Charlotte Wood Dissertation by PDF Uploads

Therapeutic Communities: Utopian Imaginaries of Wellbeing

Charlotte Wood ARC8062 5015642

Acknowledgments This dissertation was not a singular effort. It simply would not exist without the love, care, and consistent support of my family. I would also like to express my gratitude towards Professor Andrew Ballantyne and Professor James A. Craig, who encouraged me during the initial steps of this dissertation, as well as Dr Lisa Garforth and Dr Nathaniel Coleman who encouraged me closer to the end. NCU professors, you taught me not only to be a better designer, but to also how to be a better person. Class of 2020, you taught me many things (some of which I never wished to know). Thank you.

Research Question: How can therapeutic communities provide models for reimagining post-pandemic cities, and how might this enable them to move towards a new urban typology centred around wellbeing? Research Proposal: To investigate the potential role of architecture as a generator of wellbeing through the reinterpretation of therapeutic communities, into buildable design strategies. Research Aim: To develop an architectural response that operates therapeutically towards user wellbeing, by drawing upon lessons learnt from former health and medical design, to challenge the existing urban typology. In addition, this research also aspires to create new opportunities for discourse within therapeutic design.

Abstract Architecture and wellbeing are intertwined to such an extent, that our natural and built environment have become inextricable elements of ourselves; in which we can influence and are influenced by. Yet emphasis on novelty, form and aesthetic often obscures this and as such, seemingly little interest in shaping the built environment according to the requirements of inhabitant health and wellbeing exist. A recent shift regarding this relationship, however, has gradually begun to emerge within the design industry, as both architects and psychologists collaborate to implement therapeutic design as a catalyst that determines the spatial parameters of a therapeutic community. Subsequently, the purpose of this dissertation seeks to explore how architecture plays a significant role in determining therapeutic spaces; not solely as a physical location, but also as mechanisms for influencing the urban typology. Thus, it is the contention of this research, that a study regarding how therapeutic architecture influences the way a user experiences a space, in combination with evidence-based design criteria to improve wellbeing, that a new therapeutic community model will emerge. To explore this topic appropriately, an investigation between the physical and phycological link between architecture and the user must first be understood. From this perspective, a definition of the term ‘wellbeing’ will be formed using the UK government’s pillars of wellbeing within the ‘Foresight Project: Mental Capital and Wellbeing’ study. This will subsequently serve as a measure to understand and evaluate how the UK identifies wellbeing, and the responses to therapeutic design elements that have emerged from it. Moreover, this dissertation also endeavours to provide an investigation into how the complex relationship between architecture and wellbeing has evolved over time, specifically how the lessons accumulated throughout medical and healthcare architecture, may be applied within the modern urban environment. Regarding the research driving this study, evidence drawn from the architectural development of health institutions within the UK; including an analysis of Leprosarium Health Models considered one of the first examples of a therapeutic community, and the evolution of mental institutions such as Broadmoor Asylum, into psychiatric hospitals that cater towards therapy as a way of improving wellbeing, shall be explored. This serves to ascertain a clearer understanding as to how therapeutic innovation has developed and subsequently influenced the design of modern therapeutic spaces. In a similar conduct, reasons why design approaches have not been successful shall also be explored. This will help to provide a balanced argument regarding the implications and opportunities of design, and thus fairly determine how these implications may have a direct interchange between the way the physical environment impacts its users. This dissertation ultimately endeavours to provide an investigation into how the complex relationship between architecture and wellbeing has evolved over time, and how the lessons garnered from them may be applied within modern architectural design. It also seeks to reinterpret the role that therapeutic communities currently play, and thus create a new urban typology that reimagines the design of cities, with the ultimate intent of influencing resident wellbeing.

Contents Acknowledgements ........................................................................................................................................................ 2 Research Question ......................................................................................................................................................... 3 Abstract .......................................................................................................................................................................... 4 Introduction ................................................................................................................................................................... 6 Chapter 1 ........................................................................................................................................................................ 4 1.0 Literature Review ................................................................................................................................................. 4 1.1 A History of Medical Health Buildings ................................................................................................................ 4 1.2 The Emergence of Therapeutic Communities .................................................................................................... 4 1.3 The Role of Therapy within Medical Institutions .............................................................................................. 12 1.4 Modern Therapeutic Communities .................................................................................................................... 14 1.5 The Transition Towards an Integrated Model ................................................................................................... 16 Methodology ................................................................................................................................................................. 17 Chapter 2 .......................................................................................................................................................................18 2.0 Theoretical Application ......................................................................................................................................18 2.1 Psychotherapeutic Influences .............................................................................................................................18 2.2 Designing Domesticity ....................................................................................................................................... 12 Chapter 3 ....................................................................................................................................................................... 21 3.1 Research .............................................................................................................................................................. 21 3.2 Data-Sources and Eligibility .............................................................................................................................. 21 3.3 Critical Findings CWEP ..................................................................................................................................... 24 3.4 Data-Sources and Eligibility CWEP .................................................................................................................. 24 3.5 Discussion CWEP .............................................................................................................................................. 24 3.6 Critical Findings CWEP ..................................................................................................................................... 24 3.7 Data-Sources and Eligibility CWEP .................................................................................................................. 24 3.8 Discussion CWEP .............................................................................................................................................. 24 3.2 Comparison ......................................................................................................................................................... 21 Chapter 4 ...................................................................................................................................................................... 25 4.1 Utopian Models .................................................................................................................................................. 25 4.2 The Need for a New Utopia ............................................................................................................................... 25 4.3 Designing a New Utopian Model ...................................................................................................................... 26 4.4 A Framework for Heterotopia ........................................................................................................................... 26 4.5 Closing the Parenthesis ..................................................................................................................................... 27 Chapter 5 ...................................................................................................................................................................... 29 5.1 Models of the Future .......................................................................................................................................... 29 3.1 Reforming Wellbeing ......................................................................................................................................... 29 Conclusion ..................................................................................................................................................................... 31 Bibliography ................................................................................................................................................................ 32 Images .......................................................................................................................................................................... 35

Introduction

The relationship between architecture and wellbeing has historically, garnered very little attention beyond the design requirements related to healthy buildings. In more recent years though, a shift within design has seen a more holistic consciousness regarding the relationship between architecture and wellbeing. (Dalgard and Tambs, K, 1997) Such examples of this include the publication of data by the Royal Institute of British Architects and Commission for Architecture and the Built Environment (Chiesa, Fonagy and Gordon, 2009). Studies further supporting this data include the ‘Foresight Project: Mental Capital and Wellbeing,’ project initiated by the UK Government, which serve to study the notion of wellbeing (Sustainable places for health and Well-being, 2009) and provides a critical mass of evidence that has contributed to the definition of the “Five Ways to Wellbeing” (Aked, Thompson, Marks and Cordon, 2008)) outlined below. These key pillars are each associated with subjective wellbeing and draw upon large-scale and meta-analysis of exacting studies (Fig 1.). As such, these pillars will be used to define and assess the quality of wellbeing within the body of this dissertation. 1.

Connect: The quantity and quality of social connections e.g. talking and listening correlates with reported wellbeing as well as physical health.

2. Keep Active: Ample evidence from global and meta-studies demonstrate that physical activity reduces symptoms of mental and physical ill-health. 3. Be Aware: Being mindful, by paying attention to the present and being aware of thoughts and feelings, is a behaviour that reduces symptoms of stress, anxiety, and depression.

4. Keep Learning: Aspirations are shaped in early life. Those with higher aspirations tend to have better outcomes. Evidence shows that these are modified by the environment. It also indicates that later in life, those who participate in music, arts, and evening classes, attain higher subjective wellbeing. 5.

Help others: Evidence has emerged that pro-social rather than self-centered behaviour has a positive impact on happiness. Such consequences of altruistic behaviour, realter to spending on others as opposed to oneself and through volunteering.

In more recent years, the emergence of therapeutic communities has also aspired to employ the above pillars, as a method of shaping the environment in a way that contributes to patient healing, recovery, and wellbeing. These ideas are in part, a legacy to the theory and practice of evidence-based success gathered over time from within the medical field. Yet, despite this, the volume of evidence within the construction field remains relatively restricted. As such, this imparts some partial elucidation as to why evidence alone cannot be expected to anticipate therapeutic architecture, but instead, be used to determine the architectural design qualities that have in the past, influenced positive wellbeing outcomes. Furthermore, beyond a simple positive to negative dichotomy, researchers within the discipline of psychology have also suggested that wellbeing, is better identified as a profile of indicators that span across multiple domains (Fig 2), as opposed to the single defining criteria catalogued within the pillars. (Keyes, 2007) By adhering to this refinement, such conclusions alone could be reductive and misgiving, and remain applicable solely to bureaucratic rationale. To achieve these therapeutic environments, I shall embrace the tacit knowledge of research amassed over time, with reference to the above defining pillars of wellbeing as a baseline. This in turn will provide a direct interchange between the implications of the physical environment upon the user, to determine the level of success brought throughout therapeutic innovation and the current indicators used to measure it.

