Architecture for psychiatric treatment

Architecture for Psychiatric Treatment EPFL – École polytechnique féderale de Lausanne Énoncé théorique for the Master Thesis in Architecture, January 2011 Directeur pédagogique Professor Harry Gugger Professor Bruno Marchand Götz Menzel Students: Benjamin Schütz & Livia Wicki

Contents Introduction

7

Chapter 1 historic development of mental treatment

9

1.1 Middle Ages

11

1.2 From the Renaissance to the French revolution

13

1.3 The end of the 18th century – the moral treatment

16

1.4 The 19th century – construction of the asylum

17

1.5 The early 20th century – decline of the asylum

20

1.6 Deinstitutionalisation

20

1.7 Hospital-village in France – a short intermezzo

1.8 Intermediate structures

21 21

Chapter 2 Psychiatry Today 2.1 Mental disorder and society

25

2.3 The different treatment facilities

39

2.4 The patient

44

CHAPTER 3 Architecture and Psychiatry

47

3.1 Architecture and the image of psychiatry

48

3.2 Healing environments

50

3.3 Architecture for psychiatric treatment

52

3.4 Conclusion

55

Chapter 4 Case studies

57

4.2 Relation to society / Expression of building

67

4.3 Access

75

4.4 Spatial organisation

83

4.5 Window analysis

93

4.6 Outdoor spaces

99

4.7 Impressions of the interior spaces

106

4.8 Conclusion

110

Conclusion of research

112

CHapter 6

115

Annexe

115

Visual Material

118

Quotations in original language:

120

Thanks

124

If we take plants as an analogy, some which have been injured by the vagaries of the weather might well need a sheltered environment where humidity, temperature, and light are controlled in order to recover. If, however, they are retained within this environment for too long a period, they become ÂŤhothouse plantsÂť and will never be able to face the rigours of normal garden life.

Citation WHO-recommendation, psychiatric services and architecture, 1959

Introduction The present work looks at the Architecture for Psychiatric Treatment.

We are convinced that architecture has a great influence on people, and that people influence architecture as well. We are interested in the interaction between planned architecture, built space, and the people who actually use them.

This relationship is of great importance, especially in the field of psychiatry.

A mentally disturbed person perceives his environment differently than a so-called «healthy person». If the space that surrounds us can affect our perception, our sense of well being, and our mood, what is then the ideal environment for a mentally ill person?

In this work we would like to find out the specific needs that the mentally ill require from their architectural environment. In difficult times patients are particularly sensitive to their environment, which can contribute to their well-being. Might the architecture even have an influence on the healing process of the mentally ill? We consider it a worthy challenge to design a building that meets the needs of these people.

Additionally, we are interested in the relationship between mental illness and society. The handling of mentally ill people has changed considerably over time, which is also expressed in architecture. This will be discussed in chapter one. A strong stigmatisation against the mentally ill still exists. We want to find out whether architecture can contribute to the fight against prejudice and stigma.

Since we have no previous significant knowledge in the field of psychiatry, our first task is to clarify the basics and to get an overview of the topic. This includes, for example, the definition of what distinguishes an ill person from a healthy person and under which cicumstansces someone can become ill.

This theme is discussed in chapter two. The influence of architecture on the healing process and the current image of psychiatry will be discussed in chapter three. The case studies form the last part of our work, chapter four, where we compare four different psychiatric facilities.

Through this «énoncé théorique», we are opening up the large field of psychiatry, with the focus on architecture, and we will use this knowledge to develope a sound architectural design project in the next semester.

introduction

7

Chapter 1 historic development of mental treatment The History of psychiatry focuses on the handling of mental illness over the course of the ages. It aims to establish the scientific, social and medical point of view in this complex matter. The domain can be structured in three epochs. From antiquity to the end of the 18th century we can talk about history of madness. History of psychiatry in the strict sense begins with the Enlightenment in the 18th century, when efforts to systematically care for the mental ills began. Since the end of the 19th century psychiatry has become an academic science.

In this first chapter we outline the development and evolution of the architecture for mental illness. We will look at the ideologies and views that have motivated and justified the specific architectural form, but address the medical and scientific point of view just where it is necessary for the understanding of the development. This allows us to keep the historical overview brief and focus on the most important incidents.

Chapter 1: Historic Development

9

1.1 Middle Ages In the early middle ages psychological issues are seen within a theological and moral framework. Medieval society believes that individuals have free will and are responsible for their actions, but that illness (including mental illness) comes from sin and results in punishment from God or possession by the devil. In this line of argument mental illness is seen as either the result of sin or as a test of faith, and religious activity becomes a frequently used cure. Monasteries start to play an important role in the caretaking of poor people’s illnesses, but many mentally ill live nevertheless with their families and are treated at home.

The social position that lunatics occupy in medieval society is hard to identify. On one side there is a certain degree of understanding towards the suffering that mental illness brings, on the other hand a process of social regulation is gradually developed. Everybody that is abnormal is contained, marginalized and excluded.

A certain number of mentally unstable the dangerous ones, are locked up in prisons. This confinement is seen as necessary to be able to maintain the public order. There is a certain fear that the dangerous lunatics could harm the community, and that their madness could somehow spread. Prisons and other places of isolated confinement are the most common solutions that medieval society has to deal with aggressive, mentally unsound people.

Chapter 1: Historic Development

11

1 Urban implementation of the Ospedale degli innocenti in the city of Florence, 18th Century 2 The arcades function as an element of transition between public and private space

1.2 From the Renaissance to the French revolution The renaissance hospital is a place where different activities are combined: religious rites, assistance, care, trade and artistic work. Those many functions make the hospital a small city within the city.

The architects put in place a variety of different elements to visualise and reinforce the public character of those buildings. Arcades, loggias, pronaos, cloister, patios and courtyards, create transition zones between the streets, the squares and the hospital. In the case of the famous Ospedale degli innocenti built in 1429 by Brunelleschi, the arcades are not only elements of transition, but they also generate and regulate the urban space; the square of Santissima Annunziata. 1 When talking about those hospitals and their important role in the urban fabric of Florence, one could get the impression that the society of the Renaissance era took very good care of their weak members. But when reading Martin Luther’s precise description of the hospitals in Florence, it becomes clear that this kind of treatment and the social acceptance was limited to a very small number of people: «In Florence the hospitals are built like royal buildings: there is very good food and drinks for everyone, the servants are very diligent, the doctors very knowing, the linens and clothes are very clean and the beds are painted. Immediately upon arrival at the hospital the patient is undressed, and all his clothes are honestly, in the presence of a notary, put on deposit. The patient is dressed in a white blouse, and put in a nice painted bed with sheets of pure silk. Just afterwards two doctors are conducted and later the servants bring to eat and drink in proper glasses, that they do not touch because they are served on a tray. Then honest women, all veiled, serve during unknown days the poor and return home afterwards. I saw in Florence with how much care the hospitals are maintained!» 2

1 cf. Architecture et Psychiatrie, p. 18 2 Cited in C. Marcetti, Abitare la follia, taken from Architecture et Psychiatrie, p.17, see annexe for original Chapter 1: Historic Development

13

3 Urban implementation of the Narrenturm in the outer quarter of Vienna, around 1764

The lesser fortunate face another reality.

In the 16th century, through the increasing urbanisation and the accompanied depletion process, the number of unattended mentally ill grows. The straying mob is now composed of vagabonds, prostitutes, unemployed, criminals, idiots and epileptic.

The royal powers of the old Europe tried for more than two centuries in vain to reduce the number of vagabonds. In 1575 England ordered the construction of houses of correction. The Germans followed in 1620 with their Zuchthäuser, and in 1656, under Louis XIV’s regency, the first hôpital général was founded in Paris. Those General Hospitals never had any medical function, but they were a place of confinement and of forced work for the poor, the vagabonds and the mentally ill. «Despite the rough handling of insane in the middle Ages and the Renaissance, their belonging to human society was undisputed. But in the age of absolutism, madmen were banned from the streets and thus also banned from public consciousness», notes Blasius. 3 And Muriel Laharie points out, when writing about the «fool’s towers»: «Their location symbolises a no man’s land both geographically and socially. Placed between the civilized and the savaged world, on the boundary between the reassuring organization of the city and the insecurity of the surrounding forest.» 4 During the age of Enlightenment the mentally ill begin to be seen as sick human beings who are suffering from an illness and have the right to be treated, rather than beastly creatures. Critics on the living conditions in the houses of correction grow with the philanthropic movement, and the mentally ill are considered to be victims of this general confinement who ought to be separated from the criminals.

3 Cited in Blasius, 1989, p. 21, taken from Geschichte der Psychiatrie, p. 238, see annexe for original 4 Cited in Nouvelle histoire de la psychiatrie, p. 71, see annexe for original Chapter 1: Historic Development

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1.3 The end of the 18th century – the moral treatment Early reflections on the relationship between architecture and caretaking of the mentally ill dates back to the late 18th century: The surgeon J.R. Tenon proclaims in his circular of 1785 that «in contrary to the hospital buildings which are for the other sick only auxiliary means, the hospitals for the fools have themselves a function of cure […]. The fool should not be peevish during his treatment and during monitored moments he should be able to leave his loge, browse the gallery, go on a promenade and do an exercise that dissipates and that nature commands him.» 5 These kinds of reflections mark the emergence of the asylum, a place dedicated to treat the mentally ill and it is only logical that it is in this period, for the first time, that a «therapeutic value» is assigned to architecture. In the same way that social values will change over time, opinions on the therapeutic values will also change, but the discussion on that matter between architects and alienists, respectively psychiatrists, has to this day never fallen silent.

Philippe Pinel, famous for his legendary act of «releasing the madmen from their chains», argues similarly in his traité médico-philosophique sur l’aliénation mentale ou la manie in 1800. Pinel is the first to connect madness with the medical as well as the philosophical system. Although there is no doubt from today’s perspective that the release of the mentally ill was not a singular event but a long process in which different actors were involved, one can say that Pinel has been a major stimulus on the transformation of the whole asylum system, and that the origin of the «traitement moral» is to be found in that process.

The moral treatment recognises that madness is not a simple loss of mind, but a disorder of the mind. This implies that within each patient’s mind reason is to be found, and to be worked with: The «reasonable» part of the mind is to be used to cure and eliminate the «delirious» part.

The buildings for the mentally ill have thus evolved from simple prisons, with the only goal to shut away the dangerous, to asylums, dedicated exclusively to the mentally unstable and capable of providing some kind of therapy.

5 Cited from J.R. Tenon, cited in Nouvelle Histoire de la Psychiatrie, p.119, see annexe for original

1.4 The 19th century – construction of the asylum The creation of asylums is based on two assumptions: isolation, which establishes as a therapeutic procedure the removal of the patient from his environment, and the moral treatment, which gives the alienist the power to exercise his influence over the disturbed mind.

Since the first reflections on buildings specifically for the mentally ill, many theoretical works were published and often the ill were moved out of prison. Neverthless, the living conditions of the mentally ill have hardly changed. Jean-Etienne-Dominique Esquirol, favourite student of Philippe Pinel, transforms the asylum into a therapeutic community where doctors and patients live together. He believes that patients need to be separated from the outside world in order to establish a calming distance from the distractions that caused their disease. The asylums should be built outside of the city on a slope, to benefit from the purity of air and water, and to allow the mentally ill access to nature, which was supposed to have a therapeutic influence in itself. Beyond those aspects which were beneficial to the patients, there were also other important factors involved: the land price was cheaper away from the centres, and it successfully removed unwanted patients from the city, and thus from society.

After visiting a certain number of asylums in France, Esquirol hands over his report, Des établissements consacrés aux aliénés en France et des moyens de les améliorer, to the French minister of the interior in 1818. In that paper he includes precise instructions on how an asylum ought to be set up, and accompanies it with a model plan, on which the architect Hyppolyte Lebas elaborates with his own indications.

The model plan consists of two symmetrical parts: the right for the men and the left for the women, separated by a administration building. Each part includes two sets of three living quarters arranged on both sides of three service buildings. The quarters are U-shaped, organised around a courtyard and limited to a single story. Esquirol conducted many reflections on the limitations to one story quarters and explains in 1838: «Buildings where the insane are housed on the first, second or third floor, offer numerous and serious drawbacks. […] windows must be barred in all the quarters to prevent escape and suicide; and staircases must be barricaded. […] Asylums whose buildings are constructed on the ground floor have innumerable benefits. […] galleries may stay open; the insane are less homely and can go outside as they wish …« 6

6 cf. Architecture et Psychiatrie, p. 20, cited there in Des maladies mentales considérées sous les rapports médical, hygiénique et médico-légal, J.E. Esquirol, Bruxelles, 1838, see annexe for original Chapter 1: Historic Development

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public

private

4 Esquirol’s theoretical plan of an asylum, 1818 5 Schematic development of an asylum

agitation

++

--

courtyard

This composition allows for not only the separating of the sexes into two distinct parts, but also for the patients to be divided according to their social status. Deodaat Tevaearai describes in Lieux de folie, monuments de raison that the asylums have almost always a private unit reserved to paying patients and situated on the south of the complex. The common patients are classified according to their degree of agitation. A distinction is made between the quiet, the semi-agitated and the agitated to which the epileptics are added. The quiet are placed next to the private patients, and more one moves north, more the degree of agitation increases. Each division has its own confined garden, which allows patients to get fresh air and move around, without disturbing the patients with other degrees of agitation. The different services are also arranged hierarchically. The administration is located on the south end, while the chapel, the kitchen, the laundry, the boiler room and the morgue are situated towards the north.

The combination of those three elements – a powerful formula, a critical appraisal and a proposed organisation of the asylum make Esquirol a valuable reference, both for the alienists as for the architects.

Although the principles of Esquirol’s plan have been applied on various asylums, the final outcomes are often very different from the original ideal. Most often the living quarters were extended on several floors to obtain more usable space for patients and to implement the project on a smaller plot.

In The architecture of madness C. Yanni points out that the reorganisation of society into sane and insane was represented by the very existence of those large scale structures, and that architecture preformed a kind of cultural work through these buildings by making such categories obvious. The construction of a colossal asylum would communicate a division between those inside the walls (insane) and those outside (probably, but not necessarily, sane).

Chapter 1: Historic Development

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1.5 The early 20th century – decline of the asylum «Each generation faces different mental challenges in each phase of life. In situations with critical life events and phases of transitions, people are more vulnerable to mental disorders. This is especially so when difficult life events combine with difficult life conditions.

These situations can lead to mental crises which endanger mental health and cause mental illness.»1

By the early 1900s the once popular asylum has lost its prestige. Due to the remote geographical location, a cosmos of its own has developed where the asylum director is the manager of a big establishment, rather than a medical researcher. Patients are hardly able to leave the asylums, and as a result the buildings are overcrowded. 7 While alienists still believe in the endogeneity of mental illness and are constantly looking for the pathogenic part in the human body, the appearance of mental disorders due to a virus reinforces the neurological orientation of psychiatry. The great gap between the asylums with their absence of innovation and researchers at university will lead to the emergence and detachment of psychiatry from alienism. 8 The idea of taking care of the mentally ill outside of big institutions and thus avoiding a too long separation from their environment first became popular in the 1920’s. The belief is that if treating inside the asylum is not working, perhaps treatment outside would. One of the first institutions that offered an «open service» was the hospital Henri-Rousselle in Paris. Created in 1922 by the mental hygiene league, the hospital housed an acute day ward, as well as a social service and research laboratories. But despite the fact that the French minister of the interior gives orders to rename the «asile aliéné» in «hôpital psychiatrique», developments of treatment offers similar to the one of Henri-Rousselle remain an exception. In 1942 Paul Balvet notes: «the lunatic asylums have changed name, but reality is still the same» .9

1.6 Deinstitutionalisation 10

1 cited from: Psychische Gesundheit, Strategieentwurf zum Schutz, zur Förderung, Erhaltung und Wiederherstellung der psychischen Gesundheit der Bevölkerung in der Schweiz, p. 20, see annexe for original

The policy of deinstitutionalisation begins after World War II. The basic concept is to loosen up the interwoven and tight relationship between psychiatric treatment and the big institutions and to enable treatment not in an isolated environment but close to the patient. Obviously, the new antidepressant and antipsychotic drugs, which are introduced to the market in the 1950s, have a great influence on this development since they allow reducing the sometimes heavy symptoms and make patients’ treatment within society possible. The drugs help shorten the average stay in the hospital, but since most places are lacking after-treatment and rehabilitation, many patients return to the clinic. This process is critically named the revolving door-effect. It is now apparent that for too long the psychiatrists concentrated only on stationary and ambulate treatment, but that there is a need for intermediate structures like day-hospitals, which establish an interface between the inpatient and outpatient care.

