value. The implications of stigmatization occur at different levels besides being treated unfairly by the general community. Stigma from certain health professionals can lead to biased treatment against people with mental illness. Working adults may either be denied
employment or be taken advantage during work. Under insurance, usually people with mental illness face more difficulty in getting protection and coverage for mental health related issues too. Stigma in Singapore There are a few common myths that lead to stigma towards mental illness and mentally ill people in Singapore. Stigma of mental illness led to fear amongst employers to employ people who have a past history of mental illness or people who are still recovering from it. They fear of loss in productivity or potential harm and inconveniences that these people may cause them during work. On the other hand, people recovering from mental illness fear to return to the workforce due to potential discrimination that may lead to unfair treatment. In terms of funding and emphasis for mental health coverage in Singapore, compared to other health coverage like coronary heart disease, obesity etc. is lesser although mental health is equally important as physical health.
Chapter 2: Mental Illness - A Global Health Issue and Social Challenge
Common Myths that led to Stigma in Singapore
1|
People with mental illness are violent and dangerous
3|
Mental conditions are caused by personal weakness
2|
People with mental conditions are poor and less intelligient
4|
People who are depressed can snap out of it of they tried hard enough
5|
Mental conditions cannot be treated
6|
People with mental conditions cannot lead meaningful lives
7|
People with mental conditions are hopeless, have nothing to look forward to
8|
Once a person develops a mental condition, he or she will always remain sick
9|
Mental illness is similar to mental retardation
10|
Mental illness only affect the weak and the old
Stigma-Reduction Strategies As mental illness is increasingly a crucial global health issue, many parts of the world do recognise the importance of addressing it and the stigma that is associated with it. There have been many strategies being implemented at various levels, hoping to educate the public and increase their awareness about the truth of mental illness to change their perceptions and attitudes towards it, in turn reducing stigmatization against mental illness and people who suffer from it. As recommended by the World Psychiatric Association, education, protest and contact are the three most effective ways that any strategies implemented against stigma need to consider. While there are many strategies, this thesis will only focus on those which involve a certain level of direct social contact between people with experiences of mental illness and the general public to understand how these strategies can be applied in the architectural design proposal at the end.
Nationwide Campaigns Usually initiated by the government or several mental healthcare agencies or organizations combined, nationwide campaign is often a collaborative effort between multiple stakeholders. It can involve healthcare authorities and professionals, private corporations, schools, non-for-profit organizations, journalists, mass media, and of course, the success depends on the support from people who has experience with mental illness, their family members and the general public. As there is a general understanding that eradicating stigma is a long term process that requires constant commitment and support from the different stakeholders, such nationwide campaigns are usually plan for a few years.
Chapter 2: Mental Illness - A Global Health Issue and Social Challenge
Contact-based education
Social Media
Here, educational programs specifically refer to those that directly involve people who has experienced mental illness, to reach out to other people to increase their awareness and change their perception towards mental illness. This can range to involving students in a group project that requires them to interview or talk to someone with mental illness, or inviting people who are open about their mental illness to give talks in schools, workplaces, radio broadcasts, and even at special events.
This is actually made possible by the new generation of youths who are becoming more and more open to discussions in general, even on the topic of mental health. Prevalence of social media and online platforms like blogs, allows youths to leverage on it and share their experiences with thousands and even millions of people around the world who watch or read it. Moreover, many of the bloggers, YouTubers etc. are actually quite well-received and by reaching out to their fans or other viewers, they help to spread a message to people out there who are afraid to seek help for their mental condition, to share with them what they should do or feel.
Nobody would probably understand better of the feeling of suffering from a mental illness and experiencing discrimination because of it than someone who has it. Having a first-hand understanding and interaction with someone that has experienced mental illness has been proven to effectively change a personâ&#x20AC;&#x2122;s mindset towards mental illness.
Chapter 3: Rethinking the decentralised community mental healthcare system
Chapter 3
Rethinking the Decentralised Community Mental Healthcare System
3.1 Current System of Community Mental Healthcare Like many countries, Singapore has moved away from a centralized institutional model of healthcare to a decentralized community-based mental healthcare system. Only the more critical cases will be referred to Singaporeâ&#x20AC;&#x2122;s Institute of Mental Health (IMH) for treatment, otherwise many can refer to the psychiatry department in any hospital in Singapore or community mental healthcare centres located within our HDB neighbourhood. There are also helplines and personalised home caregivers for people who face difficulties stepping out of the house. The list of services under community mental healthcare range from caregiver support service, community psychiatric service to day rehabilitation centre to home help service to psychiatric nursing home. In this section, we will be looking at the benefits of a decentralised system and using the Singapore Association of Mental Health (SAMH) as a case study to examine how programs and services are being organized.
Mental Institution (Centralized healthcare) are) re)
Chapter 3: Rethinking the decentralised community mental healthcare system
Network of community mental healthcare centres (Decentralized healthcare)
Increased severity
Who is responsible for care?
What is the focus?
What do they do?
Inpatient care, crisis teams
Risk to Life Severe SelfNeglect
Medication, combined treatments ECT
Mental health specialists, including crisis teams
Recurrent, atypical and those at significant risk
Medication, complex psychological interventions, combined treatments
Primary care team, primary mental health caregiver
Moderate or severe mental health problems
Medication, psychological interventions, social support
Primary care team, primary mental health caregiver
Mild mental health problems
GP, Practice nurse
Recognition
Watchful waiting, guided self-help, computerized CBT, exercise, brief psychological inteventions
Assessment
Figure xxx: Stepped care for mental health. This shows the amount of medical esources required for different severity of cases. A decentralised system will allow a more efficient distribution of resources and hence less strain on the institutionalised care.
Shift from Centralized Institutional Care to Decentralized Care Generally, in any forms of healthcare, Singapore has recognised the need to shift away from a centralized institutional healthcare model to a decentralized community-based healthcare model to be sustainable in the long term.
“We are too hospital centric, not optimally seamless in the healthcare ecosystem, and too focused on medicalised care” Professor Philips Choo Group Chief Executive Officer National Healthcare Group
Efficient use of resources With the society becoming more educated and financially stronger, “increased expectations on the service, costs and curative ability of medicine are placing more demands on the system. There is therefore an ardent need to rethink the public
healthcare, to transform our approach from illness care to wellness care - to ensure a more sustainable system for our future generations” (National Healthcare Group, 2014) Without a decentralised healthcare system, the demand for institutionalised care would be too much to handle. A decentralised system consists of networks of healthcare providers, either private or governmental, with branches located in different parts of Singapore that work together to distribute resources according different needs and severity of cases and provide a range of services that is often more accessible to people living in the different neighbourhood compared to an institution.
