Kingseat - more research

See this link for some photos, or here, or here,

Space & Sanity - another new building type?

Refering to:
Goren, Suzanne and Rivka Orion. "Space and Sanity". Archives of Psychiatric Nursing VIII, no. 4, August 1994: 237-244.

This paper is the start of consolidating a better idea for my final design. It's difficult to find any real architectural precedents for my design as the building type for psychiatric health has changed and merged into more of a generic hospital type over the years. The large, isolated insane asylums of the past have largely disappeared as a place for psychiatric patients, and replaced by smaller community-based institutions, 'clubhouses', acute care wards in large general hospitals, or the street...
The building type I am more interesting in is the one suggested in the paper by Suzanne Goren - a hybrid of a community village, domestic dwelling and day clinic.

Historically, insane asylums reflected the assumption that insanity required buildings of surveillance and control. The designs cut residents off from the rhythms of everyday life.
During the 17th and 18th century, a significant exception to this was the village of Gheel in Belgium during the 17th and 18th century where pilgrims came in hope of a miraculous cure from insanity. They were taken in and cared for by local families clustered around a central infirmary.

Another innovation was seen in Wolfheze, The Netherlands during the 1970s where the barracks-like buildings of the traditional psychiatric institute were replaced by small scale, cottage-based designs with the ideal that this would promote normalcy.

• They were promoted as surroundings in which one could dwell - that is, experience the essence of being a human being through life, work and leisure. 
• The architecture opposed traditional institutional architecture with it's domestic emphasis and the separation of patients and staff lives. 
• Each house provided personal space, privacy and small shared spaces for eating and socialising. 
• No space was allocated for nursing stations, treatment rooms, therapist offices or staff housing

In 1981, the Wolfheze model was replicated in Israel, built on the grounds of Kfar Shaul, a traditional asylum on the site of a former Arab village, as the Intramural Rehabilitation Project (RRP). Characteristics:

• houses are small, made of common building materials of the area (stone), similar to houses found in surrounding villages - asymetrically spaced, open onto a curving treelined street
• no gates, no special locks, bars on windows
• staff do not enter without permission
• no space set aside for staff
• patients are selected if they have chronic illness which has cost them their place in society, if active traditional therapy is no longer feasible, and if they are unable to fit into a rehabilitation program designed to prepare them to return to the community
• once accepted, they have a lifetime membership - if they have to leave temporarily to be hospitalised, their place is kept for them on their return
• patients 'live within an architecture of normality...they live in a house and deal with the things in the house...they are hosts and the staff are visitors'
• everyone works, either in a sheltered workshop or  in maintaining the group's home
• they recapture autonomy and dignity

Beyond the walls of the asylum...new building type for psychiatric patients?

Summarised from:
Yanni, Carla. "Beyond the Hospital: the Clubhouse Model for Psychiatric Patients."  In The Architecture of Hospitals, edited by Cor Wagenaar, 432-442. Rotterdam, The Netherlands: NAi Publishers, 2006.
Yanni, Carla. The Architecture of Madness. Insane Asylums in the United States, Minneapolis: University of Minnesota Press, 2007.

Carla Yanni, an associated professor of art history at Rutgers University, has written extensively on the history of psychiatric hospitals and 'therapeutic design'. For example, in The Architecture of Madness. Insane Asylums in the United States, she describes the American medical establishment's preoccupation with 'therapeutic' architecture as a way to cure psychiatric disorders during the last century, and it's subsequent decline in importance.