7 cf. The architecture of hospitals, edited by C. Wagenaar, C. Yanni p. 433 8 cf. Nouvelle Histoire de la Psychiatrie, p. 430 9 cf. Nouvelle histoire de la Psychiatrie, p. 351, see annexe for original 10 cf. The architecture of hospitals, edited by C. Wagenaar, C. Yanni p.434/435

1.7 Hospital-village in France – a short intermezzo In 1960 the French propose to modernise the old hospitals by building hospital-villages. This type of institution is presented as the ideal hospital: They ask for proximity to a major city, no walls, no fence, maximum two floors, no more than three to six hundred beds and a village square functioning as the social centre, surrounded by medical and administrative buildings. In short, the aim is to mimic society fitted for the mentally ill. Instead of going into town and drinking a coffee, the patients go to the social centre of the hospital, the hospital-village has its own church, and instead of going to work, the patients participate in occupational therapy. Barely realised, the hospital-village is already considered out-of-date. This type of institution is in reality just another declination of the 19th century asylum, bearing the same problems of segregation due to its distance from society.11

1.8 Intermediate structures Intermediate structures are used where ambulant care is not enough and stationary treatment is not necessary, or not necessary anymore. It can also offer an alternative to hospitalisation. All over the world different intermediate structures exist with different ideas behind them.

The «clubhouse concept», which has its beginnings in the United States in 1984, is modelled after the Gentlemen’s Club of New York and the concept is very simple: if healthy, wealthy people benefit from an oasis in the city, a place to get away from both home and business, why should recovering mental patients do differently? The aim is to see the mentally ill and to make him see himself as a person rather than a patient, and to separate his personality from the disease. The clubhouse is not a treatment centre and hence there are no nurses and no doctors. But it provides daily activities that prepare people with mental illness to work and live independently, and it offers a place to go during the day. The concept mandates that the clubhouse is never in the same district as the mentally ill’s apartment, and therefore the first step towards an independent life is to leave home every morning, to cross the city and to gather new impressions. 12 After a short period of absolute refusal to send patients to mental clinics, psychiatry has realised that it cannot treat the mentally ill adequately without the use of a hospital. The new clinic type is the urban hospital. It is located in the centre of the city and hence in the centre of community. The urban hospital is not a place of life-long confinement, but it is exclusively used in cases of acute crisis, where use of intermediate structures is not enough.13

11 cf. Architecture et Psychiatrie, p. 34 12 cf. The architecture of hospitals, edited. by C. Wagenaar, C. Yanni, p.440/441 13 For more information on modern treatment facilities see part 2.3 Chapter 1: Historic Development

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Chapter 2 Psychiatry Today In this chapter we would like to provide a picture of psychiatric patients, and understand under which circumstances they become “users” of psychiatric facilities. We address the problematic relationship between society and psychiatry, which has always defined the handling of the mentally ill. We will look at psychiatric treatment by providing an overview of the different diagnoses, their classifications and the current treatment methods. Different types of therapeutic facilities, as well as their organisation within the mental health system, are presented in the last part.

In 1861, when the mentally ill were still treated in asylums, William D. Fearless wrote: «We all have some idea of what an asylum would be, and we hold that as the treatment of the insane is conducted not only in, but by the asylum, so no architect is competent to plan the building unless he possesses some knowledge of the treatment of the inmates.»

It is thus our goal to obtain the necessary theoretical knowledge to enable us to look closely at the case studies and to form a well-founded opinion of them.

Chapter 2: Psychiatry today

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Interaction of exogenous, endogenous and psychosocial factors in the development of mental disorders

entire organism psychotropic substances alcohol drugs medication pathogenic bacteria braintumor etc.

exogenous factors “biological”

endogenous factors mental and behavioural disorder

psychosocial factors

biography social relations society culture etc.

6 Interaction of exogenous, endogenous and psychosocial factors

cognitive structures “software” neurophysiologic processes neurochemical processes etc.

2.1 Mental disorder and society Definition of mental disorder Who decides whether someone is ill or not? How do we know if a person suffers from a mental disorder or is simply exhibiting a behaviour that might seem strange to us, but is really just a part of their particular nature?

In Wikipedia, mental disorder is defined as following: «A mental disorder or mental illness is a psychological or behavioural pattern generally associated with subjective distress or disability that occurs in an individual, and which are not a part of normal development or culture.» 14 This statement demonstrates that the definition of mental disorder is a very subjective matter, since it depends on value judgements including what is normal and what is not within a cultural context.

As vague as the definition of mental disorder is, the definition of mental health is equally so. The World Health Organization (WHO) defines mental health as «a being of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community». 15 Mental health can therefore be seen as a lifelong process. In each phase of life we have to face different challenges, which we may or may not feel capable of overcoming.

But mental health is not only an expression of strength, well-being and good mental capacities. It is also the capability to accept our own weaknesses and limits, and to effectively deal with them. 16

14 cf. Wikipedia, Mental disorder 15 cf. WHO, Mental health: strengthening our response 16 cf. Psychische Gesundheit, Strategieentwurf, p.13 Chapter 2: Psychiatry today

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Psychiatric hospitalisation by 1000 inhabitants, Switzerland 2001 10

8

6

4

2

0-

5 6-1 0 1115 16 -20 2125 26 -30 3135 36 -40 41 -45 46 -50 5155 56 -60 61 -65 66 -70 7175 76 -80 81 -85 86 -90 91 -95 96 +

0 (age)

Reported mental well being in % of men and women, Switzerland 1997 (%) 80 70 60 50

men high

40

women high

30

women low men low

20 10 15-24

25-34

35-44

45-54

7 Psychiatric hospitalisation in Switzerland 8 Menatal well being in Switzerland

55-64

65-74

75+

Total

(age)

Who can become mentally ill?

The WHO describes mental health as a result of dynamic interactions between biological, psychological, socio- economic, socio- cultural and institutional factors. Therefore mental health is a complex process that is, besides individual aspects, heavily influenced by the abovementioned external factors. 17 The susceptibility of a person to mental disorder depends on many factors such as his genetic disposition, his mental condition, and the environment in which he lives. Everyone could be touched by a mental disorder, and in fact, it is very common in our society. National and international studies 18 from the seventies to the nineties showed that almost every second person meets the criteria of a mental disorder at least once during his lifetime.

People who are confronted with a change in their life situation or who face a difficult challenge have a particularly high risk of being affected by a mental disorder. Major life transitions such as the start of school age, adolescence, entry to professional life, retirement, divorce, professional failure or experiences of violence can all generate psychological problems. The risk of becoming ill rises if several factors are present.

As we can see in the graphic on the left, young adults between the ages of twenty to twenty-five years face the highest risk of experiencing mental illness. This is often a time of instability and many life changes. After this critical age, the risk of a hospitalisation decreases constantly until the age of sixty-five, when the third stage of life begins. The increased number of hospitalisations and decreased reports of wellbeing by people who are older than sixty-five years can be explained by physical problems, which have an impact on their mental well-being, the loss of loved ones and suffering from diseases such as Alzheimer’s.

«Each generation faces different mental challenges in each phase of life. In situations with critical life events and phases of transitions, people are more vulnerable to mental disorders. This is especially so when difficult life events combine with difficult life conditions.

These situations can lead to mental crises which endanger mental health and cause mental illness.»1

Why do more people now suffer from a mental illness than in the past?

There are various opinions on the reasons for the growing number of people who seek psychiatric treatment. Some people believe that the sources of the problem are new environmental stressors, such as quick changes, pressure to succeed and unhealthy working environments. On the other hand, ideas about mental health and illness are changing, with more behaviours now falling under the category of mental illness. What before was seen as a specificity of someone’s personality is today considered a disorder that should be treated. In addition to this development, the huge progress that is being made in the fields of neuroscience and genetics now make the treatment of more and more disorders possible. For those diagnoses, the number of cases has not necessarily grown. Rather, behaviours that were once considered unchangeable parts of their personalities are now recognized as a mental illness, and thus handled with treatment. As a consequence, the number of handled cases has increased.

We can say that the growing psychological strain, the improvement in evaluations, and the higher demands on health have all contributed to the quickly growing number of psychiatric treatments.

1 cited from: Psychische Gesundheit, Strategieentwurf, p. 20, see annexe for original

17 cf. cited from WHO, Mental health: strengthening our response 18 cf. Psychische Gesundheit, Strategieentwurf Chapter 2: Psychiatry today

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On the handling of mental illness and the problem of stigmatization Society in its cultural context has always strongly influenced the handling of the mentally ill. As we saw in Chapter 1, in some periods of history the mentally ill were locked up like dangerous criminals.

More recently, a better understanding of the illnesses has developed. A new medical science field emerged and fostered the researchers’ interest in treatment methods.

One might erroneously think that now, after all of the progress that has been made, only one opinion on the handling of the mentally ill exists. In reality however, every psychiatric institution adopts, within a generally accepted framework, its proper position; it defines the word «patient» for itself.

Is the patient first and foremost a guest, or is it necessary that the institution ignores the patient’s will in certain situations, in order to improve the patient’s condition? Diverse positions make sense, since patients need varying levels of care in the different stages of their illness. These different opinions are also seen in the patient- caregiver relationship. In the example of the patient as a guest, the relationship is rather horizontal, while in the later example a strong verticality is noticeable.

Each psychiatric institution thus represents a bilateral position. On the one hand an image is conveyed to the outside. The institution shows to society, to the healthy ones, how the sick are treated.

On the other hand, it also conveys an image to the inside; it takes a stand towards the involved ones: the patients, visitors and employees.

The number of people that frequent the psychiatric services for all kinds of problems is constantly growing 19, but psychoses are nevertheless still a lot more taboo than physical illnesses. Despite the growing interest and openness towards psychiatric problems (especially towards depression), the stigmatization of psychiatry and its patients remains 20, and it will likely remain in the future, since seeing a doctor for phobias and depression will always be more difficult than having a consultations for pain of a limb or problems with digestion. Additionally, mental illness is more frightening than somatic illness.

People can generally identify with others who suffer from cardiovascular disease or cancer, despite the seriousness of the condition, but when it is a matter of mental illness, people often prefer to convince themselves that this concerns others only. This thinking maintains the stigmatisation and worsens the burden on affected people and their families. But these are not the only reasons for stigmatisation. Compulsory hospitalisation and treatment in locked wards are also highly responsible. In our society, everybody is supposed to have his life under control, and autonomy is highly valued. Knowing that one out of five patients are hospitalised against their will 21 makes people fearful and insecure. Prejudices against mental illness can also hinder people in need of psychiatric treatment from seeking professional care. Psychiatric interventions often come late, when people are already in a state of acute crisis.

19 See graphic on page 40 20 Geschichte der Psychiatrie, Krankheitslehren, Irrwege, Behandlungsformen, p. 497 21 See graphic on page 30 Chapter 2: Psychiatry today

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Admitting authorities

non-medical therapy (1%)

non-medical service (1%) other ( 4%)

legal authority (5%)

doctor (42%)

police medical team (13%)

self/ relatives (34%)

9 Admitting authorities in the the PUK-BS

Involuntary hospitalisation To go to a psychiatric hospital is never easy for a patient, and no one goes there because he wants to. Some patients do realise the necessity of their hospitalisation. In the best case the patients are appreciative that there is a place where they can be taken care of in this difficult situation.

Compulsory hospitalisations also occur in somatic institutions, but are much more frequent in psychiatric clinics. 22 Almost one out of three psychiatric hospitalisations are reported as involuntary in Switzerland. Compulsory hospitalisation occurs in 18.6% of all cases. As graphic 2 shows, it is the police and the justice system that mandate them. This high number of involuntary hospitalisations is one of the reasons for the bad reputation of mental hospitals. It is a great challenge for architects to design a building which many inpatients use against their will. The environmental setup has to focus even more on stress and discomfort reduction. 23

«[…] regarding invalidity for psychological reasons: it is difficult to access it, and perhaps even more difficult to get out, even when you feel ready.»1

The resulting costs of mental illness Statistics show that the ambulant and stationary psychiatric care represent five percent of the global health costs in Switzerland. The largest part of the costs caused by mental illness goes into the payment of pensions due to invalidity. The resulting costs of mental illness accumulate up to four percent of the GDP. 24 When considering the large amount of money that is being spent, the need for a continuous treatment plan that focuses on reintegration into society becomes obvious.

People who were once affected by a severe mental illness can often not cope with the fast rhythm of the business world any more. We were told in «les ateliers»25 that only a few companies are willing to take a chance by employing a former patient. Former patients who have the ability to work to a limited extent are often unable to find a job and remain dependent on the invalidity insurance.

Reintegration, not only socially but also economically, is therefore an issue that should be addressed on a political and a socio- cultural level and not only within psychiatric institutions.

Conclusion of mental disorder and society We have seen that the demands on mental health in our society have grown, and that the probability that someone will or should use the services of the mental health system at least once in his lifetime is relatively high. Some contradictions which psychiatry has to deal with become visible here. Although mental disorders are a common part of our society, there is a strong rejection of psychiatric institutions not only by the population, but also by the ones in need of psychiatric treatment themselves.

Stigmatisation is one of the main reasons that many people do not receive an appropriate treatment on time. It is important to improve the image of psychiatry in the population in order to reduce stigmatisation as far as possible. In chapters 3 and 4, we will discuss how this can be implemented through architecture.

1 cited from: Annual Rapports 2004, p. 4, see annexe for original 22 cf. Bundesamt für Statistik 23 See 3.2 for more details 24 cf. Psychische Gesundheit, Strategieentwurf, p. 48 25 Protected workshops of the university hospital of psychiatry (CHUV) in Lausanne Chapter 2: Psychiatry today

31

Diagnosis by type of institution F0 F1 F2 F3 F4 F5 F6 F7 F8 F9 Other 0

20

40

60

stationary clinic intermediate structure

10 Diagnosis by type of institution in Switzerland

80

100 (%)

2.2 On psychiatric treatment In psychiatry, the words «treatment» and «patient» can be misleading because, both terms are often used in a passive manner, referring to a patient as someone who receives treatment, rather than playing an active role in the healing process. In reality, the patient has to collaborate strongly and contribute his own part if therapy is to be successful. Members of the team who work closely with «patients» and with whom we had the chance to talk to, usually avoid this terms and spoke about «people » who have to be accompanied during a treatment process.

Diagnosis Three different systems exist to classify mental illnesses: the International Classification of Diseases-10 (ICD-10) of the WHO, established in 1994, the Diagnostic Statistical Manual IV (DSM IV) of the American Psychiatric Association and the International Classification of Functioning, Disability and Health (ICF) of the WHO, established in 2001. The most common one is the ICD-10 that provides codes for all kinds of diseases. 26 To understand how mental illness can, or sometimes cannot, be categorised, we have listed below the classification of the ICD-10. It will serve as a basis to discuss the problematic nature of diagnoses and the controversial specialisation of psychiatric hospitals units.

–– F0: Organic, including symptomatic, mental disorders (e.g. Alzheimer) –– F1: Mental and behavioural disorders due to use of psychoactive substances –– F2: Schizophrenia and delusional disorders –– F3: Mood / affective disorders (depression) –– F4: Neurotic, stress-related and somatoform disorders (obsessive-compulsive disorder, phobias) –– F5: Behavioural syndromes associated with physiological disturbances and physical factors (eating disorder, sleeping disorder, sexual disorder) –– F6: Disorders of personality and behaviour in adult persons (e.g. pyromania, schizoid or paranoid personality disorder, transsexualism) –– F7: Mental retardation –– F8: Disorders of psychological development (e.g. expressive language disorder, specific spelling or reading disorder, autism) –– F9: Behavioural and emotional disorders with onset usually occurring in childhood and adolescence –– In addition, a group of «unspecified mental disorders«.

26 Bundesamt für Statistik: Nomenklaturen – Internationale Klassifikation der Krankenheiten (ICD-10) Chapter 2: Psychiatry today

33

It is important to note that categorisation might be helpful for the professionals to decide on a possible treatment strategy or for statistic evaluations. But it also bears the risk of a reinforced stigmatization’ rather than trying to understand the individual and his problems multilaterally, the patient is labelled with a word or a number. 27 As we can see in the graphic 10, depression (F3) and stress related disorders (F4) are the most common disorders in our society. A series of factors influence mental health28. Depending on the diagnosis one factor can be more important than another. In both cases (depression and stress related disorders) it is interesting to note that the relation between individual and society plays the most important role.

Multiple diagnosis To explain all categories and their possible treatment methods would go beyond the scope of this work. Therefore we concentrated our studies on how mental illnesses are grouped, in order to understand to what extent they can and should be treated in separate units.

During our research and talks with different psychiatrists and psychotherapist we found out that a therapeutic program is put together for each individual. There is no standard procedure for each specific illness.

In many cases it is not easy to categorise a patient’s problem since symptoms are often not explicit and symptoms of several categories can be identified.

There is usually a primary diagnosis and a secondary diagnosis. For example F1 (Mental behavioural disorder due to use of active substance) and F6 (disorder of personality such as paranoid personality).

