Empty Wards

Ravine Mangala

EMPTY WARDS

Engaging Community for Renewed Mental Health

School of Architecture | UNC Charlotte

Ravine Mangala

EMPTY WARDS

Engaging Community for Renewed Mental Health

School of Architecture | UNC Charlotte

Š 2016 SoA UNC Charlotte. All rights reserved.

Publisher – LuLu. This book is set in various forms of Calibri.

The work in this publication is made possible with support from the School of Architecture, College of Arts + Architecture at University of North Carolina at Charlotte. http://coaa.uncc.edu/academics/school-of-architecture Inquires about this publication may be directed to Ravine Mangala at rmangal1@uncc.edu.

Cover Image: Ravine Mangala, 2015 Images this page: Geek Slop, Abandoned Insane Asylums, 2012 Image final page: Cane Hill, Mental Asylum. London, 2008

CONTENTS

PREAMBLE 4 RESEARCH TOPIC

8

LITERATURE REVIEW

10

LITERATURE MAP

26

CASE STUDIES

28

PROJECT INTEREST

50

BIBLIOGRAPHY 52 POSTSCRIPT 54

Robin Hammond, Condemned. South Sudan. 2013 4

|PREAMBLE The causes of several mental disorders are known to vary in complexity, depending on the individual and severity of his or her illness, and they come with different biological, psychological, and environmental factors contributing to their causes. Most mental disorders are a result of a combination of several of these factors, as well as some other unknown ones.

The global rise of community- engaged care for mental health was born in the early 21st century, post-deinstitutionalization, with a goal to provide support and ensure quality treatment for people with mental illness in more home-like settings, instead of confining individuals to psychiatric hospitals or mental asylums. A community-based care refers to a system of care in which outpatients are included in their communities, rather than being isolated from them and admitted into secluded facilities such as psychiatric hospitals. The distribution of community-based mental health services vary tremendously across communities, depending on the location in which a network of services is dispersed and the vulnerable population for which mental health services are provided.

The primary goal for a community-engaged system for mental health is to provide individuals facing mental health challenges with various alternatives to coping with their conditions.

This system of outpatient care encourages the idea of building and maintaining thriving communities by offering an array of services through supporting housing, short-term hospitalization for acute care, dispersed networks of medical services within communities, mental health centers, self-help groups, peer support services, and many more.

According to the World Health Organization, a community-engaged system of care is more effective because it offers services that are accessible to communities and populations of various scales. This system of care is also effective because it negates the possibility of neglect and violations of human rights, by preventing individuals to be forced to mental institutions. Since the rise of de-institutionalization, there have been countless organizations, disciplines, and movements, worldwide, who have partnered together with a mission to improve quality of life for people with mental disabilities, but the results of their efforts are small in scale compared to the larger and more complex issues that have yet been realized.

The global movement that originated from the idea of outpatient care and led to the closing of mental hospitals have left many developing countries with little alternatives to assist affected individuals, with far too many issues around the distribution and accessibility of care.

5

Humane

Orientation

Restorative

Partial Hospitalization

Institutionalization

Acute Care Human Rights

Inpatient Care Inacute Care

Psychiatric Institutions

Social Exclusion

ASYLUM 1800-1850 Moral Treatment

Prevention Scientific

MENTAL HOSPITAL 1890-1920 Mental Hygiene

Mental Health Movements and the Development of Programs since De-Institutionalization 6

Setting

Movement

Outpatient Care De-institutionalization

S.T.A.R.T Emergency Care

Social Integrity Day Centers

A.C.T

Self-help Groups Peer Support

Patient Therapy

Clubhouses

Era

Halfway Housing Social Welfare

MENTAL HEALTH CENTER 1955-1970 Community Mental Health

F.A.C.T

Employment Responsible Team Residential Care

Recreational

Family/ Network

C.S.P

COMMUNITIES 1975-PRESENT Community Support

7

Glenn Nagel, Abandoned Hospital Ward. Manteno, Illinois. 2012 8

|RESEARCH TOPIC The infrastructure of care has collapsed, and there is a need to acknowledge that designing to improve mental health deals with shaping complete environments. Understanding the complexity embedded within a region can reveal potentials for new design methods that are more conscious, responsive, and adaptive to its nature and context. Prominent mental health design issues found in different environments include social neglect, the isolation of necessities, and the inaccessibility to services for those who are in need of them. Contemporary methods of designing for mental health have evolved from an extraordinary past of psychiatric hospitals and a disturbing approach to treating the mentally ill. The largest public buildings in 19th century Western civilization were asylums, designed in rural sites to allow room for private amenities and provide a better environment for inpatients. By the 20th century, increasing admissions led to even larger psychiatric hospitals, spreading across developing urban areas to relieve overcrowding. Historically, overcrowding led to the closing of several mental asylums. The end of the 20th century initiated the de-institutionalization movement worldwide to gradually eliminate psychiatric hospitals and release patients into community-engagement services for mental health care.1 Despite deinstitutionalization, the stigma of mental illness still labels victims socially and economically problematic, and some counties continue to rely on asylums.2 Despite the brutal history of mental asylums, there is an opportunity for a new paradigm for conscious design to emerge in the contemporary age— one that prioritizes mental health for all individuals. As the natural and built environment changes and evolves, the cause of several mental health issues in the world remains unknown. Architecture, however, can be catalytic to significantly change, improve and rethink strategic priorities of a system and the people it is meant to serve.

Individuals with mental illness fall within a wide spectrum of symptoms, skills, and levels of disabilities, and because every one affected faces challenges uniquely, the appropriate place or setting that could allow one to live healthily varies significantly from another. Although the old idea of asylums were to be self-sufficient, the problem lies in the thorough institutionalization of those who resided there and continued to suffer psychological effects due to the lack of active community support, healthy community development and social endearment. The idea of an adaptive care model recognizes the importance of a cohesive and functioning system of structural organization for both rural and urban communities, by bridging solutions that may serve community needs in more appropriate scales with greater flexibility for the future.