Figure 1: Five Pillars of Wellbeing Diagram by Gov.uk

Figure 2: Conceptual Framework of the Relationship Between Urban Form and Mental Wellbeing by Journal of Urban Design and Mental Health

Chapter 1 1.0 Literature Review: To establish a framework for enhancing wellbeing through architectural design, the research seeks to identify references from a variety of different fields, with close examinations on literature sources. This research will thus be split into three domains: 1) Historical analysis; 2) Evaluation of employed therapeutic methods; and 3) Influence upon wellbeing The purpose of this literature selection, therefore, serves to provide a comprehensive background into the development of psychiatric design, whilst establishing a clearer understanding into the subject of therapeutic communities to provide substantial evidence for later discussion. This examination will then serve to critically analyse the provisions of therapeutic communities as a design tool to model new urban typologies.

1.1 A History of Medical Health Buildings: Historically, physical, and mental health was condemned due to the complexity needed to control and manage it (Relojo-Howell, 2018). As a result, the stigma and fear surrounding mental and physical illness resulted in architecture that encompassed coercive elements. This meant that treatment available was often ruthless and, in many cases, isolated patients from the rest of the community (Bil, 2016). Appropriate institutional care, however, was eventually implemented in the UK during the late eighteenth century and an even greater emphasis on wellbeing emerged during the latter half of the twentieth century, where the design of therapeutic communities being recommended by hospitals as an alternative recovery for wellbeing begun (Wilson, 2012). Initially coined from medical studies, the transition from healthcare architecture into therapeutic communities derived from studies regarding the design of medical and psychiatric care. Designed as structured, psychologically informed environments where social relationships and activities of everyday life are catered for, therapeutic communities were designed with the main purpose of improving people's health and wellbeing. Therapeutic communities, therefore, initially served as an analysis of patients who lived and endured suffering within hospitals and medical institutions. This antecedent focused almost entirely on regulating and restricting patients, with limited consideration to the environment itself. The research below, therefore, seeks to examine how the confines of an environment exacerbated or lessened patient wellbeing, and how design for the physical and mentally unwell remains an important societal problem. 1.2 The Emergence of Therapeutic Communities: Throughout the course of therapeutic design, architecture has evolved in a more conscientious way. This can be contributed towards the industry’s understanding of evidence-based design acknowledging the need for improving health and wellbeing. But how have past architectural decisions influenced this? During the medieval period, when the disabling consequences of leprosy became visible in all types of communities across the UK, some of the earliest known examples of a ‘hospital’ were formed. An example of this includes St Mary Magdalen hospital (Hampshire), (Fig. 3), where burial excavations revealed some of the most extensive excavations of leper hospitals to date. Almost 350 similar religious houses and hospitals (known as leper or 'lazar' houses) were also discovered in England between the end of the 11th century (A History of Disability: from 1050 to the Present Day | Historic England, n.d.). Analysis of these buildings indicated that formal care of the ill and infirm became part of an independent community separated from the main cities and towns. As a result, this formed an important component of the urban and social landscape of medieval Britain. Whilst these communities served to care and isolate distinct groups such as lepers, they also covered a range of varied institutions that sheltered a variety of other terminally ill patients. Fundamentally, the repute of such institutions, as well as their relative level of formal organisation, varied significantly.

Figure 3: Almshouses at St. Cross Hospital, Winchester by Historic England

Figure 4: St Mary Magdalen location outside city walls, Colchester by Ordnance Survey

The edict prohibiting of lepers from living within towns or cities may also offer an explanation as to why many leper hospitals were founded on the outskirts of urban areas (Fig. 4). A description found at Lanfranc’s foundation in Harbledown (Kent), reported that outside the perimeter of the city, segregated from the rest of the community, were ‘wooden houses assigned to the use of lepers’ (Roffey, 2012). Thus, by isolating this population, a separate community was formed. As a result of separating these individuals, it could be argued that an enclave dedicated exclusively to the leper population, formed the foundation of very early therapeutic communities. In addition, it is evident from both the documentaries and archaeological records of leper hospitals, that a diverse range of people lived and worked within these communities, each bringing with them their own unique wellbeing requirements. In addition to this segregated division, it is also possible, that a form of social stratification existed within these communities. This is reflected most notably within the spatial arrangement. For instance, at Winchester, individuals were living separately in ‘houses’ by 1400, (Roffey, 2012) with non-lepers segregated from those with leprosy. It is worth noting that the latter were generally demoted to less desirable accommodation. Another degree of social stratification may have also been present, with reported cases of patients eating in communal halls and passing on scraps to others waiting outside (Page, 1911) with further division between inmates and administrative clergy in the form of separate accommodation and reserved burial areas. For example, at Partney, excavations revealed separate burial locations for the inmates and clergy (Roffey, 2012). It is likely that wealthier residents also had access to personal wealth or property, which could have provided them with a comparatively higher standard of living (Atkins and Popescu, 2010). Consequently, this may suggest that financial solvency was a requirement in certain instances. The hierarchy of living standards portrayed, reveal a failing in the wellbeing pillars, with unfair treatment and barriers in treatment forming a clear disconnect from others. More notably, financial funding was a vital component that contributed to resident wellbeing, suggesting that a crucial measurement from the pillars of wellbeing is missing. The general architectural design for people suffering with leprosy, however, would include shared communal halls or infirmaries, with some hospitals segregating male and female members of the community through partitions of halls, such as the parallel halls found at St Mary Magdalene, Glastonbury (Fig. 5). Thus, in reference to the five pillars of wellbeing, a sense of connection was in some cases, accommodated for. By allowing open, communal spaces, those confined were provided with a space to reconnect to others. This not only enabled them to forge relationships, but also reduced the impact of isolation and the effects associated with it. Despite this intended disconnection from the rest of society, many of these leper communities were purposely sited on major highways.

Figure 5: Interior of communal hall, St Mary Magdalen, Hampshire by Jacob Schnebbelie (Vetusta Monumenta Vol 3, 1796)

In addition to enabling family and friends to visit, this also allowed patients to beg for alms and offer prayers for the souls of benefactors. Further analysis of these communities also identifies the unique spatial planning and built forms of these distinct communities. Careful layout of rooms and orientation of structures that missionary leprosarium models provided, indicated that spatial parameters were specifically designed to imitate healthy villages. This perhaps sought to create a sense of ‘home’ for leprosy sufferers, fitting the third pillar of wellbeing – to take notice. The evidence supporting this helps us further understand how architecture not only served as a tool in disease prevention, but also aspired to preserve a sense of humanity among leprosy outcasts. Emphasis on hygiene and diet; often from the house's own fields and livestock, were another major contributing design factor. Evidence portraying the therapeutic effect brought by horticultural work and exposure to nature were recognised by the addition of rooms that overlooked and connected to fragrant gardens and healing herbs (A History of Disability: from 1050 to the Present Day | Historic England, n.d.). The second and fourth pillar of wellbeing, to keep active and keep learning, are also evidenced here, as residents were encouraged to take part in the upkeeping and growing of crops and plants. This meant a sense of routine was established - a key component which modern therapeutic communities foster as a tool for therapy. Multiple other elements of the wellbeing pillars were also embraced, as gardening fosters mindfulness and learning which keeps the mind stimulated. More obvious, is the pillar of giving, as the planting and growing of plants served to benefit the whole community. The act of giving subsequently meant that patients could be valued for the contribution they made, rather than being solely defined by their ill-health. Overall, levels of support and wellbeing within individual leprosaria appear to be comparatively mixed. Whilst some were designed and offered better support, the general evidence suggests that these communities provided a reasonable standard of wellbeing. This, therefore, provided a fundamental structure for the formation of therapeutic communities to develop from. However, whilst many of the factors defined within the pillars of wellbeing are accommodated for, other considerations, such as social stratification, wealth and domesticity are overlooked and missing from the government’s measurements of wellbeing. This suggests that the pillars are potentially reductive, thus definitions that are simplified to such an extent, that a distorted impression of wellbeing is given for those relying on it as a tool for design.