Mental illness is currently considered to be treatable but not curable. There is no vaccine or instant cure as there is for an infection.It remains shrouded in mystery which contributes to the stigma associated with psychiatric illness. Those recovering from severe psychiatric illness must deal with this social stigma, in addition to their often difficult path to recovery.
Architecture plays a much less significant role in this path to recovery than it did 100 years ago. For the past 40 years, "...almost every developed country has abandoned the mass institutionalization of the mentally ill" (1). The role of the environment is less clear than the role of biology. While it's true that long term stays in mental health units are far less common now than 50 years ago, there is debate over the need for permanent places where people with mental illness to reside long term. Large hospitals where patients dwell for a lifetime are no longer a cherished or central part of psychiatric practice, though they do still exist.
As the pyschiatric profession has shifted its attention to noninstitutionalised, milder cases of mental illness, architecture has declined in it's importance in psychiatric therapy.
Deinstitutionalisation reached it's height during the 1970s both in the USA, Britain and in New Zealand. Drugs improved and allowed many patients to live comparatively normal lives within the community, but only with support. Those without support fell through the cracks. Critics of pharmacological intervention described the drugs as just a replacement for the old chains and shackles of insane asylums, and the adverse effects of these drugs meant that many people with schizophrenia and bipolar disorders refuse to take them. Those with no support often found themselves on the streets - estimates of the percentage of homeless people suffering from mental illness in the USA ranges from 25 to 40%(find reference). So, the final architecture for a welfare-dependant schizophrenic after institutionalisation was not a building, it was the street...

Where does a recovered person go after a hospital stay?

In 1948 a group of patients recently released from a state hospital began meeting casually to help each other adjust to their new lives. They, along with 2 investors, began Fountain House in New York city. This was the start of the 'clubhouse' model - 300 have since been initiated worldwide.
The main features:

• provide a place to work and interact, support each other adjust to life outside hospital
• not a hospital, not walled or confining; no bars on the windows or doors
• modeled on gentlemen's clubs of New York - if healthy, wealthy people benefit from a civilized oasis in the city, a place to get away from business and home, recovering mental health patients could too
• focused on building a community rather than based on a medical model; a casual environment for daily interaction
• look beyond the patient (therapy, medication) to the person (relationships, work, living)
• not a hospital, not a treatment centre - no doctors or nurses or treatment administered; this separates the person from the disease
• not a residence - no one lives there; spatially separate from 'home'
• a member's diagnosis has nothing to do with their status at the clubhouse
• codes of behaviour and rules apply
• architectural brief was to be  like a small hotel, the communal areas without the bedrooms; the common areas of many hotels are similar to gentlemen's clubs - a 'club' ought to look and feel quite different to home
• the recovering person must travel from home to here - it is a place to go during the day; the movement from home to club and back again is part of the steps in learning to live away from hospital - it requires the patient to encounter other people and new spaces
• A Victorian critic of the 19th century institution described living as a patient in an insane hospital 'he will breath the same air, occupy the same space and be surrounded by the same objects night and day'. Whereas the clubhouse model is more like real life.

((Finish this))

(1) Melling, Joseph and Bill Forsythe. Insanity, Institutions and Society, 1800-1914: A Social History of Madness in Comparative Perspective. London: Routledge (1999), 18.

Architectural Determinism & the Placebo Effect

Summarised from Jencks, Charles. 'Maggie Centres and the Architectural Placebo." In The Architecture of Hospitals, edited by Cor Wagenaar, 406-412. Rotterdam, The Netherlands: NAi Publishers, 2006.

In this chapter, Charles Jencks describes the beginning of the story around the Maggie Centers - the cancer care centres in Britain initiated by his late wife, Maggie. Before this, he'd had a healthy skepticism about architectural determinism (environment can change behaviour).
During a debate on the BBC with a doctor about the role of architecture, much to everyone's surprise he took the role typically claimed by doctors - "architecture matters for cultural reasons, not because it affected patients that much" - while the doctor took his line - "architecture really does matter for health". When asked why, the doctor stated that if the architecture was really bad, they wouldn't even show up for work.

Another key which unlocked his thoughts about architectural determinism was the concept of a placebo - in it's simplest sense, a placebo is a fake cure that works because of people's belief in it. I was pretty interested in this given my previous life as a medical writer and researcher - over 10 years of my life was taken up analysing and writing up medical research using placebo study designs...