9

6. Overloaded Patrick Geddes, Andres Duany

5. Incomplete S. Curtis, W. Gesler, Camillo Sitte

4. Capitalist Itai Palti, Moshe Bar, Aldo Rossi

3. Deprived Henri Lefebvre, C. Alexander

3. Stagnant Susanna Kaysen, Michel Foucault

1. Neglected Robin Hammond

An Urban Transect: Regional Challenges in Design for Mental Health 10

|LITERATURE REVIEW I. INTRODUCTION: FROM MENTAL ASYLUMS TO COMMUNITY-BASED CARE Contemporary methods of designing for mental health have evolved from an extraordinary history of treating individuals with mental illness and confining them to large psychiatric facilities since the early 19th century. In former and contemporary psychiatric facilities, wards define particular types of divisions within the institution realm. Contemporary psychiatric hospitals have emerged from the failures of former asylums and the consequences of their immoral treatment for patients with mental illness. Since the rise of the professional doctor, institutionalization for those with mental illness has been constantly evolving. Until now, however, the method used to cope with mental illness focuses on curing disabilities, rather than tolerating them and those affected by various mental health challenges.

Robin Hammond, Susanna Kaysen, and Michel Foucault, along with many other researchers and practitioners, have identified similar criteria in which both former mental asylums and contemporary psychiatric wards fail as places dedicated to care for people with mental illness. A popular issue found in the way facilities are designed for treating mental illness is the evident the lack of community engagement. Despite different challenges that mental health care facilities face, the concept of an institution hinders the idea of complete environments, where there may be more opportunities for services to disperse and better serve more people.

II. THE (URBAN) TRANSECT: DESIGN CHALLENGES / OPPORTUNITIES IN A REGION Understanding the complexity embedded within a region’s nature and context can reveal the potentials of a new framework for designing conscious, responsive, and adaptive environments. The use of Patrick Geddes’s concept of the “Valley Section” and Andrés Duany’s “Sprawl Transect” is to classify scales of urban facets. The different scales then serve as avenues to explore some of the most complex issues of the organization and distribution of architectural services in rural and urban settlements.3 Hence, these design challenges and opportunities are explored via “transect zones,” where the first part of a region is most rural and the sixth is most urban in density.

11

community dis-engagement

social neglect

aggressive restraints displacement and loss

Asylum Isolation Dwelling

Hamlets: Neglect in the Most Rural Settings 12

1. Hamlets: Neglect in the Most Rural Settings Mental health advocate, Robin Hammond, has begun to seek common grounds with design practice and mental health research by studying the relationship between historic asylums and contemporary mental institutions. Former psychiatric facilities were self-sufficient to promote the well being of their patients through private amenities like workshops, swimming pools, farming and vegetable gardens, which encouraged community engagement.

Today, one of the prominent issues in design for mental health care deals with social neglect.

In the least urban environments, mental illness is not always addressed as in other more developed areas. Because of their urban character and identity, preserved places like hamlets experience more crises than anywhere else along the urban transect. Meanwhile, the inevitable legacy of the stigma that is associated with mental illness is often hidden at a much larger scale, with almost no resources left to aid those who live there. Generations following deinstitutionalization have only known displacement and loss of proper psychiatric facilities, to which severe psychological trauma has remained a constant variable with painful consequences.

Hammond’s research emphasizes that the social effects of neglect “destroy infrastructure” and “kill several people,” and that mental health consequences on the few who survive from negligent experiences impact the rest of their lives. In the least urban environments, any form of conflict in policy and natural disasters keep funds away from necessities like health and education. For those who suffer with mental illness, “that’s when hospitals become prisons, ignorance results in neglect, and care only relies on aggressive restraints in both institutions and homes.4 Although primarily focusing on places facing the aftermath of socioeconomic crisis, Hammond’s research confirms that worldwide the stigma associated with mental illness is ever growing. Institutionalized or learned behavior alone does not guarantee recovery because the effects of mental challenges are always there to last. With mental illness, what hinders development is not always a physical or psychological flaw: “Discrimination, neglect, and the absence of policies to assist” those affected are just as harmful. At the very least, there is an opportunity to remove “the alibi of ignorance,” by being aware and shining a light on those issues.

13

psychiatric wards

minimum security

maximum security professional doctor

Isolation Asylum Dwelling

Villages: The Growth and Continuation of a Stagnant Model 14

2. Villages: The Growth & Continuation of a Stagnant Model In her 1993 memoir, American author Susanna Kaysen recalls her experience at a psychiatric ward (formally known as Somerville Asylum) in a suburb of Boston. Based on Kaysen’s account, what failed in former isolated mental asylums has to do with the lack of options for patients and the corrupt idea behind minimum-security and maximum-security wards. The gap between the two standards of security is markedly distant from each other. In minimumsecurity wards, “chicken wires” and “bars” obscure every window, bathrooms are without doors or toilet seats, and patients’ rooms are “seclusion rooms”— empty and dehumanizing.

In maximum-security wards, the approach to securing the mentally ill is “supreme,” where architecture deliberately fails to reveal whatever lies beyond its intense point of security.5 Kaysen’s account justifies that institutionalization for inpatient treatment has always been long-term, and maximum-security was considered a humane approach to providing safe accommodation in an environment where patients needed to be prevented from self-harm.

Throughout her memoir, the author reveals that the larger issue, however, is found in the obscurity that overshadows different degrees of intensity used to secure and confine inpatients. Former ways of designing for mental health care meant having wards maintained and secured to their maximum. Although several asylums have been demolished, abandoned, or naturally destroyed, in contemporary design for psychiatric hospitals, architecture continues to carry former design methods— driven by the obsession to maximize security, seclude individuals, and offer no alternatives for a natural experience of the larger environment in which one are forced to reside.