1.3 The Role of Therapy within Medical Institutions: The legacy of care and confinement within architectural models such as the leprosarium model, have since had an impact on wellbeing by inspiring innovation that intended to mitigate or cure other illnesses. Thus, as the care and wellbeing of patients evolved, healthcare and medical architecture turned institutionalised. As such, those suffering from physical and mental conditions were still subjected to exclusion and confinement (Patterson and Bosanquet, 1966). Limited knowledge and research regarding various conditions, particularly mental illness, often meant that a variety of patients were admitted and housed in similar isolation away from the community (Chrysikou, 2014). Such brutal treatment of patients existed as a norm until the promotion of more humane treatment. Advocates of this approach supported the theory that wellbeing linked to and subsequently supported non-restraint movement; thus, the asylum became the historical equivalent of the modern psychiatric hospital. However, whilst the Victorian mental asylum carries negative connotations as a place of misery, the very first built in the early 1800s, were in fact part of a new, more humane attitude towards healthcare and wellbeing. From the beginning of the 19th century, early UK asylums were designed to support mental recovery. With support from reformers such as Harriet Martineau and Samuel Tuke, who spurred a shift in attitude towards mental healthcare, by initiating recognition towards mental illness as something that might be cured or alleviated. As a result, authorities attained a legal responsibility for the care of patients admitted into purpose-built accommodation. However, unlike the leper houses, many of these asylums were placed within the built urban environment. Subsequently, although admittance still confined patents, there was an intention to reintroduce residents back into society. Furthermore, whilst some of these buildings were designed with high walls and locked doors, many others, including Broadmoor Asylum, were designed with spatial therapy in mind. This included design considerations that enabled access to outdoor spaces, with cultivated lawns and leafy walkways. This indicated that lessons related to the connection of outdoor spaces were recognised as an important factor that catered towards wellbeing. The feature of green spaces not only promoted a sense of calmness and reflection, but also demonstrated a mindfulness, which then strived to reduced symptoms of stress, anxiety, and depression. Moreover, patients were encouraged to enjoy sports with staff, or undertake occupational therapy in a purpose-built farmyard (Fig. 6). This enabled an increase in social interaction, which in turn, allowed stronger connections to develop and contributed to stronger social support networks. It also enabled physical activity to reduce symptoms of mental and physical ill-health by stimulating the production of endorphins. This in turn distracted the mind from the daily stressors of confinement. Thus, an overlap between the pillars of awareness, connection, and keeping active occur, which suggests a complexity of factors are responsible and therefore less straightforward than a singular, defining component. In addition, whilst this caters towards many of the pillars of wellbeing, a major part of this approach links towards a connection with nature. Therefore, elements of wellbeing are ignored when relying solely on the pillars to define therapeutic design. In a similar fashion to the Leprosarium communities, men and women were also separated through the construction of separate wings (Fig.7). This split emerged from the belief that men and women were intrinsically different, and thus separation was required as a necessity for implementation of moral management over patients. This clear divide also had some bearing upon the different therapeutic regimes which were gender-appropriately given (Scull, 1989). For instance, men were given woodwork and gardening, whilst women were tasked with laundry or sewing as part of their occupational therapy. As such, this divide became a vital part of the asylum’s therapeutic regime by providing activities as an aid to recuperation from physical or mental illness.

Inevitably though, as time passed, the moral treatment of those physically or mentally ill collapsed despite the success seemingly garnered. This shift was likely due to a combination of mass incarceration and demoralised workforce during the industrial revolution, which meant asylums were suddenly filled with “chronic” cases. Consequently, when the 19th century came to an end, asylums began to take the form of the proverbial design we often associate with and recognise today. This sudden transformation in design suddenly obscured whatever was once therapeutic about such places, eventually lending to the medical term “institutional neurosis,” causing patients to become passive, demotivated, and dependent on the staff and institution structures. As treatment of patients became more institutionalised, the solution to the issue often led to clients being housed in the same way as criminals (Foucault, 1977). Examples of this include reports of patients confined to rooms without clothing or heating, chained to walls or beds. Treatment and care remained like this until the modern successor to eighteenth and nineteenth century wellbeing arrived.

Figure 6: Exterior of Broadmoor Asylum, Berkshire by BBC

Figure 7: Broadmoor Male and Female Division, by Wiki

1.4 Modern Therapeutic Communities: Before the 20th century, elements belonging to community care predominantly belonged to the hospital. Towards the later part of the century, support in the community gradually shifted towards care outside hospitals, and facilities provided by the National Health Services and Local Authorities gradually became part of the community care packet. Development of secure units substituted, in part, the custodial provision of the old asylums, whilst the local psychiatric unit began to be considered as a part of the urban typology. Community care, therefore, became a package of local provision, distinct from the distant asylum care. As such, care within the community offered a very distinct alternative care approach that occurred outside of the traditional health and medical setting. Within the contemporary era, the operation and design of the therapeutic community has continued to dramatically evolve. Instead of being isolated or built with borders that separate residents within the spatial parameters of the urban typology, the therapeutic community has instead, begun to take form within the residential setting. In addition, whilst the leprosarium model generally catered to physical ill-health, and the asylum for the criminally insane, modern therapeutic models cater towards a variety of people, each with their own unique wellbeing requirements. Whilst the majority still exist to support the treatment of mental or physical health, communities have proven efficacy with many other chronic, relapsing health conditions. Alternative communities include treatment for addictions, rehabilitation in penal institutions and schools for children with extreme emotional disorders (Types of TCs, n.d.). Other types of communities are designed for disabled and non-disabled residents alike. These do not offer any treatment as such but instead provide alternative lifestyle choices. Finally, a smaller minority of therapeutic communities offer faith-based community support and living, which do not require any specific client (Types of TCs, n.d.). Connection to the community setting play an integral role in the success of these models. For instance, the therapeutic group ‘Recollection,’ which caters to individuals living with dementia, hold activates within community settings (Fig. 8). This enables participants to access care provision in creative spaces associated with imagination and wellbeing, as opposed to clinical spaces associated with ill-being. More importantly, participants were not labelled as ‘patients’ but individuals who are united by creativity and not their dementia. Public settings also allow inclusion of family members or carers, offering support and connection not only to the patient, but to other members of the community (Recollection: Art Therapy for Individuals Living with Dementia, 2016). Perhaps most striking about this shift, is the co-responsibility patients are allocated. Underlying each community variant, is a defined role or set of duties that is delegated to each member, which tend to be allocated according to seniority, individual progress, and productivity (Chiesa, Fonagy and Gordon, 2009). The general purpose of this, is to provide a method of sustaining the appropriate functioning of the community. Therefore, instead of being passive recipients within the system, organised roles ensure that patients actively assume the essential roles that would usually occur in the social functioning of the hospital and the home. As such, the therapeutic community functions in a similar conduct to traditional domestic structures, with a reflection of hierarchical order between the eldest and youngest members of the community. Through the sharing of domestic and social spaces, patients are free to comment on each other’s behaviour and attitudes. The intention behind this, is that patients tend to share similar problems and thus, easily identify issues, whilst offering constructive feedback and support to help mitigate or alleviate stress within the community. Encompassed within the safety of these spaces, is a mutual process that becomes contained and manageable, instead of overwhelming and exclusive (Pringle, Chiesa, 2001). As a result, the daily interactions with patients in the milieu of the therapeutic community setting, similarly promotes close and supportive relationships that improve the wellbeing of inhabitants. However, unlike past models, these close working relationships are used as a technique which consciously equip residents with independence and confidence to work through interpersonal difficulties together. Another notable change in operation, is that whilst most patients were admitted to the leper hospitals and asylums, many contemporary therapeutic communities accept people who admit themselves. No force or coercion is used to detain residents, and most communities maintain the right for individuals to leave at any given time (Types of TCs, n.d.).

On reflection, incorporated most obviously within the main therapeutic community design principles, are a sense of belonging, safety, openness, participation, and empowerment. Therefore, whilst the architectural design programmes may differ, institutional remnants, stigma, and interventional accuracy from past models, appear to maintain some elements of design that has survived within newly built facilities, indicating lessons which can be used to reimagine future spaces. However, because the role of these communities varies significantly, the design parameters essential for influencing wellbeing are often obscured and difficult to define.

Figure 8: Types of modern Therapeutic Communities, by The Consortium for Therapeutic Communities

Figure 9: Therapeutic Communities for people with dementia within secondary mental healthcare, by The British Association of Art Therapists

1.6 The Transition Towards an Integrated Model: Since the first emergence of therapeutic communities, the design frameworks used to support resident wellbeing have developed and expanded rapidly. Yet, despite their prevalence, many misconceptions surrounding their response to therapeutic design remain. This in part, may be due to the varying shifts in attitude surrounding health, but also to the long and complex history surrounding wellbeing. Limited structures for providing a comparable base and a lack of consensus on what a therapeutic environment really means within these specific models, are also partially responsible for this confusion. As such, the lack of research surrounding the design of wellbeing, has produced an accumulation of unintegrated design knowledge, impossible to comprehend in its totality. Whilst some attempts to scientifically prove the effectiveness of wellbeing are acknowledged (Albrecht, Seelman and Bury, 2001), limited, evidencebased practices underpinning design have provoked a lot of scepticisms and uncertainties regarding the future of therapeutic community design. This unclarity within the context of therapeutic communities, has since resulted in a profusion of design approaches and models (Fig 8), each with their own unique treatment and design protocols. This has contributed to a sense of confusion which has subsequently been detrimental to the planning and implementation of community projects. Furthermore, the extent to which these adaptations retain traditional elements of the therapeutic community model is not known, casting uncertainty about the effectiveness of the therapeutic community modality. As such, the literature review raises numerous questions which require further attention and deliberation. Of pertinence here, is whether the therapeutic community could be manipulated into a new model that works towards future, imaginaries of wellbeing, hence provide a historically immanent model which can move beyond the existing and be applied towards the future. To consider a more suitable physical milieu for the delivery of a utopian imaginary, the assumptions and uncertainty surrounding therapeutic communities and wellbeing must be reshaped. From this perspective, I shall question what the future of the built environment might be and how it could encourage better wellbeing outcomes. According to the director of the ‘Centre for Therapeutic Community Research’, George DeLeon, the notion of the therapeutic community as a model, has been implemented through a variety of incarnations throughout history, “communities that teach, heal, and support, appear in religious sects and utopian communes, as well as… mental health reform movements,” (De Leon, 2000). He further explains that the social environment becomes a method of influencing individual behaviours, lifestyles and identities, thus, the ‘community model’ becomes the method itself. In terms of treatment and design reforms “community as method” can be understood as the key component linking both historical examples. To test whether this is true, the collaboration between architects and psychologists must be examined. This will determine how implementation of evidence-based theories could act as a catalyst that determines the future spatial parameters of therapeutic communities, but also, how the built environment might enable healthier lifestyles and greater community cohesion, thereby contributing to a great sense of overall wellbeing and happiness. Additionally, there is a sense of unclarity regarding what the term wellbeing means, specifically, how it is incorporated within the therapeutic community. Whilst the wellbeing pillars offer some attempt at explaining this, limitations indicate that the definitions for each could be oversimplified. Reducing the criteria involved excludes important variables that are vital to understanding what makes it so important. This subsequently means that design parameters based upon them, could be misleading and inaccurate. Finally, whilst previous systematic reviews indicate that therapeutic communities tend to be effective in mental health and social engagement outcomes, they have not fully explored or evaluated their effectiveness upon the wider community. I therefore seek to explore how these communities can be reinterpreted to cater towards a broader spectrum of residents.

