'Architecture as Medicine' - The Importance of Architecture for Treatment Outcomes in Psychiatry.
By STEFAN LUNDIN AND LENA FROM
The Psychiatry Department of the Östra Hospital based its document “Realising a vision”1 on its political remit and its care ideology. From this, the aspects were then extracted which they believed to have a special bearing on the architecture – The six little houses.
The department´s vision stands on two legs. We want to: - achieve a welcoming and healing nursing environment for in-patients - reduce and counteract prejudices concerning mentally ill persons and mental illness.
In the preceding chapter, Erik Brenner describes the background to our wanting to put the patient at the centre of things by means of the new building.1 He also describes our conviction that the design of the building is of importance both for the patient’s wellbeing and to visitors, families and staff. I shall presently describe where we turned for inspiration in designing the new nursing building and why we believe access to greenery and spacious premises, among other things, to be so important. The department´s vision took shape during 1999 and 2000. The gist of it was compressed into an image which came to be called “The six little houses”. These houses contained concepts and values, stated on the previous page, of importance for the activity. It was the image of the six little houses we took with us when communicating the vision of the activity to the architects. I have chosen to describe each building separately. Each description starts with a text about the underlying idea of the building and ends with the way in which it is perceived today. In conjunction with the section dealing with House 6, “Colour and design promoting healing processes”, a description is also given of our main sources of inspiration.
House 1 An externally attractive impression, with justice done to the natural setting and smooth communications with the result of the Östra Hospital. The first thing one sees – whether as patient, member of staff or visitor – is the exterior of the building. This is the first signal transmitted to the person approaching. A beautiful building with care devoted to its design and materials conveys a sense of people having given the matter thought and signals: “I count for something.” Psychiatry has long been a low-status speciality, even among other medical specialities, and this of course is also reflected by the image the staff have of themselves and the role they play. To counteract prejudice, it was important to avoid giving the building an isolated, “backyard” position on the hospital campus and instead to make it one of a number of buildings, accessed just as easily as all the others. Spontaneous remarks by patients, staff and visitors show the huge importance attached to the thought of someone really having taken the task absolutely seriously and exerted themselves to create a beautiful building showing respect for everyone who will be using it. Communication with the other hospital buildings works well and the building feels like a natural part of the Östra Hospital.
House 2 Low-rise, small-scale building development comprising units of 2 or 3 storeys. Care units on floors 1-2 for maximum ground contact/proximity. The view from the patients’ rooms, e.g. out over the surrounding natural scenery, to be taken into account. A positive diversion is an environmental factor which increases the proportion of positive feelings, captures attention and interest and can restrain or alleviate uneasy thoughts. Most such diversionary factors are elements which have been important to man in all ages: nature, with trees, flowers and water, laughter and humour, kindly or smiling human faces, music. Nature’s impact on man’s state of mind has been described in a variety of studies. Sometimes a beautiful picture of nature will suffice to achieve this effect. This has been studied in patients in painful states following surgery. Patients who have been able to focus their gaze on nature through a window or on nature in picture form have needed less pain relief than others. The same effects ought to be attainable in patients suffering mental pain. How many do not feel more inner tranquillity when close to still waters or a whispering woodland? In the new Östra Hospital Psychiatry Department, the smallness of scale only becomes apparent after one has entered the building. Viewed from outside it seems anything but small. Many people have expressed their surprise over this. Once inside and following the entrance route, one sees the low-rise buildings surrounding the gardens. People find it hard to get their bearings inside the building. There are many different levels which do not become visible until one has advanced some way into the building, and it is not entirely easy for the visitor to know which level to choose in the lift. A hospital campus in a big city does not present the best of opportunities where the view from the patients’ rooms is concerned, and so the in-built gardens with their beautiful greenery have had to do service as a natural setting. Being able to go outdoors easily without having to ask is of course a great liberty for the patient. The sunny parts of the gardens are favourite spots. The small kitchen garden was planted with a variety of vegetables and flowers in the very first year. The large fixed table is often used as a sunbathing veranda.