French philosopher, Michel Foucault, questioned society’s standard view of treating people with mental illness in his 1961 Madness and Civilization. He argues that in the renaissance, treatment for mental illness was actually far better than what they have become, because they were left to be ‘different’ rather than ‘crazy’ and medically institutionalized. His research reveals that the idea of institutionalization was born in the mid 17th century, forbidding those with mental illness to wander freely, and instead removing them from their communities and confining them to asylums. Although his research affirms that now there are better drugs and treatments for patients, the rise of the “professional doctor” denoted a dehumanizing attitude toward people.6 Over the last centuries, design for mental health has remained stagnant; the urgency to focus on methods that are intentional, effective, and responsive to critical needs has carried the same approach since the early years of de-institutionalization.

15

to reclaim urban life

right to the city

right to nature to reclaim nature

Isolation Asylum Asylum

Towns & Small Cities: Deprivation of Necessities When Environments are Drained with Content 16

3. Towns & Small Cities: Deprivation of Necessities when Environments are Intentionally Drained with Content In 1968, Henri Lefebvre wrote “The Right to the City, in which he focuses on a new approach to urban engagement. Professor David Harvey best summarized Lefebvre’s text as “far more than the individual liberty to access urban resources: it is a right to change ourselves by changing the city…The freedom to make and remake our cities and ourselves is, I want to argue, one of the most precious yet most neglected of our human rights.”7 The right to nature entered into social practice thanks to leisure, exchanged in value, for people to buy or sell.

Lefebvre writes that “the city is no longer lived and it is no longer understood practically,” as it has been thoroughly commodified as a privileged space for the consumption of products.

Today, cities and their commonplaces are still rotting. Their “naturality” is counterfeited and traded,” destroyed by “commercialized, industrialized and institutionally organized leisure pursuits.” Cities have become objects of cultural consumption for tourists and spectators, eliminating urban life from urban inhabitants who want to make use of their cities. As a result, nature has become the “ghetto of leisure pursuits…the separate place of pleasure and the retreat of creativity.”8 The right to the city is a cry and a demand to claim nature, for the desire to enjoy it amidst a deteriorating city. It is not about the idea of returning to traditional cities, but rather a transformed and renewed right to urban life, with new parameters for successful planning.

An ongoing urban issue is the focus on capitalism over urbanization, the double process of industrialization and urbanization that has not yet been mastered. Industrial production, after a certain growth, produces urbanization, providing it with conditions, and possibilities.

The World Charter on the Right to the City says, “Everyone has a right to the city without discrimination of gender, age, race, ethnicity, political and religious orientation,” whether permanent city-dwellers or nomads.”9 Further specifications on city-dwellers are made, stating that vulnerable people include those faced with poverty, in health and environmental risk, victims of violence, the disabled, migrants, refugees and all other groups. Like different forms of rural and suburban dwellings, the human need for particular services in populated towns have a similar sense of inaccessibility. In town planning and urban design, different pattern languages may begin to describe problems and bring issues to light, according to Christopher Alexander.10 In town planning alone, a form of language can be adapted as a method to help improve the way urban neighborhoods and communities are shaped.

17

to reclaim urban life

right to the city

right to nature to reclaim nature

Capitalism Capitalism Urbanization

Large Cities: City’s Focus on Capitalism over Urbanization 18

4. Large Cities: People as Influences of the City’s Focus on Capitalism over Urbanization Several historic asylums hold records that identify their designs as exercises in different rising architectural styles. Many of which carried throughout their life spans construction failures that were prominent before they were even completed. The primary need for larger asylums was because of cities expanding beyond their rural boundaries. Regional centers are unique because their planning models concentrate vibrant programs where population is larger. In the works of authors like Ado Rossi, organizational structure is what creates an identity of the urban artifacts that relates to the unique character that pleases both “society and the individual.”11 In “A Manifest for Conscious Cities,” architect Itai Palti and neuroscientist Moshe Bar claim that urban streetscapes are opportunities to help alleviate mental health challenges such as stress, anxiety and overcrowding. In places like Times Square, busy city streets can increase “cognitive load” in users, causing their attention capability to diminish. Considering some design challenges faced in large cities, the authors express that maximizing efficiency by thoughtfully planning the streets and spaces people occupy and experience daily is a step towards creating a shared urban environment that is mindful of its people. The playful scale of large cities could start to combine “cutting-edge date, technology and planning techniques to address stable patterns of behavior” such as the flow of pedestrian and vehicular traffic, while also temporarily adapting to short-term contexts driven by crowds.12

A study by the University of California found that “curiosity may put the brain in a state that allows it to learn and retain any kind of information.”13 Conscious cities might equally arouse curiosity through playful urban interventions. A bigger issue in large cities is the attention to capitalism over the “human experience.” A study by the University of Michigan focuses on the benefits of interaction with nature in contrast to urban streetscapes, suggesting that there are opportunities for natural environments to be recreated in a city.14 In contemporary design, there are only “a small number of buildings” with applied environmental psychology and neuroscience to enhance user experience. The proven advantages of natural light and views of nature are only the beginnings of conscious architecture. Carrying a similar mindset towards complete urban surroundings can really invoke a sense of hopefulness and further encourage and support facilities that need it most.

19

poor living conditions

ambiguous boundaries

seperation from community

inpatient independence

Incomplete Environments Institution Incomplete Environments

Metropolis Areas: Lack of Optimal Environments 20

5. Metropolis Areas: Opportunity for Creating Optimal Environments In a 2009 case study, “A Complex Rebirth of the Clinic,” medical researchers and practitioners investigated the effects of a community-based care model of inpatient care for mental illness on patients and staff in a psychiatric inpatient unit in East London. The (then) new model for psychiatric care emerged to connect patients with the surrounding community. “Although deinstitutionalization has been considered a beneficial development, it has also possibly resulted in more patients being relocated to prisons or ending up in poor living conditions after they are discharged.”15 The authors of the case study identify community-based models of psychiatric inpatients units that “foster interaction” within the community in which the unit is located. The study reveals the benefits of having public spaces available in facilities for visitors, staff, and patients to use, as well as flexible environments that appear familiar and allow patients to feel more at home. The study also recognizes the ambiguous boundaries and risks that the community-based care model creates when inpatients have the opportunity to be more independent. Some key concepts that were part of the research led by the study include the following: The emerging community-based care model should consider new geographical location within community settings, rather than isolated settings, with open wards that allow and encourage interaction between patients and the outside world because access to an individual’s local community and surrounding activities strengthens connectivity.