Or F5 (eating disorder) and F4 (boarder-line personality disorder).

27 cf. Geschichte der Psychiatrie, p. 500 28 See 2.1.2 for further information

Specialised units There is a big controversy on whether separation by disorders brings more advantages or disadvantages to patients and members of the staff.

Most psychiatric facilities treat patients of several diagnoses. The economic reality is one of the reasons for this. It is not possible to provide specialized units for each mental disorder, since there are not enough patients (besides in big cities) from one diagnosis within the catchment area. The other negative aspect of specialised units is the above mentioned difficulties of categorising patients.

Since they often show unclear or several symptoms at a time, disagreement between professionals is very common. According to Dr. Grandgirard, units do often refuse their responsibility for a patient and resulting disputes between units occur quite frequently. There are some clinics in bigger cities, such as the psychiatric university clinic in Lausanne or the psychiatric university clinic in Zürich, that group disorders in specialized units. Structuring the institution for easier organisation, but also making treatment more efficient for specialists (more patients in less time), are the advantages of specialised units.

The medical team that works on one unit benefits when patients of several diagnoses are treated together. Working with the mentally ill can be very exhausting. A diversity of diagnoses within one unit brings therefore a welcomed change. 29 As we were told in different clinics, it certainly makes sense to treat some specific mental disorders in specialized units. Patients who abuse psychoactive substances (F1) are usually taken care of separately. Since their symptoms differ from other categories, specialised treatment methods are applied. Patients with mental retardation (F7) are usually also separated from patients of other diagnoses. They seek physical proximity while most other patients need physical distance when they are not well.

Patients whose mental disorders have strong physical effects, eating disorders, for example, are often treated in the psychosomatic unit of a general hospital. Another possibility is to treat them in specialised rehabilitation clinics that provide care for somatic and psychological problems.

Besides all these arguments for and against specialisation, we should not forget that there is a scientific interest in treating patients in university hospitals, where patients are separated by disorder.

Only this isolated environment allows serious clinical research on treatment methods for specific disorders.

M. Grandgirard: «The CPNVD in Yverdon-les-Bains has, in comparison to the psychiatric university clinic Cery of Lausanne, the advantage that everything is centralised.

Patients do not need to change units. In Cery it happens quite often, that the team changes opinion about how to treat a patient. As a result patients are redirected to another unit, since their condition seems to fit better in there.»

29 According to M. Grandgirard Chapter 2: Psychiatry today

35

Treatment approaches30 As we have seen by now, patients can have different symptoms and their causes are often hard to clearly identify. These complex situations make it necessary to choose treatment methods for each patient individually. Below we present some of the common therapies that can be grouped into four categories. This allows us to get a picture of the treatment, the facility where they are given, and the people who are involved.

The psychotherapeutic approach Psychotherapy is a form of psychological treatment that uses the patient-physician’s relationship to discover the source of unrest, freeing mental functioning and promoting healing. There are several types of psychotherapies; the most known and recognized in psychiatry are the psycho-psychoanalytic therapy (derived from psychoanalysis), family psychotherapy and systemic cognitivebehavioural psychotherapy 31. Most therapies are carried out in an office or in the patient’s room.

The physical approach This approach consists of relaxation through massages or other similar exercises, but physical exercise is an important part as well. A skilled staff member or a physiotherapist usually accompanies the patient. Common locations are gymnastic halls or the patient’s room.

The pharmaceutical approach The pharmaceutical approach has the goal of decreasing the patient’s symptoms. The patient’s stabilisation with medication (antipsychotics and antidepressants drugs) is often the prerequisite to carrying out other therapies.

Ergotherapy A patient learns or relearns activities of daily life by improving his motoric-functional, psycho-functional and senso-motoric abilities. This method groups together activities like handicrafts, playing, pottery, painting, gardening, cooking and other tasks of daily life. Ergotherapists usually accompany patients on these activities, and they take place in workshops or other spaces suitable for the relevant activity.

According to the systemic approach, therapies can only be successful if the patient is not taken as an isolated individual, but rather if all parts of his life are taken into consideration. As a result, the patient’s environment, including people such as his family, friends and colleagues, also play an important role. The availability of places where friends and family members can be received is a factor that should be considered in the planning of psychiatric facilities.

Mrs. Sonja Flick: «Mental disorders can be treated but often they cannot be healed. It is therefore the task of our psychiatric facilities to improve the patient’s life quality and to help him find new perspectives.»

30 cf. Health Search Engine, Current Diagnosis & Treatment in Psychiatry 31 Cited in: Annual Rapports 2006, p. 11, see annexe for original Chapter 2: Psychiatry today

37

Coverage by type of treatment facility acute crisis

rehabilitation

reintegration

prevention

stationary acute hospital stationary rehabilitation hospital day-care hospital day-care centre sheltered workshop therapeutic club long-term structures ambulatory

stationary clinic

11 Coverage by type of treatment facility

intermediate structure

ambulatory

long-term structure

2.3 The different treatment facilities The field of psychiatry has rapidly grown, and different branches like the forensic, the military or the pathological psychiatry, were formed. Today, the field of general psychiatry is divided up into three age branches to better respond to the respective age-related needs. With the deinstitutionalisation process, 32 psychiatric treatment was split up into different institutional types.

Nowadays, treatment options are no longer limited to stationary care. Since the mid-eighties, in fact, the average length of stay in psychiatric hospitals has declined steadily. In return, outpatient and semi-inpatient treatments have gained importance. 33 This is mainly due to two factors. First, the entire health care system suffers greatly under financial pressure, and to save money, the length of hospital stays are kept as short as possible. Second, awareness has developed that each hospital stay separates the patient from his familiar surroundings, and for a successful treatment, the surroundings are of great importance. For these reasons, the psychiatric clinic has been transformed into a place of acute crisis intervention, in which patients spend only a short period of time.

In the following paragraphs we will briefly introduce the four types of institutions, and then discuss the benefits and risks of the above mentioned separation from familiar environments.

«The statistics on psychiatric hospitals in Switzerland 2001 list 48 364 stationary hospitalisations and 2 139 semi-stationary hospitalisations. (...)

An examination of 1 343 patients in seven psychiatric clinics of the canton Zürich showed that 44 percent of all patients would not need stationary treatment.» 1

Stationary clinic The stationary psychiatric clinic is a total institution, 34 which means that it cares for the patient twenty-four hours a day during his stay and plans his daily life in its entirety. Two different categories exist: hospitalisation for acute care and hospitalisation for rehabilitation. 35 The hospital for acute care accommodates patients in an immediate crisis. The facility’s main goal is to stabilise the person as quickly as possible. Due to the elevated suicide risk, acute clinics have an important security infrastructure.

The modern hospital is built in the middle of the city. This central implementation does not only ease the reintegration process of patients, but it is also an important step towards the desired dedramatisation of the clinic. 36 The stationary rehabilitation clinic, on the other hand, sits in most cases outside of urbanised areas in order to benefit from remoteness and nice scenery. Many private clinics are set up as rehabs, and patients usually transfer to them once their condition is stabilised. In most cases those clinics do not offer emergency admissions, but rather the patients arrive on referral from their doctor or from another psychiatric institution.

32 See 1.6 for more information 33 cf. Annual Rapport 2000, p. 4 34 Goffman in Asylums, p.XIIV: «A total institution may be defined as a place of residence and work where a large number of like-situated individuals, cut off from the wider society for an appreciable period of time, together lead an enclosed, formally administered round of life.»

34 cf. Annual Rapport 2006, p. 8 36 cf. Annual Rapport 2003, p. 9

1 Gesundheitsdirektion des Kantons Zürich, 2002 cited in Psychische Gesundheit, Strategieentwurf, p.42, see annexe for original

Chapter 2: Psychiatry today

39

& DREN CHIL SCENTS LE ADO

RLY ELDE E L PEOP

S DULT

AMBULA TORY

INTERM

EDIATE

A

HOSPITA

L

32.33 2’778

30.64

33.65 2’759

3’426

40.17 2’737

33.72

51.53 2’892

3’169

49.36 2’833

58.27

52.14

53.49

50.52

46.80

Average lenth of stay (days) in stationary psychiatric hospitals

1998

1999

1988 1989

2’624

2’445

2’438

2’439

2’345

Number of hospitalisations

1990 1991 1992 1993 1994 1995 1996 1997

12 Fields of psychiatric services 13 Average length of stay in stationary psychiatric hospital/ Number of hospitalisations

Intermediate structures Whenever ambulant care is not enough and stationary treatment is not necessary, or no longer necessary, the intermediate structures enter into action. They can also offer an alternative to hospitalisation. In contrast to ambulant care, the day-care hospital is usually not an anonymous office building where patients come upon appointment to one session, but rather a centre where patients can spend their day, where they are involved in a therapeutic program and where they start socialising again.

A large variety of different intermediate structures exist, all with a different focus. In the day-care hospital, the medical aspect is important and doctors and nurses are part of the team. Some of them are organised similar to clinics, but they offer a big advantage in that the patient does not have to give up his familiar surroundings during the treatment period, but instead goes home every evening.

In the day-care centre, the focus lays on the active reintegration process. The program offers a variety of therapeutic activities where the patients play an active role. This can be in the form of creative group therapy, fieldtrips, garden work, cooking and similar activities.

Sheltered workshops, another type of intermediate structures, offer small working tasks in a protected environment. Most of the patients are recently released from a stationary hospitalisation where their days were planned from A to Z. The workshop’s goal is to fill the patient’s suddenly empty days. In a later stage, the patient relearns tasks that should facilitate reintegration in the traditional labour market.

Therapeutic clubs are patient’s associations with the main and overall goal to socially reintegrate psychiatric patients to society and to prevent relapses. Activities might be organised by the members, but casual encounters around a cup of coffee are more common. Professional staff is still present, but while the patient-caregiver relationship in a day-care centre is vertical, the patient-caregiver relation in a therapeutic club is completely horizontal.»

When looking at the variety of offered therapies, it becomes apparent that it’s not a simple question of treating only the proper psychosis, but its «side-effects» as well. The programs of such facilities give a patient structure in his daily life, raise his self-esteem, and help him to learn or relearn tasks of his everyday life. The programs also focus on the social structure of a patient by involving his family and friends, with the overall goal of enabling a patient to live his life autonomously again.

«For patients with serious mental illnesses and social handicaps that are nowadays treated repeatedly in stationary clinics, the option of ambulant and semi-stationary facilities is insufficient.

As a result of this lack of coordinated services, this category of patient spends more time in clinics than the average patient, and therefore appropriate, efficient and economic care is not guaranteed.» 1

Ambulatory An ambulatory treatment is an extra-clinical treatment that does not interfere with the patient’s activities. 37 The treatments consist of consultations with a psychiatrist or a psychologist and are sometimes accompanied by family or couple discussions. 38 Patients profit from ambulatory consultations at different stages of their illness. As many persons frequent ambulatories, good accessibility is essential.

They are therefore situated in city centres, close to the clients.

1 cited from: Psychische Gesundheit, Strategieentwurf, p.

8, see annexe for original

37 cited in Annual Rapport 2003, p. 12 38 cf. Annual Rapport 2000, p. 5 Chapter 2: Psychiatry today

41

Number of persons using psychiatric services per year 200000

150000

100000

50000

0 stationary clinic intermediate structure ambulatory

14 Number of persons using psychiatric services per year in Switzerland

Long-term structures Some mental disorders (dementia, autism and mental retardation amongst others) produce so big impacts, that the patient will never be able to lead a total independent life anymore. Long-term structures accompany those persons over several years. Residential homes and sheltered employment schemes for long-term patients form those kinds of structures.

Advantages and risks Given that patients are nowadays quickly released from hospitals, although the continuation of therapy is in most cases indispensable, the intermediate structures have become even more important. 39 It is therefore not surprising that in recent years, focus was put on the continuity and cooperation between the different caring institutions to prevent patients from slipping through the net. It has also been shown that if patients are released too quickly from hospitals, and if they do not go through further therapy, the recidivism rate is elevated, and thus the probability that those patients will end up in the hospital again. Good cooperation between the various treatment facilities led to a significant decrease in instances of the so called «revolving door effect». 40 The development of different treatment facilities brings many benefits for most of the patients.

Nevertheless, they can lead to the neglect and marginalisation of those who are disorientated in view of the complexity and fragmentation of the various offers. A new category of patients has developed, who receive treatment too late and only in moments of acute crises. For these patients, the diagnosis in itself is not a discriminatory criterion. The origin of the delay often lies in problems of access and inadequate guidance to the required resources. Coordination between multiple actors and bad transitions from one establishment to another can be another reason. Collaboration, not only with primary care physicians and nurses in health centres, but also (if needed) with the police, patients’ associations and social services, is essential. 41 A strong continuity in care through the many types of treatment seems to be the overall goal. But a physical discontinuity in the different facilities can also have advantages. The physical separation of treatment locations makes the patient aware of his therapeutic improvements. The moving from one establishment to another can be seen as one step forward in the healing process. 42

“Nowadays a clinic is not a hotel, nor a supervised residential group.

It is a place to treat acute crisis, and patients should be aware of this fact. If patients feel too comfortable and if the environment is too luxurious, they may not be as motivated to get well and leave the comforts and security of the clinic.» 1

1 J. Montandon, director CPNVD 39 According to J. Montandon 40 cf. Annual Rapport 2002 41 cf. Annual Rapport 2004, p. 6 42 cf. Annual Rapport 2005, p. 8 Chapter 2: Psychiatry today

43

2.4 The patient What does it mean for a patient to be in a stationary psychiatric hospital?

The stay in a stationary psychiatric clinic is not an easy matter for a patient or his relatives. The patient is pulled out of his environment and his social network, and he loses the different roles he played within society. 43 He finds himself in several humiliating situations due to the loss of a part of his personal integrity, which is caused by incapacitation and the loss of privacy. For someone who has never been touched by such a situation, it is hardly possible to imagine what patients and their relatives have to go through.

For this reason we would like to conclude this chapter with a quotation from Rae Unzicker. She was an advocate that stood up for the mental health patients’ rights. She describes what patients experience once they are in the mills of psychiatric hospitals. Even if nowadays a big effort has been made to improve the situation, these statements still have a lot of truth and they help us to understand the patients’ situation.

«To be a mental patient is to be stigmatized, ostracized, socialized, patronized, psychiatrised.

To be a mental patient is to have everyone controlling your life but you.

You’re watched by your shrink, your social worker, your friends, your family.

And then you’re diagnosed as paranoid.

To be a mental patient is to live with the constant threat and possibility of being locked up at any time, for almost any reason.

To be a mental patient is to live on $82 a month in food stamps, which won’t let you buy Kleenex to dry your tears. And to watch your shrink come back to his office from lunch, driving a Mercedes Benz.

To be a mental patient is to take drugs that dull your mind, deaden your senses, make you jitter and drool and then you take more drugs to lessen the «side effects».

To be a mental patient is to apply for jobs and lie about the last few months or years, because you’ve been in the hospital, and then you don’t get the job anyway because you’re a mental patient. To be a mental patient is not to matter.

To be a mental patient is never to be taken seriously.

To be a mental patient is to be a resident of a ghetto, surrounded by other mental patients who are as scared and hungry and bored and broke as you are.

To be a mental patient is to watch TV and see how violent and dangerous and dumb and incompetent and crazy you are.

To be a mental patient is to be a statistic.

43 cf. Asylums – Über die soziale Situation psychiatrischer Patienten und anderer Insassen, p. 25

To be a mental patient is to wear a label, and that label never goes away, a label that says little about what you are and even less about who you are.

To be a mental patient is to never to say what you mean, but to sound like you mean what you say.

To be a mental patient is to tell your psychiatrist he’s helping you, even if he is not.

To be a mental patient is to act glad when you’re sad and calm when you’re mad, and to always be «appropriate.»

To be a mental patient is to participate in stupid groups that call themselves therapy. Music isn’t music, its therapy; volleyball isn’t sport, it’s therapy; sewing is therapy; washing dishes is therapy. Even the air you breathe is therapy and that’s called «the milieu.»

To be a mental patient is not to die, even if you want to -and not cry, and not hurt, and not be scared, and not be angry, and not be vulnerable, and not to laugh too loud -- because, if you do, you only prove that you are a mental patient even if you are not.

And so you become a nothing, in a no-world, and you are not.» 44

44 Cited from: To be a mental patient, 1984 Chapter 2: Psychiatry today

45

15 From One flew over the cooko’s nest, Warner Bros. Entertainment, 1975

CHAPTER 3 Architecture and Psychiatry Description of a bad experience in a psychiatric hospital, written in 1954: «Once inside the door of the hospital the patient is usually taken from an entrance hall to a records department where a member of the staff will examine his documents. After this he will be escorted down long corridors where he will see numbers of patients sitting or walking aimlessly, perhaps exhibiting gross evidence of desocialisation and eccentricity.