Having greater ownership of one’s health A more sustainable long term healthcare system is also one that views the recovery process and achieving good health as a holistic process that involves the support from the community e.g. family members, care providers, support groups, volunteers. There is a need to move away from
Chapter 3: Rethinking the decentralised community mental healthcare system
Legend District boundary Community-based mental healthcare service centres Central water catchment
Figure xxx: Distribution of community mental healthcare centres, operated either by government and private healthcare provider
transaction medicine where patients are told what to do. (National Healthcare Group, 2014) The new healthcare model should instead, empower patients to take a greater ownership of their health beyond taking medicine or receiving medical treatments. These includes adopting a healthier lifestyle, early detection through appropriate health screening, engagement with the community, learning new skills to keep oneâ&#x20AC;&#x2122;s mind active etc. However, this requires the collaboration of community partners to make this work, to develop a strong ecosystem of health, social and mental well-being. As mentioned, the decentralized healthcare system that we are looking at is an integrative one in which besides medical care, there are aftercare services, rehabilitative programs, vocational training, leisure and recreational programs, community engagement programs that are designed to ensure the well-being of the patients after clinical recovery.
It is also therefore the reason why this thesis is looking at the decentralized mental healthcare system in Singapore to understand how we can better improve the system through architecture to reduce stigma in the aspects of mental illness.
â&#x20AC;&#x153;Our healthcare model is based on a hospital-centric and reactionary model of care. This model will not be sustainable in the long term. We are going through a paradigm shift in the way we provide care from episodic care, to care that is holistic and proactive.â&#x20AC;? Associate Professor John Abisheganaden Head and Senior Consultant Department of Respiratory and Critical Care Medicine, Tan Tock Seng Hospital
Thesis Design Question 1:.What is lacking in the design of existing community mental healthcare centres in our HDB neighbourhood to reduce stigma?
Figure xxx: Some examples of community mental healthcare organizations as part of Singaporeâ&#x20AC;&#x2122;s decentralized integrated mental healthcare system.
Design of Existing Community Mental Healthcare Centres With the increasing focus on mental healthcare, we do see improvements in the provision of care and support for people with mental health issues that visits any community mental healthcare centre.
Wider variety of programs With the support from volunteers in the community and increased funding from government, organizations or philanthropists, a more holistic system of programs has already been developed to ensure a more complete and faster recovery of people with mental health issues. Vocational training, leisure and recreational programs, programs that promotes individual empowerment etc. are available in many of the centres now. Patient-centric services and programs We do recognise the need to shift away from a â&#x20AC;&#x2DC;one-size-fits allâ&#x20AC;&#x2122; approach in terms of mental healthcare as well, since different patients have different needs and severity of mental health issues. The wide range is also the cater to these
different patients to ensure a more sensitive care for them. However, to reduce stigma of mental illness, especially through the approach of increasing direct social contact between people with mental health issues and members of the community. There are certain points about the existing community mental healthcare centres that we need to rethink such as the enclosed compound and little community-centric programs.
Enclosed compound Currently, most of the community mental healthcare centres are located either in the HDB void deck or within commercial buildings like shopping centres. Like most childcare centres, elderly homes etc., these centres usually occupy a vacant space available and set up their services and conduct programs within their stipulated compound. While we understand there is a need for privacy and segregation for certain patients,
Chapter 3: Rethinking the decentralised community mental healthcare system
some parts of the center can be open up for some of the programs e.g. leisure, vocation can be integrated with the existing functions in the neighbourhood.
Less community-centric Some of the programs do encourage patients to interact with family members, volunteers, students etc. but perhaps we can to rethink about how these programs can also be community-centric to encourage members of the community to show their support for the programs and promote community engagement. As mentioned in the earlier section, direct social contact, otherwise interaction, between people with mental illness and members of the community not just help the mentally ill to re-integrate slowly back to the community, but it is also one of the most effective ways to change the publicâ&#x20AC;&#x2122;s attitudes and behaviour and hence, break down stigma of mental illness. This will set of a positive
set of changes which include encouraging people to set forward and seek help or treatment instead of delaying. We will first look at an example of a local community mental healthcare provider, Singapore Association of Mental Health to examine what can be learnt.
Case Study: SAMH About SAMH The Singapore Association for Mental Health (SAMH) was established in 1968 as the first community mental health agency in Singapore with the aim of providing quality step-down care and rehabilitative services to persons with mental health conditions. It is a non-profit, voluntary welfare organisation seeking to promote mental health in the community and improve the rehabilitation and reintegration of persons with mental illness. (Singapore Association of Mental Health, 2015) SAMH currently operates on nine centres in Singapore with a comprehensive range of services. Services includes Counselling, Volunteer Programme, Caregiver Support, Peer Support, Community Mental Health Education, Mobile Mental Health Outreach Team and Bukit Gombak Group Homes Aftercare.
Chapter 3: Rethinking the decentralised community mental healthcare system
SAMH Bukit Gomak Group Homes (BGGH)
SAMH Insight Centre, Oasis Day Centre (ODC)
SAMH Activity Hub @ Pelangi Village
Mobile Support Team, Club 3R
SAMH YouthReach
SAMH Creative Hub
Legend District boundary
SAMH Creative Mindset
SAMH Headquarters, Club 3R
SAMH community mental healthcare service centres Central water catchment
Figure xxx: Distribution of SAMH centres in Singapore
Creative Hub/Creative Mindset
Insight Centre - Counselling services
Promotes psychological wellness and mental health recovery through expressive arts and creative therapy. Also provides education and training in mental health through art
Provides counselling services to people with mental health issues and their family members Insight Centre - Support services (Caregivers)
Club 3R A drop-in centre for persons recovering from mental illness. It provides platform for them to develop personal, social and vocational skills.
Runs support groups for people with mental health issues and their caregivers to equip them with necessary skills to better understand and cope with their loved onesâ&#x20AC;&#x2122; mental health conditions
Bukit Gombak Group Homes (BGGH)
Oasis Day Centre
Provides opportunities for individuals with stabilised mental health conditions to experience community integration. Also provides vocational and psychosocial rehabilitation services to its residents
Provides psychosocial rehabilitation and vocational training for persons with mental illness that encourages community integration. Activity hub @ Pelangi Village
YouthReach Specialises in integrating children and youths idenitified with emotional and/or psychological issues. Also offers psychosocial support and life skills training to children and youths and their families
Figure xxx: Main function of each SAMH centre
Conducts rehabilitative programmes to assist residents of Pelangi Village in their recovery and re-integration into the community. Servies include occupationa therapy, social work, vocational services, psychological services, art and music therapy.
Care & Support Engagement
Education
Personal well-being
Figure xxx: The range of programs and services by SAMH can be categorized as shown above.