There is an opportunity to promote a sense of refuge through new methods of designing to provide a community for patients, by breaking from the past negative association of the old asylum model of isolation and separation from communities. As the authors of the research express, what is needed and useful for architecture to better respond to mental health issues are adaptive models, where building functions can change over time to accommodate critical needs for vulnerable population segments across various urban scales.

Camille Sitte’s take on the art of building cities suggest that metropolitan city design is based on its artistic fundamentals and artistic instincts that have always “resided within us”. An adaptive care model for community-engaged services can begin to celebrate former notions of organization between buildings and public spaces and their expanse within the city boundaries, irregularity in form, arrangement in space, and architectural character.16

21

inclusive cities

nature of cities

conscious design

patterns of behaviors

Community Urban Stimuli

Conurbations: Overload of Information 22

6. Conurbations: Information Overload A goal for the designer should be to deepen his understanding of the nature of cities, their historic essence and ever-chaining continuous life, which can be achieved by observing the environment’s development over time and space.17 Patrick Geddes once named the “conurbation” to identify a new scale of thought and organization or much denser human population, with an understanding and realization that villages, towns, and cities are rapidly expanding as society is changing from being an entity that is largely of the same kind to something completely different. With new forms of urban facets, a developing model of design through which understanding of traditional forms of functions can be applied to new thoughts for solutions is needed to formulate effective design methods—ones that begin to challenge environmental, social, and political problems associated with conscious design.

Conscious Cities Lab is a platform for collaboration and research, with a concept to build better environments that are aware and responsive to people’s needs through data analysis and the application of cognitive sciences in design. The use of technology to interact with services and organization would enable cities to become aware of people’s activities and make sense of everything that is going on inside of it. The multi-disciplinary platform also addresses the need for cities to become aware of the different problems embedded within it in order to enhance the way people use the built environment.

There is an opportunity to improve people’s wellbeing through design strategies that consider people’s needs, so that cities become “healthier, more inclusive and democratic.”18 When streets are overloaded with stimuli, for example, environments that are consciously designed with cutting-edge technology could help itself adapt for the benefit of people living there.

Conscious Cities Lab suggests that for cities to work in favor of improving the population’s mental health, they do not have to instantly change over a short time; simple, semi-permanent improvements could be make according to patterns of behaviors. For example, characteristics of a conscious environment can begin to encourage playful learning for younger generations, outside the institution realm, offer more opportunities for social interactions where older generations may suffer from loneliness, and be designed to affectively respond to different mood and behaviors.

23

Decadence Lost, Abandoned Mental Institution. Columbia, SC. 2013 24

III. CONCLUDING SUMMARY: AN INCLUSIVE AND ADAPTIVE CARE MODEL Historically, the idea of outpatient care is what led to the closing of several mental asylums, which then forced patients to seek treatment elsewhere. As a result, urban development and population growth prompted the rise of several existing community-based care service models that are found in most urban areas worldwide. Awareness and knowledge about mental health issues have grown tremendously over the years through initiatives and movements that work to try to remove the global stigma associated with mental illness. Because the care model has drastically changed since the rise of the institution and the professional doctor, the distinct values of organizing these urban facets amongst varying scales in search for an acceptable framework of methods for community-engaged services is to focus on the human interaction and its response to different forms of architectural organization in order to rethink ways that design can aid the treatment, prevention, and improvement of mental conditions.

To design for better mental health, everything must consciously reverberate, by acknowledging that the understanding of the unique conditions of an entire region’s nature and context is extremely valuable. The global initiation and spread of de-institutionalization did not just leave less-traumatized people; it brought forth the hope for improved infrastructure and systems that needed to be there primarily to aid and protect people with mental disabilities and provide them with an inclusive sense of community. As many rural and urban settlements are still far from a working and promising mental health care system, the effort to solidifying an infrastructure that provides people with community-engaged alternatives to coping with mental health challenges is essential.

The idea of the urban transect recognizes the importance of creating a cohesive and functioning system of structural organization for mental health, not one that is divided or segregated, but rather one that is considerate and responsive to various forms and scales of human settlements. To avoid repeating former mistakes of isolating services by segregating architectural type based on urban character and identity of different population segments, design that advocates mental health should consider all types of settings and diversity of people. Severe mental illness can alone overwhelm one’s will, but the struggle for an individual to heal in the cruelty of confinement and the ambiguity of a constantly evolving world is far more dangerous.

25

Isolated dwellings, like hamlets, have the strongest relationship to historic mental asylums.

Rural environments such as these allow mental facilities to be self-sufficient, while isolating people from their families and communities.

Any form of conflict in policy and natural disasters in places set apart from urban centers de-prioritize health and education.

Social neglect in the least urban environments destroy the potential of rebuilding infrastructure, often turning hospitals into prisons.

Contemporary psychiatric hospitals have emerged from the failures of asylums and the consequences of their immoral treatment towards inpatients.

Although the need for larger mental institutions spread into denser areas, inpatients were still deprived from necessities like access to nature.

Failures of former asylums largely deal with the lack of community endearment and the seclusion of patients from their surrounding nature and context.

The right to nature entered into social practice because of leisure, exchanged in value, for people to buy and sell.

Minimum and maximum-security wards are considered dehumanizing methods to confining inpatients.

The naturality of cities and their commonplaces are rotted, counterfeited and traded, destroyed by a commercialized, industrialized and institutionalized society.

Until now, the method is to cure, rather than to tolerate.