He will see the many beds all alike and the absence of other furnishings, the walls of a dull, uniform institution buff or brown, and the windows small, high, barred and often dirty. There will be evidence of locks, and he will hear the keys of his attendants. The ward will have a stale smell and often provide evidence of the inadequacy of the sanitary arrangements.

He will be forced to perform even the most private activities where he can be seen both by other patients and the staff. Within a crowd of such patients there will be no opportunity to form friendships with a small group or to feel any drive to identify himself with those around him.» 45 This quotation is more than fifty years old, and the conditions in clinics have greatly changed since (just as the scientific field of psychiatry has changed). But even though the conditions described are not comparable to current standards, many people still seem to have this picture in mind when they think of psychiatric facilities.

In this chapter we want to show architecture’s influences on psychiatry’s image in society, as well as its great potential in transmitting a message. We would also like to point out the impact that architecture has on the institution’s users and the factors that deserve profound consideration when planning a psychiatric facility.

45 cf. part 2.1.4 (on the handling of the mentally ill) Chapter 3: PSYCHIATRY & Architecture

47

3.1 Architecture and the image of psychiatry As we have seen in chapter 2, 46 every psychiatric institution takes a bilateral position on the treatment of the mentally ill: toward society on the outside, and toward the patients on the inside. The first part discusses how the position regarding society can be architecturally translated and points out the potential consequences.

Most people do not know life inside a psychiatric clinic, and opinions are based upon rumours. The psychiatric hospital is generally associated with negative attributes, while a somatic hospital also produces positive experiences, such as birth of new life.

For those who know neither (ex-) patients nor staff, the building in its physical appearance needs to stand in as the only reliable representation of the psychiatric treatment apparatus. 47 Movies, especially, often transmit an exaggerated image of the clinics’ conditions. Filmmakers like to use old prejudices and describe psychiatric institutions as prison-like complexes with wide white corridors where patients are detained rather than healed. Even if the practices have evolved, there is still the image of exclusion and imprisonment reflected by the walls, behind which we don’t really know what happens.

Architecture is thus an important mediator, which transmits the proper and current conditions of psychiatry institutions to society.

The decision to no longer build psychiatric clinics outside of urbanised areas, but rather in the centre of society, constitutes an important step in reducing the stigmatisation. At the same time this decision produces new risks, since patients are sometimes exposed to staring gazes. This constant balancing act between the individual and society illustrates the institution’s bilateral position, and is by far not the only one. Should the clinic transmit a hotel-like atmosphere where patients feel at home, or should it rather have a hospital-like atmosphere where the patients realise that they are in a clinic, 48 and thus in a state of acute crisis? Should contact with society be actively encouraged, or should the architecture provide places where the patient can retreat, where he feels protected? And in the same logic, there is also the question of whether psychiatric structures should exist in an ostentatious way, or on the contrary, blend in with their environment and be as nondescript as possible. A façade that expresses the psychiatric function of a building makes the institution exist socially. But this same façade can also increase stigmatization, since it allows people to identify the nature of the institution from afar. 49 When new psychiatric facilities are being planned, it is common to find hostility among neighbours who justify their opposition by technical, regulatory or esthetical arguments. They consider it difficult to openly display their hostility toward a population that is, in their eyes, in trouble, dangerous or disturbing. The architecture is thus a pretext for people’s fears of the patients, and the architect finds himself caught between a client who needs the structure and the local population, who are sceptical about the psychiatric facility. History has shown that those projects that offer an additional value to the local population have a greater chance of gaining the approval of the community where they are built. In

46 cf. part 2.1 (on the handling of the mentally ill) 47 cf. Architecture et santé mentale, p.5 48 Question asked by J. Montadon 49 cf. Architecture et santé mentale, p.5

the best case, the structure can offer activities and public services to the locals, consequently building a bridge between the two worlds that have not gotten to know each other. 50 In an effort to combat stigmatisation, some psychiatric structures have changed their name to «intervention centre» or «psychiatric care,» instead of «psychiatric hospital». This camouflage can have an impact in two directions; on the one hand, these other terms can be used to make the structure invisible to society. This act worsens the stigmatisation, since it conveys the impression of self-accusation and shame. On the other hand, the term might be used for a structure where the aim is to treat the client as a person rather than a patient. Schott and Tölle state that: «Traditionally and in the literal sense the word patient means: suffering, being passive. The modern psychiatry in contrast, wants as much activity as possible from the patient: he should help himself and his fellow patients as far as possible. » 51 It could thus be in this line of thought that the facility’s management decided to camouflage the structure and to melt it into the urban pattern. 52 As we previously mentioned, the institution’s position on the handling of the mentally ill is also transmitted toward the patients and the employees on the structure’s inside. To underline the horizontality of the patient-caregiver relationship, the administration at the day-care centre Adamant have consciously decided to renounce the use of a break room reserved exclusively for the staff members. As we will discuss in more detail in chapter four, the institution’s goal is to create casual interactions. It was thus the responsible persons’ decision that the caregivers and the patients use the same coffee machine and the same microwave; their coffee and food is the same. Furthermore, their observations have shown that if an exclusive break room exists, the team members use it a lot more than necessary. 53 There are thus many details, like the example just mentioned, the existence of isolation rooms, or whether the patient can lock his room, which illustrate the institution’s position toward the inside.

We believe that architecture can convey the natural existence of psychiatric structures within our society by considering the environment and seeking a dialog with the local population. Architecture should manifest in a subtle manner the presence of psychiatric facilities, while providing a positive image at the same time. Spaces can tear down prejudices, where encounters between patients and the population occur naturally, without being forced. It also helps when psychiatric facilities reveal something of themselves. A transparent institution (not only in the physical sense), transmits a different image to the outside than a sealed off building. We think that there are only advantages to be found if the structure offers activities and services open both to the public and to the patients.

50 cf. Architecture et santé mentale, p.1 51 Cited from Geschichte der Psychiatrie, p. 502, see annexe for original 52 For more information on stigmatisation see part 2.2 (diagnosis) and 3.1 (architecture and the image of society) 53 According to A. Vallet, nurse in Adamant Chapter 3: PSYCHIATRY & Architecture

49

3.2 Healing environments In this section we would like to present the factors that can contribute to a healing environment, as well as those which should be avoided. The following research was construed for the healthcare sector in general, but may very well be applied outside this branch for preventive purposes. According to the motto: «what heals the sick is also good for the healthy», and many factors relating to the construction of psychiatric care facilities are also valid for residential constructions.

After an overview of the general principles that contribute to a healing environment, the components specific to psychiatry will be presented.

What is a healing environment?

«Design is so complicated that it would be impossible not to rely heavily on intuition, regardless of the number of scientific studies that are brought to the table.

Good healthcare design is equally dependent on art and science. […] The most successful design will be a marriage of craft and research.» 1

According to Jain Mallkin in The Architecture of Hospitals, 54 the term «healing environment» describes a physical setting and organizational culture that are psychologically supportive, with the overall goal of reducing stress in order to help patients and families cope with illness, hospitalization, and sometimes, loss.

But what should this setting look like? We found in many books descriptions and recommendations on how to create such settings, but they were often very vague. Since it is difficult to put into words what a healing atmosphere should look and feel like, statements on such environments often seem dull, leading the reader to think that those recommendations are simply part of common sense.

Despite the sometimes vague recommendations, some scientific approaches, like evidence-based design (EBD), do exist to analyse healing environments. EBD is a field of study that emphasizes the importance of using credible data in order to influence the design process. The approach has become popular in healthcare architecture in an effort to improve the patients’ and staff’s well-being.55 According to EBD 56 several environmental measures allow a better patients and staff outcome.

While for the patients, it is important to reduce pain and depression, the reduction of stress is important for all engaged parties: staff, patient and family. Scientific studies have shown that the exposure to high levels of daylight and to nature can significantly alleviate pain and depression.

Other researchers suggest that real or simulated views of nature can produce restoration from psychological stress in a short amount of time. Stress is also clearly reduced when a setup is provided that allows for good sleep and a low noise level. This can be achieved through single bedrooms and buildings with high acoustic performances. Single bedrooms are not simply more comfortable for the patients, but they are also perceived to be less stressful for both family and staff members than the ones containing several beds.

It is interesting to note that having carpets instead of vinyl for floors in patient rooms seem to increase the average length of stay.

1 Kirk Hamilton, Associate professor of architecture and fellow of the center for health systems & design at texas A&M University

54 The Architecture of Hospitals, p.265-266 55 Definition from Wikipedia, Evidence Based Design 56 The Architecture of Hospitals, p.258-289

The important role of gardens and parks in hospitals 57 For patients, visitors or members of the staff, spending long hours in a hospital can be a stressful experience. Nearby access to a natural landscape or a garden can enhance people’s ability to deal with stress, and thus potentially improve health outcomes.

As we have already seen in chapter one, greenery, sunlight and fresh air were regarded as essential components of the healing process during the nineteenth century. But with the asylum’s loss of prestige, the therapeutic value of access to nature disappeared from mental hospitals at the turn of the twentieth century, and some years later also from general hospitals. Air conditioning replaced natural ventilation, outdoor terraces and balconies disappeared, nature succumbed to cars and parking lots, and indoor settings designed for efficiency were often institutional and stressful for patients, visitors and staff.

Significant research in the 1980’s and 1990’s helped to support the belief that views of or time in nature have a positive influence on health outcomes. It was shown that gardens were important because they represented, in many respects, a complete contrast to the experience of being inside a hospital: domestic versus institutional scale; natural versus man-made; rich, sensory experience versus limited sensory detail; varied, organic shaped versus predominance of straight lines; places to be alone versus few places offering privacy; fresh air versus controlled air.

In the last ten to twenty years, efforts have been made to reintegrate greenery and nature into healthcare buildings, but too often these good intentions never see their day (or only in an atrophied way), due to tight budgets.

The above mentioned positive effects are even greater if patients, staff and visitors do not only have a view and access to small green patches, but rather if they can profit from veritable parks and gardens. They provide a setting where physical, horticultural, and other therapies can be conducted.

Their setup also offers a needed retreat from the stress of work for the staff. The green creates a relaxed setting for patient-visitor interaction away from the hospital interior.

57 The Architecture of Hosptials, p. 314-329 Chapter 3: PSYCHIATRY & Architecture

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3.3 Architecture for psychiatric treatment In the preceding section we have seen what conditions are needed for a healing environment in general. In this part we want to focus on psychiatry and its specific needs.

Promoting encounters «If the task of psychiatry is to repair the lack of connection between the patient and his environment, it can lean on architecture and consider it as an active partner that can provide a positive image of psychiatry and of its presence in the world.»1

In contrast to somatic hospitals, psychiatric facilities can only rely in a limited way on technical support in the healing process. 58 The relationship between staff and patient goes beyond the simple accompaniment during a treatment period, 59 and interactions (mainly between therapists and patients, but also with visitors and other patients) constitute an important part of the available «healing tools». The mentally ill, especially people suffering from depression and similar psychoses, often retreat and encapsulate themselves in their shell. It is thus important to bring those people into contact with others.

In a regular hospital, the patient lays down during his recovery, generally passive in his bed. Encounters with members of the staff do not have the same importance as in psychiatric facilities. On the contrary, in order to be as efficient as possible, the circulation setup in a general hospital focuses on preventing encounters. 60 The biggest difference between a general hospital and a psychiatric facility can therefore be found in the quality of the spaces that allow interactions between the involved parties. Let’s take one of our case studies, the acute day care clinic in Zürich, as an example: unlike that building, treatment rooms should not feature a long and narrow corridor without daylight, and with the only function to allow users to get from point A to point B. It should instead be a place to hang out, where informal encounters are possible.

B. Laudat 61 suggests, that a new handling for the management of square meters ought to be invented to assign surfaces more wisely. This means that spaces which are not linked to specific functions, and that are usually called hallways or circulation areas, should be given more importance, since all those spaces are essential for the practice of psychiatry.

The feeling of security in a psychiatric clinic Due to the patients’ situation of acute crisis and the new and unknown environment of a psychiatric hospital, the feeling of security is often not present. But this feeling of safety and well-being is the first prerequisite for the re-establishment of the patient’s normal relations with his environment. 62 Insecurity engenders anxiety, which is the cause of much disturbed behaviour.

1 Cited in Architecture et Sante Mentale, p.5, see annexe for original 58 L’architecture au service du soin, p.1 59 cf, Mener un projet architectural en psyschiatrie, p 10 60 cf, Architecture et psychiatrie, p.41 61 Cited from Architecture et santé mentale, p.4 62 cf, Architecture et psychiatrie, p.57

How can we create an environment that improves feelings of security?

A recommendation of the WHO on psychiatric services and architecture 63 from 1959 says that familiarity with places and persons increases the patient’s sense of security. In those parts of the hospital, which are used for sleeping, meals and rest, it is important that the architectural environment conveys harmony of proportions and colours, and that appropriate materials are used. Natural wood, wool, and leather are acceptable materials in all cultures. These are materials that people like to touch as well as to see. A thick skin, like the façade of the CPNVD from our case studies, can appear protective. But it can also produce fear and be perceived as too repellent and too institutional.

Particular care must be taken to help the patient orientate in time and space. 64 A simple building layout with obvious travel paths and clear signage, so that visitors and patients do not need to ask for help, support the feeling of security. Openings and access to plants that change with the seasons, as well as the availability of clocks, provide decoration and information as part of the daily activities, and allow for orientation in time.

Protecting the patient from himself The security issue in psychiatric facilities is very important and often contradictory to other needs of the patient.65 Some important questions to consider include: How to respect the privacy of a patient in his room if it is necessary to keep an eye on him?

How to allow him to communicate with the exterior, to benefit from the city although the window has to be locked?

Those questions show how difficult it often is in psychiatry to give a clear answer. In the end, each hospital management must decide which of the factors are more important to them than others.

We will see in chapter four more precisely how the high demands on patients’ safety in the psychiatric clinic in Yverdon-les-Bains (CPNVD) necessitate that many doors and windows cannot be opened without a key. The clinic La Métairie on the other hand, has put the focus on other factors, and can in return not offer the same security measurements as the CPNVD. In intermediate structures security is still an issue, but to a lesser extent than stationary clinics.

Since the patient visits the intermediate structure independently, one can assume that he does not harbour immediate suicidal thoughts. In the day care hospital Adamant for example, a workshop was organised before boarding the barge to discuss what it means for the patients and the staff members to visit, respectively to work on the water.

Daniel, patient: «When you are depressed, it may be dangerous on a boat. In the evening, in winter, you can get rid of yourself in the water.

This is easier than jumping in front of a car, right?»1

1 Cited from the article: En plein Paris, l’hôpital du vogue à l’âme, see annexe for original

63 WHO, Psychiatric services and architecture, p.26 64 cf. WBDG 65 cf. Architecture et psychiatrie, p .61 Chapter 3: PSYCHIATRY & Architecture

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Privacy in psychiatric clinics In stationary clinics, privacy is an important issue in order to keep a patient’s dignity, since he lives in the hospital and spends every minute of his days and nights in it. He should have as much visual and acoustical privacy as possible, and he should also be in control of it.66 This can be achieved through single bedrooms, with the possibility to close the door when desired, or by offering several types of common spaces. It is also important to create spaces where private family meetings can take place, while assuring a high level of acoustic isolation. But as discussed before, the need for privacy often contradicts others essential needs, such as supervision and intensive care, and makes this matter another delicate tightrope walk.

In intermediate structures, privacy is much less an issue since patients have the possibility to return to where they live. Patients that frequent intermediate structures are usually in a different treatment phase than the ones in stationary clinics. The intermediate structures consequently devote a lot of their efforts to encouraging interaction and the re-socialisation. 67

Promoting choices/patient’s sense of competence Due to the circumstances, an admission into a psychiatric clinic is never easy. Every person has the need, to a certain extend, to organise his everyday life himself. Even though some of the patients are relieved that they can delegate the responsibility, personal freedom is severely limited in stationary clinics. Adults, who are used to having their lives under control, and to being autonomous, come into a system in which every detail of their daily routine is prescribed; patients become completely dependent. In regards to total institutions, Erving Goffman notes that: «Total institutions disrupt or defile precisely those actions that in civil society have the role of attesting to the actor and those in his presence that he has some command over his world – that he is a person with «adult» self-determination, autonomy, and freedom of action. A failure to retain this kind of adult executive competency, or at least the symbols of it, can produce in the inmate the terror of feeling radically demoted in the age-grading system.» 68 It is thus very important to provide each patient with the opportunity to control his immediate environment as much as possible. This may include: lighting level, type of music, seating options, and also the possibility to have access to kitchen facilities, where snacks or meals can be prepared by the patient. A patient’s sense of competence is encouraged, when spaces are easy to find and to use without asking for help.69

66 cf. Pratiques de soins en psychiatrie et réflexions sur les éléments du programme architectural, p. 7–9 67 cf. WHO, Psychiatric services and architecture, p. 24 68 Asylums, p. 43 69 Cited from WBDG

Flexibility Psychiatric facilities and treatment ideologies are subject to quick and frequent changes. Practices have evolved considerably in the last decades, and the options for patients have to be adapted constantly. 70 Therapy rooms, in particular, have to be built in a flexible and multi-purpose way. This allows not only for different activities in the same spaces, but it also prevents unnecessarily quick obsolescence. The clinic La Métairie is a good example: the institution from the middle of the nineteenth century is a listed building and changes are almost not possible. We will see in the following chapter how the management is aware of the organisational problems linked to the outdated layout, but has very limited options regarding architectural modifications.