The placebo effect is very well documented in the area of pain relief, for example. Looking up any therapeutic medical research paper on a study using a double-blind placebo study design will give examples of the strength of this effect - a placebo is used in these cases to find the percentage patients showing this placebo effect and compare with effects found in those given the actual therapy (the difference above this being the significant effect). My background gave me this knowledge already, but what I didn't realise was that there is more to the placebo effect than I'd initially learnt:

1. The "Style Effect" - brand name placebo pills relieve pain better than generic placebos, and blue coloured ones work better as sedatives than red placebos. Style and brand obviously matter...
2. The "Cultural Effect" - the placebo effect is highly variable across cultures. For example, the healing rate seen in Germans with ulcers taking a placebo is twice as high as rates seen in patients taking placebos in the rest of the world (and almost 3 times that of patients from the Netherlands or Denmark). It seems to be the individual's varying cultural influence, not just their psychology, that matters.
3. The "Doctor Effect" (or "Caregiver Effect" ) - the more convinced a doctor is that a drug or placebo will work, the more likely it is that it will. Their conviction and enthusiasm has an effect on the patient.

These 3 effects work only because they affect personal belief.

Obviously some medical conditions will respond more than others - pain relief more so than, for example, cancer. However, with cancer other psychosomatic and physical aspects play a role. Lowering stress is well documented to strengthen the immune system in certain circumstances (find ref).

Thus, Jencks argues that the Maggie Centers and their architecture do make a difference in the quality of life and survival rates by reducing stressors in the patients life and providing more support and access to effective treatment. He goes on to say that the additonal 3 placebo effects outlined above come into play here - famous architects are employed to design the buildings because they inspire the caregivers and the patients - but ultimately, the ethos, the team spirit created between the patients and caregivers - that has to be supported by the architecture - is more important. His concluding statement in this respect is:

"Good architecture can make a difference when it underscores the style and approach of an institution. Put as a theory, I would say that when the style and content of an institution are mutually supporting, they can produce the Architectural Placebo."

The main book referred to by Charles Jencks about the placebo effects described above was Daniel Moerman, Meaning, Medicine and the 'Placebo Effect', Cambridge, 2002 (others included Dylan Evans, Placebo, the Belief Effect, HarperCollins, London, 2003;  David Peters, Ed. Understanding the Placebo Effect in Complementary Medicine, Churchill Livingstone, 2001).

The Maggie Center service has 4 main goals, which the architecture & art support:

1. to lower stress through teaching various methods of coping and relaxation
2. to provide psychological support to deal with the loss of control that cancer brings
3. to help patients find the information they need and understand all the potential therapies on offer
4. to operate in a peaceful and striking environment (in which art and gardens play an important role) which supports the activity of the patients and caregivers and other staff

The Maggie Centers are a hybrid of 4 building types

- a house that is not a home (warm, friendly, familiar, domestic)

- a museum that is not a museum (art works, gardens, unexpectedly expressive architecture, providing a meditative and creative place)

- a church that is not a church (a place with the appropriate atmosphere to ask questions about the meaning of their life)

- a hospital that is not a hospital (therapies, counselling)

Evidence Based vs Sensory vs Social Design

Evidence

Evidence-based design - like evidence-based medicine (which I'm intimately familiar with, being in mind my previous life as a medical writer and editor), it is research-informed. The results affect patient medical outcomes, staff satisfaction and facility operations.

Evidence-based design looks at building design - the physical space, but also the sensory environment of sight, sound, touch and smell.

Evidence-based design research is divided into 5 areas:

1. Access to nature. This research focuses on human responses to indoor plants and gardens, outdoor gardens, views of nature (both artificial and real) and natural light.

2. Control. This focuses on patient options and choice, access to privacy and navigating through a building. A sense of control is important to people's feelings of self-esteem and security. Lack of control can lead to results such as depression, passivity, elevated blood pressure and reduced immune function. The more a person has a sense of control over his or her environment, the more he or she might be able to manage the negative effects of a source of stress.

3. Positive distractions. For example nature, water, play areas, art, music, etc.These can provide a sense of engagement and well-being. Evidence shows that without this, patients can feel numb and depressed. Research in environmental psychology describes several sources of positive distraction: (1) happy, laughing faces, (2) the presence of pets or nonthreatening animals and (3) nature such as trees, plants and views of natural landscapes. In one study, researchers compared the pain levels of patients undergoing laceration repair surgery with or without headset music. Patients with headset music perceived noticeably less pain.

