Creating a therapeutic space for people with Body Dysmorphic Disorder

Creating a therapeutic space for people with Body Dysmorphic Disorder Saule Virbickaite ID 6594976 Fig 2

Designing a patient centred clinic with a positive vision and idea that the balance between architecture, nature, beauty and community has a beneficial effect to the patients

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Module leader Selma Porobic Main tutor Sid Porobic 15-12-2017

Contents Page

List of Figures 3 Abstract 4 1.0 Introduction 5 2.0 Design Research Activity 6 2.1 Research Methods 2.2 Research Activities 2.3 Case Studies 3.0 Analysis and Summary of Findings 9 4.0 Design Research Conclusion and Final Design Brief 9 4.1 Design Brief 5.0 Design Embodiment Research 12 6.0 Concept Design 12 7.0 Selection of Concepts 13 8.0 Development of Ideas 14 9.0 Final Solution 14 10.0

Research Reflections 14

References 15 Bibliography 16

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List of Figures

Figure 1 Metamorphosis of a Monument. Leung, F. and Duquet, M. (2017).

Figure 2 Andrew. Martin, D. (2017).

Figure 3 Sketch of pillars in Coventry Cathedral. Saule Virbickaite (2017).

Figure 4 Sketch of a pillar in Coventry Cathedral. Saule Virbickaite (2017).

Figure 5 Sketch of the Coventry Cathedral ceiling. Saule Virbickaite (2017).

Figure 6 Photograph of the Coventry Cathedral interior. Saule Virbickaite (2017).

Figure 7 Sketch of the building-tree concept. Saule Virbickaite (2017).

Figure 8 Section of the formal Technical School. Saule Virbickaite (2017).

Figure 9 Section of the formal Technical School. Saule Virbickaite (2017).

Figure 10 Section of the formal Technical School. Saule Virbickaite (2017).

Figure 11 Section of the formal Technical School. Saule Virbickaite (2017).

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Abstract

Body Dysmorphic Disorder is a mental health condition affecting a large part of our society but because of different stereotypes attached to our view of mental illnesses it’s hard for people to understand the importance of patients’ experiences and well-being. Nowadays hospitals focus on trying to heal as many people as possible without considering changing their stark and spiritless atmosphere. However, patient centred institutions provide not just medical assistance but also create a friendly, comforting ambience using natural elements by creating a healing environment.

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1.0

Introduction

The body is a physical structure holding person’s organs, skin, bones and flesh together.

Human body has a significant meaning in many cultures. It is a sacred vessel protecting person’s mind and soul. Any manmade or natural alterations to a human body that are different from a particular beauty standard can seem to be unnatural and odd especially for a conservative mind. “Or do you not know that your body is a temple of the Holy Spirit who is in you, whom you have from God, and that you are not your own?” (1 Corinthians 6:19). Why in many religions you need to keep your body pure and try to perfect? Nowadays individualism and originality are being praised as great values, but a lot of people in our society are too scared to be different. It takes a lot of courage to stand out from the crowd and understand that everyone is unique, for some it is easier to blend in stay unnoticed. A lot of people have issues with their body image. The media and social networks project unrealistic beauty standards and everything besides that is viewed as undesirable and shameful. Trying to be perfect even when knowing that no one is, is harmful not just to your body but mind too. Body Dysmorphic Disorder or BDD is a mental health condition characterized by persistent and intrusive preoccupations with an imagined or slight defect in one's appearance. (Adaa.org, 2017). BDD is commonly considered to be an obsessivecompulsive spectrum disorder based on distinct similarities it shares with obsessivecompulsive disorder. (Physio-pedia.com, 2017). People who are suffering from this illness can dislike any part of their body usually it is their hair, nose, skin, stomach or chest. Usually these flaws and defects are minimal and faint or completely non-existent. People may think that it is not that important because despising a particular body part is common, however, the difference between BDD sufferers and people with low self-esteem is that the idea of having a perceived imperfection can haunt BDD patients everywhere they go. They can’t control their thoughts or focus on anything besides their flaws and imagining unrealistic scenarios of what would their life would be if they looked perfect. Some spend several hours or whole days thinking about their appearance, on average between 3 and 8 hours a day.