«We must remain humble, it is the patients who will use and define the space in the end.» 1

3.4 Conclusion One can easily find a variety of advice concerning the planning of psychiatric buildings, and when one suggestion is isolated from another, they all seem very reasonable. Problems arise when one has to make compromises between all of these recommendations. What is in this case more important?

What will be impossible to discount?

For some issues such as the part on promoting choices, we were not at all aware of its importance.

In others, like patient’s privacy, we had an idea of the theme, but were surprised by the far-reaching architectural consequences. Certain points did not give us truly new insights. The section on the important role of gardens and parks is not only important to us in relation to society. In our opinion, parks and gardens are essential to the environment of mental hospitals, and are too frequently left out. For this reason we decided to elaborate on that topic to a certain extent.

The conversation with the architect of the Adamant, Mr Ronzatti revealed that he under no circumstances wanted to design a project with specific intentions regarding the type of institution. He believes that the spaces, if they are designed specifically for the treatment of psychiatric problems, are regularly overloaded with and compromised by intentions.

We think it is important for architects to know all the above described factors. But it seems to us even more important that architects design real spaces. In this respect, we agree with Ronzatti’s statement. Too often an unreal atmosphere reigns in psychiatric facilities, too often psychiatrists and architects want to design a building that has a soothing, calming and relaxing effect, and too often the result is one that we perveive as strange and unnatural in its whole.

1 J. Oury on the role of the architect, reproduced by J. Montadon

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Criteria for selection of case studies geographic location in the city centre

on periphery of the city

CPNVD in Yverdon-les-Bains

Ambulatory (1h)

building in rural area

La Métairie in Nyon

Day-care hospital (8h)

Clinic (24h)

type

recently built

old, adapted to nowadays standards

KSPAP in Zürich

not built for current purpose

Adamant in Paris

private

public

private/ public

Coverage by type of treatment facility acute crisis

rehabilitation

reintegration

prevention

CPNVD (hospital) la Métairie (hospital) PUKZH-Militärstrasse (crisis intervention hospital) PUKZH-Militärstrasse (acute day-care hospital) PUKZH-Militärstrasse (rehabilitation day-care hospital) stationary clinic

Adamant (day-care centre)

intermediate structure

Adamant (therapeutic club)

ambulatory

16 Criteria for selection of case study 17 Coverage by type of treatment facility

Chapter 4 Case studies As we have seen in the theoretical part, there are large differences in psychiatric institutions. The structures’ ranges in coverage of the healing stages, as well as their philosophies in translating their missions, vary greatly. Few deny that an institution cannot cover the full range of the healing process. But where should the cuts be made, and how can the different stages be distinguished? What are the psychiatric facilities’ needs and how are they transposed? What kind of relationship is maintained with society? These are the questions we want to treat in our case study from an architectural perspective, to obtain the broadest possible overview.

We decided to look at four psychiatric facilities: two stationary psychiatric clinics and two psychiatric day-care clinics. These four institutions vary greatly in their missions, the implementation of their visions, the degree of integration into society, and in their construction year. This diversity makes a comparison particularly interesting.

The Centre de Psychiatrie du Nord Vaudois (CPNVD) in Yverdon-les-Bains was inaugurated in 2005. It is one of the first stationary psychiatric clinics in Switzerland that seeks a strong integration in the urban structure of a city.

La Métairie, a private stationary clinic in Nyon was opened in 1860 and is today the last remaining psychiatric clinic in the french spoken part of Switzerland.

Die Klinik für Soziale Psychiatrie und Allgemeinpsychiatrie ZH West (KSPAP) lays in the centre of Zürich. It consists of an acute unit, a crisis intervention unit and a rehabilitation unit that are autonomous but share the same therapy rooms to profit from synergies. The institution is located in a former office building.

Adamant, the day-hospital, is located on a barge on the river Seine in the heart of Paris. It is part of the big psychiatric hospital Esquirol and opened its doors in this new location in July 2010.

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500m

18 CPNVD, overview of location 19 CPNVD, siteplan and access

4.1 General Infromation CPNVD Offer Stationary hospital and ambulatory Philosophy Let the patient feel that he is in a hospital, where he gets professional treatment, and which he has to leave as soon as his condition allows him to.

Systemic approach: emphasises on integration of patient’s environment in therapy Technical data Construction: 2003 Admission hours: stationary clinic 7/7 days – 24/24h, ambulatory 5/7 days – 8/24h Floor surface: approx. 7200 m2 Capacity: 56 beds (3x14 beds adult psychiatry, 14 beds geriatric psychiatry) Average length of stay: 17 days More Units are not separated by disorders, except geriatric unit Patients are under occupied during the day. Many linger around, watch TV and are bored.

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20 La MĂŠtairie, overview of location 21 La MĂŠtairie, siteplan and access

La Métairie Offer Private stationary clinic for private and semi-private insured patients Ambulatory, covered by basic health assurance Philosophy Providing psychiatric care with high hotelier standard Emphasises on the patient’s autonomy Technical data Construction: 1860, (listed building) Admission hours: stationary clinic 7/7 days – 24/24h ambulatory 5/7 days – 8/24h Floor surface: approx. 3000 m2 (only main building) Capacity: 35 beds in 2 units (only main building) Average length of stay: 28 days (varies strongly: one patient is there since 30 years) More: This psychiatric clinic is not well accessible by means of public transport but since its clients are rather wealthy, they arrive usually by car or taxi.

Units are not separated by psychosis (except addiction disorders)

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22 KSPAP, overview of location 23 KSPAP, siteplan and access

KSPAP Offer Provides three units for three different states of health: crisis intervention, acute day-care clinic and rehabilitation clinic Philosophy To provide services for as many as possible, the patient comes only according to a previously defined plan of therapeutic activities The patient should not hang out in the centre before or after the therapeutic activities Technical data In current premises since: 1983 Floor surface: approx. 2500 m2 Admission hours: crisis intervention 7/7 days 24/24h, acute day-care clinic 7/7 days 13/24h on working days, 4.5/24h on weekend Clinic for rehabilitation: 5/7 days 8/24h Length of stay by unit: 6 days in crisis intervention, 3 – 9 months in acute day-care Clinic or/and rehabilitation clinic More The institution works only with patients that come voluntary and collaborate New concept of day-care hospital that provides also a small number of beds for a stay of maximum six nights. This can be an alternative to stationary care in some cases and provides a continuous treatment.

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500m

24 Adamant, overview of location 25 Adamant, siteplan and access

Adamant Offer Combination of day-care centre and therapeutic club Philosophy Provide informal therapy in a comfortable environment Open door policy Emphasize on horizontal relation between care-team and visitor in the therapeutic club Technical data Running since: July 2010 Floor surface: 600m2 Admission hours: 5/7 days – 8/24h Average length of stay: 2 weeks – 15 years Capacity: 120 persons per day More Bar is managed by therapeutic club.

Belongs to Hôpital Esquirol of Paris. Employees work in several facilities on different days to promote continuous care by same staff and exchange knowledge.

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26 – 28 CPNVD, exterior view

4.2 Relation to society / Expression of building The physical presence of a psychiatric institution can substantially shape its image in the population and make an important contribution to combat stigmatisation. The building’s appearance is also indicative of the position that the psychiatric structure takes toward its users and toward society.71 In this part we want to discuss the issues, which we treated in the theoretic part of our work, by providing concrete examples.

CPNVD The psychiatric clinic in Yverdon is located only six hundred meters from the train station and the city centre in a former industrial area surrounded by diverse educational institutions and some smaller businesses.

The building finds itself in a rather difficult environment where no one would expect a psychiatric institution. It was not an easy task to find a good architectural solution to make it blend in with the surroundings, while at the same time claiming its specific role. It was an advantage that the psychiatric clinic was one of the first new constructions in this area; there were no alarmed neighbours raising objections.

Today, the institution integrates itself to some extent into its surrounding by means of proportions, rhythm of the façade and alignments with the nearby industrial buildings. But at the same time, it marks its autonomy by its strong shell of red tinted concrete and by its freestanding form.

Through its shell and rather small openings, the building expresses a protective character. The institution’s strong appearance fulfils two important roles: firstly, it shows to the public that mental illness is part of our society and that people with mental disorders are not to be excluded from the same. As we have seen in the previous chapters, this helps to reduce stigmatization and prejudices.

Secondly, the building’s presence communicates to the public that there is a place where they will be looked after, should the need arise.

As a consequence of the prominent location in the emerging neighbourhood, encounters between patients and the public have to be planned carefully. In the CPNVD, a public restaurant, where employees from the vicinity can eat lunch or have a coffee, promotes natural encounters that ultimately contribute to a lessoning of prejudices. The protected but still open forecourt, where patients hang out, is also an important transmitter of the institution’s image. But encounters could have been pushed further by a shared outdoor space that invites patients as well as the public. 72

71 See chapter 2.1.

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29 – 31 La Métairie, exterior view

La Métairie In contrast to the CPNVD, the clinic la Métairie, through its remote location to the city, does not seek connections to society. It provides the patient with a calm and protected ambience, not through a strong shell like the CPNVD, but through its location in a big park surrounded by trees.

The clinic is 1.2 km outside of Nyon’s city centre, on the shore of lake Geneva. Direct views in from the outside of the plot are not possible. The clinic’s strength is the peaceful and relaxing environment. Many foreigners are attracted by the discreet setup. Those clients want to get treatment in an intimate environment without the risk of being noticed by the public. Since this place is not primarily a centre for crisis intervention, it places emphasis on the patients’ amenities.

Patients usually do not leave the plot during their stay and do not participate in events that take place in the clinic’s vicinity. Certain patients might perceive this as a positive characteristic of the clinic, although it can be a disadvantage for some. The patients are isolated on the plot and little walks to the city are not possible because of its distance.

To handle the increasing demands for ambulatory treatment in the region, the clinic developed an ambulatory a couple of years ago. 73 In contrast to the stationary part of the clinic, local patients with general insurance may also benefit from the large range of options. Thanks to the ambulatory, the clinic’s therapy options more efficiently use their capacities, and the private hospital was able to establish a presence in the local health care system.

73 cf. 150 ans histoire de La Métairie, p. 39 Chapter 4: Case studies

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32 – 34 KSPAP, exterior view

KSPAP The day-care hospital is, thanks to its central location, optimally linked to the public transportation system. Office buildings, educational institutions, a restaurant, several apartment blocks and a former military site, which is now used by the police, surround the institution. The building was originally conceived as an office building and a warehouse, and corresponds to the vicinity’s prevailing typology. The KSPAP is thus camouflaged in a building, which reveals nothing of its function.

The institution presents itself by craftwork in the shop windows of the former retail space, which today hosts the cafeteria. Due to the camouflage, the KSPAP misses the opportunity to convey a more favourable image of itself to society. Instead, it hides in the disguise of a regular office establishment, or even a warehouse. As a pubic institution, the KSPAP could provide its surroundings with an additional value. That could be a little plaza used as a meeting place or a cafeteria accessible to the public. 74 One must note, however, that those responsible are not happy with certain issues themselves, and would like to change things, but are unable to do so. This is an often seen problem: a psychiatric clinic is housed where a building is available, and those in charge have to make the best of it. Awareness should therefore be triggered in higher spheres.

74 See 3.1 for further information Chapter 4: Case studies

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35 – 37 Adamant, exterior view

Adamant The day-care centre Adamant lies only three hundred meters away from the big train station «Gare de Lyon».

Due to the exceptional and isolated location on the river, many questions in relation to the environment do not arise in the first place. Classical psychiatric related challenges, such as disagreeing neighbours or the access’ design, do not even come up. As a houseboat, and therefore not place bound, the design does not need to produce a specific relationship to the surroundings. Dimensions, proportions, and materials derive rather from the naval industry. Nonetheless, the centre tells the observer a lot about its clients. The fully glazed façade with wooden movable flaps opens to all sides and seeks visual contact. At the same time, it remains an autonomous island in the middle of the city. The Seine and its banks, unlike the rest of Paris, offer something special: a lot of unspoiled space. The rooms of the Adamant have therefore a quality that other places in the capital can only get with a lot of money: a view and clearance.

To enter the boat, visitors must leave the ground first. This step seems a little bit as if, metaphorically speaking, one is leaving society. From the water a more distant view of the city is possible and problems can be considered from another angle. The view and the air around the institution make an important contribution to this process.

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public accessible space

38 – 40 CPNVD, sequence access 41 CPNVD, entrance hall 42 CPNVD, site plan access

4.3 Access The clinic near the city centre, which we have praised repeatedly, makes a major contribution toward reducing the existing stigmatization. 75 The challenge for the architect begins, however, when a new person is admitted to the hospital. The close vicinity to the city centre turns into a risk of stigmatization since, starting from that moment, it is not about psychiatry in general and how it is perceived in society anymore, but rather about an individual who becomes a patient. The central location contains the risk that the person is recognized and experiences personal stigma. 76 Admission to a psychiatric stationary hospital seldom happens on the patient’s request, and it is in any case a very difficult situation. The first impression when entering a hospital is therefore essential, and can influence to a large extent whether the hospital stay is experienced positively or negatively.

CPNVD The freestanding building is situated on a plot that is accessible from three sides. There are four entrances: the main entrance via the forecourt, the access for emergencies which is directly reachable from the road, the access to the ambulatory which is located on the north-western side, and the delivery on the south-east. The employees have an additional entrance through the parking garage.

When approaching the building, the expressive character and the form are distinguishable from afar.

The main entrance’s access is not head-on; one has to go along the smaller part of the two wings. The forecourt, which the patients and visitors use to sit outside, reveals itself at the last moment. Since a green open area separates the clinic from the neighbouring plot, outsiders are kept at a distance.

The lateral access maintains the intimacy, and visibility is only possible over the green area.

The red-coloured concrete walls and the red floor penetrate the building’s interior and form a fluid transition from the outside to the inside. This makes the entrance hall appear as an exterior space.

The generous glazing also allows for good visual contact between the two areas. The importance of the green space here becomes apparent again. It prevents passers-by from approaching too close to the entrance area. The intimacy, despite the generous glazing, is thus also preserved here.

In the historical overview we discussed the Ospedale degli Innocenti. 77 As back then, many different elements are used to form the access to the CPNVD. Their common goal is, rather than separating the clinic from the city, to form a slow transition from one to the other. They prevent a sudden threshold, while still preserving the patients’ privacy.

Inside the building, the foyer has on either side of the main entrance double height areas. These are equipped with sofas and allow patients and visitors to meet and interact. Located in the axis of the entrance is a wall that separates the public part from the internal areas, and also houses the reception. The reception is therefore clearly visible, but not overly imposing. Via the foyer one can reach the restaurant, which is open to the public.

75 cf. part 3.1 76 See 2.1. for further information 77 See 1.2 Chapter 4: Case studies

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public accessible space

43 – 45 La Métairie, sequence access 46 La Métairie, siteplan access

La MĂŠtairie The building is situated on a large plot, which is fenced in by trees and bushes that block the view of the clinic. Only after entering the plot does the building become visible.

The driveway leads frontally to the building and emphasizes its symmetrical and lord-like character very well. Nevertheless, when approaching, only portions of the building are recognisable as the trees filter the view. In addition, a large tree stands exactly in the axis of the entrance and hides the view of it until the last moment.

The sophisticated privacy protection is apparent. From the clinic, one has neither a direct view of the access road nor the entrance area. The privacy is thus optimally protected both from the outside and the inside.

A few steps lead into the clinic’s vestibule. When arriving in this space, one has the feeling of absolute freedom of movement, as different directions in the building are available. In addition, the first thing one sees is the facing living room with a generous glazing behind which the park is identifiable. The institution’s philosophy becomes clear immediately upon entering: the patient should feel as free as possible and like he is at home. No supervision is noticeable and one can leave the building at any time, without being seen by the receptionist.

On either side of the vestibule, long corridors lead to the units. Sofas and armchairs invite one to relax and to exchange. Only behind the vestibule is the foyer with the reception located. The reception is comparable to that of a hotel, and personal interaction is important. This space is the node of the strictly symmetrical clinic. In the central axis, behind the foyer, the living room is located.

The carpet, the couches, the fireplace, the piano and the paintings on the wall are reminiscent of a comfortable upper middle-class living room.