Key Focus
Current SAMH Intitiatives
Service/Centre
Mental health awareness
Students from Hwa Chong Institution raises awareness through efforts ranging from merchandise, conducting street sales, mobilising volunteers, to video production
Community Mental Health Education
Students from Victoria JC organises an awareness event called - Shattering the Silence
Community Mental Health Education
Collaborations/Partnerships for mental health promotion - Love Action Project, New Union, CalliberLink
Community Mental Health Education
Peer specialists to conduct mental health training for grassroots volunteers and give talks and interviews to students
Community Mental Health Education
Clients are taught to recognise early signs of relapses and medication management as they gain further insight into their illness and enhance their coping skills/Family psychoeducation programme
YouthReach, Bukit Gombak Group Homes
Key Focus
Current SAMH Intitiatives
Service/Centre
Psychiatry care/treatment
Dual Diagnosis Programme - caters to people with a co-occurring (primary) psychiatric disability and a (secondary) intellectual/development disability
Oasis Day Centre, Insight Centre
Clinical services
Activity Hub @ Pelangi Village Activity Hub @ Pelangi Village
Education/ Training
Music therapy services
Psychiatry rehabilitation
Psychosocial and rehabilitative activities - encourage community integration Recovery-oriented rehabilitative environment coupled with individual care plans
Club 3R, Oasis Day Centre, Insight Centre Bukit Gombak Group Homes
Chapter 3: Rethinking the decentralised community mental healthcare system
Immediate Support
Helpline services, face-to-face sessions, email enquiries
Counselling
Reach out to people (70%) and their caregivers who are not linked to mental Mobile Support Team health services in the community and usually identified by the police, grassroots, Town Councils and HDB offices Aftercare services
Provide care and guidance for ex-residential clients who have moved out of BGGH into the community
BGGH Aftercare
Support clients with case management for their medical, financial, emotional, employment, accommodation and social reintegration needs. This allows the clients to live independently in the community.
BGGH Aftercare
Socio-recreational activities (annual get-together)
BGGH Aftercare
Key Focus
Current SAMH Intitiatives
Service/Centre
Personal relaxation
YouthReach Idol singing competition
YouthReach
Weekly sports activities e.g. basketball, annual bike hike, 1-day island hopping
YouthReach
Sponsored river cruise trip along Singapore River, Domes and Skyway at the Gardens by the Bay
YouthReach
Cooking for Beginnersâ&#x20AC;&#x2122; sessions
YouthReach
EQUAL (Equine Assisted Learning) sessions
YouthReach
Vocational training / social enterprise to prepare trainees for open employment
Oasis Day Centre, Insight Centre
Personal empowerment
Occupational therapy - Leisure programmes e.g. cookies dĂŠcor & baking session, Activity Hub @ Pelangi - Creative activities e.g. batik painting & hama beads, Village - Physical programmes e.g. sports competition, outreach exercise, - Vocational programmes e.g. pre-discharge survival skills training, - Community integration e.g. outings, baking session, flamenco dance Social work services Expressive arts & creative therapies
Activity Hub @ Pelangi Village YouthReach, Creative Hub, Creative Mindset
Key Focus
Current SAMH Intitiatives
Service/Centre
Interaction
Family Cooking Event between the staff from the Jardine Group and YouthReachers + family members
YouthReach
Bringing in volunteers to conduct activities for YouthReachers
YouthReach
People with lived experience of mental health conditions in outreach engagements
Community Mental Health Education
Mostly individuals involved in SAMH service programmes such as Oasis Day Centre, Club 3R, Bukit Gombak Group Homes, YouthReach, Creative Hub and Activity Hub
Volunteer Programme
Interact with SAMH clients as befrienders, teach-a-skill instructors or programme Volunteer Programme facilitators, while indirect service volunteers hep with ad hoc projects such as public forum duties and administrative support Volunteers from NIE, SOTA, SMU, Singapore Sailing Team, SP
Volunteer Programme
3.2 Potential of Architecture to Change a Negative Mindset In this section, using a series of predecents that illustrate how architecture may change a negative mindset, this thesis will start to look at what are the possible design guidelines that can be adopted to develop a new type of decentralized community mental healthcare system which will aid in changing peopleâ&#x20AC;&#x2122;s attitutdes and behaviour towards mental illness. The following precedents will be evaluated according to how well it integrates with or engages the community and how well the spatial strategies implemented help to change the negative mindset of the community towards a stigmatized social issue. By studying the precedents, this thesis answers the sub-question: How can spaces be designed to change a personâ&#x20AC;&#x2122;s negative mindset towards a social issue?
Chapter 3: Rethinking the decentralised community mental healthcare system
Thesis design question 2: How can spaces be designed to change a personâ&#x20AC;&#x2122;s negative mindset towards a social issue?
The series of precedents wil be studied in the following way: 1. Purpose of study 2. Background 3. Problems/Motivations 4. Concept and process - how does it deal with stigma 5. Result - what is the effectiveness 6. Lessons learnt - what design guidelines can we adopt?
Precedent 1 - Turning a Mental Institution into a neighbourhood Centre for Addiction and Mental Health Redevelopment Project Type: Institution, neighbourhood Location: Ontario, Canada Site: 1001 Queen Street West, Toronto Size: ~ 109 000 m2 Year of development: 2005 â&#x20AC;&#x201C; present Purpose of study The focus in studying this case study is not on the design/architecture of the new CAMH healthcare facilities but on the urban design of the entire Queen Street West site about how new streets, landscape and new programs are introduced to integrate CAMH healthcare facilities and the surrounding neighbourhood to change the prevailing stigma against the site and mental illness. Figure xxx: Rendered perspective of the new CAMH compound which is redesigned into a neighbourhood like environment
Chapter 3: Rethinking the decentralised community mental healthcare system
Background The Centre for Addiction and Mental Health (CAMH) is Canada’s largest mental health and addiction teaching hospital as well as one of the world’s leading research centers in the area of mental health and addiction. CAMH combines clinical care, research, education, policy development and health promotion to help transform the lives of people affected by these illnesses. (camh: Centre for Addiction and Mental Health, 2012) The main purpose of the multi-phase CAMH Redevelopment Project is to replace the stigmatized traditional mental health institution at the Queen Street West site with a vibrant and mentally- healing neighbourhood that comes with non-CAMH facilities like leisure retail, recreation, commerce, housing etc. alongside with CAMH new facilities. This is to promote a ‘normalized’, inclusive and comfortable living environment that not only promotes recovery among CAMH patients to be more empowered and also change attitudes among the general populace.
Figure xxx: Previous development of Queen Street site still results in stigma against the site and mental illness.
Previous development which separates it from the rest of the neighbourhood The first redevelopment in the early 1970s showed a movement from a massive centralized institution to a mental health campus model which consist of ‘multiple scattered, detached treatment units’. However, the redevelopment model only seemed to focus on improving overcrowding and reducing the need for confinement and surveillance instead of better treatment approach and recovery environment for the patients . The building remained isolated from the surrounding neighbourhood, with movement being constrained within the compound . Since the approach to treatment was still the same hence the redevelopment model became obsolete after 25 years. (Horowitz, 2015). It was until the formation of CAMH in 1998 and the proposed ‘Vision and Master Plan’ in 2001 to redevelopment the Queen Street West site again that created hope in an effective new model for mental health.