(Phillips, 2009). In some severe cases paranoia is caused. This is the feeling that everyone is looking and judging your presence and it is so strong that sufferers avoid social situations and isolate themselves even though they fear loneliness. This disorder is so common that “it is estimated that approximately 0.5-0.7% of the UK population have it.”

(Ocdaction.org.uk, 2017). Some patients believe that talking about it and sharing their experiences is vain and narcissistic; afraid of being criticized, laughed at and that people won’t think that it is a serious issue. Stigma around Body Dysmorphic Disorder and mental illnesses in general is very common, people tend to hide their problems and are reluctant to seek any professional help. There is a need to support people with mental issues living in the community because they are a big part of our society. Mental health clinics and their design must be socially integrated and connected to the community beyond the institution.

How is it possible to create a therapeutic space that attracts people and makes them feel safe and not excluded?

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2.0

Design Research Activity

2.1 Research Methods and Ethics Qualitative and secondary quantitative research methods are used to understand and achieve the value for the end user- people who are suffering from Body Dysmorphic Disorder.

2.2 Research Activities There is no place in the UK created specifically for people effected by BDD. Mental health centres are mostly located in and around London, not in The Midlands which would be easily accessible from every corner of UK. Good architecture and design is an integral part of the healing development process. Patient centeredness is the concept of a healing environment with prioritization of patient autonomy and choice. Care is coordinated to their individual requests. The patient is an independent person who arrives at the medical encounter with explicit, specific concerns. Elizabeth Bromley discusses the idea of a patient centered hospital in her article ‘’Building patient-centeredness: Hospital design as an interpretive act’’ as an environment that is intimate, inspirational and joyful no matter the size of the building.

Sense of ‘’smallness’’ that is introduced into the space gives it a home-like feeling to patients and staff to empower and encourage ill people to engage into their own healing process. It is a sensible balance of health, care and community. Mental care hospitals have a certain stereotype attached to them, they are viewed as asylums with endless corridors and medical staff controlling every step or action that patients take. They are often subordinated to personnel and can experience a deficiency of respect from staff and society. Labelling mental health patients as haunting and dangerous isolates them from the local community.

The hospital environment must help people integrate and not separate patients from everyday life. It should provide settings and a considerate ambience that recognises individuality and diversity.

The first hospitals as we know them were built by knights of the Middle Ages. (Sternberg, 2009). Before that Ancient Rome and other societies didn’t have any hospitals, patients who were considered ill were visiting temples and were treated with a healthy diet, music, sleep, pure water and most importantly- prayer, hope and faith. Soldiers were treated on the battleground, terminally ill were divided in colonies but not for their own advantage, rather for the safety of society, to stop the expansion of the disease. Fundamentally hospitals were never designed to be healing focused, the main purpose is to keep the ill person near doctor. Human subjects are turned into docile bodies. The beginning of the curing environment- hospital that doesn’t look or feel like one. Patients should be treated like guests; tools of care and other necessities should not be displayed. They need to be aware that ‘’the hospital identity is hidden but not erased’’ (Bromley, 2012) but it doesn’t require for the hospital to have a cold and hostile atmosphere.

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Dr. Thomas Story Kirkbride was an advocate of an asylum structure based on ethics and function, influenced the design of almost all American mental organisations in the late nineteenth and early twentieth centuries (Sternberg, 2009). His ideas spread across England and France. The institution’s main features had to maintain mental and emotional health by providing spaces for physical activity and pleasing surroundings. Beautiful gardens, parks, sculptures and fountains scattered around the main ward not just camouflage the hospital’s protective character, but also create a space for ill people to enjoy. It was a pure getaway where their emotions could be calmed and eased. Kirkblade was convinced that daily exercise and hard work were crucial to mental wellness. Patients must move freely, socialise and communicate with others, make food and eat together as a community. The doctor believed that the beautiful scene with lots of natural light ‘’restored patients to a more natural balance of their senses’’ (Sternberg, 2009). The main tasks of this research for creating a healing space is designing a ‘’therapeutic landscape’’ which consists of social, physical and symbolic surroundings as they take part in physical and mental wellbeing. The nature needs to be perceived as a healer, social interactions of patients, medical staff and community are important to break the outdated mental illness stigma. There is a necessity to showcase patients’ feelings and educate the public on this issue.