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public accessible space

47 – 50 51

KSPAP, sequence access KSPAP, siteplan access

KSPAP The day-care hospital is located in a former office building and surrounded by dwellings, a restaurant and tertiary education institutes.

The institution presents itself with shop windows to the street. Upon first visit, one is therefore trying to enter through the door between the windows, behind which the clinic’s cafeteria is located.

This door is closed however, and only when searching further does one find a discrete entrance on the lateral access road. Since there is no direct view from the street, the main entrance is very discrete.

The entrance door opens into a dark room. From there one has the possibility to go via the staircase to the upper floors, which houses the consultation and therapy rooms. Another corridor leads from the entrance room to the cafeteria, where patients and the staff spend their breaks. The secretariat is located between the cafeteria and the staircase, where it is hidden behind the doorframe of a former office. It therefore has no view of the entrance.

The atmosphere of an office building, in which several companies were installed, is still very present.

There is no entrance hall, which would establish a relationship to the outside, and which would also promote casual encounters and provide a place for an undisturbed conversation, without obstructing the passageway. The cafeteria was originally a retail space orientated toward the street. The connection between today’s entrance area and this room was added later and produces a restless atmosphere. Visual contact to the entrance area, which would be useful in promoting cohesiveness, is missing.

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public accessible space

52 – 55 Adamant, sequence access 56 Adamant, siteplan access

Adamant In contrast to the two stationary clinics, the architects did not deliberately design the arrival. It derives rather from the natural conditions: Adamant is a houseboat and houseboats can only be reached via the riverbank and the landings. A common feature with the CPNVD can nevertheless be found: On the landing a mounted bench invites people to sit down. Upon arrival, one crosses, just as in Yverdon, an outdoor area which is used by the patients and the staff to smoke and to talk.

When passing through one of the many doors into the arrival area, a person directly faces the administration. But unlike in the other case studies, there is no reception. Glazing with integrated blinds separates the entrance area from the administrative part. Those arriving thus have a filtered view of the desks and of the river Seine.

The entrance area hosts several functions. It is at the centre of the institution and leads into the large, circular rooms at either end of the ship. Via two flights of stairs one can also reach the lower deck, or go into the already mentioned administration. Built-in benches, tables and chairs invite one to stay.

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common space room for therapeutic purpose office patient room horizontal circulation vertical circulation entrance

3rd floor

ground floor

2nd floor

N

1st floor

57 CPNVD, plans, spatial organisation

10

20m

4.4 Spatial organisation In this part we want to show how the four establishments translate their different treatment approaches into the spatial structure. The analysis will help us to understand the institutions’ functionality and give us an overview of their organisation.

CPNVD The H-shaped building has two wings with three floors each, which are connected by a central administration block of two floors.

The ground floor is divided into an internal and a publicly accessible area. The public part consists of a spacious foyer, a restaurant and a conference room. A side entrance leads to the ambulatory on the first floor. Therapy rooms, the emergency access and a technical part form the hospital’s internal space and are also located on this level.

Psychiatrists, psychologists, social workers, and the administration have their offices on the first floor. The four stationary units are located on floor two and three. Each unit consists of twelve patient rooms, examination rooms and some spaces for the staff. The patient rooms are grouped into entities of four, and every entity shares a living room. This subdivision allows for a family-like atmosphere among the patients, despite the size of the complex.

The building offers the patients a series of retreat possibilities that become gradually more public toward the outside. 78 This is important because the patient arrives in a very poor health condition and must feel strongly protected during the first phase. Because of the central location within the city and the limited outdoor areas available to the patients, the internal common areas become even more important for gathering and socializing. Much attention was also dedicated to ensuring that the team members have opportunities to withdraw from the patients. A system of doors creates a clear division of the staff and patients’ areas on the first floor. The employees of the stationary clinics underlined several times the importance of retreat possibilities.

The presence of an administration apparatus that is inaccessible and secretive about what goes on behind the scenes gives the clinic an institutional appearance. There is a risk that the patient feels «administrated» and not in control of his destiny.

78 See also p. 91 Chapter 4: Case studies

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common space room for therapeutic purpose office patient room horizontal circulation vertical circulation entrance

2nd floor

1st floor

ground floor

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58 La MĂŠtairie, plans, spatial organisation

20m

N

La Métairie Originally, the clinic had only one main building. Over the course of time, three other buildings were built in order to respond to the rising demands. The so-called «Villa», the first added building, houses today primarily older and long-term patients. The most recent building dates back only a couple of years and includes an ambulatory, a spa and other treatment rooms.

We will limit our case study to the original main building, which still forms the heart of the structure. Its plan reflects the organisation of a classical asylum as Esquirol proposed it. 79 Originally the separation of men and women took place in either wing of the symmetrical layout. The agitated patients were located in each of the extremities with their own closed courtyards, 80 which are only accessible through the building. The premises listed building and adjustments are only possible to a limited extent. The building, therefore, has barely changed from its original form but is today used according to contemporary principles. The patients are no longer segregated by gender and separations are made according to diagnoses rather than degree of agitation.

All the common rooms, therapy rooms and rooms for the staff are situated on the ground floor.

The patient rooms are located on the upper floors. Originally, the second floor was reserved for the nurses, who at the time were rather «dames de compagnie», but today patients also use this area.

From an hotelier’s point of view, the building offers an additional value through its history and the impressive architecture, but viewed from a functional angle, it is not efficient. Due to the symmetrical and linear organisation, the paths are unnecessarily long and synergies within the complex cannot be used in an optimal way. However, there are also spatial qualities, such as the corridors on either side of the vestibule that are equipped with sofas and invite people to linger.

A particularly high level of attention is paid to the patients’ liberty. It is striking that, except for a few offices and technical areas, the whole building is accessible to the patient.

79 cf. 1.4: 19th century – construction of the asylum 80 cf. 4.6 : exterior spaces Chapter 4: Case studies

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common space room for therapeutic purpose office patient room horizontal circulation vertical circulation entrance

2nd floor

basement

1st floor

59 KSPAP, plans, spatial organisation

10

20m

N

ground floor

KSPAP The building has been modified only slightly for its new use, and the original functions (office and storage building) are still very present. It is not surprising that the layout focuses on the most efficient distribution of rentable square meters. This means that between the spaces with specific functions, few activities can take place, and the building also appears rather closed on the inside.

All three units are located on different floors but share most of the therapy rooms which can be found on all floors. The crisis intervention unit, where patients have the possibility to stay up to six days in exceptional cases, is located on the ground floor. The cafeteria and the group kitchen, which are used for cooking in a therapeutic environment, are also located on the ground floor, but on either side of the isolated crises intervention unit. The rehabilitation unit finds its place on the first floor. It comprises several therapy rooms that are also used by the other units. The acute hospital with some examination rooms and offices is situated on the second floor. Some more therapy rooms, which are used by all units, can be found in the basement.

A logical organisation of the functions can only partially be identified. Since the building’s structure was already there, the functions had to be placed in rooms that were suitable but sometimes located far from each other. Unfavourable associations, complicated connections and unused synergies had to be accepted. The separation of the community kitchen from the cafeteria by the crisis intervention unit is just one of many compromises that were made.

Since the patient is not supposed to linger in the building before or after his consultations, little space has been dedicated to informal encounters. The cafeteria, which is connected to the main entrance, is the only room that is freely accessible to all patients and staff members.

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common space room for therapeutic purpose office horizontal circulation vertical circulation entrance

upper deck

lower deck 5

10m N

2.5

60 Adamant, plans, spatial organisation

Adamant This floating construction has an upper and a lower deck. The spacious entrance area is located on the upper deck and is adjoined by a small administration area. A therapeutic club rents the rotunda on the lower end of the barge. It is equipped with a bar and seating possibilities, and functions as the reception area of the day-care centre. The room in the other rotunda of the upper deck is used for various activities. On the lower deck three more spaces serve as multi-purpose rooms and can be closed if needed. There are also two meeting rooms, where private conversations are possible.

The construction is characterised by a high degree of flexibility. Few rooms are separated by walls, with the exception of the administration area on the upper deck and the two meeting rooms on the lower deck. Most spaces on the barge are used for various activities. Fixed equipment, such as the kitchen, the bar or the few sanitary installations, limit and structure the fluid space. The upper and lower decks distinguish themselves by different ceiling heights and different acoustic properties. On the lower deck, one can barely hear noise from outside, since the room is up to the knees below the water level.

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commoncommon space space Sequence –areafrom private to public commoncommon space part space of circulation part of circulation area The visualisation of the spatial sequences from the most public to the most private spaces shows room forroom therapeutic for therapeutic purposepurpose office office the huge differences between the psychiatric institutions, at a glance. patient patient room room In the CPNVD the ramifications and the gradual transitions stand out most. In contrast to La Méhorizontal horizontal circulation circulation tairie, there is more happening in the private part. The floor with offices in between the patient vertical vertical circulation circulation

rooms and the exterior space acts as a buffer zone and strengthens the feeling of retreat in the stationary units.

The diagram of La Métairie shows that the transition from the areas that are the most private to those that are the most public happens more abruptly. The layout is similar to a hotel, where the client’s room is connected to the common spaces without any intermediate steps. In comparison to the CPVND, we have to consider the fewer patients and the building’s location in a protected park that makes this more open organisation possible. A significant difference also exists in the position and number of rooms reserved for employees, which are all directly accessible from the public area.

This increases the staff’s availability and has a positive effect on the atmosphere of a transparent organisation. It is the patient that can retreat more than the employees, rather than vice versa.

common space common space part of circulation area room for therapeutic purpose office patient room horizontal circulation vertical circulation

CPNVDCPNVD

61 Spatial sequences from private to public

La Métairie La Métairie

In a day-care hospital, the patient comes, as the name already suggests, only during the day. The ability to retreat, therefore, does not have the same importance as it does in a stationary clinic.

In Z체rich, apart from the few short-term inpatient rooms, the patient only attends the facilities for a clearly defined program and a clearly defined amount of time, and always stays in the same room.

This explains the high density of therapy rooms in comparison to freely usable common spaces. On the graphic we can also see that the therapy rooms are scattered and that the connections are organised in an awkward way.

The graphic of Adamant shows the very simple structure, which is due to its size and its open organisation. Everything is close and it is easy to keep the overview. The high number of common spaces and the central organisation show that the informal social interactions receive much more importance in Adamant than in Z체rich.

PUKZHPUKZH - Milit채rstrasse - Milit채rstrasse

Adamant Adamant

not accessible to public

not accessible to public

accessible to public

accessible to public

most private most private

most public most public

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62 La Métairie, original (ca. 1860) 63 La Métairie, replacement (ca. 2006)

64 La Métairie, original (ca. 1860) 65 La Métairie, replacement (ca. 2006)

66 La Métairie, replacement (ca. 1986) 67 CPNVD, original (2004)

4.5 Window analysis On this and the following pages we will take a close look at the windows of psychiatric facilities to analyse not only their relationship to the outside, but also their position toward the clients. Unfortunately, we were not able to visit the small stationary part with the patient rooms in the KSPAP in Zürich. This made a serious analysis impossible. Adamant has no patient rooms as a day-care centre.

The two intermediate structures are therefore not discussed in the first part of the analysis.

Comparison of patient room windows The compilation of the six different window types shows the evolution that patient rooms have undergone. In the examples of the La Metairie, it is apparent that the original windows, dating from 1860, were designed to the last detail specifically for psychiatry. The newer replacement windows are standard models from the catalogue. In the most recent example, the patient windows of the CPNVD, the development leads back to a specific typology with a sophisticated system.

In the time of the earliest windows represented here (fig. 62 and 64), there were two ways to protect patients from themselves. Either the openings were designed to be too small to jump out of, or a metal grill on the outside was installed. Although the glazed surface is in both cases relatively large, the view outside is nevertheless very limited. The oldest example stands out due to the strong presence of subdividing glazing bars that make the windows less transparent. It conveys, just like the grid in fig. 64, a feeling of confinement.

For the newer standard windows (fig. 63 and 65), no special considerations about the demands on psychiatric windows are visible. We suspect that the security precautions decreased with the rise in drug treatments, and that the approximation to a hotel room and the feeling of liberty became more important. The latest window type (fig. 67) shows again a sophisticated security system, without giving the patient the feeling of imprisonment. The two functions of a window, ventilation and view, are separated.

The analysis clearly shows how big the impact of the different parts of an opening (frame, glazing bars, dimensions, and materials) is. They can transmit any feeling between «locked up» and «liberty«.

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0

1

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68 La MĂŠtairie, single room

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70 CPNVD, double room

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Patient room The opening in the CPNVD is more than a simple window. It is the connection to «the world out there». This feeling is reinforced by the fact that the golden window frames are the only elements that are visible on the red façade, as well as in the white room. 81 In contrast to the clinic la Métairie, it is the separation between the inner and outer space, and at the same time, the threshold between the hospital world and the outside. The opening is relatively small, since the patient needs to feel protected and not displayed. Its sill has the right dimension and height to sit comfortably in the window. Since it is aligned with the outer façade, the patient can sit very close to «the world out there» but feels at all time the wall’s protective thickness. He is, so to speak, between the inside and the outside.

As opposed to la Métairie, the window is not perceived as a hole in the wall, but rather as an opening to the outside. The sill’s height and the window that reaches all the way up to the ceiling reinforce this impression. The window is custom-built and makes, through the material’s choice, dimension and the ventilation grill, no reference to the domestic.

It was important to the architects that each patient’s room always have two windows. The view is not guided and the patient can always choose between different perspectives. In double rooms, the architects didn’t want to give one bed a preferred status. Even in double rooms every patient has his own window in the longitudinal axis of the bed. In contrast to general hospitals, there are no «window-beds» or «corridor-beds«.

The patient room in La Métairie is similar to a hotel room, which expresses a domestic scale by the furniture, the decoration and the standard window. As in Yverdon, a view is available through two windows.

When the patient looks out of the window, he sees the clinic’s park. As opposed to the view from the CPNVD, nothing in his range of vision can remind him of society «out there«. The window therefore does not form a threshold between the hospital world and the outside world.

81 cf. Pathfinders, p. 122 Chapter 4: Case studies

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CPNVD

La Métairie

PUKZH - Militärstrasse

Adamant private 71 CPNVD, exterior view 72 La Métairie, exterior view 73 KSAP, exterior view 74 Adamant, exterior view

75 CPNVD, relation interior – exterior 76 La Métairie, relation interior – exterior 77 KSPAP, relation interior – exterior 78 Adamant, relation interior – exterior

buffer zone

public

Window analysis – common spaces The diagrams on the left clearly show that all four examples use large glazing in the common areas.

They are located on ground floor level and have, with the exception of la Métairie, contact to the public space. The connections of inner to outer space are designed differently because the rooms have differing requirements of intimacy.

In the CPNVD, the cafeteria and the conference room seek, by their function, the strongest relationship to the outside. The green area provides the necessary privacy without restricting the view.

In La Métairie, «outdoors» is still part of the clinic. The question of the window’s size and position in the privacy context does not arise here. The openings should instead provide a smooth transition to the protected outdoor area and allow views to the greenery.

The KSPAP presents itself by a street facing the shop window. The cafeteria that is located just behind it is not publicly accessible and maintains an atmosphere protected from unwanted views.

Unfortunately, the view to the outside is not filtered but blocked by a partition wall. The interior consequently has no possibility of establishing any kind of connection to the exterior.

In Adamant, the distance to the city, as well as the wooden shutters, make a uniformly glazed façade possible. When the day-care centre is closed, the shutters act as a protective skin. During opening hours they will be flipped up to let light and air into the rooms, and to at the same time filter the gazes. Thanks to the shutters, people can know from afar if the day-care centre is open and ready to welcome the users.

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79 CPNVD, view public accessible open space 80 CPNVD, plan public accessible open space

81 La Métairie, view public accessible open space 82 La Métairie, plan public accessible open space

4.6 Outdoor spaces We reported extensively on the positive qualities of outdoor spaces in the third chapter. 82 If they manage to offer an additional value to everyone, they can positively influence the clinic’s reputation within the community. The outdoor spaces affect patients and employees in a favourable way, since it offers them recreational and meeting places.

Publicly accessible outdoor spaces Although publicly accessible outdoor spaces are open to everybody, they belong clearly to the psychiatric facility. Through this affiliation, the patient gets the feeling that this place «belongs« to him, and other users are perceived as guests. This encourages not only the patient’s sense of security, but also fosters – in the ideal case – encounters between patients and the community.

CPNVD: While the north-facing facades are reserved for accesses, the forecourt and the open spaces on the south-eastern and south-western side of the clinic form the publicly accessible outdoor spaces. The forecourt works well in its role as a place of arrival and as a protected abode for the patients. The south-facing open space is protected from the traffic and would have the opportunity to be used. Unfortunately, its potential is not realized. The green space between the clinic and professional school acts, in reality, as a «restricted area» between the two worlds. We were able to observe how patients and students sat only on either rim of this zone. This observation convinced us that there is a demand for using this open space. But trees, which would provide shade, and other furniture that would make the space usable, are lacking. In our opinion this place has the ideal conditions to bring the patients in contact with society. Since the students frequent the professional school for a longer time period, they get used to the presence of the patients. Fright and staring might give way to a naturalness and form the basis for casual encounters.