House 3 Seclusion in the form of single rooms, coupled with opportunities for socialising. Modules of 4 patient equivalents each. Flexibility of unit sizing. Sheltered patios. A feeling of being in control of one’s physical surroundings derives, for example, from being able to shut oneself in, being able to vary the lighting in the room, and having an architectural design with a signage system that makes it easier to find one’s way around in the building. Lack of independent control has proved to entail many negative effects, including depression, helplessness and impaired cognitive achievement capacity. Patients in a psychiatric care unit will by confronted in the course of their stay by people with a variety of problems and difficulties. Some of these confrontations occasionally lead to aggressiveness and even physical violence. Units with a fairly small number of patient equivalents (12-14 beds) and opportunities for seclusion can be a way of eliminating these risks. If, additionally, one can offer a range of opportunities for socialisation/non-socialisation, one can be certain of the ingredients of a secure and tranquil environment being in place. Experience to date, 15 months on, as Lennart Brogren also points out elsewhere in this book, is that violent incidents and the need for coercive measures, e.g. shackle restraint, has declined. In certain units the change has been of great magnitude. The sheltered patios – the gardens, as we now prefer calling them – mean a very great deal for the patients’ sense of being able to move about freely (cf. the text by Carina Tenngart Ivarsson). The value of being able to just walk out into green surroundings without having to ask permission first cannot be overstated – once again, a feeling of being in control.
The gardens are big and are to be looked on as part of the care unit. There have been instances of patients absconding through them. Some of the staff consider them a factor of insecurity and are afraid of someone getting hurt, e.g. if a patient manages to get up on the roof. In the small units consisting mainly of single rooms, oversubscription is not possible. The rooms can only accommodate the beds they are planned for. This has been a deliberate choice on the part of the operation, but with the wisdom of hindsight it is worrying. What do you do when, as the physician in an emergency department, you have a patient who is in great need of admission and the place is full up? You cannot discharge the patient who is least ill at that particularmoment so as to admit an emergency patient to the care unit instead. Very active planning work is needed on the subject of discharge and subsequent outpatient care.
House 4
Care and treatment to be integrated within the unit. Communication between units to satisfy security requirements. All treatment staff must be present in the care unit, available to the patients. This means the doctor, psychologist, social worker and others all having their consulting rooms within the department. In this way all caring staff can see and meet the patient in different situation and thus gain a better overall picture, which in turn should enhance the prospects of individualised treatment. Psychiatry has high security requirements, from the viewpoint ofpatient and staff alike. The communication routes between departmentare a central parameter of security thinking. The paths must be short and simple. Neighbouring units must be able to get quickly into position in an emergency. By gathering all offices/consultation rooms into one part of the department, a unit has been created which supports the integration requirements but can easily be segregated from the care units if necessary. To make dependable provision for secrecy requirements we have been very demanding about acoustic conditions in our offices/consultation rooms, with the result that it is now practically impossible to hear if anything happens in the room. Knowing what we do today, we would have liked the “Chinese wall” stipulations to have been a little less exacting in the corridor directions but still no less exacting between rooms. The building supports the security requirements through internal communication routes providing linear links between the storeys.
House 5
Emergency care kept separate from planned care. To optimise the preconditions for planning of care and for treatment, planned care must be available in such forms that it will not be affectedby emergency care. Planned care can, for example, be needed in connection with investigations and prior to admission to a residential treatment centre. Due to the constantly growing need for emergency places, we are unable at present to offer planned care. Finding enough beds to go round is a serious problem in our operation. Very active planning is needed, together with outpatient care, to make possible the admission to in-patient care of emergency applicants in need of it.
House 6
Colour and design promoting healing processes.Hospital buildings often lack the qualities which are important for apositive experience. This can mean access to daylight, a view of thenatural surroundings and variations of head room and room configuration.
(Lundin, S. and From. L., 2009. Architecture as Medicine - The importance of architecture for treatment outcomes in psychiatry [eBook]. English edition 2010. Gothenburg. ARQ – the Architecture Research Foundation. Available via: http://www.white.se/en/news-press/362-good-architecture-improves-care-new-study-at-ostra-hospital [Accessed 8th October 2014].)