2.3 Case Studies To explore this topic in a deeper way I am using a variety of case studies and ideas based on books and articles to help with understanding how Body Dysmorphic Disorder affects sufferers in their everyday life, how humans understand beauty and what is an architect’s view on hospital design from patient’s perspective. Professor of Psychiatry and Human Behaviour Katharine A. Phillips dedicated her book ‘’Understanding Body Dysmorphic Disorder’’ to people who want to understand this relatively common but under recognised illness. She collected a broad variety of interviews and BDD sufferers’ experiences. Phillips shows that BDD patients worry about how they look to the point it distresses and causes a lot of personal problems. Constant mirror checking or avoiding, comparing yourself to others, covering body parts they hate and trying to be perfect or at least ‘normal’ is devastating.

Body Dysmorphic Disorder is more than a bad hair day; it is a difficult illness, but, it can be treated. Jennifer’s story shows how lack of confidence in teenage years can evolve into a serious body image issue. Phillips describes her as an attractive 22-year-old with no visible flaws in her appearance. “At first, Jennifer was reluctant to discuss the details. “Well, I just think I’m not pretty,” she said. I know what you’re going to say. You’re probably going to tell me I look fine—everyone does— but I know it’s not true. I look terrible!” She said that everything started when she was about 11. She was preoccupied with looking at in her opinion, uneven nostrils, she thought that one of them was sticking out more than the other.

But later, she found a new obsession over her appearance and skin became the new target.

Thoughts about imagined marks and blemishes that made her so ugly didn’t allow her concentrate during class, preoccupations took over her mind and drained her energy. Crying and calling her mom to pick her up from school and spending hours at home in front of the mirror picking her skin with needles dipped in alcohol made things even worse. Another patient, Ian, started spending all of his time in his room because of anxiety that his facial features are too big for his face possessed his thoughts. “I have this tape in my head that says, ‘I hate how I look.” Ian was thinking about his face so much that every time looking in the mirror he was thinking about suicide. He started failing in school but he couldn’t help himself to get rid of the negative concerns. A big part of Body Dysmorphic Disorder patients has an agonising relationship with mirrors. “Mirrors reflect their greatest hope— that they look okay— and their deepest fear— that there’s something terribly wrong with how they look.” Over 90% of people with BDD check themselves in not just mirrors but other reflective surfaces like shop windows, car bumpers, computer screens and so on for and excessive period. “When I go to museums,” he said, “I count my freckles in the reflections of the paintings instead of looking at the pictures.” Some people get a temporary relief while 7

looking at the mirror but mostly people feel even worse because mirrors confirm their biggest fear- that they look hideous and grotesque. Just like people with different eating disorders, people with BDD see themselves differently than they actually are. The causes can be genetic, biological, abuse or sexual trauma that affect their brain distorting their self-image.

They don’t only believe that they look normal, but they see differences from an imagined beauty standard.

But why do people view things as beautiful or ugly? Social psychology professor Arnulf Kolstad discusses this topic in his essay ‘What happens if Zeleste becomes and Architect” (Cold, 2001). Looking at his daughter Zeleste who is twirling in a pink dress wearing multiple gold and silver accessories had him wondering why she prefers these colours and why is she so happy while wearing them? “Does her happiness and increased well-being have anything to do with her visual perception at all?”. Kolstad thinks that people generally feel good in environments they find aesthetically pleasing and that are giving an aura of hospitality. What we define as appealing is usually what develops our comfort and wellbeing. Age, maturity and understanding determines different preferences of what is beautiful and not. But to the contrary, others can influence your opinion. Enjoyment can be passed on from one person to another, there is a synergetic (cooperative) effect when people unite and are a part of mutual impacts. “When something is looked upon as beautiful by somebody, this increases the possibility that other persons exposed to these preferences will react in the same manner. <…> This is the reason why there are common style and art tastes in a specific culture or society.” Probably that’s why we are so dependent on social media and beauty trends it dictates. Most people don’t think that a something is beautiful until a celebrity or a big part of the community think it is. “By its very nature, an aesthetic feeling is incomprehensible and fundamentally obscure in its evolution to the person experiencing it.”