Chapter 2 2.0 Theoretical Application: To understand the interplay between change and continuity, this chapter focuses on the interdisciplinary studies that underpin the therapeutic community. Through this, I aim to explore the patterns and trends that have occurred within evidence-based design and analyse the influence this has had upon wellbeing. I shall then illustrate the logic that sustains the therapeutic community model as an extension to the global contemporary era, by negotiating the possibilities behind reimagining a new utopian imaginary of wellbeing. 2.1 Psychotherapeutic Influences: Credited with coining the term therapeutic community in his 1946 paper, "The hospital as a therapeutic institution or milieu,” was psychiatrist and psychoanalyst, Thomas Main (Main, 1946). The concept underpinning this considered interactions between client and psychiatrist as the most important component of treatment. This became converted into a residential model that involved clients and therapists living together in a participative, group-based approach (Interpersonal Theories, 2021).

Figure 10: Therapeutic Community Model, by HMP Grendon

The term was later developed by American psychiatrist Harry Stack Sullivan (Harry Stack Sullivan | Biography, Contributions, & Facts, n.d.), who’s extension of the model developed into one of the primary modes of treatment used within the acute hospital setting (Nurses' Role in Milieu Therapy, n.d.), and subsequently became a major theoretical concept used within current planning (Chrysikou, 2014). Sullivan’s theory hypothesised that interactions between clients was the most important approach to wellbeing (Fig.1o). This in part, was based on numerous medical essays published between 1924-1947, which advocated for a host of changes to psychiatric institutions. Some of the primary agendas driving this included a growing emphasis on human rights and advances in social sciences which critiqued psychiatry and the boundaries that constituted mental illness (Sullivan, 1924). Such drivers included developments within medical treatment, which showed that mental illness could be treated and that institutionalisation itself, was iatrogenic, spurring the transition to outpatient

treatment. Additionally, new legislation limiting admittance to institutions further set precedent that the community was the best place for treatment. In today’s health-care environment, inpatient hospital stays are habitually too short for clients to develop any meaningful relationships with each other. Management of the milieu instead, remains the primary role of the nurse. Consequently, the concept receives limited attention. Despite this, the notion of ‘community’ within the UK has guided a paradigm shift in therapeutic provisions, including a large reduction in demand for hospital architecture and a corresponding surge in demand for residential facilities within the local community (Chrysikou, 2014). Moreover, by shifting towards the community setting, pressures on nurses and family are reduced, inadvertently benefiting their wellbeing too. The importance of reinterpreting the therapeutic community model, therefore, goes far beyond catering to those already physically or mentally ill, but also to the wider community. 2.2 Designing Domesticity: When residential facilities were considered in the context of care, they were assumed to be domestic in character. The psychiatric term of ‘domesticity,’ describes alternative psychiatric environments that escape normal institutional references. In architectural terms, domesticity includes buildings that appear domestic in character as opposed to institutional. If the optimum milieux for wellbeing is assumed to resemble immediate references to the structures of healthy communities, the optimum solution for design can be considered closer to that of the home. Parallelly, the space syntax of regular housing, as well as the social provisions within them, provide potentialities of applying therapeutic models which reinterpret social cohesion and wellbeing of the wider population. For instance, studies reveal that growing up in the UK could not only double the chances of someone developing schizophrenia, but also increase the risk of other mental disorders such as depression and chronic anxiety. Urban typologies with blocks of high-rises and limited communal spaces, contribute to this by discouraging a sense of community and isolating residents (Effectiveness of Therapeutic Communities in the Treatment of Self-harm in People with Personality Disorders, 2019). This limited social bonding and cohesion within the community increases “social stress”. Here we can draw lessons from Sullivan’s theory of psychiatry, illustrating that the social barriers which mediate the effect of wellbeing, are missing within the existing urban typology. Here we can see how architectural design interacts with the milieu, and the need for therapeutic design principals which include upon the wider community. 2.3 Forgotten Elements of Wellbeing: Mechanisms by which the wider detrimental factors impact mental and physical health, are often more complex and inter-related, frequently emerging over extended periods of time. Figure 1 is a model of the main health determinants developed by Dahlgren and Whitehead. It places the individual and their ‘constitutional factors’ such age and gender within the centre, surrounded by individual lifestyle factors. Beyond these individual factors are the wider determinants, such as the conditions surrounding a person’s daily life, and the broader socioeconomic, cultural, and environmental conditions which occur within them. Most notably, the model’s multiple layers are shown as interlinked, emphasising the complexity underpinning health which determine people’s overall wellbeing. Another built space recognised within the literature review, but excluded from the wellbeing pillars, is the role of nature and connection to nature. This is not just marginal, but also relevant to the health and happiness of individuals (Kellert, 2014). In 1984, Ar. Roger Ulrich performed an experiment in a hospital, whereby 23 patients had a bed with a window facing a brick wall, whilst another 23 had a bed that overlooked a landscape. The views of nature and fresh airflow linked to a reduction of stress and anxiety, improving wellbeing and overall health (Schweitzer Et Al., 75). Similarly, a connection to nature and the outdoors was a key element in creating restorative environments within the leprosarium and asylum model.

Figure 11: Dahlgren and Whitehead model of the main determinants of health by Gov.org

Figure 12: Design Theory for Reducing Aggression, by Ulrich (2012)

Methodology The methodology adopted in this research involves an investigation into theories and research from a variety of fields. I therefore associate this divide and the subsequent domination of pedagogies by analysing a combination of architectural, medical, and psychological disciplines to define and reinterpret the role of therapeutic communities. This will include an analysis of secondary data. Discussed alongside this will be an assessment of the design qualities used to understand the various approaches taken to accommodate inhabitant wellbeing. The research, therefore, seeks to attain the following objectives:

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To examine the history of mental health establishments within the UK to determine how they have influenced the design of modern therapeutic buildings.

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To assess the physical and psychological impacts therapeutic innovations have had upon user wellbeing.

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To apply the conclusions of the above as drivers for a new, utopian urban typology with the intent of influencing inhabitant wellbeing.

Reflections upon fostering the addressed theories and case studies mentioned above, endeavours to provide a clearer understanding of the opportunities and constraints brought by therapeutic communities. Moreover, I aim to ascertain whether these utopian ideals could exist within more dramatically unequal societies and subsequently influence inhabitant wellbeing. Extracting the critical typologies from these studies will serve to identify the potential barriers linked to changing orthodox design and urban planning components of existing cities, thus determine whether it is possible for therapeutic environments which focus on wellbeing to exist through architecture, and subsequently be applied as models that reimagine the urban typology. While this investigation specifically responds to the unique needs of the UK, it is hoped the conclusions made not only build upon and challenge existing work, but also open new opportunities for discourse within therapeutic architecture elsewhere.

Chapter 3 3.0 Research: In more recent times, increased attention has been given to the study of wellbeing, however few explore the extent to which community intervention influences it. Even fewer suggest design parameters to accommodate these requirements. Considering this, I aim to analyse the level of wellbeing within the UK and use it to inform proposals for a new urban typology that influences resident wellbeing. The following discussion employs a cross-sectional and prospective study to explore how the values and principles of wellbeing continue to have relevance for critical pedagogy and analysis today, whilst also considering the application of the findings into models that inform and improve local planning for wellbeing. 3.1 Data-sources and Eligibility Criteria: A title search of Therapeutic Community was performed in National Institute for Health and Care Excellence, National Health Service, National Institute for Health Research and Office for National Statistics, using the keyword “wellbeing” for the years January 1900 to December 2020. Additional reviews found in the reference lists of the eligible studies, which did not appear in web-sources search, were also included. Further to the language and time-period criteria, eligible review studies met the following inclusion criterion: • • •

Inclusion of literature and/or a systematic review evaluating the impact of either therapeutic community or wellbeing. Quantitative or qualitative evaluation of the findings. Exclusion of results without a methodology description.