4. Social support. This includes provision of support for family members and cultural sensitivity, and social interactions. Environmental psychologists have found that individuals with a high level of social support experience less stress and greater wellness, with more favourable recovery indicators than people with lower levels. Social interaction in healthcare facilities can be influenced by furniture placement and floor/room layouts. Heavy or unmovable furniture inhibits social interaction, while comfortable, movable furniture that can be arranged in small, flexible groups can facilitate it.

5. Environmental stressors. This includes research on noise, glare/light levels and indoor air quality.
Environmental elements can increase stress if their disturbing presence is difficult to minimize.

Levin, Debra E. Design based on the evidence. Healthcare Design Magazine. August 31, 2002. pp6-7

See this link to a significant review of the literature by Robert Ulrich, plus an article in The Lancet (!) by the same author.

Social & Sensory

While scientific studies have confirmed that health can be positively affected by social support, very little research has been done on how the architecture of hospitals, the physical and sensory environments,  can facilitate social interactions.


The Vidar Clinic in Jarna, Sweden has gained a reputation for being a leading model in human-centred design. It's a 74-bed clinic for people with chronic diseases. It offers a wide variety of social settings within which the patient's experience is heightened by stimulation of their senses - the sculpted volumes of the spaces, layering of colour on the walls, day light, views to the surrounding landscape, textures comfortable to touch and the smell of fresh baking in the morning.

The non-hierarchical way the staff work together is mirrored in the layout of the building.

Day rooms that invite - the day rooms are roughly in the middle of each patient wing and the smell of fresh baking draws patients, doctors, nursers and therapists out of their rooms mid morning for morning tea and informal meetings. The day room interiors are visible from the corridors but each also offers areas to be more private (alcoves for reading or private conversations), and tables for group activities. They have a fireplace, a piano, large windows, skylights, plus a domestically sized kitchen for patients to prepare their own food if they want to. The day rooms also have outdoor verandas for small groups of people.

Corridors as streets - straight double-loaded corridors are life sapping spaces... This clinic has ones which have subtle changes in direction to break up the segments. They occasionally widen into alcove spaces to rest or socialise with skylights overhead.

The heart - most of the social spaces are at the core of the building clusters (dining room, cafe, assembly hall) around a central courtyard. So theses spaces are alive and busy while the patient room wings are quieter and more private. One of the courtyards includes a second level, open air arcade where patients, even those in wheelchairs, can be in the fresh air and also see down into the courtyard.

The cafe provides places where people can sit, be on view, and watch others. It's not a separate room as such, but an alcove-like widening of the main corridor with views into the courtyard. The cafe also serves members of the public, local community.

Communal dining - the walls in the dining hall are a subtle ochre, floors are broad planks of pine and the tables are clear coated hardwood. There is a row of openable windows with views out to the fields. The patients, doctors and staff members all dine here. The midday meal is served on the table, not buffet style, to encourage interactions.

Seipl-Coates, Susanne. "Social Spaces at the Vidar Clinic in Jarna, Sweden and their Role in the Healing Process." In The Architecture of Hospitals, edited by Cor Wagenaar, 406-412. Rotterdam, The Netherlands: NAi Publishers, 2006.

An article by Juhani Pallasma - 

Evolution of the thesis topic...Retreat & Refuge versus Confinement & Surveillance

Things emerging as significant areas of 'research' for my thesis:

• evidence based design for hospitals (sounds boring but vitally important for 'humanised' design)
• modern treatment of psychiatric disorders, for example
• only acute cases tend to be 'hospitalised', all others use community-based treatment, compared with the old model of segregating patients, taking them out of their community and retreating into the country
• nature as a healing factor is being isolated into small manageble units to bring inside the hospital rather than the hospital being within a natural setting as such - eg. pictures, views outside, courtyards inside the building itself rather than the building being physically sited within a rural area or large park like grounds
• 'confinement and surveillance' - the similarity between prisons and old psychiatric hospitals (control, security, surveillance)
• 'retreat & refuge' - also the similarity between spas/retreats and psychiatric hospitals (retreat & refuge)

So perhaps instead of a mental health unit, the design could be 'preventative' mental health in the form of a retreat or refuge. Like a spa but with an emphasis on restorative of mental health rather than pampering and luxury.  A place anyone could go, without the stigma of 'mental illness'.