(Rader and Vygotsky, 1973). Beauty perception can induce emotional and cognitive pleasure and it doesn’t decrease accordingly to maturity and wisdom. There is no direct connection of visual preferences and health, well-being but delightful environments and objects can increase positive mood and this can influence physical and especially mental wellness in a pleasing manner and improve healing process. “Optimistic, happy attitudes about yourself, other people and the world in general, influence some basic physiological and biological processes” (Cold, 2001).

One of the greatest Finnish architects and designers Alvar Aalto started creating a very important architectural piece of our century in early 1930s. Paimio Tuberculosis Sanatorium is a monument of functional design and modern principles of art but most importantly it is an architectural metaphor of hope and healing. Whilst working on this project Aalto fell ill and had to spend some time in a hospital where he could analyse the environment from a patient’s point of view. He was cautious of all the surroundings especially in the ward where patients must spend most of the time usually looking at the ceiling when there’s no other interesting visual stimulus. Anything can start annoying and irritating patient from the colour of the walls to the noise water makes when splashing into the washbasin. The architect believed that the client of the design should be “man at his weakest.” (Cold, 2001). The designer should think about the tiniest and most insignificant details of the building to help patients move, orientate and use the space as well as create the feeling of safety, ease, meaning and intimacy. Every patient’s experience is completely different from the medical and nursing staff or visitors. Hospitals that are created like factories and turn the ill person into the object of remote, mechanical medical care lacking individuality. in hospitals, more attention is payed to the work environment than therapeutic atmosphere.

“It is obvious that the caring environment should offer the patient a safe place from which he can observe his world and self.” (Cold, 2001). Primarily the healing surroundings should provide experiences of life and hope. “There is no difference between a curing environment and a positive living environment in general.” (Cold, 2001).

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3 .0 Analysis and Summary of Findings Case studies found in Katharine A. Philips book ‘’Understanding Body Dysmorphic Disorder’’ helped me comprehend the mental health struggles BDD patients have to deal with every day. Creating a healing environment by using the patient centeredness concept seems to be appropriate way to design a mental health centre for people with BDD. Developing it in the centre of UK would help people access it without difficulty from every part of the country.

Through my ideas and research, I came to conclusion that the institution has to be not just functional but aesthetically pleasing, in order to create a healing environment all of the surroundings have to be visually attractive as it is important to the general well-being.

4 .0 Design Research Conclusion and Final Design Brief In conclusion, my designed mental care centre has to be located in Midlands, location and easy access is really important. Thinking about every little detail while designing it in order to understand and help patients while developing a patient centred space which could be open to the public too for educational purposes. Bringing community and patients together would eliminate stereotypes about patients with Body Dysmorphic Disorder and mental illnesses in general.

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4.1 Design Brief •

Name, title, date Saule Virbickaite, Body Dysmorphic Disorder Mental Health Centre, 9th February

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Introduction Body Dysmorphic Disorder or BDD is an underestimated mental health condition affecting up to one in every 100 people in UK. The number is approximate because sufferers are too ashamed and are reluctant to seek any professional help. Designing a space that would create a healing environment for patients and also educate community, would help society understand this under recognised disorder and accept people with this mental illness.

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Project aim create a therapeutic space that attracts people and makes them feel safe and not excluded

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Project objectives Raise awareness about BDD provide safe, healing environment for BDD patients change the look and ambience of the location by transforming not just the interior but also building surroundings, use of the natural objects and materials

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Target audience The majority of people with BDD are young adults (18- 39 years old) but it can occur during the childhood or adulthood. The disorder affects men and women almost equally it just appears as different symptoms and concerns about different body parts. Patients can be from different social backgrounds but causes of this disorder can be different (genetic, brain malfunctioning, sexual trauma, abuse, etc.).

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Initial design constraints User Factors: creating space per the concept of the patient centeredness Environmental Constraints: carefully changing the landscape and surroundings per the use of the area (domestic, industrial etc.), keeping in mind that the mental health centre and some of its premises will be open for public too.