Figure xxx: Rendered perspective of new CAMH Block F
Problems
Stigma attached to Queen Street West site The 27-acre site has been a space for treating mental illness for over 150 years. (camh: Centre for Addiction and Mental Health, 2012) The first construction of a mental institution on Queen Street West was in the 1850s and it was named the Provincial Lunatic Asylum. Over the years, there had been multiple physical transformations of the site but the changes were all centered around the need to maintain order and a firm social structure to help people with abnormal behavior to recover and hence, the site had rigid lines and angles as well as walls around it to divide the patients from the general population.
Figure xxx: Previous development of Queen Street site showed its segregation from the rest of community
Concept and Process
From an institution to a neighbourhood The concept of the redevelopment project is creating an urban village where non-CAMH development like housing, commerce (cafes, restaurants, offices, galleries, libraries, retail shops etc.), recreation (parks, shared community facilities) are being introduced in the redevelopment masterplan to integrate both CAMH facilities and neighbouring existing amenities to create a comfortable, yet safe and welcoming street life where “the stigma of institution can disappear into the rhythm of normal daily activities associated with city living”. (Horowitz, 2015) The inclusion of non-CAMH development is also essential to promote patients’ employment which empower them as contributors to the community like any other healthy human being in Toronto. The new CAMH hopes to foster inclusion and desegregation, appreciating the many ways our social and physical environment may influence mental health, in turn lifting the stigma of mental illness and support the patients’ growth.
Public street Public streets create the main connections between CAMH and non-CAMH buildings. A public transit bus route will also come through the centre of the site. This provided an active setting for patients, staff, visitors and the general public to use the site. Many patients are also free to leave their units during the day to visit the non-CAMH amenities in this new neighbourhood instead of being confined to a large institutional complex.
CAMH Development Rather than a single address for the entire site, each CAMH building has its own street address. Nonetheless, despite the presence of many other functions within the site, there are quiet, landscaped outdoor courtyards at the upper levels of the CAMH buildings to provide a secure and protected environment for the patients. Non-CAMH Development Non-CAMH buildings are distributed through the site of the ten blocks. Appropriate studies of the activities and land use in the surrounding areas has been done to determine the suitable usage for each of these spaces for effective planning of a vibrant neighbourhood. There is a high degree of art galleries, leisure retail and food-related services along the Queen Street West road. In addition, the region which the site is located in, known as the West Queen West neighbourhood, has been known for its vibrant arts and cultural scene since the 1900s . On the other hand, the south side of the site has very few amenities for people in the community to gather. The understanding of these helps the planners to determine the location and scale of the different uses e.g. galleries, cafes, retail, offices and housing. Below shows the table of suggestions of non-CAMH development in each of the blocks as suggested by CAMH.
Brookfield Street Givins Street
1001 Queen Street West
Bus stop
- Enclosed hospital compound where movement is restricted within. - Single address for the entire site
- Plot of land is being sliced up to connect with the surrounding existing street
Ossington Avenue
New Street
- New streets form and each of the new buildings has its own unique address - Well-connected to surrounding streets - Public bus route through the centre of the site that makes the place even more accessible by anyone
- Enclosed hospital compound where movement is restricted within. - Single address for the entire site
Figure xxx: Interior view of The Living Museum which is designed as an art studio
Chapter 3: Rethinking the decentralised community mental healthcare system
Queen Street West
A B C D I H E
G F
Legend Non- CAMH development
Grocery, specialty food, convenience, health and personal care
Cafes, restaurants, bar
Clothing, accessories, leisure retail
0
Residence Art gallery
50
100
Automotive
Results
Lesson Learnt
At the most surface level, people would at least find it easier to transit across the site like any other parts of the neighbourhood. and be able to use the green spaces like any public space. Willing people from the community are also visiting some of the cafes, galleries or retail stores in this new CAMH neighbourhood compound. As some of the staffs in these stores are actually recovering CAMH patients, patrons are able to interact with them as they purchase things.
Neighbourhood-liness To create platforms for people to interact with, the space has to relate to the people, something that makes them feel familiar, comfortable and useful.
No longer will the Queen Street West site be seen as a cordoned off building that housed â&#x20AC;&#x2DC;crazy peopleâ&#x20AC;&#x2122;, but an extended inclusive neighbourhood that not only provides a platform for patients to reintegrate back into the community, but also enable anyone to use the public spaces and create opportunities for direct social contact. Through social contact and the environment in the long run, this will slowly change peopleâ&#x20AC;&#x2122;s perception towards Queen Street West and mental illness.
Program diversity A diversity of programs cater to a larger population of people willing to visit the extended neighbourhood and use the space. Green common spaces Green spaces has a close link to our mental wellness. Building frontage Relatable and attractive building frontage e.g. cafes, retails is more likely to pull people in Connectivity & Accessibility This allows people to transit to and from the area easily. Ease of mobility makes a space more welcoming.
200m
Precedent 2 - A Second Identity, A Different Perspective The Living Museum Type: Museum, art studio Location: New York City, United States Site: Creedmoor Psychiatric Center, Queens Size: ~ 3,700 m2 Year of development: 1983 Area of issue: Mental illness Purpose of study The focus here is how a different entity of space can be introduced within a mental healthcare facility - Creedmoor Psychiatric Center, to provide a non-clinical safe haven for people with chronic mental illness to reside and to also give them a platform to keep them occupied and explore their potential talents. This gives them a new identity of perhaps an artist or a poet rather than just a mentally ill patient. People who visit the museum may view their works and even purchase them. Recognising the potential and capability of these patients changes their perception towards them.
Figure xxx: Interior view of The Living Museum which is designed as an art studio
Chapter 3: Rethinking the decentralised community mental healthcare system
Background The Living Museum at Building 75 of Creedmoor Psychiatric Center was originally an art studio, which was converted from a cafeteria in 1983 by psychologist Dr Janos Marton and artist Bolek Greczynski. The main purpose was just to provide a space and resources for those suffering from mental illness to create art, to turn their disabilities into a creative advantage. Today, the space is covered with the work of over 500 then and current artists-in- residence - all of them patients with mental illness. (Zaringhalam, 2014) The idea is also to create a safe haven for mentally ill patients to reside and spend time of something meaningful if they cannot handle the fear in the outside world.
“Use your vulnerabilities as a weapon” Bolek Greczynski on the main reason why the arts studio was created for people who suffer from mental illness. This phrase “remains the museum’s guiding mantra almost twenty years later.” (Zaringhalam, 2014)
only keeps them occupied, but even empowers them. “Once you are caught by the bug and the idea that you are an artist, the only thing you want to do is create create create. It’s so satisfying and so essential to your life.”
Figure xxx: John Tursi, a patient at Creedmoor Psychiatric Center, working on a wire coat hanger sculpture at the Living Museum
Trauma evokes creativity and motivation “Another aspect that makes creativity important is the issue of trauma, of PTSD. When you are hurt, when you are under attack, when you are an outsider – that motivates people. People with mental illness certainly qualify; they experience a lot of hardship and discrimination and rejection and that requires from them a song.”