From a patient’s point of view, the gradual transition from private to public spaces works well in the clinic’s interior. 83 But this same system is not used rigorously enough in the outdoor areas. A gradation of outdoor spaces is missing and patients, who are not able to leave the clinic’s grounds for walks, have limited outdoor spaces to choose from.

La Métairie: A seven hectares large park with a variety of different greenery surrounds the private clinic. On the edge of the plot a sophisticated planting system protects the hospital from views in three layers. Bushes, medium-sized trees and long-stemmed trees, like for example black pines, form a green border. The park contributes a lot to the hospital’s peaceful environment and offers all the advantages that we described in detail in «the important role of gardens and parks». 84

82 See 3.X. for further information 83 cf. 4.4.

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83 KSPAP, view, public accessible open space 84 KSPAP, plan, public accessible open space

85 Adamant, view, public accessible open space 86 Adamant, plan, public accessible open space

KSPAP: Zßrich’s day car clinic has no publicly accessible outdoor area. The access road leading to

the main entrance and to the delivery platform could nevertheless be seen as such, since people often smoke in this quiet side street. But the spot does not belong to the clinic and no equipment, inviting people to stay there, is installed.

Adamant: The outdoor space in the day care centre is limited to a few square meters. If the weather is nice, the users linger on the gangways, which are equipped for this purpose with large benches. Due to the periodic floods and the resulting evacuation procedures, the city keeps the river’s banks free of infrastructure. The hospital management nevertheless had the option to rent a small open area just in front of the Adamant. There are currently a few sparse trees and a few chairs.

The administration is considering purchasing more furniture so that the open area can be used during the summer for activities. During their lunch breaks, employees of the nearby office buildings use the promenade for jogging, picnicking or a stroll. If the day clinic carried out activities on the bank, a zone of natural encounters between the employees and the clinic users could emerge.

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87 CPNVD, view, private open space 88 La Métairie, plan, private open space

89 La Métairie, view, private open space 90 La Métairie, plan, private open space

Protected Outdoor Spaces We named those spots in the fresh air, which are only available to users of the institution, and where they are protected from curious eyes, «protected outdoor spaces». In this framework patients can explore the soothing effects of nature without being able to harm themselves or to run away in a confused state.

As mentioned before, one of the main goals of psychiatric treatment is to lead patients back into society. Many people retreat after a collapse and every step towards reintegration needs to be relearnt. The protected outdoor spaces are an important feature, since they allow the patient to perceive and to observe the outside world in a safe setting. «The world outside» consists not only of social contacts and role distributions, but also of the weather conditions, smells, sounds and more, all of which affect our psyche. To us, the protected outdoor spaces are a stopover in the therapy process, where the patient, alone or in groups, consciously or unconsciously, perceives all those external factors. One can imagine, for example, a group therapy or an art therapy taking place on the rooftop terrace in the fresh air. The aim is to get the patient out of the interior’s protective and insulating atmosphere.

CPNVD: The roof terrace on the second floor forms the clinic’s protected outdoor space. Theoretically both adjacent units have an entrance, but in the hospital’s daily life only the geriatric have access. 85 The place is either designed for patients who are in an immediate crisis and are thus not able to leave the building, or for confused patients who cannot find their way around (especially patients suffering from dementia). Their states do not permit leaving the building. Other patients do not want to go in the forecourt for fresh air, but prefer the more sheltered atmosphere of the roof terrace. The safety precautions are high enough that patients can go outside without supervision.

In our opinion, too few patients can benefit from the terrace. Patients whose conditions are stable enough should have access even if their unit is not directly linked to the terrace. To us, this outer space is aggressive and not very comforting. This is due to the red colour that might be too present, but also to the bare surfaces and the hard lines. In addition, one feels observed due to the many windows. We regret that there are not more plants or flowerbeds available. They could contrast with the red colour and the patients would have, although limited, access to nature.

La Métairie: The two lateral courtyards go back to the days when patients were separated according to their degree of agitation. 86 The two courtyards are located in the longitudinal axis to each side of the main building. They are only accessible from the building, and a sophisticated natural barrier of a fence, a ditch, and bushes on either side separates them from the park. Available seating and table tennis suggest that this place is used for smoking and recreational activities. The patient is under the open sky and still protected. A few steps and a glazed terrace join the interior and the courtyard. The location thereby attains a character similar to a villa’s garden and seems very pleasant, even though it is completely closed.

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91 KSPAP, view, private open space 92 KSPAP, plan, private open space

93 Adaman, view, private open space 94 Adamant, plan, private open space

KSPAP: The space between the L-shaped day hospital and the neighbouring building is a patio of

sorts, and is only used during good weather. The cafeteria that has a direct door is the most frequently used point of access, but it is also accessible from the staircase. The space is relatively quiet but has a slightly threatening effect, since it is clamped between the two high buildings. Visual contact to and from the road is reduced, thanks to an opaque, shoulder-high gate.

Adamant: The day centre Adamant does not have a true protected outdoor space. The long balconies on the riverside are the only places one could assign these qualities to. On the upper deck, only the administrational part gives access to the balcony, and therefore it is exclusively used by the team to smoke. On the lower deck’s balcony, a staff member must always accompany the patients for safety reasons. We regret that the centre does not have a more generous place in the open air, where safety concerns are no issue. Many houseboats have roof terraces where potted plants protect from others’ gazes. We wonder whether this could have been an ideal option for a protected outdoor space for the day care centre. On the other hand, the whole building is, for a large part, glazed, and in summer the majority of the windows are open. As a result, the demand for a protected outdoor space may not be as great as elsewhere.

Conclusion Outdoor spaces Acute care hospitals have a legitimate claim for protected outdoor spaces, in order to allow troubled patients access to fresh air in a protected environment. In intermediate structures an outdoor area is just as beneficial, but it cannot be considered an absolute necessity. As we have seen, there are various ways to design such a place.

Too little attention is generally paid to the quality of external spaces, and their potential is therefore not exploited. This may (as in the case of Adamant) already occur in the design phase, or it may be neglected in the organisation and management of the institution (as in the case of the CPNVD).

Little effort would be needed to make these areas more attractive. Plants have a big impact on the atmosphere, but they need maintenance, and the question of who will take responsibility arises. Nevertheless, it seems beneficial to include plants in therapy, and the maintenance could be part of it.

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4.7 IMPRESSIONS oF tHE iNTERIOR sPACES CPNVD, Yverdon

95 Patients room 96 Common space geriatrie 97 Cantine

98 Entrance hall 99 Corridor patients area 100 Room for ergotherapy

La MĂŠtairie, Nyon

101 Corridor 102 Patients room 103 Living room on the extremity of the building

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KSPAP, Z端rich

107 Office/private discussion room 108 Tabletennis in basement 109 Corridor

110 Waiting area 111 Music therapy/ pleasure therapy in basement 112 Art therapy room on 1st floor

Adamant, Paris

113 Library on lower deck 114 Multipurpouse room with stored tools for therapeutic activities 115 Group discussion

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4.8 Conclusion CPNVD The psychiatric clinic in Yverdon-les-Bains was built only a few years ago in close collaboration with the responsible specialists. The architects succeeded in translating the exact ideas of the leading medical team into a sensitive project. The building is able to convey the institution’s clear position towards society and towards its users. The striking red facade and the clean, white interior underline this bilateral position.

We understand Mrs Montandon’s belief that a stationary clinic is not a hotel, and that the patients should be aware of their condition. In our opinion, however, the architects were in some points too severe. We wonder whether it was really necessary for the patients’ rooms to be that bare and only sparsely furnished, or whether the roof terrace, which is characterised by hard lines and the pervading red colour, can fulfil its objective as an outdoor space. There is some doubt on whether or not an environment that is at times perceived as uncomfortable, and that the patient wants to leave as quickly as possible, can have a positive effect on the healing process, since the patient mobilises all his energies.

We like this project because of the many stages between the most private and the most public areas that are provided to the patients, and also because so much attention was paid to the protection of their privacy.

La Métairie After seeing the CPNVD, we also visited the private clinic La Métairie in Nyon. We were surprised that two hospitals, which have on first sight similar missions, can have such differing layouts.

Some reasons can be found in the larger budget of La Métairie, as well as in the higher demands of the clients. But more importantly, when this clinic was built more than a hundred and fifty years ago, the average length of stay was a multiple of the average in today’s acute care hospitals. Therefore, the clinic more resembles a rehabilitation hospital than an acute hospital. The average length of stay in La Métairie is even today longer than in the CPNVD, for example.

At the beginning we were sceptical about the concept of the private hospital, where the patients are treated like in a first-class hotel. We recognise however, that people should be treated within their cultural environment so that they can feel comfortable, We believe that the freedom and the possibility to benefit from the undisputed healing effect of nature as a therapeutic tool are the advantages of this clinic. It clearly offers the possibility to retreat and gain peace of mind. The charm of the property comes from, among other elements, the historically significant architecture, although the spatial organisation is no longer very efficient according to today’s standards.

La Métairie makes an important contribution as a component of the broad offer of mental health facilities that cover all individual needs.

KSPAP The KSPAP in Zürich addresses patients already in a state of crisis and covers with its care a large part of the healing process. Due to the additional supply of short-term beds, it is also a real alternative to stationary treatment.

In order to stay efficient, a conscious decision was made not to create a hangout place like in Adamant, where patients can come and go as they wish. Many therapeutic club-like structures exist in Zürich, but in other locations.

It is interesting to see that the institution is able to fulfil its mission despite the unfavorable architectural conditions. The centre however, can, not nearly exploit the therapeutic potential of informal encounters that happen before and after scheduled consultations.

We regret that all efforts to give the centre a more personal touch and to make it more comfortable only occurred in the individual rooms. The long corridors appear even more anonymous and give the whole building a constricting character.

Adamant The atmosphere in the day-care centre corresponds much more to a cosy corner pub than to a psychiatric setting. In this regard the dedicated medical staff and the architect succeeded in creating an open meeting centre. In the first place, one enters a houseboat and not a psychiatric institution.

This circumstance might help to create, seemingly without effort, an atmosphere that is in no way reminiscent of an institution. This absence of a medical environment brings a therapeutic impact to the building.

Due to the day-centre’s small size, many different therapeutic rooms had to be housed in one space.

Modifiable premises were the most obvious solution. But the architecture’s flexibility is only able to develop to its full extent, because the organisation of the staff is also very flexible.

The project, however, fascinates us mainly because the centre is able to create with simple means an island in the city centre. Through the step from land to barge, one seems to leave society for an instant, and receives therefore a distant view of the same.

General We tried to break down the complex apparatus of the four case studies into their architectural components. We do not judge the individual institutions as good or bad. All of them show remarkable as well as less favourable solutions to complex situations.

Each of the examples addresses a different target group, take on a different position in the handling of patients, and has a different starting position. All these factors influence the architecture.

The diversity of the case studies allowed us to obtain a broad overview of different approaches. We realised that if a psychiatric facility covers a too wide range of the healing process, contradictions may arise in dealing with patients and their environment. We particularly noticed the importance of the structures’ flexibility and adaptability for changing ideas and needs.

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Conclusion of research Thanks to the elaboration of the theoretical part, in combination with the practical case studies, we obtained a broad overview of a topic about which we knew little in the beginning of the semester. The more knowledge we gathered, the more our interest grew. The field of psychiatry is incredibly large, and we were unable to examine all the aspects extensively in the given time frame. The work could still be enriched with many further topics, but it would be beyond the scope of this énoncé théorique. We tried to find a good balance between a wide coverage and the in-depth discussion of certain points.

Through the case studies we have come in contact with many interesting people, and we were able to conduct detailed visits with several psychiatric institutions. We were not able to accommodate all of the acquired information in this work, but they will be of great use in the upcoming project.

Those undergoing Psychiatric treatment and the «healthy» members of society are still in a complicated relationship, the gap between the two worlds is still large, and the issue of stigma still exists. It is therefore necessary to work actively on integrating the two groups, and we believe that architecture can provide an important contribution.

To date, there are two different architectural approaches to respond to the situation. On the one hand, a building can draw attention to itself and its purpose , therefore creating an awarness. On the other hand, a building can also be very unpretentious, integrate itself into the environment, and thus show that psychiatry is just one part of society. In any case, it is important that the architecture is designed according to the institution’s purpose and needs. It should not pretend to be something it is not. The two approaches should not be forced, but sensitive, and above all, adjusted to the patient’s condition. A space should be created in which society and psychiatry meet naturally.

It has been shown that the boundaries between a person who is classified as healthy or ill are extremely blurred. The patient’s stage of illness is often difficult to determine and alters constantly. Due to a lack of alternatives, too many patients are admitted to stationary hospitals. With its crisis intervention unit, the KSPAP in Zürich suceeded in creating a new model that could be classified as falling between an intermediate and a stationary structure.

The institution decided on an innovative approach that we believe to be

a promising one. The model’s flexibility is advantageous and will possibly become a new trend in the mental health system.

An architct for such building therefore does not deal with just sick or healthy people, but with the whole range in between. This requires not only a high degree of flexibility in the administration and staff, but also in the architecture.

But this also means that a single ideal environment for the mentally ill does not exist. The ideal space depends rather on the patient’s stage of illness. A well-functioning space for the mentally ill has basically the same requirements as such a room for the healthy’ Just as in an ideal residence, a stationary clinic should protect from noise, offer retreat opportunities and promote social interaction. Like the corner pub, an open day centre should welcome everybody, offer a platform for exchange and cooperation, and have quiet seating corners where personal discussions can take place.

In addition however, the room for the mentally ill has to offer more. The organisation of a psychiatric institution, specifically its architecture, influences the patient-patient and staff-patient relationship greatly. Often these different requirements are in conflict with each other. For example, there is a tension between maintaining the patient’s privacy and the necessary control of their actions and activities. It is also the task of the architect to create a protection zone, in which the patient feels comfortable and is able to open up, while at the same time preventing the creation of an «illusionary world», which is so far removed from reality that the patient does not want to return to his old environment. The question also arises over to what degree the space should be open to the outside, in order to enable communication between the patient and the outside world, while still guaranteeing secure accommodation.

The balancing act between the above mentioned requirements constitutes the challenge to the architectural space to be created - and therefore to us.

We believe that the questions raised here are not to be answered in general, by a one size fits all response, but that they need to be answered individually with architectural finesse, according to each situation and considering all of its components.

We are looking forward to developing a balanced and well-planned architectural project for this exciting Themenfeld in the next semester.

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CHapter 6 Annexe Bibliography 150 ans Histoire de La Métairie / Clinique La Métairie (ed.).

Nyon, 2009 Architecture et psychiatrie / sous la dir. Viviane Kovess-Masféty ... [et al.].

Paris: Moniteur, 2004.

Asylums: Essays on the social situation of mental patients and other inmates / Erving Goffman. - 3rd pr.

Chicago: Aldine, 1968.

Geschichte der Psychiatrie: Krankheitslehren, Irrwege, Behandlungsformen / Heinz Schott, Rainer Tölle.

München: Beck, 2006.

Les espaces de la folie / Jean-David Devaux.

Paris [etc.]: L’Harmattan, 1996.

Lieux de folie, monuments de raison: architecture et psychiatrie en Suisse romande, 1830-1930 / Catherine Fussinger, Deodaat Tevaearai.

Lausanne: Presses Polytechniques et Universitaires Romandes, cop. 1998 Nouvelle histoire de la psychiatrie / sous la dir. de J. Postel et C. Quetel. [Ed. rev. et augm.]

Paris: Dunod, 1994.

Pathfinders / Devanthéry & Lamunière, avec un essai de Joseph Abram.

Gollion: Infolio éditions, 2005.

The architecture of hospitals / Cor Wagenaar (ed.)

Rotterdam: NAi Publishers, 2005 The architecture of madness: insane asylums in the United States / Carla Yanni.

Minneapolis, Minn.: University of Minnesota Press, 2007.