Aesthetic Direction: aesthetically pleasing atmosphere created using natural elements

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Project management Initial research: 2nd October- 3rd November Conceptual development: 3rd November- 15th December Design development: 10th December- 5th January Prototyping: 3rd January- 9th February 10

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5.0 Design Embodiment Research The concept of a patient centred hospital and A. Aalto’s, Dr. T. S. Kirkbride’s opinion that hospital has to have a healing atmosphere not just inside but outside too, merging interior and exterior together, bringing a little bit of nature inside the building. It is known natural elements as light, trees, plants and an organic environment can influence the overall human well-being. While researching on the kinds of BDD treatment I found out that the most commonly used healing types are cognitive- behavioural therapy, which teaches to recognise irrational thoughts and change negative thinking patterns), antidepressant medication, and supervised physical activity and exercise. These types of therapy are limited, also they might differ depending on the age of the patient and the severity of the illness. The National Institute for Health and Care Excellence advises that the patient’s family or carers should be involved in the care and support of the ill person also depending on the cultural and religious background healthcare professionals lead the therapeutic process. All these factors determine the creative solution of the mental health centre referring to the original research question.

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Concept Design

My initial idea was to use all three buildings of former Smethwick Campus of Sandwell College. Site is located in the centre of Smethwick, ~3,6 miles West of Birmingham city centre, on the south edge of Crockett’s Lane. All the buildings are abandoned but Sandwell Council has plans to redevelop the site into housing units (Sandwell Council 2016).

The location is served by good public transport links, Victoria park and a lake are visible from the site. It is surrounded by residential houses and easy access to the local facilities. After presenting my initial research ideas I was advised to use only one of the buildings because of its large size and ability to maintain all the needs and requirements of the BDD mental health centre. The building I have chosen is the former Technical School which has three floors and is over a thousand square meters in size. There is quite a lot of free space around it which makes this site perfect for a garden leading patients and visitors to the Victoria park and creating a renewed outlook on Smethwick and the city’s changing landscape.

One of my biggest inspirations is Coventry Cathedral. With a stunning interior with an interesting approach on using concrete and wood creates an ethereal aura. My favourite elements are pillars supporting the roof. Architect Basil Spence designed them in a contemporary way with a symbolic twist, minimalistic shapes form objects resembling trees (See Fig 4- 6). It just shows that everything originates from nature, forests full of trees create calming and spiritual atmosphere.

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7.0

Selection of Concepts

The knowledge that architecture and interiors can affect peoples’ mood and health means that emotional and physical environments should interact in order to benefit patients and visitors. The type of architecture called biophilic design suggests that nature itself has a healing effect (Sternberg, 2009). The addition of gardens, prayer rooms, views of nature, spaces where family members can spend time with ill relatives, open spaces and most importantly - light can improve patients’ well-being. As mentioned before, the building that I have chosen has three floors, each floor will be based on the symbolic meaning of a tree.

The first floor will represent the top of the tree with residential and therapy rooms. The ground floor will resemble the stem; it is the first thing people see when entering the forest, this floor will be open for the public. Lastly the lower ground floor will depict roots with workshops, spaces for group activities, like a shared kitchen and educational spaces for visitors (See Fig 7). By removing part of the roof and replacing it with glass natural light will flood the whole first floor and bring more cheerfulness and hope for patients. Because there is no need to house all patients coming to the institution, I have decided to create up to ten rooms for ill people to stay from a few days to a few weeks depending on the case. Rooms would have large windows with a view, bathrooms, in each one of them as well as comfortable furniture not just for patients but for people who are visiting them. Creating a living-room-like spaces inside each ward will bring a sense of homeliness. People would not just stay there but also would have individual and group therapy sessions. The ground floor will be open for the public with a café where patients would have an opportunity to work and interact with community, visitors centre, gallery displaying patients’ artwork and artists who are bravely talking about mental health issues and BDD, also an indoor garden, plants would flourish from the ground floor through the existing void and would reach the first floor.

Leaves partially covering the void will filter the light coming through the glass roof creating layers of light on the ground floor. On the lower ground floor, will have different interactive spaces to fulfil different artistic or other needs to express themselves with workshops and spaces for socialising as well as sharing their experiences with visitors in educational rooms.

