Can design promote healing?

As seen in Healthcare Design, Vol. 10, No. 2

Throughout the last century, the shift in perception of mental illness from incurable to controllable has expanded the possibilities of traditional healing. Medication and therapy are now seen as successful techniques for managing mental health disorders. Rehabilitation facilities that incorporate holistic programs should consider the impact of the physical environment on patient's mental, emotional, and physical states. Evidence-based design (EBD) provides opportunities to enhance patient well-being through manipulation of the physical environment to support environmental needs.

Although the application of EBD in the healthcare arena is well researched, understanding how the physical environment affects patients undergoing psychological rehabilitation is limited.1 This research, together with a conceptual design, was developed with the goal of understanding how EBD principles could be used to sculpt the space within long-term facilities to better meet the needs of adolescents.

Historical context: behavioral health facilities

In the mid-1800s, writings by psychologist Dr. Thomas Kirkbride suggested the design of psychiatric facilities should be cheerful, discarding “everything repulsive and prison-like.”2 By 1875, researchers found that “many great lessons taught by Dr. Kirkbride … were lost and mental healthcare [has] frequently been based on narrowly defined institutional models.”3 In the 1930s, another investigation, conducted by the precursor to the American Medical Association, uncovered “[o]vercrowding, understaffing, rampant inappropriate political influence and lack of treatment.”4 A century of unhealthy institutions encouraged the stigma associated with insane asylums. Fortunately, Kirkbride's recommendations echo a modern movement that promotes “the importance of the physical environment for psychiatric rehabilitation.”5

Defining the adolescent

Adolescents routinely face negative societal stereotypes. The ambiguity of the phase between childhood and adulthood challenges adolescents to define themselves and society to place them. Changes in identity, biological development, and peer interaction result in behaviors that are mistrusted by adults.6 Compounding that is a period of “rapid physical, mental, and emotional change” that can complicate the diagnosis of adolescent mental illness.7

Defining evidence-based design

One criticism of design has been an absence of analytical reasoning. If design practitioners did not previously have the opportunity to defend design solutions, they do now, courtesy of EBD. Much like evidence-based medicine, EBD is defined as “a process for applying research findings about the physical environment to improving the design.”8 Roger Ulrich's study, “View through a window may influence recovery from surgery,” linked the natural world to healing through quantitative data.9 Ulrich's work has since inspired studies linking architectural characteristics with well-being and stress reduction.10 These results provide designers with greater validity.

Practitioner research

A team from Perkins+Will, an architecture and design firm specializing in healthcare design among other disciplines, conducted resident interviews at a behavioral health facility in Suburban, Md. The facility treats adolescents, ages 12 to 18, suffering from behavioral and emotional disorders. The interview conversations were prompted by interior imagery of shape and form, color, applied pattern, seating, and lighting. Conclusions based on interviews are as follows:

• All interviewees requested individual “calm down” spaces with detailed, realistic imagery. EBD research suggests privacy as a stress reducer and imagery, such as art and murals, as a positive distraction for patients.

• Cool colors of blue and purple were preferred by all participants. Numerous studies associate cool colors with feelings of calm.11

• Residents disliked strong primary colors, children's toys, and small-scale furnishings.

• A desire for improved daylight was apparent. Daylight serves as a connection to nature and, therefore, a distraction from the difficulties of treatment.12

• Images with varied seating options and arrangements were highly regarded. More seating options offer patients more choice and control of the environment.

• Males favored seating focused around the television demonstrating the adolescent desire to connect to peers through media and peer observation to further identity development.6

From these findings, three priorities were established to inform the programming and design: (1) available and designated areas for privacy, (2) seating options, and (3) increased daylight.

From research to design

The conceptual design focused on corridors and lounge spaces within the existing unit floor plate since they are prime spaces for residents to freely interact, a crucial component in treatment.13 The concept within lounges and corridors required delicate balance of solitude within openness and innovation within a normalizing environment.

Large and ambiguous group lounges send mixed messages as residents are required to alter behavior while the space remains unchanged. In unidentifiable rooms, residents “find themselves forced into random, relatively undirected behavior patterns.” 13 As seen in the illustrations, the ellipse, a shape that was well received by interviewees, segregated a generic lounge space ( figure 1). Smaller ellipses represent private refuge areas while the largest ellipse identifies the media lounge ( figure 2). Intermediate ellipses designate small group seating. Dropped ceiling elements, color and furniture configurations signal further functional segregation. All lounge sub-spaces benefit from large picture windows and large walls for mural opportunities. Corridors were shaped to discourage an institutional feel; expanding upwards, increasing opportunity for light penetration with clerestory windows. The clerestory further helps define circulation and lounge boundaries. A design solution of clearly delineated spaces avoids ambiguity of function and, therefore, ambiguity of action for occupants. Built-in seating and encircling walls within private nooks create safe levels of seclusion ( figure 3). Clustered seating was chosen for group activities, based on Holahan's 1972 and Gabb's 1992 studies that found sociopetal seating arrangements promote socialization ( figure 4). 14,15 Television viewing was placed furthest from the private space, using group seating as an acoustic buffer. The radially positioned sofas at the media space offer a variety of relaxed seating positions. Additionally, the designated space enables connection between peers and media, serving purposes of bonding and positive distraction. Paramount to type of seating are issues of safety. Secure seating in private nooks and heavy sofas in media viewing restrict its use as weapons. Nevertheless, some mobility is desirable to foster group interaction and control of the environment.

Conclusion

By considering evidence-based design principles, adolescent developmental needs, and the environmental needs of the mentally ill, the study created a foundation of understanding. By incorporating opportunities for patients to connect to nature, choose and control their surroundings, and experience privacy, social support, and positive distraction EBD allowed for development of a holistic environment to maximize healing.

Clearly, designers can help behavioral health patients overcome the difficulties of mental illness and thus, contribute to the health, safety, and welfare of the society as a whole.

Jamie C. Huffcut is a project designer on the healthcare team at Perkins+Will in Washington, D.C. She can be reached at jamie.huffcut@perkinswill.com.

References

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Behavioral Healthcare 2010 October;30(9):33-35