G. Thornicroft

Henri Lefebvre

David McDaid

C. Alexander

Michel Foucault

Robin Hammond

Susanna Kaysen

David Harvey

Winnie S. Chow Stefan Priebe

Social/ Urban NEGLECT Most Common in Isolated Dwellings/ HAMLETS

Seeking New Methods in a World of Complexity 26

The Growth and Continuation of a STAGNANT Model for Care in Rural Settings like VILLAGES

DEPRIVATION of Nature and Context when TOWNS are Drained with Content

|LITERATURE MAP

Urban streetscapes are opportunities to help alleviate mental health challenges such as stress, anxiety, and overcrowding.

The recent model for psychiatric care emerged to connect patients with the surrounding community.

Cities can began to maximize their efficiency by thoughtfully planning the streets and spaces people occupy and experience daily.

Community-based models of inpatients units foster interaction within the community, and allow patients to feel more at home with public spaces available in facilities.

Cities should benefit from applied environmental psychology and neuroscience to enhance the user experience.

New methods can promote a sense of refuge, breaking away from the past negative idea of the old asylum model of community isolation.

In places where human population is much denser, streets are overladed with stimuli, making it more challenging to adapt to people’s needs.

They can become more aware and responsive through data analysis and the application of cognitive sciences.

If cities were conscious, they would adapt to improve the human experience of the built environment.

Stefan Priebe Camillo Sitte

Matthias Gruber Itai Palti Moshe Bar Aldo Rossi

The Focus on CAPITALISM over Urbanization in LARGE CITIES

Andres Duany

Sarah Curtis W. Gesler

Patrick Geddes Conscious Cities

Susan Francis

INCOMPLETE Environments in Place of Optimal METROPOLIS Areas

Un-adaptable Streets, OVERLOADED with Stimuli in CONURBATIONS

27

human exposure to NATURE helps REDUCE mental illness

mental asylums made up 43% of all hospital BEDS

90% DECLINE in supply of inpatient psychiatric beds

CITY life increases RISKS of mental illness

1800- 1850 1890- 1920 1955- 1970 1975- Present

Program: Mental Asylum Setting: Isolated Dwelling

Transition Program: Outpatient Care Setting: Urban Community

From Mental Asylums to Community-Based Care 28

|CASE STUDIES INTRODUCTION: A CONTROVERSY Mental disorders are highly prevalent and disabling behavioral conditions, carrying with them decades of controversy about whether support services should be provided in communities or restricted to hospital settings. Issues surrounding mental health have become more than a simple public problem because there is an extensive treatment gap. Although there are effective methods of treatment and prevention, many affected individuals remain untreated because of scarcity in mental health services, depending on the identity and setting of a place. The treatment gap for people with mental disorders is universal and varies significantly across regions. Where the gap is wider, mental health services are simply limited or inaccessible.19 Since care for people with mental disabilities has become a growing public health concern, architecture must began to address this major public health challenge by contributing to a global social movement that strengthens mental health for all people.

Mental health is a fundamental component of health. Globally, there is a large gap found between the number of people needing treatment for mental disabilities and the number of people receiving treatment. The two sets of case studies examine the general availability of these resources in both rural and urban sections. There is an opportunity to improve design for mental health with the way services are distributed and made accessible to different population segments. The selected case studies could potentially aid in understanding and adapting new framework for a community-based design project that focuses on selected disorders.

Precedent mental institutions and present psychiatric facilities support the need for both community and institutional services regardless of location or regional setting, or availability of existing resources. The analyses of the case studies emphasize the need for a balanced approach—for both community and institutional services for mental health support. From the age of mental asylums to contemporary time, rural areas are proven to have low levels of resources, with a tendency to focus primarily on institutional care. More populated and denser areas like villages and towns tend to provide additional outpatient services. Urban cities and metropolis areas, with even greater density, seem to vary in the types of services they provide, including both inpatient and outpatient care. The ideal community of care should meet individuals’ needs by providing different forms of care with alternatives that help foster independence, diverse lifestyles, occupation, and social desires.

29

Setting: Total Area: 103, 483 mi2 Total Population: 4.471 million (2016) Population Density: 15 (People/ km2) Project: What: Historic Asylums of New Zealand When: 19th Century Institutionalization Why: Isolation of Services for Mental Health Care

4. Hamilton Large City: Majority Resided Town: A Psychiatric Hospital

3. Wellington Large City: Majority Resided Hamlet: A Hospital for Mental Illness

2. Christchurch Metropolis: Majority Resided Large City: Mental Health Services Provided

1. Dunedin Large City: Majority Resided Village: An Asylum for Mental Illness

New Zealand, Distribution of Mental Health Services, 19th Century Insitutionalization 30

N

|CASE STUDY NO. I I. AN INFRASTRUCTURE FOR CARE: AN INPATIENT INSTITUTIONAL MODEL 19th Century Institutionalization, New Zealand

Dunedin South Island, 1865

Christchurch South Island, 1868

Wellington North Island, 1870

Hamilton North Island, 1936

Largest City until 2010 Auckland Population: 127,000 (2016)

Largest City in South Island Population: 375,000 (2016)

Capital City and 2nd Largest City Population: 405,000 (2016)

Most Populous City of Waikato Region Population: 230,000 (2016)

1980 10.2 1960 16

2012 2.3 1990 8.5

2002 6.7

Hospital Beds per 1,000 People (World Health Organization, The World Bank Group, 2016) 31

Insane Seacliff

Sane Dunedin

15 miles Travel Distance to Seek Care From Large City To Village

N

In a rural site north of Dunedin, only small hospital buildings and a few building foundations remain of Seacliff Lunatic Asylum. There is great energy that radiates from the scale and architecture of Seacliff. After its completion in the late 19th century, this asylum was the largest building in New Zealand housing over five hundred patients. The “fantasy castle� design of the building as a place for treating mental illness is most intriguing. Throughout its lifespan, the building experienced numerous construction failures that were prominent before it was even completed.20 The architecture style of the building alone offers an opportunity to recognize that this asylum 32

1. SEACLIFF LUNATIC ASYLUM Seacliff, South Island Late 1800’s- 1942 Setting: Isolated Village Access: From Dunedin

Program: Lunatic Asylum

was specifically designed as an exercise in Gothic Revival architecture. Like several other growing asylums of the time, the need for an asylum near Dunedin was because of the city expanding. Former site conditions of Seacliff in comparison to the current site conditions will shows a strong relationship between the large asylum building and the larger urban context of Dunedin.21 Apart from the remaining small buildings, the current site conditions of Seacliff appear to be surrounding dense woodland and a few surviving buildings and ruins.