It will have an entrance to the garden with a greenhouse where subjects will be able to grow and take care of plants as a form of therapy; fruits and vegetables grown there could be used and sold in a café and shop on the ground floor.

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8.0 Development of Ideas I need to consider that the former Technical School building is grade II listed, its facade is an important architectural element and altering it by changing windows and roof I would change the whole ambience of the site and the area surrounding it. Also by trying to bring some nature inside of the building and creating an indoor garden I would have to think of a way to support the whole ground floor and would take into account how to keep the temperature constant while having parts of the roof replaced with glass.

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Final Solution

To create a therapeutic space that is welcoming and not excluding. I will create a connection between patients and community. ‘’If people are not talking about it how can anyone understand it?” (Queer Britain. The search for the Perfect Body, 2017). Body Dysmorphic Disorder mental health centre will be partially open for public but at the same time it will keep patients’ privacy safe by dividing uses of the building according to different floors. It will be naturally and aesthetically pleasing surroundings are important to the healing process.

Merging the interior with the exterior will bring a tiny part of nature inside in a form of an interior garden, while building a greenhouse outside in the garden will form a relationship between the building and garden.

10.0 Research Reflections It took me a lot of time and effort to research for this project but therefrom I got a great amount of inspiration and new ideas that will help me move forward and further develop the project. I am extremely interested in healthcare and therapeutic environment design; research guided me to a deeper understanding to patients wants and needs.

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References Adaa.org. (2017). Body Dysmorphic Disorder (BDD) | Anxiety and Depression Association of America, ADAA. [online] Available at: https://adaa.org/understanding-anxiety/relatedillnesses/other-related-conditions/body-dysmorphic-disorder-bdd.

Bible Gateway. (2017). Bible Gateway passage: 1 Corinthians 6:19 - New International Version. [online] Available at: https://www.biblegateway.com/passage/?search=1+Corinthians+6:19.

Bromley, E. (2012). Building patient-centeredness: Hospital design as an interpretive act. Social Science & Medicine, [online] 75(6), pp.1057-1066. Available at: http://www.sciencedirect.com/science/article/pii/S0277953612004054?via%3Dihub#bib 50.

Cold, B. (2001). Aesthetics, well-being, and health. Aldershot, Hants, England: Ashgate, pp.118-119, 126-127.

Nice.org.uk. (2017). Obsessive-compulsive disorder and body dysmorphic disorder: treatment | Guidance and guidelines | NICE. [online] Available at: https://www.nice.org.uk/guidance/cg31/chapter/1-Guidance#step-1-awareness-andrecognition.

Ocdaction.org.uk. (2017). Body Dysmorphic Disorder (BDD) | OCD Action | The UK's Obsessive Compulsive Disorder Charity. [online] Available at: http://www.ocdaction.org.uk/support-info/related-disorders/body-dysmorphia.

Phillips, K. (2009). Understanding body dysmorphic disorder. Oxford: Oxford University Press.

Physio-pedia.com. (2017). Body Dysmorphic Disorder - Physiopedia. [online] Available at: https://www.physio-pedia.com/Body_Dysmorphic_Disorder#cite_note-Koran-6.

Queer Britain. The Search for the Perfect Body. (2017). [video] Directed by D. Carson.

London: BBC1. [online] Available at: https://learningonscreen.ac.uk/ondemand/index.php/prog/0F600E0E?bcast=124677397 Rader, M. and Vygotsky, L. (1973). The Psychology of Art. The Modern Language Journal, 57(5/6), p.291.

Sandwell Metropolitan Borough Council. (2017). Planning applications. [online] Available at: https://webcaps.sandwell.gov.uk/publicaccess/simpleSearchResults.do?action=firstPag e.

Sternberg, E. (2009). Healing spaces. Cambridge: The Belknap Press of Harward University Press Leung, F. and Duquet, M. (2017). Metamorphosis of a Monument. https://koozarch.com/2017/04/14/metamorphosis-of-a-monument/.

Martin, D. (2017). Andrew. [Oil on canvas] https://www.saatchiart.com/art/PaintingAndrew/700636/3514251/view.

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