Initial record searches yielded 433 potential reviews. After applying inclusion and exclusion criteria, 2 records were used in the final study (Fig 12).

3.2 Critical Findings CWEP: The first study draws upon the research of the Community Wellbeing Evidence Programme (CWEP) conducted in 2018 by the Economic and Social Research Council on behalf of the What Works Centre for Wellbeing. Adopted in this research was a two-stage process of assessing wellbeing, which included extensive stakeholder engagements such as workshops, questionnaires, community sounding boards, and one-to-one interviews. These sought to identify priority, policy-related topics within which evidence reviews were undertaken. The CWEP brings together evidence regarding the relative impacts on wellbeing of policies/projects. Within this is a scoping review of 34 reviews, predominantly focused on the “boosting social relations” and monitoring the outcomes of these intervention upon community wellbeing. One of the priority topics identified in this study, included the role of boosting interpersonal relations, as a crucial component of individual and community wellbeing (Community Wellbeing Evidence Programme 2015). Within this study, 8 types of intervention approaches were also identified: community hubs; events; neighbourhood design; green and blue space; place-making; alternative use of space; urban regeneration; and community development. Worth noting, is that most interventions involved more than one approach thus, occupied more than one category. Of these community interventions, 9 incorporated an aspect of social relations including social cohesion, bridging social capital, trust, quality and quantity of social networks and social interactions with neighbours, friends, and family. The majority of these were assessed as being of poor or poor- to moderate methodological quality. Regarding sample location, 23 of the 51 studies were carried out in urban settings, and included a variety of densely populated mixed neighbourhood, to apartment blocks and single streets.

Figure 12: Systematic review process of studies investigating wellbeing and community, by Author

Measurements of wellbeing included attitudes towards the neighbourhood, pride in the local area, levels of civic activity, sense of community, and family wellbeing. Within the included studies 7 community hub interventions examined an element of community wellbeing. Co-housing promoted the strongest sense of community among residents. Of pertinence, was that these communities were fostered by events and shared amenities. Moreover, these were also found to promote family wellbeing, such as incorporation of community gardens which allowed families to spend time together. 3.3 Discussion CWEP: One of the main strengths of the CWEP methodology is that it incorporates a full systematic review that used structured assessments and data extraction that specifically focused on wellbeing. The overall results yielded supporting evidence for the overarching hypothesis that community models can influence wellbeing by boosting social relations. As the evidence stands however, it is difficult to say which community element is most effective, as the studies did not compare approaches, preventing any strong recommendations in favour of one approach. Whilst the research presents some evidence in support of the association between community models and wellbeing, study limitations and risk of bias should also be considered. Firstly, the term wellbeing is not defined clearly, therefore excluded studies which assessed wellbeing but did not define it, may be absent from the results. Secondly, a lot of the studies were based on surveys and interviews. This selfreported information may therefore have excluded participants deemed ineligible based on the assessment tools used; moreover, feedback is subjective and potentially unreliable. 3.4 Critical Findings AMPS: The second study serves to draw upon mental health surveys within the UK from the Adult Psychiatric Morbidity Survey (APMS) which is carried out every 7 years by the National Study of Health and Wellbeing. The last set of results conducted in 2014 are the fourth in a series of surveys and interviews which studied the wellbeing of 7,500 adults from England who were 16 and over. Monitoring wellbeing in England has been provided through the Psychiatric Morbidity Survey since 1993 and recorded the prevalence of mental and physical health conditions conducted every seven years (1993, 2000, 2007, 2014). Due to adopting the same screening assessments and methodological approach, these surveys are regarded as the most consistent programme in the world (McManus et al. 2016). According to these surveys, around 1 in 6 adults has a common mental disorder, with the highest reported amongst women (1 in 5 or 20.7) compared to men in (1in 8 or 13.2%). Additional focus was given to the comorbidity of chronic physical health conditions within the latest report from 2014 which indicated that those afflicted with a physical health condition suffered from at least one comorbid mental disorder. The neurotic disorders reported were anxiety, depression, generalised anxiety and depressive episodes, compulsive disorders, phobias, and panic. The most common was a mixture of anxiety and depression (88 cases per 1,000), with generalised anxiety as second most prevalent (44 people per 1, 000). The main sociodemographic characteristics linked to this (59%) were predominantly women between 35 to 54 years old, who were divorced/separated, or in a single parent/one family unit (Singleton et al., 2001). Physical health complaints were also quite prevalent, with half of those with a neurotic disorder reporting one physical health issue and 67% of those with psychosis also reporting a longstanding physical health condition. 3.5 Discussion AMPS: The APMS was analysed to explore the role of physical and mental illness towards wellbeing. The results indicated a rise of suicidal thoughts/attempts within the population, with an increased risk to those with physical/mental multimorbidity. As such, the results lend support to the notion of reinterpreting the therapeutic community model as a generator of wellbeing within the wider population.

It should be noted however, that my study focused specifically on the reported effects of physical and mental health and the connections to anxiety and depression. This pragmatic decision was informed by sample size and aimed specifically to maximise statistical power. However, more notable is the potential side effects of medications amongst those with physical/mental health issues, which may explain increased reports of anxiety and depression. In terms of reporting and publication bias, unpublished studies were not included within this review. Additionally, bias within study selection is also highlighted, for example in Bischof and colleagues’ study sample included participants from both general and clinical settings, a factor which may have influenced results. Specifically, participants recruited by phone from the wider population, may have over-reported conditions or behaviours, whilst those from treatment may have only reported on conditions or behaviours experienced in medical care. This mixed sample methodology, therefore, may not provide a clear indication of wellbeing amongst the target population.

3.6 Comparison: A major challenge when trying to integrate the findings from across both studies, was the inconsistent use of terminology regarding wellbeing. Moreover, subjective wellbeing also varies between individuals. Nonetheless, low measurements were linked with the presence of chronic physical conditions whilst stronger links associated to mental disorders comprised by different types of depression and anxiety. Of importance, are the structured use of assessment and qualitative studies used, which are based on diagnostic criteria, rendering the surveys comparable with other global mental health surveys. Furthermore, recording wellbeing elements in a survey like NPMS, provides a prevalence that permits estimations amongst the general population who may not be in contact with health care services. Data from the first sample examines the role of boosting social relations between people, as a key ingredient to the wellbeing of the community, whilst the second draws upon statistical data recording the prevalence of mental and physical health conditions. Comparing the two samples indicates that the rise of anxiety and depression is predominantly affecting the same milieu. Although empirical studies into the role of wellbeing have been conducted, limited attention has been given to physical/mental co-occurrence within the therapeutic community. More research is required into the role of specific therapeutic community model conditions, to inform the development of effective design parameter for wellbeing. To strengthen the results, further studies which clarify the association between both, should investigate the spatial conditions within the milieu. This will shed some clarity on how the design parameters within the sample may have influenced wellbeing. A more detailed analysis into these results could subsequently help designers conceive spatial parameters that reimagine future design.

Chapter 4 4.0 Utopian Models: Utopian studies are an interdisciplinary field of study which investigates the many forms of utopianism; utopian politics, literature, art, theory, and intentional communities. Whilst it is recognised that there are many integral components to its meaning, within the context of this dissertation I shall focus on the ‘community or society’ aspect as a subset of a wider set of desires and hopes. Originally coined from Ancient Greek, the word ‘utopia’ was a term created in 1516 by Sir Thomas More. Derived from the combination of the Greek words οὐ meaning “not” and τόπος meaning “place,” the meaning roughly translates to describe a “no-place” or more specifically, something that does not exist1. The expression is generally used to define an imagined community or society, which possess a highly desirable or nearly perfect set of conditions for its residents (Giroux 2003). Within standard usage however, the definition has adapted, lending its meaning to the description of a non-existent community considered considerably better than the existing society (Rüsen, Fehr and Reiger, 2005). Thus, by seeking to reinterpret therapeutic communities into buildable design models that reimagine post-pandemic cities, a new utopian imaginary of wellbeing emerges. Whilst the cultural prominence of utopias centred around wellbeing is abundant, there have been few studies that examine the role of utopian thinking towards therapeutic communities. This chapter, therefore, examines the use of the imagination in the design process, and how it may be employed to posit better and improved wellbeing parameters. It also considers the relationship between the social psychological implications of utopian thinking, to derive potentialities for a new urban typology catered towards the improvement of resident wellbeing. 4.1 The Need for a New Utopia: Currently we live within built spaces that have been contrived from the realisation of another kind of utopia: the capitalist vision of individualism, consumerism, and materialism. Formed through a seductive chain of routine, inertia, and automatism, it is a utopia that has since been exploited by commerce and fuelled by advertisement. This vision of utopia has ultimately formed a destructive loop that has contributed to an unsustainable and unsatisfactory reality, with direct impacts evidently made upon the health and wellbeing of society (Dittmar, Kapur, 2011). Moreover, this becomes a utopia of consumer desires supported by liberal and neoliberal thinking, which is narrower than and contrary to the wider definition of wellbeing I endeavour to work with. Findings from numerous reports (Relojo-Howell, 2019) indicate that excessive consumption and isolation has contributed to residents living a more stressful life, bringing dramatic consequences to their overall health and wellbeing. Supporting this statement, are British datasets which measure and monitor the UK’s level of wellbeing. Comparisons between the UK’s wellbeing to the rest of the world reveal a noticeable prevalence of depressive and anxiety disorders within the population, which have steadily grown over time. Additionally, increased feelings of loneliness and decreased feelings of satisfaction and worthwhile, were also highlighted as problems in need of urgent attention (Jones and Randall, 2019). Whilst the realisations of a capitalist vision may not have initially set out to be destructive to wellbeing, we can see how it had strived to collectively achieve a specific lifestyle. This perhaps, is only comprehensible if one looks first at the logistics behind them, but also to their articulation to the ideals withheld by society. Therefore, beyond its immediate denotation, the term’ utopia’ carries a connotative power of ambition and hope. What especially engages with this vision, is the optimistic intentions associated with it. Subsequently, a utopian reality must be engaging as a vision - a vital component missing within the current built space. It is the contention of this, that an imaginary society better than the current, existing community, shall emerge.