Figure xxx: Some works by the mentally ill patients
Motivations The main motivation is not to attempt to change people’s stigmatization towards mental illness. but to make one thinks of himself as a mentally ill artist, which is much more comfortable than that of a mentally ill patient. This second positive identity induces greater healing for the patients. However, why art but not something else? Some reasons are as follows:
Art keep patients occupied in a meaningful way Patients in the Creedmoor Psychiatric Center often have a lot of time on their hands. Providing them with a proper space and something to create not
Figure xxx: Compilation of different works of the patients at the Living Museum.
Concept and Process
toward people with chronic mental illness (CMI).
Before deciding that it was going to be an art studio, Dr Janos Marton just wanted to pick out the advantages of an asylum and revitalize it. This includes providing protection and recognition for the patients within the compound. In addition, unlike art therapy community where works are kept confidential for the purpose of treatment, here at the Living Museum, patients are allowed to publish their works under their own name and even meet visitors to talk about their works.
Students who visited the Living Museum, as compared with those who did not visit, have more positive attitudes toward people with CMI. Among the students who visited, however, those who reported having spoken individually with a patientartist (N=44), paradoxically, indicated less-positive feelings toward people with CMI. (Cutler, Harding, Hutner, Cortland, & Graham, 2012)
Results
Giving new positive identities to patients suffering from mental illness to allow them to leverage on their potential talents to create or perform. On one hand, it empowers the individual hence promoting their recovery. On the other hand, members of the community who are exposed to their works and creations will not just be amazed by the capabilities of these people with mental health issues, but may also be motivated to interact with them to understand more. This can effectively change their negative perception and behaviour towards mental illness in the long run.
Although this project is not intended to reduce stigma of mental illness, its nature induce such an outcome. While the patients adopt a second identity, people from the community who visit the museum develops a different perspective of looking at these patients. Their impressive works draw the people’s perception of these patients as ‘crazy and scary’. Instead their creative works encourage them to even approach the patient artists to discuss about their works.
“Instead, I became eager to chat with the museum’s artists about their work. Their psychiatric state was immediately irrelevant to me, except in the sense that, for many of them, their symptoms were a prime source of creative inspiration. Indeed, that very shift in perspective - that reidentification from mentally ill to chronically creative—lies at the heart of an arts asylum like The Living Museum”
Lessons learnt
However, as seen from the result after the group of medical students visited the Living Museum, some “indicated less-positive feelings”, this could be due to the content of certain works being uncomfortable to visitors. (Leonard, n.d.). Either way, people could become more fearful of those suffering from chronic mental illness, or some could find it easier to understand the inner struggles of these patients more through these works. There is always two sides to an issue, but proper education and awareness programs about mental illness to the public can complement to such an approach as of the Living Museum and reduce the possible negative connotations.
Maryam Zaringhalam, a visitor to the Living Museum, on how his experience and change in perception after the visit.
A study was also conducted on a group of medical students that require them to visit the Living Museum, to examine if it can reduce their stigmatization of people with chronic mental illness. During the visit, students interacted with artists and discussed about the experiences creating art. Students completed a self-assessment survey developed to measure attitudes and feelings
Figure xxx: Some works maybe disturbing to some. As such education beforehand is required to minimize such attitudes
Chapter 3: Rethinking the decentralised community mental healthcare system
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Precedent 3 - Giving Ownership to the Disadvantaged The Star Apartments Type: Social housing Location: Los Angeles United States Site: Maple Avenue and 6th street, Skid Row Size: ~ 8825 m2 Year of development: 2013 Purpose of study There is a prevalent stigma of social housing in many Western countries, including United States. Though the main aim of this project is not to reduce stigma but more to provide a multi-use shelter for the chronic homeless population in Los Angeles, its integrative affordable housing with the urban fabric within one building is doing its part in changing people’s perception towards social housing. Street-facing public uses and common spaces open to everyone within the housing compound is a strategy to “integrate people who have been pushed to the edge of the society back to the working gears of the city” (Ferro, 2014)
Figure xxx: Interior view of The Living Museum which is designed as an art studio
Chapter 3: Rethinking the decentralised community mental healthcare system
Background
Concept and Process
The Star Apartments is a project by Michael Maltzan Architecture and non-profit organization Skid Row Housing Trust (SRHT). SRHT recognizes the disadvantaged and often discriminated people in the population and one of their goals is “to break down stigma and NIMBY-ism” (Amelar, 2015). Star Apartments is the third project collaboration between the two parties to design affordable housing for the chronically sick and mentally ill homeless people. The main purpose of the architect, Michael Maltzan, in this project was to provide homeless people and other groups of disadvantaged people an affordable housing with supportive services that helps them to integrate with the society as much as possible. The reason for an iconic building is to “give residents a sense of pride in their home” (Kim, 2014)
Integration with surrounding community The need to introduce supportive services is because Maltzan believed that just providing beautiful proper housing for the homeless is not the complete solution to help them in their daily lives and integrate with the community. There is a need to create a mixed-use building that would include retail component that is open to the public so the first floor is mainly retail shops, offices for counselling and a medical clinic which serves residents and surrounding communities. Communal spaces for social interaction As one proceeds upwards, the focus is on the residents’ needs for healthcare and supportive social services, plus the 102 apartments. Lastly, there is an open air-deck on the second floor with community garden, running track, a basketball court, an exercise room, art room, library, classrooms and a community kitchen to foster interaction between the residents. The community kitchen also comes with a dining room to provide space for people to learn cooking and some of the vegetables and fruits can be obtain from the community garden.
Figure xxx: Open-air deck that offers the different communal spaces, including indoor rooms for art, dining and exercise. Figure xxx: Rendering of Star Apartments showing the integration with the streets of the surrounding community.
Problems Skid Row has a century worth of history for being a place where Los Angeles’s community of homeless and transient people, as well as a place where hospitals abandon poor and mentally ill patients are (Ferro, 2014). These groups of people are often discriminated by the society and some even feel that these people should isolated on the outskirts of town. (Ferro, 2014)
Iconic structure As mentioned earlier, the reason for an iconic building is to create a sense of pride amongst the residents. Living in an equal and even ‘better’ housing than surrounding context blends with the more affluent neighbourhood which encourages permanence for the residents. (Kilston, 2014)
Results
“Having a beautiful view and a great space to live in helps the residents feel great, and it’s great for the people who work here. Design is very underappreciated at times, especially with marginalized communities. It shows people care.” Joey Aguilar, Manager of Resident Services, on the reason why design is important for social housing.
“Normally public housing is all indoors. Here it’s all outdoors. We have beautiful walkways, and the terraces. It’s amazing.” Bill Fisher, Resident, on the reason why some residents in the Star Apartments love the space.