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References from the Internet Antipsychiatrie. Glossar, Dokumentation und Kritik der Kritiker, Sponsel, Rudolf. Aus unserer Abteilung Medizinische Psychosomatik, Psychopathologie und Psychiatrie (DAS), IP-GIPT. Erlangen: http://www.sgipt.org/medppp/antips1.htm Annual Rapports 2000 – 2006, Institutions psychiatriques du canton de Vaud, edited by the cantonal commission of psychiatric coordination. Document downloaded from: http://www.chuv.ch/psychiatrie/dpc_home/dpc_infos/dpc_infos_direction/dpc_rapports.htm L’Adamant: l’ hôpital psychiatrique sur l’eau, PratisTV, 2010. http://www.pratis.com/shared/skins/ pratis_med/modules/webtv/video_player.php?id=2351 (rev. 18.12.2010) Antipsychiatrie. Glossar, Dokumentation und Kritik der Kritiker / Sponsel, Rudolf. Aus unserer Abteilung Medizinische Psychosomatik, Psychopathologie und Psychiatrie (DAS), IP-GIPT. Erlangen: http://www.sgipt.org/medppp/antips1.htm (Rev. 30.10.2010) L’architecture au service du soin, B. Laudrat, 2005. Document downloaded from: http://www.architecture-santementale.com/publications-trinh-laudat.asp (rev. 09.10.2010) Architecture et santé mentale, B. Laudrat, 2005. Document downloaded from: http://www.architecture-santementale.com/publications-trinh-laudat.asp (rev. 09.10.2010) Current Diagnosis & Treatment in Psychiatry, Health Search Engine. http://psychiatry.healthse.com (rev. 01.11.2010) En plein Paris, l’hôpital du vogue à l’âme, Eric Favereau, Libération.fr, Paris. http://www.liberation. fr/societe/0101648819-en-plein-paris-l-hopital-du-vogue-a-l-ame (rev. 18.12.2010) Evidence Based Design, Wikipedia. http://en.wikipedia.org/wiki/Evidence-based_design (rev. 20.10.2010) Mener un projet architectural en psyschiatrie, B.Laudat, J.-C. Pascal, S. Coureix, Y. Thoret. http://www.em-consulte.com/article/68663#N1017A (rev. 09.10.2010) Mental disorder, Wikipedia. http://en.wikipedia.org/wiki/Mental_disorder (rev. 20.10.2010) Mental health: strengthening our response, WHO, 2010. http://www.who.int/mediacentre/factsheets/fs220/en/index.html, rev. 15.12.2010 Nomenklaturen – Internationale Klassifikation der Krankenheiten (ICD-10), Bundesamt für Statistik. http://www.bfs.admin.ch/bfs/portal/de/index/infothek/nomenklaturen/blank/blank/cim10/02.html (rev. 26.12.2010) Pratiques de soins en psychiatrie et réflexions sur les éléments du programme architectural, MNASM , 2007. Document downloaded from: http://www.mnasm.com/downloads/new_Version impression.pdf (rev. 10.10.2010)

Psychische Gesundheit, Strategieentwurf zum Schutz, zur Fรถrderung, Erhaltung und Wiederherstellung der psychischen Gesundheit der Bevรถlkerung in der Schweiz, Nationale Gesundheitspolitik Schweiz, 2004.

Document downloaded from: http://www.bag.admin.ch/themen/medizin/00683/01916/index.html?lang=de Psychiatric services and architecture, WHO, Geneva, 1959. Document downloaded from: whqlibdoc.who.int/php/WHO_PHP_1.pdf Recommendations for a therapeutic environment of psychiatric hospitals, WBDG (building design guide). http://www.wbdg.org/design/psychiatric.php (rev. 5.11.2010) To be a mental patient, Rae Unzicker, 1984, National Association for Rights Protection and Advocacy (NARPA). http://www.narpa.org/to_be_a_Mental_Patient.htm (Rev. 20.12.2010)

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Visual Material Visual material by the authors, unless stated otherwise.

1 City plan of Florence, based on historic map by Pitini 2 Arcades of the Ospedale degli innocenti, http://www.flickr.com/photos/poluz/2445240745/sizes/o/in/photostream/ 3 Schematische Josephinische Landesaufnahme Wien, 1764 4 Lieux de folie, monuments de raison: architecture et psychiatrie en Suisse romande, 1830-1930 / Catherine Fussinger, Deodaat Tevaearai.

Lausanne: Presses Polytechniques et Universitaires Romandes, cop. 1998 5 Lieux de folie, monuments de raison: architecture et psychiatrie en Suisse romande, 1830-1930 / Catherine Fussinger, Deodaat Tevaearai.

Lausanne: Presses Polytechniques et Universitaires Romandes, cop. 1998 6 Einführung in die Psychiatrie, Göthe Universität Frankfuhrt am Main 7 Daten zur Versorgung psychisch kranker in der Schweiz - Arbeitsdokument 4, Schweizer Gesundheitsobservatorium 8 Psychische Gesundheit, Strategieentwurf zum Schutz, zur Förderung, Erhaltung und Wiederherstellung der psychischen Gesundheit der Bevölkerung in der Schweiz 9 Patientenstatistiken Psychiatrische Klink PK, 2009 10 Daten zur Versorgung psychisch kranker in der Schweiz - Arbeitsdokument 4, Schweizer Gesundheitsobservatorium 11 Coverage by type of treatment facility 12 Fields of psychiatric services, Annual Rapport 2005, Institutions psychiatriques du canton de Vaud 13 Average length of stay in stationary psychiatric hospital/ Number of hospitalisations, Annual Rapport 2006, Institutions psychiatriques du canton de Vaud 14 Number of persons using psychiatric services per year, Inventar psychiatrischer Einrichtungen in der Schweiz 2006, Schweizer Gesundheitsobservatorium 15 Movie, One flew over the cooko’s nest, Warner Bros, Entertainment, 1975 16 Criteria for selection of case study 17 Coverage by type of treatment facility 29 La Métairie, exterior view, 150 ans Histoire de La Métairie / Clinique La Métairie (ed.).

Nyon, 2009 41 CPNVD, entrance hall, Pathfinders / Devanthéry & Lamunière.

Gollion: Infolio éditions, 2005.

42 CPNVD, site plan access, based on plans by Devanthéry & Lamunière Architects, Lausanne 51 KSPAP, siteplan access, based on plans by Hochbauamt Kt. ZH

56 57 59 60 72 80

81

84 88

92 95 98 102 103 105

Adamant, siteplan access, based on plans by Seine Design, Paris CPNVD, plans, spatial organisation, Devanthéry & Lamunière Architects, Lausanne KSPAP, plans, spatial organisation, based on plans by Hochbauamt Kt. ZH Adamant, plans, spatial organisation, based on plans by Seine Design, Paris La Métairie, exterior view, from http://www.lametairie.ch/ CPNVD, plan public accessible open space, based on plans by Devanthéry & Lamunière Architects, Lausanne La Métairie, view public accessible open space, 150 ans Histoire de La Métairie / Clinique La Métairie (ed.). Nyon, 2009 KSPAP, plan, public accessible open space, based on plans by Hochbauamt des Kt. ZH La Métairie, plan, private open space, based on plans by Devanthéry & Lamunière Architects, Lausan KSPAP, plan, private open space, based on plans by Hochbauamt des Kt. ZH Patients room Entrance hall, Bauwelt, n° 37, 2003 Patients room, http://www.lametairie.ch/ Living room on the extremity of the building, http://www.lametairie.ch/ Dining room, http://www.lametairie.ch/

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Quotations in original language: Chapter 1 1.2 From the Renaissance to the French revolution Architecture et psychiatrie , p. 17: «À Florence les hôpitaux sont construits comme des bâtiments royaux: il y a de la très bonne nourriture et boissons pour tout le monde, les valets sont très diligents, les médecins très savants, les linges et les vêtements très propres et les lits sont peints. Dès qu’un malade est amené à l’hôpital, on le déshabille de tous ses vêtements qui, en présence d’un notaire, sont honnêtement laissés en dépôt. On l’habille d’un bourgeron blanc, on le met dans in beau lit peint, avec des draps de pure soie. Juste après, on conduit deux médecins et plus tard les valets amènent à man-ger et à boire dans des verres propres, qu’ils ne touchent pas étant donné qu’ils sont servis sur un plateau. Ensuite des femmes honnêtes, toutes voilées, pendant des jours, presque inconnues, servent les pauvres et après rentrent chez elles.

J’ai vu à Florence avec combien de soin les hôpi-taux sont entretenus ! » Blasius, 1989, p. 21, taken from Geschichte der Psychiatrie, p. 238: «Im Zeitalter des Absolutismus wurden Irre, deren Zugehörigkeit zur menschlichen Gesellschaft im Mittelalter und in der Renassance trotz aller Härte des Umgangs unbestriiten war, von der Strasse und damit aus dem öffentlichen Bewusstsein verbannt […] .»

Nouvelle histoire de la psychiatrie, p. 71: «Leur emplacement symbolise un «no man’s land» à la fois géographique et social, placé entre le monde civilisé et le monde sauvage, à la limite entre l’organisation rassurante de la ville et l’insécurité de la forêt environnante.»

1.3 The end of the 18th century – the moral treatment Nouvelle histoire de la psychiatrie, p.119: «À la différence des bâtiments d’hôpitaux qui ne sont pour les malades que des moyens auxiliaires, les hôpitaux pour les fous font eux-mêmes fonction de remède […]. Il faut que le fou, durant le traitement, ne soit point contrarié; qu’il puisse, dans les moments où il est surveillé, sortir de sa loge, parcourir la galerie, se rendre au promenoir, faire un exercice qui dissipe et que la nature lui commande.»

1.4 The 19th century - construction of the asylum Architecture et Psychiatrie, p. 20. Cited there in Des maladies mentales considérées sous les rapports médical, hygiénique et médico-légal, J.E. Esquirol, Bruxelles, 1838: «Les établissements dans lesquels les aliénés sont logés au premier, au second, au troisième étage, offrent de nombreux et de graves inconvé-nients. […] il faut grillager les croisées de tous les quartiers pour prévenir les évasions et les suicides ; il faut entourer de grilles les escaliers. […] Les asiles dont les bâtiments sont construits au rez-de-chaussée présentent des avantages sans nombre. […] les galeries peuvent rester ouvertes ; les aliénés sont moins casaniers, peuvent sortir à volonté…»

1.5 The early 20th century – decline of the asylum Nouvelle histoire de la psychiatrie, p. 351: Paul Balvet: «L’asile d’aliénés a changé de nom, la réalité est restée.»

Chapter 2

Who can get mentally ill?

Psychische Gesundheit, Strategieentwurf zum Schutz, zur Förderung, Erhaltung und Wiederherstellung der psychischen Gesundheit der Bevölkerung in der Schweiz, p. 20: «Jede Generation muss in jeder Lebensphase andere psychische Herausforderungen bewältigen. In Situationen von kritischen Lebensereignissen und in Phasen von Lebensübergängen sind Menschen verletzlicher, insbesondere wenn dazu noch erschwerte Lebensbedingungen kommen. Solche Situationen können zu psychischen Krisen führen, das Gleichgewicht der psychischen Gesundheit gefährden und psychische Krankheiten auslösen.»

The problem of stigmatization Geschichte der Psychiatrie, p. 502: «Traditionell und dem Wortsinn nach heisst Patientsein: leidend, passiv sein. Demgegenüber will die moderne Psychiatrie möglichst viel Aktivität des Patienten: Er soll sich selbst helfen, soviel er kann, und auch seinen Mitpatienten, soweit es möglich ist, beispielsweise in der Gruppenpsycho-therapie und in der soziotherapeutischen Gruppenarbeit.»

The resulting costs of mental illness Annual Rapports 2004, Institutions psychiatriques du canton de Vaud, edited by the cantonal commission of psychiatric coordination, p. 4: «[…] ce qui concerne l’invalidité pour raisons psychiques, il est dificile d’y accéder, et peut-être encore plus difficile d’en sortir, meme lorsqu’on se sent prêt.»

Treatment approaches Annual Rapports 2006, Institutions psychiatriques du canton de Vaud, edited by the cantonal commission of psychiatric coordination, p. 9: «Forme de traitement psychologique qui utilise la relation médecin-malade pour découvrir la source des troubles, libérer le fonctionnement mental et favoriser la guérison. il existe plusieurs types de psychothérapies; les plus connues (et reconnues en psychiatrie) sont la psycho- thérapie psy-chanalytique (dérivée de la psychanalyse), la psychothérapie familiale systémique et la psychothérapie cognitivocomportementale.»

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Intermediate structures Psychische Gesundheit, Strategieentwurf zum Schutz, zur Förderung, Erhaltung und Wiederherstellung der psychischen Gesundheit der Bevölkerung in der Schweiz, p. 42: «Im Jahr 2000 (Krankenhausstatistik, 2001) sind 48 364 stationäre und 2 139 teilstationäre Hospitalisationen in der Psychiatrie erfasst worden. Eine aktuelle Stichtagerhebung über die Behandlungssituation von 1 343 PatientInnen in sieben psychiatrischen Kliniken des Kantons Zürich zeigt, dass 44 Prozent der PatientInnen nicht in einer Klinik behandelt werden müssten.»

From the movie L’Adamant: l’ hôpital psychiatrique sur l’eau «L’hôpital de jour […] permet au patient qui est stabilisé d’une crise après une hospitalisation de pouvoir regagner son domicile tout en bénéficiant des soins plus important qu’une consultation tout les semaines ou tout les mois. La plupart des patients qui fréquentent l’hôpital de jour ont été hospitalisé plusieurs moins, voir des années pour certains, et pour eux la sortie de l’hôpital est un problème. Il y a vingt ou trente ans, ces patients là, étaient condamné à rester à l’hôpital / à l’asile. Ils restaient sur un fauteuil devant la télé fumant une cigarette. Ils ne sortaient pas, parce que leurs psychoses ne les permettaient pas d’accéder à la vie dans une cité […]. C’est pour ces patients là, que la structure de l’Hôpital de jour existe.»

Ambulatory Annual Rapports 2003, Institutions psychiatriques du canton de Vaud, edited by the cantonal commission of psychiatric coordination, p. 12: «Ambulatoire se dit d’un traitement extra-hospitalier qui n’interromt pas les activités du malade.»

Advantages and risks Psychische Gesundheit, Strategieentwurf zum Schutz, zur Förderung, Erhaltung und Wiederherstellung der psychischen Gesundheit der Bevölker-ung in der Schweiz, p. 8: «Für PatientInnen mit schweren psychischen Krankheiten und mit sozialen Beeinträchtigungen, die heute wiederholt stationär behandelt werden, stehen nicht in ausreichendem Mass abgestimmte ambulante und teilstationäre Dienste zur Verfügung. In Folge dieses Mangels an koordinierten Angeboten ist eine zweckmässige, wirksame und wirtschaftliche Behandlung und Betreuung psychisch kranker Menschen nicht immer gewährleistet.»

Architecture and the image of psychiatry Geschichte der Psychiatrie, p. 502: «Traditionell und dem Wortsinn nach heisst Patientsein: leidend, passiv sein. Demgegenüber will die moderne Psychiatrie möglichst viel Aktivität des Patienten: Er soll sich selbst helfen, soviel er kann, und auch seinen Mitpatienten, soweit es möglich ist.»

What is a healing environment?

Citation by Henri Maldiney in Architecture et santé mentale, p.5: «Un espace universel déqualifie et banalise le corps, Un espace totalitaire le met au pas et l’aliène en l’assujettissant, Un espace d’accueil de la dimension du corps gratifie l’homme et lui permet d’être lui-même.»

Architecture for psychiatric treatment Architecture et santé mentale, p.5: «Si la psychiatrie s’attache à réparer le défaut de lien entre le patient et son environnement, elle peut s’apppuyer sur l’architecture, en la considérant comme un moyen qui permet, patiemment, de redonner aux gens qui souffrent une image positive de leur corps et de leur présence au monde. Constuire pour l’homme qui souffre d’une maladie mentale constitue une magnifique preuve de reconnaissance.»

Promoting encounters Architecture et santé mentale, p.4: «Il y a donc une nouvelle question des metres carrés à inventer.»

Protecting the patient from himself En plein Paris, l’hôpital du vogue à l’âme: «Quand on est déprimé, c’est peut-être dangereux un bateau.» De nouveau, la peur: «A 17 heures, le soir, en hiver, on peut se débarrasser dans l’eau. C’est plus facile que de se jeter sous une voiture, non ?»

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Thanks For professional support: Sonja Flick, head of department rehabilitation unit of the KSPAP, Zürich Marc Grandgirard, assisant doctor in psychiatry, Lausanne Dr Nicola Gervasoni, medical director of the clinic la Métairie, Nyon Inès Lamunière, architect of the CPNVD, devanthéry&lamunière architectes, Lausanne Dr Jo Montandon, head of department of the CPNVD, Yverdon-les-Bains Gérard Ronzatti, architect of Adamant, Seine Design, Paris Katiuska Stekel, responsable of the Atelier Brico-CESservices («les ateliers») of the psychiatric university hospital CHUV, Prilly In the day-care centre Adamant: Arnaud Vallet, nurse; Linda De Zitter, psychologe; Lisa Prévot and others

For editorial support: Yara Greuter, Basel Kim Handel, San Franscisco Merle Zadeh, Frankfurt

For the accompaniment: Professor Bruno Marchand Götz Menzel Professor Harry Gugger