4.2 Designing a Utopian Imaginary: Utopianism, construed both as a pedagogical method and as a design process, is submitted as the engagement of the senses to bring a site and its components to life within the embodied imagination (Waterman, 2018). In architectural terms, utopian design allows us to venture down untried pathways and find optimistic ways for wellbeing to be introduced into quotidian spaces. Furthermore, when asked to denote what had been the most important factor in advancing therapy, optimistic thinking from new patients within the therapeutic community, correlated with feedback which sought the instillation of hope (Case study 1: Deinstitutionalisation in UK mental health services, n.d.). Support by several utopian theorists argue that the notion of utopian thinking, is something that the general population can freely engage with (Fernado, 2018). Subsequently, as these worlds are imagined and take form within the mind, the utopia creates the potential to motivate individual engagement with society, thereby, the utopian imaginary of wellbeing becomes an important driver of social change. In addition, as both the designer and resident become more present and embodied within the design, a more human presence is added into the imaginary. Thinking in these terms enable us to view the vision as more than being primarily statistical or visual, but instead very personal. In architectural terms, the creation of a new utopian imaginary, not only begins to describe spaces that link communities and wellbeing, but also serves to contrive a space that is dictated by evidence-based design, rather than discordant materialistic impressions of consumerism. Thus, by allowing the architect to employ and engage with neurosciences, the designer can propose buildings that are based upon scientific knowledge; not ego, ideology, or fashion, to enhance and improve the resident’s overall health and wellbeing. Therefore, in socio-political and economic terms, utopian thinking within architecture has never been more important, whether it be poetically polemical or philosophically convincing and imaginable. A utopian vision is about hope and escaping the constraints of the existing, to something that is better and optimistic. I argue that the imagination, therefore, is just as necessary to everyday life as the practicalities of reality are. This superfluity is not just necessary, but utopian. However, whilst the ideals of utopian thinking may offer us a vision of the potential role therapeutic communities could provide in modelling the future urban typology, they fundamentally remain imaginary and fictitious. As such, how could the proposal for new design strategies be implemented between the real and the illusory? 4.3 A Framework for Heterotopia: Originally used within medicine to describe a cell or group of cells living non-malignantly within a host cell or tissue, the term ‘heterotopia,’ derives from the combination of the Greek words eτερό meaning “other” and τόπος meaning “place.” This amalgamation can be construed to describe a “other-place” or a thing that does and does not exist simultaneously (Utopia and Heterotopia – Making Difference: Architectures of Gender, 2017).

Adapted by Michel Foucault in 1966, the term is often used to outline the division between utopia and heterotopia, distinctively as the ‘unreal’ and the ‘real’ respectively. In his lecture to architects, both the notion of utopia and heterotopia are described as ‘spaces which are linked with all the others, and yet at variance somehow with all the other emplacements’ (Serres, 2020). Applying this concept to past therapeutic communities, we begin to identify the hospital and the asylum model as heterotopic spaces. For example, both the leprosarium hospital and Victorian asylum, were institutions where individuals whose condition or behaviour lay outside the norm were placed. This heterotopia of deviation subsequently, created spaces that were both isolated and penetrable, but not freely accessible like a public place. These semi-permeable spatial states can be understood as allowing the passage of specific elements while simultaneously acting as a barrier to others. Therefore, these therapeutic community models acted as parallel spaces that held undesirable bodies, which in turn allowed a utopian space to be possible.

Figure 13: Heterotopia spatial concept, by Burak Pak (2018)

As these models progressed and deviated to become a package of local provision, distinct from the care within the hospital and asylum setting, an attempt to reterritorialize the therapeutic community model by reinscribing what was once a zone of condemnation, into a therapeutic space was made. Heterotopia can, therefore, similarly be used as a method of explaining the reinterpretation of therapeutic communities: spaces transformed into being, disrupting the apparent continuity and normality of typical, everyday space in a way that is not detrimental to their host (the urban typology). By identifying the distinct conditions which sometimes act at odds or become contradictory within this urban sphere, we begin to view the community as a layered structure of heterotopic nodes and networks (Figure 13). Thus, the role of heterotopia could be deemed as an essential factor in evaluating and understanding the built environment. Applying this theory as a testing grounds for existing spatial conditions, offers us with the potential for fruitful, new design norms. However, what is critical to note here, is that Foucault saw these temporal utopian visions as problematic. He contended that it was quite limiting to bind the difference in the tone of utopia as modes of thinking that were specific to different periods. Therefore, it is more generative to consider the methods of alternative practice and discourse within their own present, ‘let knowledge of the past work on the experience of the present.’ Heterotopia connects to this process and implies that we should instead learn from these utopian fragments. Subsequently, when aspiring towards future spatial parameters, it is vital to avoid using historical models as a forward projection of the past, but instead, as an amenable framework that could be altered and adapted. 4.4 Closing the Parenthesis: Following Thomas More, utopia can be used to conceptualise wellbeing not as the absence of influences on people, but as a practice of shaping one's life in interaction with them. User-influencing design approaches can help to continue the tradition of socially engaged design, with tempered, non-utopian goals, but at the same time with improved understanding and more effective tools concerning how evidence-based research within psychotherapeutic research mediates our existence. Whereas following Michel Foucault, heterotopia allows us to create a place that is both real and unreal at the same time, as opposed to the utopia vision, which is solely imaginary. These intentional

heterotopias can create new conceptual spaces which shape alternative orderings and challenge the limits traditionally conceived by the therapeutic community, to separate the social, physical and economic dimensions of daily life. Secondly, it suggests that the enactment of design is initially triggered by resident’s health requirements, followed by community practices but also by relational-spatial processes embedded in both the local global network. Within the human scale, alternative design strategies are produced, therapeutic design is disclosed, and spaces of wellbeing can be created. Apart from the representational differences posed by the two philosophical approaches, lessons learnt from utopia generally act best as a reference for future architectural design, by allowing the imagination to be both as specific and as comprehensive as it can be, whilst heterotopias offer better testing grounds for current spatial conditions, enabling lessons from past fragments of utopia to guide future design frameworks.

Chapter 5 5.0 Models of the Future: At a time when the need to develop healthier cities is reaching a crossroads, it is not hyperbolic to realise that we face difficult choices that have the potential to lead to different futures. The focus on using the therapeutic community as a utopian model of wellbeing, offers us with an optimistic vision of unlocking these urban health possibilities. This utopian vision of urban change and renewal imagines the green shoots of revival clearly through a host of policies and projects that support better health. In this scenario, flexible design strategies to reduce stress and gridlock; walking, cycling and public transport which addresses over-reliance on the car; access to safe, affordable housing, and outdoor spaces underscore a commitment to community wellbeing. In turning our attention to improving the health of the society, the argument is increasingly being made that advances in urban wellbeing, where large numbers of residents spend unhealthy amounts of time, will remain stagnant or potentially become worse unless we reform our design approach and practices. Long, stressful commutes, presenteeism and lack of communal spaces are all issues coming under the spotlight as governments and public health authorities attempt to explore alternative ways to improve wellbeing. 5.1 Reforming the Wellbeing Pillars: Having explored the case studies, historical foundations, psychotherapeutic influences, and philosophical theories underpinning therapeutic communities, consideration as to how reinterpretation of the model into buildable design strategies are formed can begin. The next critical part of the investigation, therefore, refers back to the government’s ‘Five Ways to Wellbeing’ pillars and explores how they can be applied and adapted within this vision. Whilst it is acknowledged that these pillars could be reductive and misgiving, they offer a baseline for which imagined spatial parameters could be created from. I therefore propose taking these ideas from policy as a measurement and subjecting them to a utopian reimagination which draws on the notion of a wellbeing community model. Connect: Provision of ‘everyday public spaces’ within therapeutic community models, provide residents with the opportunity to connect, and thus become a significant design parameter of wellbeing (Cattell, 2008). Although individual user requirements differ, some crucial qualities include accessibility and proximity to communal resources. This increases the chance of encounters. Adaptable spaces without prescribed functions to allow flexibility of space. Familiarity is created through domesticity, providing a sense of safety and familiarity. Pedestrian-oriented streets correlate with a sense of community (Lund, 2002). In summary, communal areas exclusive to residents encouraged relationships and nurtured support networks – essential components of wellbeing. Keep Active: Access to external or internal environments where exercise takes place promote physical health, promoting endorphins which improve wellbeing (Bauman, 2007). Design strategies that further promote activity, include high residential density to provide closer proximity and convenience, with pavements to promote walkability. Finally, the use of stairs for those without physical restrictions, not only distribute separate functions across multiple floor levels, but also encourage further movement along circulation routes. Be Aware: Natural landscape qualities have been widely and for a long time associated with a range of health benefits (Thompson, 2011). Being mindful and taking notice could include provision of windows or doors connecting to, outdoor spaces, to help distract the mind from the daily stressors of confinement. Flexible spaces that encouraged incorporated this, significantly increase observations, encouraging individuals to be more mindful and aware of the present moment.