Most accessible archives relating to the history, culture, and people of Dunedin testify of the progression of repetitive interiors that were prominent during the building’s lifespan and are still common in many health facilities today.

33

Insane Christchurch

Sane Christchurch

3 miles Travel Distance to Seek Care From Metropolis To Large City

N

Sunnyside has a particular legacy because of its changes in site identity. The hospital’s name and building functions have also changed over time. In the mid 19th century, the original building asylum became vacant, and another improved mental facility was completed near the old site. A few years following the addition, another new facility was constructed to accommodate more patients. 1873 held over 123 “inmates,� and the rise in number 34

2. SUNNYSIDE ASYLUM Christchurch, South Island 1863- 1999 Setting: Large City Access: From Christchurch

Program: Mental Asylum

of people who suffered with mental illness became a primary issue. Because of the building’s changes over time, the architecture has played an important role in maintaining a stable environment within its context.22 The history and legacy of this institution has always remained within a much denser and larger urban context, now revealing its innovation as a health institution continues to emerge and develop beyond its city boundary.

35

Insane Rangitikei

Sane Wellington

93 miles Travel Distance to Seek Care From Large City To Hamlet

N

From the accounts of those who have experiences from this place, Lake Alice is one of the most complex asylums noted throughout New Zealand’s history. The hospital building and its place identity suggests that architecture design can and should effectively promote healthy living by creating hopeful, engaging communities for many who suffer in silence, instead of constrained, hopeless environments. Lake Alice was a self-sufficient psychiatric facility in the most rural area north of Wellington. Like some other historic mental facilities, to promote the well being of its patients, the facility had several private amenities, including workshops and recreational pools, farming and vegetable gardens.23

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3. LAKE ALICE HOSPITAL Rangitikei, North Island 1950- 1999 Setting: Hamlet Access: From Wellington

Program: Mental Hospital

For this abandoned ward, architecture and urban design had slowly shaped its built environment over time. Since Lake Alice shut down in 1999, plans to redevelop the rural site have not moved forward. The identity of the site has changed tremendously over the course of the last century through deinstitutionalization, financial difficulties, and the ongoing deconstruction since 2008. Today, the few remaining hospital buildings on site include its Maximum Security Unit, surrounded by debris of past building demolitions. Lake Alice is another example of how abandoned psychiatric hospitals can continue to alter over time and how their spatial changes can silently impact surrounding rural and urban communities.

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Sane Hamilton

Insane Te Awamutu

18 miles Travel Distance to Seek Care From Large City To Town

N

Through an experimental journey of learning about New Zealand’s asylums, geographical changes seems to be the focus of Tokanui’s evolution as one of the few abandoned asylum that have led to the several community-engaged services that are active today in urban areas across the North Island. In its functioning years, this self-sufficient hospital was a major employer in the rural area, serving many families over generations. Deinstitutionalization led to the closing of Tokanui in 1998, and patients were not the only ones left to seek treatment elsewhere. After the hospital had closed, there was an urge for medical practitioners to travel oversees to study other facilities.24 38

4. TOKANUI PSYCHIATRIC HOSPITAL Te Awamutu, North Island 1912- 1998 Setting: Town Access: From Hamilton

Program: Psychiatric Hospital

The wide spectrum of symptoms, skills, and levels of disability, and every one affected faces challenges uniquely. As a result, the appropriate place that will allow individuals to live healthily will always vary significantly across that spectrum. The place identity of all of these asylums is unique in that it offered an environment that unintentionally encouraged community engagement. Like several other mental asylums, Tokanui Psychiatric Hospital was also self-sufficient, residing alone on a large rural site north of Hamilton. The closing of the hospital was largely due to the lack of active community support, healthy community development and social endearment.

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Setting: Total Area: 163, 696 mi2 Total Population: 38.8 million (2004) Population Density: 251.3 (People/ mi2) Project:

1. Northern Conurbation: Majority Reside Conurbation: Mental Health Services Provided

What: Traditions Behavioral Health of California When: 21st Century PostInstitutionalization Why: Community-based Services for Mental Health

2. Central Metropolis: Majority Reside Metropolis: Mental Health Services Provided

3. Southern Large City: Majority Reside Large City: Mental Health Services Provided

4. San Diego Large City: Majority Reside Large City: Mental Health Services Provided

California, Distribution of Mental Health Services, 21st Century De-institutionalization 40

N

|CASE STUDY NO. 2 2. A COMMUNITY FOR CARE: AN OUTPATIENT COMMUNITY-BASED MODEL 21st Century De-institutionalization, North America

Northern California/ Bay Area

Central California

Southern California

San Diego California

Most Populous of San Francisco Population: 856,095 (2010)

Fresno as 5th Largest in CA Population: 502,303 (2010)

Los Angeles as 2nd Largest in USA Population: 4,094,764 (2010)

Furthest South Along Pacific Coast Population: 1,376,173 (2010)

2012 2.9 1990 4.9 1960 9.2 1980 6 2002 3.4

Hospital Beds per 1,000 People (World Health Organization, The World Bank Group, 2016) 41

Insane Oakland

Sane San Francisco

Urban Campus Relationship to Care/ Services Within Conurbation

N

On the opposite extreme of isolated mental asylums of New Zealand, Traditional Behavioral Health is an organization that has been serving the persistently mentally ill in California since 1996. The organization includes both inpatient and outpatient mental health services, dispersed across rural and dense areas in California in order to reach more people and better serve communities.25 Interspersing services across a region has become a common aspect of the community-engaged care model for mental health since de-institutionalization.