Lessons Learnt
Levelling status through quality of spaces To reduce stigma, one solution is to try to level one’s status with that of the people in the community.
“How can the homeless be viewed as equal if their housing is not?” Theresa Hwang, SRHT community architect, on the reason why the need to provide good quality housing for the homeless.
When the marginalized people own something or are recognized with more equal status from the rest of the society, other people are less likely to discriminate them.
Presence of street-related and community spaces In terms of spaces, street-related programs and community spaces should be provided. Streetrelated programs enable the building and hence the residents to bridge with the other buildings and street-life. Community spaces keep the residents engage and be involve in doing something more purposeful.
Exploded Axonometric
Chapter 3: Rethinking the decentralised community mental healthcare system
5 4
3
1 2 6
1 2 3 4 5 6
Patio Exercise Dining/Kitchen Library Art Garden
Podium level
Open corridor
Modular apartments
Community programs Street retail, health clinic, offices, parking
North-south section
Chapter 4
Design Principles for Differing Needs
3.3 Design principles for different levels of engagement Like many other demographics, people with mental health issues is not a homogenous group, which their conditions, their needs, their recovery rates are not the same. Someone who is extremely ill and struggling to perform the normal day duties has very different needs from one who is recovering or from one who almost seems perfectly normal apart from times of relapse. Some need more personal time with themselves, with the healthcare professionals, while some are at the stage which need more acceptance and inclusion by their friends, family and the community. This section seeks to identify a few key needs of people with mental health issues that are already seeking help with mental healthcare centres. This is essential in determining what kind of quality of spaces is necessary for their recovery, for different levels of engagement.
Social inclusion and contribution (community, work, friends, family) Focusing on strengths and wellness rather than weaknesses, problems and illness
Doing whatâ&#x20AC;&#x2122;s important to you
Striving to reach your potential
Empowerment
Recovering your life rather than recovering from symptoms
Identifying and maintaining what keeps you well
Hope and optimism about the future
What is recovery?
An ongoing personal and unique journey
Self-care and self-help
Making choices
Gaining an understanding and a sense of control over your life and illness
Defining or redefining a sense of identity which includes by is not defined by mental illness
Achieving your goals, hope and dreams
Social and Emotional-based Design Principles Individual healing -For patients who are at the early stage of treatment and not yet ready to engage with the community, this is the area which provides a therapeutic environment for clinical rehab, counselling, therapies Empower independence Strongly encouraging individuals to perform tasks without help, build their confidence levels Self-upgrading (learning, physical fitness) Picking up of skills, awareness of how to cope in the future, improving physical fitness Realising dreams and expanding potential Identifying dreams and giving them a training ground and opportunities to adopt a second identity â&#x20AC;&#x201C; poets, artists, barista, baker, cook (culinary), musician, performer, hand-crafter. And then mastery through employment. Active engagement with community Sharing knowledge and experience, exercising together, having conversations, working together Contribution to community Manage the public spaces, knowledge sharing, working and volunteering
Physical Design principles Increasing emphasis on personal freedom Crowding, noise, poor indoor air quality and light Being outside can promote mental well-being, relieve stress, overcome isolation, improve social cohesion and alleviate physical problems Patients with conditions such as neurosis and eating disorders may benefit from group treatment with larger shared rooms to foster a sense of group responsibility Co-location is a trend in primary health care delivery that combines leisure, retail, and residential multuse buildings in order to maximise efficiencies of services Light â&#x20AC;&#x201C; bright light (artificial or natural) can improve health outcomes such as depression, agitation, sleep, circadian rest-activity rhythms, and length of stay in dementia and bipolar seasonal affective disorder (SAD) patients. Further to this, studies show that exposure to morning light is more effective than exposure to evening light in reducing depression Elimination of environmental stressors -Noise, glare and air quality -Wayfinding - a critical element in the elimination of stress Safety -Anti-ligature, anti-slip surfaces, universal access, ergonomics and adherence to all the relevant standards in building construction Security -Good security design allows the freedom of movement for patients within the limits of their condition -Design must also consider the protection of staff, other patients, visitors and members of the public. Observation -Innovative ways to increase the potential for staff to check on patients can be seen in a number of new facilities -Providing secure courtyards -Wide corridors with regular gathering spaces enable a low key approach to observation and single loaded corridors with uninterrupted views to external spaces also allow staff to continue with their work while keeping an eye on activities
throughout the facility Avoidance of visual disturbance -Ample space and minimal clutter â&#x20AC;&#x201C; through colour, light, furniture and art -A calm environment free of technological distractions allows patients time and space to reflect -Art depicting nature contributes to a calming atmosphere Colour -Blue, brighter colours less arousing -Colour can be used as a wayfinding strategy Group Interaction -Single rooms better than multi-bed rooms -Providing lounges with comfortable furniture arranged in small flexible groupings -Access to outdoor spaces that are large enough for different social and cultural groups to inhabit Access to nature -Patients and family who use hospital garden report positive mood change and reduced stress
Chapter 5
Site Selection and Study
PEI CHUN BOON TECK
TOA PAYOH CENTRAL
TOA PAYOH CENTRAL
BOON TECK
PEI CHUN
Density: 27,808 ppl/km2 Heart of Toa Payoh region Vibrant HDB neighbourhood
Density: 36,105 ppl/km2 Mainly residential Old school HDB neighbourhood
Density: 28, 613 ppl/km2 Residential+schools+industrial Typical quiet neighbourhood
Wide range of facilities e.g. - Public library - Community centre - Hawker centres - Supermarkets - Sports complex - Toa Payoh Town Park - Shopping streets - HDB office building - Church - Bus interchange+MRT station
Mid range of facilities e.g. - Sensory Park - Hawker centres - Wet market - Temple - Community centre - Medicare centre - SAMH Club 3R - Care counselling centre - Wide range of houseware related shops at the void decks
Mid range of facilities e.g. - Community centre - Polyclinic - School - Hawker centre - Wet market - Temple - Neighbourhood park
Neighbourhood park Boon Teck - 36,105 Ppl/km2
Sensory park
Pei Chun - 28,613 Ppl/km2
Toa Payoh Town Park + Stadium
Toa Payoh Central - 27,808 Ppl/km2
Golf course Safra Clubhouse
| FITNESS/GREEN SPACES
Hawker centre Jackson Square
Shophouse shopping street Toa Payoh Hub
| MARKET/RETAIL/FOOD CENTRE
Bishan Toa Payoh Town Council Community Centres (CCs)
Toa Payoh Branch Transport Hub, HDB Gallery Chung Hwa Medical Institution Toa Payoh Public Library
| HUBs/CCs/Library
Chapter 6
Design Framework & Development
6.1 Thesis Concept This chapter explains the framework and the reasoning behind the proposed interventions. By providing the framework, this thesis seeks to answer the next sub-question: which physical interventions within the existing urban fabric of the HDB neighbourhood can improve the individual outcomes of the recovering mentally ill patients in Club 3R @ Toa Payoh and provide platforms for social engagement between them and members of the community? The research and studies as well as the analysis of the area played a key role in the formation of the framework and the scope of intervention. The key findings are briefly summarized below.