Keep Learning: The physical environment of the home and classroom are associated with mediating variables that influence intellectual development. Domestic parameters such as clean, tidy, open spaces, provide users with a sense of ease and security (Guo, 2000). Careful consideration towards seating distance and orientation also promotes social engagement. Unobstructed eyes contact further promotes interactions (Marx, 2000). At a more prosaic level, thermally comfortable, adequately lit, secure rooms with fresh air circulation assist in the concentration and drive to learn. Help Others: Finally, altruistic trends generally occur in rural environments. This perhaps implies, that access to nature, through the integration of more green spaces, could be valuable component considered within the utopian design of the urban environment (Korte, 1974). This is more prevalent in communities which include positive environmental and physical characteristics of space design (diversity, proximity, accessibility, and quality) (Anderson, 2014).

Conclusion Originally I endeavoured to explore the potential for a new utopian framework by reinterpreting the role therapeutic communities play, then reimaging them as a model for wellbeing within the urban typology. Overall, there is some evidence to suggest that the therapeutic model is perhaps more likely to offer an effective intervention that focuses specifically, on inhabitant requirements and social growth as a rationale for promotion. Initial findings revealed that the design parameters linked to wellbeing varied significantly throughout the development of the therapeutic community, indicating a lack of a clarity in the definition of wellbeing and the design parameters needed to support it. This is partially a reflection of the complexity surrounding wellbeing, where shifts in stigma, thinking and treatment did not develop linearly. It also illustrates that a model has not yet emerged from the experimentation phase, which would enable the development of a ’tried and tested’ care model to have a more global implementation. Therefore, it is crucial to underline the significant lack of clarity regarding the definition of wellbeing, and the subsequent measurements reliant on it as a structural basis for design. Whilst attempts to stipulate its meaning have been made, such as the government’s “Five Pillars of Wellbeing,” definitions are often oversimplified and reductive. The importance of highlighting this is to accentuate that whilst a basic framework exists, a vast pool of unintegrated knowledge is not eloquent in its totality. Therefore, whilst the definitions offered a useful guideline, further investigation regarding this term is required. The overall findings suggest that therapeutic design and wellbeing are closely affiliated, not least because they focus on creating atmospheres that are unique to the requirements of an individual, but also, because the use of “community as a method,” has helped shaped our response to wellbeing throughout history and vice versa. Lessons garnered from the past (leprosarium and asylum model) typically identify ‘community as a method.’ Contrary to initial assumptions, adaption of this method within the contemporary setting reveals variants of the therapeutic community, not only have the potential to change health, but can also influence individual behaviour, lifestyle and identity. The results garnered form the secondary data, highlight an alarming rise in physical and mental health problems within the wider milieu, particularly within anxiety and depression, which had increased form 39 per cent in 2000 to 24 per cent in 2014. The notion of reinterpreting the therapeutic community model as a generator of wellbeing for the wider urban typology, therefore, becomes an urgent requisite. A holistic understanding of enactment, however, looks beyond the physical place of the community, and instead towards a hopeful, optimistic vision of utopian thinking. By allowing the imagination to be both as specific and comprehensive as it wants, reimagining therapeutic communities, allows the relationship between wellbeing and utopian thinking to consistently construct hopeful growth. Contrary to the traditional notion of utopia however, the therapeutic community can be viewed as multiple, yet related scales that act as a layered structure of heterotopic nodes and networks. This is because each unique requirement of an individual demands a distinct set of conditions that may sometimes be contradictory and at odds. Therefore, the view that utopian thinking and therapeutic design are both intrinsic and vital elements to wellbeing, is more than purely imaginary or inert physical settings where recovery and healing occurs. Instead, it becomes key to understanding the role of a therapeutic community model. Accordingly, in consideration of this rationale, and measured against the aims delineated in the abstract, the overall findings indicate that the therapeutic community is more than just a method of psychiatric treatment, but instead a model with the potential to reinterpret the urban typology and subsequently, provide a utopian imaginary that influences wellbeing.

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Bibliography:

Adult Psychiatric Morbidity Survey 2014. 2014. [online] Available at: <https://files.digital.nhs.uk/pdf/q/3/mental_health_and_wellbeing_in_england_full_report.pdf> [Accessed 5 January 2021]. Aked, J., Thompson, S., Marks, N. and Cordon, C., 2008. Five ways to wellbeing. [online] New Economics Foundation. Available at: <https://neweconomics.org/2008/10/five-ways-to-wellbeing> [Accessed 10 March 2020]. Albrecht, G., Seelman, K. and Bury, M., 2001. Handbook of Disability Studies. [online] SAGE Publications Inc. Available at: <https://us.sagepub.com/en-us/nam/handbook-of-disabilitystudies/book10687> [Accessed 4 January 2021]. Anderson, J. (2014). Urban design and well-being. Cambridge: Doctoral thesis, University of Cambridge. Atkins, R. and Popescu, E., 2010. Excavations at the Hospital of St Mary Magdalen, Partney, Lincolnshire, 2003. Medieval Archaeology, 54(1), pp.204-270. Bauman, A., & Bull, F. (2007). Environmental correlates of physical activity and walking in adults and children: A review of reviews. Loughborough: National Centre for Physical Activity and Health, for the National Institute of Health and Clinical Excellence (NICE). Bil, J., 2016. Stigma and architecture of mental health facilities. British Journal of Psychiatry, [online] 208(5), pp.499-500. Available at: <https://pubmed.ncbi.nlm.nih.gov/27143013/> [Accessed 13 April 2020]. Blogs.ethz.ch. 2017. Utopia and Heterotopia – Making Difference: Architectures of Gender. [online] Available at: <https://blogs.ethz.ch/making-difference/2017/11/16/utopia-and-heterotopia/> [Accessed 5 January 2021]. BrainKart. 2021. Interpersonal Theories. [online] Available at: <http://www.brainkart.com/article/Interpersonal-Theories_24185/> [Accessed 10 January 2021]. Cattell, V., Dines, N., Gesler, W., & Curtis, S. (2008). Mingling, observing, and lingering: everyday public spaces and their implications for well-being and social relations. Health Place, 544–561. Chiesa, M., Fonagy, P. and Gordon, J., 2009. Community-Based Psychodynamic Treatment Program for Severe Personality Disorders: Clinical Description and Naturalistic Evaluation. Journal of Psychiatric Practice, 15(1), pp.pp.12-24. Chrysikou, E., 2014. Architecture for Psychiatric Environments and Therapeutic Spaces. IOS Press; Illustrated edition.

Currentnursing.com. n.d. Nurses' Role in Milieu Therapy. [online] Available at: <https://currentnursing.com/pn/milieu_therapy.html> [Accessed 14 January 2021]. Dalgard, O. and Tambs, K, K., 1997. Urban environment and mental health: A longitudinal study.. British Journal of Psychiatry, pp.530–536. Designcouncil.org.uk. 2009. Sustainable places for health and Well-being. [online] Available at: <https://www.designcouncil.org.uk/sites/default/files/asset/document/future-health-full_1.pdf> [Accessed 29 April 2020]. De Leon, G., 2000. The Therapeutic Community. Springer Publishing Company LLC.

Dittmar, H., Kapur, P. (2011). Consumerism and Well-Being in India and the UK: Identity Projection and Emotion Regulation as Underlying Psychological Processes. Psychol Stud 56, 71–85. Encyclopedia Britannica. n.d. Harry Stack Sullivan | Biography, Contributions, & Facts. [online] Available at: <https://www.britannica.com/biography/Harry-Stack-Sullivan> [Accessed 27 December 2020]. Fernando, J., Burden, N., Ferguson, A., O’Brien, L., Judge, M. and Kashima, Y., 2018. Functions of Utopia: How Utopian Thinking Motivates Societal Engagement. Personality and Social Psychology Bulletin, 44(5), pp.779-792. Foucault, M., 1977. Discipline and Punishment. New York: Pantheon. Guo, G., & Harris, K. (2000). The mechanisms mediating the effects of poverty on children’s intellectual development. Demography, 431–447.