Unlike former mental asylums, mental health services provided through TBH like Alameda is 42

1. ALAMEDA HEALTH SYSTEM Oakland, Northern California/ Bay Area 1996- Present Setting: Metropolis Access: Northern California

Program: Structured Outpatient Care

designed for individuals to go through completing a structure outpatient program. Through community support, the program is meant to offer assistance and supportive treatment for a certain prior of time during an individual’s journey to recovery. Such structured outpatient care programs are developed to address medical, psychiatric, psychological, and social needs of an individual at his or her level of care. Some of the benefits inducing of this communtyengaged program include allowing individuals to attend treatment while living at home; helping families develop coping skills for maintaining in community; educating people about different diagnosis; providing solving and conflict management skills; and many more.

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Insane Lompoc

Sane Fresno

Community Bldg.

Relationship to Care/ Services Within Metropolis

N

Outpatient community-engaged services for mental health come in many forms, varying in program of available services, building type and the urban identity of its location. Of its many partners, Traditional Behavioral Health of California focus on serving communities of people that reside within close proximity of the location of a particular service. Lompoc’s current building is essentially a small campus within a large city. The distribution of community-engaged services like Lompoc, for example differs a lot from former isolated facilities because the building is set within a larger urban context--not only making its services more easily accessible to all, but also allowing those who benefit from its services an opportunity 44

2. LOMPOC MENTAL HEALTH SERVICES Lompoc, Central California 1996- Present Setting: Large City Access: Central California

Program: Outpatient Substance Abuse

to engage with the surrounding community.26 The outpatient program through Lompoc specifically focuses on substance abuse and offers mental health services plans with specific goals to improve access to mental health care, advising and assisting with preventative measures, and providing treatment methods for individuals to overcome substance abuse.

With a community-engaged service like Lompoc, individuals suffering from substance abuse car to maintain a flexible schedule with the staff as they work on treatment goals with other medical professionals due to improved access to mental health care.

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Insane Norwalk

Sane Los Angeles

Self-Contained Relationship to Care/ Services Within Large City

N

Since de-institutionalization, there have been many mental health movements across America and other parts of the world with a goal to provide a diverse set of programs where individuals would be able to choose according to their specific needs. Another partner of California’s Traditional Behavioral Health is Telecare, an outpatient care that focuses on Assertive Community Treatment in southern California. Telecare operates under a ‘full-service partnership’ model that focuses on providing support to individuals so that they may have successful community living.27 Telecare is one of the largest outpatient care providers of its kind and is known for the positive impact it makes in people’s lives, local communities and 46

3. TELECARE ATLAS 7 Norwalk, Southern California 1965- Present Setting: Metropolis Access: Southern California

Program: Assertive Community Treatment (ACT)

overall systems of mental health care. Both clients and peer staff members focus on recovery, growth, and personal inspiration.

Like many outpatient mental health care services, Telecare’s programs are many-- distributed across five other states with 60 other programs under eight major categories of services to support individuals with severe mental illness. Its innovative ACT program in southern California is tailored to individuals with co-occurring issues such as homelessness, substance abuse and developmental disabilities.

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Sane San Diego

Insane San Diego

Community Bldg.

Relationship to Care/ Services Within Large City

N

Serving the San Diego area, the Maria Sardinas is a wellness and recovery center that focuses on psychosocial rehabilitation through a form of community-based care known as Short Term Acute Residential Treatment (START). Through this type of outpatient program, the focus is more on re-establishing an individual’s life from the consequences of a mental illness, through recovery, rehabilitation and community integration. Within a community, those who chose to partake of this form of outpatient care typically participate in smaller building settings where services are generally geared towards fulfulling the plan goals of acute residential care.

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4. MARIA SARDINAS WELLNESS AND RECOVERY CENTER San Diego, California 1996- Present Setting: Metropolis Access: San Diego

Program: Short Term Acute Residential Treatment (START)

Some of the benefits of a START community-engaged program include promoting wellness, stability, and quality of life. This program works with a goal to prevent or minimize psychiatric episodes resulting in hospitalization, eliminate the effects of mental illness and reduce the likelihood of someone re-experiencing symptoms of an illness.28 Typically immersed within a community, the program improves functioning in social, volunteer, and employment activities by assisting clients with community integration and self-sufficiency. With various services offered, individuals can receive life skills development to employment services.

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|PROJECT INTEREST To carry this objective, adaptivity and flexibility are key to implement a program whose design methods are intentional and responsive to individuals’ needs. The building program will be an emerging model that delivers care and provides a safe community in an environment where young victims of mental illness can feel hopeful and engaged to the nature of their surrounding context as they journey towards independence. The design project will focus on engaging with individuals who are at critical periods of transition by building diverse communities.

Through architecture, the design project will be explored through an adaptive communitybased care model, which will encourage partnerships between communities and individuals who experience episodes of mental illness by focusing on providing better care, improving transition planning, and increasing patient and community education. Through a better understanding of nature and context, there is an opportunity to use innovative technology to recognize the design impact on a community-engaged system. The use of big data, for example, can enable the designer to even further understand the context of different environments and identify population sections that are vulnerable to greater mental health risks. Sustainability and resiliency are also critical in growing and maintaining healthier communities.

It is essential and fundamental that design for mental health moves away from the institution and becomes more mindful of people’s differences by responding to individuals’ needs within all kinds of communities. Until now, several psychiatric hospitals are still exclusive, some even more than those of the past. To further develop the goals and objectives of the project, the design will focus on selected mental health conditions from a particular group of people in order to look at different ways and adapt different methods to innovate design that engages the idea of community for better mental health. There is a lot that can be learned from the way former mental asylums were designed and how their services for mental health were distributed and made accessible to those in need of them. The old idea of psychiatric facilities tried to create communities within themselves; however, their failures came from a system of confinement and exclusivity in communities where patients were treated like diagnoses and were restricted from being able to connect with their surrounding nature and context.