BOON TECK
Thesis design question 4: which physical interventions within the existing urban fabric of the HDB neighbourhood can improve the individual outcomes of the recovering mentally ill patients in Club 3R @ Toa Payoh and provide platforms for social engagement between them and members of the community?
Recap of Research and Analysis In summary, impeded recovery of mentally ill patients caused by stigmatization against mental illness can be greatly improved by focusing on creating direct social contact between these recovering patients and members of the community. Research has shown that when the public have some form of positive social engagement with these recovering patients, they are more likely to change their perception and behaviour towards them compared to educationbased strategies. This would allow the recovering patients to be able to better re-integrate back to the community, which in turn, constitute a faster recovery for them. The Singapore Association of Mental Health, one of the mental health welfare organizations in Singapore, is chosen as a case study to examine the range and types of programmes and services in the current community mental healthcare centres, as well as to examine how and why they are created for the patients. At the same time,
this thesis identifies the general problem that all the centres are relatively closed up from the surrounding environment despite the fact that certain activities and programmes do not require segregation or privacy. Thereafter, three precedents were selected to study how spaces can be created or designed to reduce stigma towards a social issue. The first precedent, CAMH redevelopment project, illustrates that converting a mental institution into an extended neighbourhood that complements the surrounding and creating employment opportunities for the patients in non-CAMH facilities like cafes and retail, help to reduce stigmatization against them and the site itself. The Living Museum shows how giving a second identity to mentally ill patients as artists, poets etc and letting the public be aware of their new identity and capabilities helps to change their perception towards them and even spark off conversations with them. The third and the last precedent, the Star Apartments, shows at
how giving homeless and disadvantaged people the ownership of a proper housing block which consists of large communal spaces within the building and common amenities like clinic and retail which are open to the public can change publicâ&#x20AC;&#x2122;s perception towards them. Thereafter, this thesis understands that different people with mental health issues have different needs and hence has identified five socialbased design principles to create possibilities of integration. They are Empower independence, Self-upgrading (learning, physical fitness), Realising dreams and expanding potential, Active engagement with community, Contribution to community. In addition, to create conducive environment for the recovering patients, this thesis has also identified physical design guidelines like lighting and elimination of environment stressors. Basically, the physical interventions should be guided by these principles and guidelines in finding ways for integration and proper execution,
in turn achieving effective direct social contact. For the site at Toa Payoh in particular, one of the key findings from the analysis is that there is already a relatively rich neighbourhood right where the centre, Club 3R, is located. There are amenities like hawker centre, sensory park, provisional shops, clinics. The neighbourhood itself is also near the heart of Toa Payoh where the interchange and shopping street are. However, of course, the centre is very disconnected from its surroundings. In addition, there are no continuous connections to the heart of Toa Payoh, which limits the vibrancy of the neighbourhood to mainly the residents of the area. Most of the public spaces are also not sheltered which makes them uncomfortable for anyone to stay in the open for long. As the area is an old neighbourhood, many of the shops attract more of the older people or people who visit them out of daily necessity.
Design Concept This thesis looks at how direct social contact can be achieved by looking at the integration of certain activities, programmes and trainings in the current community mental healthcare centres with that of the community in the neighbourhood. It explores how a public space can serve as an interface for engagement between members of the community and patients recovering from mental health issues. As mentioned earlier, current mental healthcare system has already shifted from a centralised institution to a network of decentralised centres located within the HDB neighbourhood. Basically, this thesis finds the need to redefine a typical centre such that it is more integrative with urban fabric of the neighbourhood to better allow recovering patients to return to the community as well as enhancing the neighbourhood to provide a more supportive environment. This is done by further ‘diffusing’ the centre into a finer network of small sub-centres. Figure 6.12: Recall proposed site extent (Own illustration) 1
1
Current
2
Proposal
2
Cafe
Music therapy room
Bakery
Lounge room
Art studio/gallery
Extended hawker area
Workstation
Extended provision shop
Figure 6.11: The proposal of this thesis is to ‘diffuse’ the current mental healthcare centres into small sub-centres connected into a finer network. (Own illustration)
To establish this new idea of mental healthcare centre i.e. a network of small spaces within the neighbourhood, there is a need to determine what exactly are the small spaces that form the network by relooking at the activities and programmes of current mental healthcare centres as well as key existing amenities in the neighbourhood that we can tap on. For example, it can include new provisional shops and cafes that hire patients to provide a platform for them for their vocational trainings; a communal kitchen for baking sessions and events; a mini IT centre for learning skills like computer; mini studios/workstations for creating arts and crafts as well as a gallery space for displaying them etc. These are some examples to illustrate how the new idea of community mental healthcare centre will appear.
Figure 6.1c: Images of of types of small spaces
Afterwards, identify public spaces that can be used to introduce new spaces and how the selected amenities can be improve or extended such that they accustom to the needs of the patients. This is important because these are the areas that most of the residents will frequent and acting on them will ensure a more positive outcome that the thesis aims for, which is encouraging direct social contact. Lastly, to establish a movement flow from space to space within this network which will further increase the opportunities of social engagement, the framework creates a direct and enjoyable connection between these new spaces which will stimulate people to move from space to space. The connection is established in two steps. Firstly, at least every two spaces will be visually connected. Secondly, a dedicated pathway will be created to not only guide people, especially the patients, from space to space but to provide smoother accessibility in areas where there are barriers or poor connection e.g. carpark spaces. Besides the effects on the larger scale that focus on creating this new â&#x20AC;&#x2DC;centreâ&#x20AC;&#x2122;, there are also positive effects on a smaller scale. As new spaces will be created and some existing amenities will be improved/regenerated, the willingness of residents or even other people to use the public spaces will increase. Moreover, routing these small spaces together makes accessibility even easier, which will make the neighbourhood more vibrant and possibly more physically active.