Giroux, Henry A. (2003). "Utopian thinking under the sign of neoliberalism: Towards a critical pedagogy of educated hope"(PDF). Democracy & Nature. Routledge. 9 (1): 91–105. Historicengland.org.uk. n.d. A History of Disability: from 1050 to the Present Day | Historic England. [online] Available at: <https://historicengland.org.uk/research/inclusiveheritage/disability-history/> [Accessed 20 April 2020]. Jones, R. and Randall, C., 2019. Measuring National Well-Being: International Comparisons. [ebook] Available at: <https://www.ons.gov.uk/peoplepopulationandcommunity/wellbeing/datasets/measuringnationalw ellbeinginternationalcomparisons> [Accessed 12 January 2021]. Kellert, S., 2014. Birthright. New Haven: Yale University Press. Keyes, C., 2007. Promoting and protecting mental health as flourishing: A complementary strategy for improving national mental health. American Psychologist, [online] 62(2), pp.95-108. Available at: <https://pubmed.ncbi.nlm.nih.gov/17324035/> [Accessed 13 April 2020]. Page, W., 1911. A History of the County of Hampshire. British History Online, [online] 4. Available at: <https://www.british-history.ac.uk/vch/hants/vol4> [Accessed 29 April 2020]. Korte, C., & Kerr, N. (1974). Response to altruistic opportunities in urban and non-urban settings. Social Psychology, 183–184. Lund, H. (2002). Pedestrian environments and sense of community. Journal of Planning Education and Research, 301–312. Main, T., 1946. The hospital as a therapeutic institution. [online] PubMed. Available at: <https://pubmed.ncbi.nlm.nih.gov/20985168/> [Accessed 4 January 2021]. Marx, A., Fuhrer, U., & Hartig, H. (2000). Effects of classroom seating arrangements on children‘s question-asking. Learning Environments Research, 249–263

Patterson, R. and Bosanquet, G., 1966. Eadmer's History of Recent Events in England (Historia Novorum in Anglia). The American Historical Review, [online] 71(3), p.926. Available at: <https://academic.oup.com/ahr/article-abstract/71/3/926/50148?redirectedFrom=fulltext> [Accessed 31 April 2020]. Places, spaces, people and wellbeing: full review. 2018. [online] Available at: <https://whatworkswellbeing.org/wp-content/uploads/2020/01/Places-spaces-people-wellbeingfull-report-MAY2018-1_0119755600.pdf> [Accessed 11 January 2021]. Pringle, P. and Chiesa, M. 2001. From the therapeutic community to the community: developing an outreach psychosocial nursing service for severe personality disorders. Therapeutic Communities. 22 (3), pp. 215-232.

Relojo-Howell, D., 2018. How Consumerism Affects Our Well-being | Psychreg. [online] Psychreg. Available at: <https://www.psychreg.org/consumerism-well-being> [Accessed 15 March 2020]. Roffey, S., 2012. Medieval Leper Hospitals in England: An Archaeological Perspective. Medieval Archaeology, [online] 56(1), pp.203-233. Available at: <https://www.researchgate.net/publication/272223768_Medieval_Leper_Hospitals_in_England_A n_Archaeological_Perspective> [Accessed 19 April 2020]. Rüsen, J., Fehr, M. and Reiger, T., 2005. The necessity of utopian thinking: A Cross-National perspective. [online] ResearchGate. Available at: <https://www.researchgate.net/publication/298096458_The_necessity_of_utopian_thinking_A_Cr oss-National_perspective> [Accessed 29 January 2021]. Serres, M., 2020. Heterotopian Studies – Michel Foucault’s ideas on heterotopia. [online] Heterotopiastudies.com. Available at: <http://www.heterotopiastudies.com> [Accessed 30 December 2021]. Scull, A., 1989. Social Order/Mental Disorder: Anglo-American Psychiatry in Historical Perspective. [online] Routledge & CRC Press. Available at: <https://www.routledge.com/Social-OrderMentalDisorder-Anglo-American-Psychiatry-in-Historical-Perspective/Scull/p/book/9781138315983> [Accessed 1 March 2020]. Sullivan, H., 1924. Schizophrenia: Its Conservative and Malignant Features. American Journal of Psychiatry, 81(1), pp.77-91. Therapeuticcommunities.org. n.d. Types of TCs. [online] Available at: <https://therapeuticcommunities.org/what-is-a-tc/types-of-tcs> [Accessed 3 January 2021]. The King's Fund. n.d. Case study 1: Deinstitutionalisation in UK mental health services. [online] Available at: <https://www.kingsfund.org.uk/publications/making-change-possible/mental-healthservices> [Accessed 13 January 2021].

Thompson Coon, J., Boddy, K., Stein, K., Whear, R., Barton, J., & Depledge, M. (2011). Does participating in physical activity in outdoor natural environments have a greater effect on physical and mental well-being than physical activity indoors? A systematic review. Environ Sci Technol, 1761– 1772. Waterman, T., 2018. Making Meaning: Utopian Method for Minds, Bodies, and Media in Architectural Design. Open Library of Humanities, 4(1). Wilson, S., 2012. Therapeutic communities in mental hospitals. Therapeutic Communities: The International Journal of Therapeutic Communities, [online] 33(1), pp.55-70. Available at: <https://www.emerald.com/insight/content/doi/10.1108/09641861211286320/full/html> [Accessed 15 April 2020]. Ukdiss.com. 2019. Effectiveness of Therapeutic Communities in the Treatment of Self-harm in People with Personality Disorders. [online] Available at: <https://ukdiss.com/examples/therapeuticcommunities-self-harm-treatment.php?vref=1> [Accessed 30 December 2020].

Images:

Figure 1: World Health Organisation. (2004). The 5 Ways To Wellbeing. Available at: https://5waystowellbeing.org.au/about-wellbeing/ [Accessed 24 November 2020].

Figure 2: Hajrasoulih. A. and Francis. J. and Edmondson. J. (2018). Conceptual Framework of the Relationship Between Urban Form and Mental Well-Being. Available at: https://www.urbandesignmentalhealth.com/journal-5---urban-form-and-mental-wellbeing.html [Accessed 24 November 2020].

Figure 3: (1975) St Cross Hospital, Almshouses, St Cross Road, Winchester, Hampshire. Available at: https://historicengland.org.uk/images-books/photos/item/AA092195 [Accessed 30 November 2020] Figure 4: The sites of Colchester's medieval hospitals and religious institutions. Available at: http://cat.essex.ac.uk/reports/EAS-report-0076.pdf [Accessed 30 November 2020]

Figure 5: Schnebbelie. J. (1796) Interior of communal hall, St Mary Magdalen Available at: https://www.researchgate.net/publication/272223768_Medieval_Leper_Hospitals_in_England_An _Archaeological_Perspective [Accessed 31 November 2020]

Figure 6: Exterior of Broadmoor Asylum Available at: https://www.bbc.com/culture/article/20161213-how-bedlam-became-a-palace-for-lunatics [Accessed 30 November 2020]

Figure 7: (1885) Block plan of Broadmoor Criminal Lunatic Asylum. Available at: https://classic.europeana.eu/portal/en/record/9200579/cgnxs4cr.html?utm_source=newwebsite&utm_medium=button [Accessed 04 December 2020]

Figure 8: Types of modern Therapeutic Communities. Available at: https://therapeuticcommunities.org/what-is-a-tc/types-of-tcs/ [Accessed 06 December 2020] Figure 9: (2016) Therapeutic Communities for people with dementia within secondary mental healthcare. Available at: https://www.baat.org/About-BAAT/Blog/39/Recollection-Art-Therapy-forIndividuals-Living-with-Dementia [Accessed 05 December 202]

Figure 10: Akerman. G. (2013) Therapeutic Community Model. Available at: https://www.researchgate.net/figure/Therapeutic-community-model-of-change_fig1_235003804 [Accessed 18 December 2020]

Figure 11: Dahlgren and Whitehead. (1991). Model of Health Determinants. Available at: https://www.gov.uk/government/publications/health-profile-for-england/chapter-6-socialdeterminants-of-health [Accessed 10 December 2020]

Figure 12: R. Ulrich, L. Bogren, S. Lundin (2012) A Design Theory for Reducing Aggression in Psychiatric Facilities Available at: https://www.semanticscholar.org/paper/Towards-a-designtheory-for-reducing-aggression-in-UlrichBogren/9c07b5972f8704b7d6e21a7a79f2852ada4490b7/figure/0 [Accessed 16 December] Figure 13: Burak P. (2018) Production of heterotopia and isotopia. Available at: https://www.researchgate.net/figure/Production-of-heterotopia-and-isotopia_fig4_326143856 [Accessed 16 December 2020]