'Meaning of Place for Identity, Spirituality & Mental Health'

Summarised from the chapter of the same name (pp155- in:
Curtis, Sarah. Space, Place and Mental Health. Farnham: Ashgate Publishing, 2010.

Perceptions of space may become disturbed in patients with psychotic illness - things we take for granted in everyday life are disrupted.
Phenomenology raises basic questions about these 'taken for granted' senses of being in the world and encourages us to try and explain them (see my previous blog entries on sense of place, Martin Heidegger etc). Research into this suggests that phenomenology may have a role in developing knowledge about schizophrenia. (see pp 156-157). Phenomenological perspectives remind us that the fact that one perceives the world in particular ways considered 'normal' does not necessarily mean that the world has an independent existence that exactly corresponds with our perceptions. Everyone perceives their environment slightly differently, but also through a 'shared lens' of biologicially or socially constructed frames of reference.

Societies have always had and ambivalent attitude towards individuals whose perceptions of the world differ from the majority - they tend to be either labelled as strange/psychotic/deviant and stigmatised or punished, or they are are valued and treated as sacred (tortured genius/savant etc)

Cultural diversity in concepts of wellbeing

There is significant cultural and social variations in the way we understand our relationship with both the natural and the built environment. Many cultures are less individualistic than the dominant European and North American cultures, and instead view natural landscapes and relationships with these as being very important for psychological and physical wellbeing.
Generally it seems that access to natural resources is essential for the general health of particularly aboriginal/native populations. Health for Maori is seen as a combination of mental, sprititual, family and physical wellbeing (p175). Alienation from the land has spiritual, social and psychological implications (as well as economic and political). See this research paper for more on this.

Also in the same book (Curtis, Sarah. 'Post-asylum geographies of mental healthcare.' in Space, Place and Mental Health. Farnham: Ashgate Publishing, 2010.

Newer mental healthcare units tend to emphasise the 'homely' and comfortable in their design though individual patient rooms still have obvious security and surveillance elements which detract from this feeling of homeliness eg. vision panels in the doors, sloping tops, recessed doors and handles, screens on the windows.  A paper reporting on discussions about the design of a new mental healthcare setting was interesting:

•  Nursing staff and consultants felt the security and surveillance features described above did little to encourage more relaxed social interactions between patients and staff, and impinged on patients privacy and liberty
• They also commented that it's impossible to reconcile all the needs and preferences  for hospital facilities for a diverse group of patients varying in age, gender, culture, ethnicity and faith groupings as well as in diagnosis.

For more on this, see these links:

• Sarah Curtis Creating ‘therapeutic landscapes’ for mental health carers in inpatient settings: A dynamic perspective on permeability and inclusivity
• ibid. Therapeutic landscapes in hospital design: a qualitative assessment by staff and service users of the design of a new mental health inpatient unit