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David McDaid and Graham Thornicroft, “Policy Brief: Mental Health II- Balancing Institutional and Community-Based Care,” (European Observatory on Health Systems and Policies, 2005), Pg. 2-6.

2 Winnie S. Chow and Stefan Priebe, ”Understanding Psychiatric Institutionalization: A Conceptual Review,” (BMC Psychiatry, 18 Jun 2013).

3 Andrés Duany, “The Urban Transect: Urban Design Derived from Nature,” (Duany PlaterZyberk & Company, LLC., 2014).

4 Robin Hammond, “Engaging the Arts to Advocate for Individuals with Mental Illness,” (The Columbia Global Mental Health Program, 2013).

5 Susanna Kaysen, Girl, Interrupted, (Turtle Bay Book, 1993), Pg. 101-106.

6 Michel Foucault, Madness and Civilization: A History of Insanity in the Age of Reason, (New York: Vintage Books, 28 Nov 1988).

7 David Harvey, “The Right to the City” (New Left Review, Oct 2008).

8 Henri Lefebvre, “The Right to the City”, in Kofman, Eleonore; Lebas, Elizabeth, Writings on Cities, (Cambridge, Massachusetts: Wiley-Blackwell, 1996), Pg. 158.

9 World Charter of the Right to the City, “Article I. The Right to the City & Article II. Principles and Strategic Foundations of the Right to the City” (World Charter, 2005).

10 Christopher Alexander et al., A Pattern Language: Towns, Buildings, Construction, (Oxford University Press, 1977).

11 Aldo Rossi, The Architecture of the City, (The Institute for Architecture and Urban Studies and The MIT Press, 1982), Pp. 3-35.

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|BIBLIOGRAPHY Itai Palti and Moshe Bar, “A Manifesto for Conscious Cities: Should Streets be Sensitive to Our Mental Needs?” (The Guardian, 28 Aug 2015).

13 Dr. Matthias Gruber, University of California, “How Curiosity Changes the Brain to Enhance Learning.” Cell Press NewsOct 2, 2014.

14 Marc G. Berman, John Jonides and Stephen Kaplan, “The Cognitive Benefits of Interacting with Nature,” (Psychological Sience Vol. 19 No. 12, Dec 2008).

15 Sarah Curtis, W. Gesler, Stefan Priebe, and Susan Francis, “New Spaces of Inpatient Care for People with Mental Illness: A Complex ‘Rebirth’ of the Clinic?” Vol. 15, No. 1 (Interior Design Educators Council, 2009), Pp. 340-348.

16 Camillo Sitte, The Art of Building Cities, (New York: Reinhold Pub. Corp., 1945), Pp. 8-10.

17 Patrick Geddes, Cities in Evolution: An Introduction to the Town Planning Movement and to the Study of Civics, (Ernest Benn Limited, 1968). Pp. 6-18.

18 Conscious Cities Lab, “An Introduction to Conscious Cities,” (Conscious Cities Lab, 22 Feb 2016).

19 Robert Kohnet al., “The Treatment Gap in Mental Health Care,” (Bulletin of the World Health Organizaton, Nov 2014). Pp. 858-853 20 Warwick Brunton, “Mental Health Services: Lunatic Asylums, 1840s to 1900s” (Te Ara, The Encyclopedia of New Zealand, 13 Jul 2012), Pg. 2.

21 A. H. McLintock, “Disasters and Mishaps- Fires: The Seacliff Fire” (An Encyclopedia of New Zealand, 1966).

22 Mental Health- Christchurch Office Holdings,” (Archives New Zealand, 1853-1960).

23 “Uncovering the Truth: Lake Alice Psychiatric Hospital” (Lake Alice Hospital, 2007).

24 Catharine Coleborne et al, Changing Times, Changing Places: From Tokanui Hospital to Mental Health Services in the Waikato, 1970-2012 (Waikoto Mental Health History Group, 2012 ) Pg. 68-83.

25 Traditional Behavioral Health, “TBH Partners with Programs All Over California,” (Napa, California) Web. Nov 2016.

26 Santa Barbara County, “Department of Behavioral Wellness: A System of Care and Recovery,” (www.countyofsb.org), Web. Nov 2016 27 Telecare, “ATLAS 7: Norwalk, CA,” (www.telecarecorp.com), Web. Nov 2016.

28 Community Research Foundation, “Maria Sardinas Wellness and Recovery Center: START Program,” (www.comresearch.org), Web. Nov 2016.

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|POSTSCRIPT The last two centuries have experienced critical change in systems of mental health care from relying solely on large, isolated mental facilities to the initiation of building community mental health centers. The current model of community-based care for mental health is similar to an umbrella containing several other supporting members of different programs types and services.

Although the idea of embedding the treatment and prevention of mental illness within communities is seen to be positive, the current model of community-based care is known to not be as effective for all individuals as there is no evidence that engaging in community care over the last many years has indeed solved and eliminated several social and urban issues that come with the stigma associated with mental illness. In the case of de-institutionalization, as the number of patients were encouraged or rather forced to be released into communities, the quality of care decreased and the availability of services also become small in number. Small community buildings, homes or centers dispersed within communities also face the general problem of scale, but only to another extreme, as they have difficulties accepting large number of patients in need of assistance and support.

Some forms of community treatment programs work well at certain regional scales, and for other scales and dimensions along the urban transect, treatment programs have experienced more failure due to the character and identity of the particular place in need of mental health services. An explorative, flexible architectural design project would help understand what aspects make design for mental health effective. With a seemingly increase number of people reporting to experience different forms of mental disorders, the question becomes more about the role an inclusive community plays in meeting the needs of individuals who need accessible mental health services. As community mental health system develops and moves forward, there is hope that the system of care for patients with mental illness will also continue to stabilize its presence within communities regardless of regional scale.

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