Figure 6.13: Identifying public spaces to be use for intervention
Figure 6.14: Visual and physical connection of public spaces
Legend for all maps Boundary
Coffeeshop
Location of SAMH Club 3R
Clinic
Bus stop
Wet market
Car park
Shelter
Existing HDB buildings
Provisional shop
Existing park
Retail
Existing hawker centers
Resting space
New infrastructure on existing public spaces
Bakery/Bread shop
Extension from current amenities/Way markers
Beauty shop
New connection Exisiting connection
Other specialised shops
B
A
1
C 2
D
E
3 F
4
Scale 1: 2500
Figure 6.15: Summary of existing services to determine characteristic of each intervention (Top) Figure 6.16: Characteristics/Guidelines of each sub-area (Right)* * Note that most of these areas will have a supervison area for staff to moniter the patientsâ&#x20AC;&#x2122; performance ** The original centre acts as the anchor point for more serious or private corner for healing and treatment
op ise e sh rc ll g y e n r n x io u te i sta op tr o -e s l o s a i y h l a y d e u E t r e o c te ov ks ap fe/ cr ke fo t/m iva bli or pr er iva Pr W Ar Re Ca Ba E. Th Pr Pu E. el
ns
Area
Description of surrounding
A
B
C
D
E
F
1
2
3
4
Relatively quiet; large open space; links to the park; pavilion to conduct small events or games Right next to a hawker centre which is usually crowded at night; faces the front of a HDB
Leads to the main entrance of the park; currently a badminton court with playground; quite hot; faces the back of a 4-level HDB Relatively quiet; links to the park; elevated ground in relation to area C; quite sheltered; faces the front and back of a HDB Relatively quiet; faces the carpark and main road, faces the front of a HDB, seats for resting
Relatively quiet; faces the main road, currently a residue space; next to a garbage collection point, next to area D and E
In between a small coffeeshop and a permanently closed hardware store; links to the park In between a coffeeshop and a market&hawker centre; back of HDB
In between a provisional shop and a vet clinic
In between a small coffeeshop and a salon, currently a sheltered area with a ramp link to 2nd floor of HDB, faces the traffic junction
u /co
ng
i ain
e
g un
dio
tu cs
Selection of main zones The design intent of this thesis here is to rethink the notion of network of community mental healthcare centre. While we understand that patients need extreme privacy while undergoing certain treatments and trainings, beyond that, they also need platforms to give them the opportunity to be more involved in community activities to allow the society to also see them beyond their disability as well, hence integrate back into the society. In addition, research and past campaigns held in other countries have shown that direct social contact with people with mental health issues is one of the most effective ways to combat stigma. Thus, this thesis seeks to rethink the design of community mental healthcare centres that do not only provide a sanctuary for them but also a platform that empowers them to take on tasks and explore their talents in a more integrative, less closed up environment in the neighbourhood. And most importantly, allowing the public to view them beyond their mental disability as people with a second identity through interacting with them and seeing their works. Hopefully, in the long run, this will change the perception of the public about mental illness and thus reducing stigma.
Individual healing
Realising dreams and expanding potential
Active engagement with the community
Understanding of this network is portrayed as a walk in which the public can take to experience the different settings and possibly interact with the patients on different ways. This is intended in order for the public to view this network as a more â&#x20AC;&#x2DC;normalised environmentâ&#x20AC;&#x2122; though majority of it is designed for people with mental health issues.
Drop-in
Counselling, assessment
Learn experiences from existing patients
Residents/Patients
Therapy, rehabilitation, counselling
Rebuild personal and professional identity
Public
Education, awareness
Passive contact with patients
Visitors
Education, awareness
Support for patients
Staff/Volunteers
Organizer
Caregiver
Engagement with community
Learning new skills, relaxation Active engagement with patients Active engagement with patients Constant engagement with patients
WITHIN semi-private to public spaces designed for mental health health patients
Counselling room Private garden Kitchen
Cafe/Eatery
Drop-in
Gallery Residents/Patients
Therapeutic room Information passage Public
Activity room Garden Spritual room Library
Visitors
Mini theatre Staff/Volunteers
Chapter 7
Final Design - The Walk
The Walk: Redefining the new network As mentioned earlier, currently, the network of centres provides rehabilitative programs, vocational training, recreational programs, community engagement programs etc, that are designed to ensure the well-being of the patients after clinical recovery. In this thesis, my intent is to relook at the current idea of ‘network’ to one that enhance and integrate some of these programs with public spaces. In summary, the social design principles for a new idea of network should include three main points: individual healing, realising dreams and expanding potential, and lastly, active engagement with the community. --> individual healing, empower independence, self-upgrading, realising dreams and expanding potential, active engagement with the community and contribution to the community. This new network would be one that consist of two or more zones within the HDB neighbourhood that are on close proximity from one another, each with different key functions and encourages a different level of interaction with the patients. The understanding of this network is portrayed as a walk in which the public can take to experience the different settings and possibly interact with the patients on different ways. As people transit from one zone to another, they are in turn, encouraged to walk through the existing neighbourhood. This is intended in order for the public to view this network as a more ‘normalised environment’ though majority of it is designed for people with mental health issues. The Therapeutic Sanctuary, Arts@63 and the Gastronomy which form the anchor points of the walk. After walking through the intersecting rich neighbourhood streets filled with a variety of shops and a big hawker centre, people will be encourage start from the Therapeutic Sanctuary to experience a more solemn yet peaceful environment where current patients and walk-in new patients will head here for mainly therapy, more private vocational training as well as for a retreat. Here, the level of interaction is relatively low due to the intended quiet setting. Afterwards, they can walk along the sidewalk the existing Toa Payoh Sensory Park which acts as an appropriate transitional space from the Therapeutic Sanctuary. Upon exiting the sidewalk, they will reach Arts@63, where things start to get less solemn and vibrant with the arts scene created by the patients within the zone. Here, people can get to appreciate
their works and start to view the patients beyond their mental disability. They can even interact with some of the patients performing in action. Thereafter, they will walk through the same park but through the route where the existing different sensory equipment are located. These equipment are re-adapted as educational booths to educate people about mental illness through various senses {this part unsure yet}. Located at the end of the park is the last zone, the Gastronomy where food becomes an element for dialogue and conversations to take place between the two parties. This place also serves as an extension to the existing hawker centre that is frequent by many people especially during peak hours. Here, the setting is almost public whereby ex-mental illness sufferers and recovering patients serve as staff and management body of the food spaces here, serving food and having open conversations with anyone while dining. Design Concept The new network of community mental healthcare sub-centres seek to exhibit the concept of vanishing boundaries from the core to the periphery. Within the ground floor of each zone, spaces are more structured at the core which surround a courtyard. The courtyard is intended to provide a soft touch to the hard structured spaces. In turn, the structured spaces serve as supports for flexible spaces around and above them to unfold and be configured. These flexible spaces almost seem like merging with the surrounding context, making it undistinguishable whether it is part of the neighbourhood or part of the zones. The horizontal planes and relatively porous volumes above, seek to imply the lightness and freedom of spaces there. As safety, access to green or nature and ample natural lighting are 3 most important design elements when designing for mental health context, they also have been taken into account in this thesis design proposal.
Site Plan
Scale 1:2000
Ground Floor Plan Scale 1:500
ARTS @ 63 Here, people can get to appreciate their works and start to view the patients beyond their mental disability. They can even interact with some of the patients performing in action.
GASTRONOMY Here, food becomes an element for dialogue and conversations to take place between the two parties. This place also serves as an extension to the existing hawker centre.
THERAPEUTIC SANCTUARY Here, presents a more solemn yet peaceful environment where current patients and walk-in new patients head here for mainly therapy, more vocational training as well as for a retreat.
Therapeutic Sanctuary
Arts@63
Gastronomy