Designed for Healing - Architectural Review

(editorial):
Of all the branches of architecture, hospital design presents the greatest of challenges. It addresses the human dimension from birth to death; the architect must create a building primarily for people, but one in which form follows medical function in a variety of very particular ways. A key task is to ensure that efficiency of service is enhanced by the building envelope and the technology that fits within it. That technology changes more frequently, and across a greater range of areas, than it does in many other business environments; the task of designing for anticipated change, but without knowing quite what that change might be, is particularly difficult. Equally difficult is the creation of architecture that will provide the sort of civilised workplace which helps to attract and (just as important) retain good medical staff. But the challenge facing the architect does not end with the provision of a building that is fit for purpose merely from the point of view of the health service provider. If only it were that simple.
The next group of people for whom the design is important are those who visit. Although unlikely to be in the state of distress of many of the patients, they nevertheless are confronted by what at best will be unfamiliar surroundings, and at worst complex and confusing signage and routeing regimes, culminating in cramped and inconvenient spaces in which most of their interaction with a patient will take place. Of course the most important people of all are patients themselves, but patient-based design appears still to be a novelty in a branch of architecture which has become so specialised that general architectural values are frequently underestimated or ignored. Too often, proposals reflect this year's clinical fashions, and the apparently unavoidable consequences of narrow attitudes to budget, materials and layout. Outcomes are downplayed in favour of outputs.
As the buildings in this issue show, the timeless attributes of civilised healthcare environments can be achieved through good architecture, but not if it is ruthlessly constrained or directed by financial regimes based on a misunderstanding of the human and economic costs of poor design. What patients want and need are well-tempered environments where they can suffer and recover in peace and quiet, where sleep is regarded as important rather than an interference with breakfast delivery regimes, and where facilities are designed to ensure privacy and hygiene on the one hand, and decent and accessible facilities for visitors on the other. The case for proper lifetime cost analysis, discussed elsewhere in this issue, is particularly pertinent in the case of healthcare buildings, since the effectiveness of their performance over time will not simply justify the capital investment made to create them, but will contribute sooner or later to the wellbeing (and sometimes a decent environment in which to die) of us all. PAUL FINCH

See this issue: The Architectural Review 217. 1299 May 2005

Research links for hospital design

Environmental and therapeutic issues in psychiatric hospital design: Toward best practices. Psychiatric Services.

Impact of the physical environment of psychiatric wards on the use of seclusion. British Journal of Psychiatry

The physical environment is presumed to have an effect on aggression and also on the use of seclusion on psychiatric wards. Multicentre studies that include a broad variety of design features found on psychiatric wards and that control for patient, staff and general ward characteristics are scarce.
Data on the building quality and safety of psychiatric as well as forensic wards (n = 199) were combined with data on the frequency and type of coercive measures per admission (n = 23 868 admissions of n = 14 834 patients) on these wards, over a 12-month period. Overall, 14 design features had a significant effect on the risk of being secluded during admission. The ‘presence of an outdoor space’, ‘special safety measures’ and a large ‘number of patients in the building’ increased the risk of being secluded. Design features such as more ‘total private space per patient’, a higher ‘level of comfort’ and greater ‘visibility on the ward’, decreased the risk of being secluded.

Healing environment: A review of the impact of physical environmental factors on users. Building & Environment.

Physical environmental stimuli that turn healthcare facilities into healing environments through psychologically mediated effects: systematic review. Journal of Advanced Nursing

Patient Preferences for Single Rooms or Shared Accommodation in a District General Hospital. Scottish Medical Journal.


To determine whether patients who have used a Scottish district general hospital would prefer single or shared accommodation on a future admission. We surveyed 80 in-patients in January 2008 in order to obtain 20 medical and 20 surgical patients in single rooms and the same number in shared accommodation. Each patient received a sever point questionnaire that had been validated in another centre. Forty four men and 36 women, median 64 years, who had been in hospital for a median of 4.5 days (range 1 to 53 days) participated in the survey. Seventy per cent of patients in shared and 40% of patients in single rooms said they would prefer shared accommodation during a future hospital admission. Those expressing a preference for shared accommodation were older (median age 68 versus 58 years) and had been in hospital for longer (median 5.5 versus 3.5 days) than those who said they would prefer a single room. It is likely that the desire for company among older people who have to spend a week or more in hospital is driving the responses we obtained. Our findings do not support claims that the argument in favour of 100% single rooms is 'overwhelming'

Are decisions about hospital design made upside down? Journal of Medical Ethics

A Review of the Research Literature on Evidence-Based Healthcare Design Health Environments Research & Design Journal

CONSIDERATIONS IN DETERMINING A MODEL FOR THE MENTAL HOSPITAL. American Journal of Psychiatry

Applied Psychology for interiors

Summarised from
Augustin, Sally. Place Advantage. Applied Psychology for Interior Architecture. New Jersery: John Wiley & Sons. 2009

Quite a useful book though definitely written for the more general reader (rather than professional) which made it easy to read but felt sometimes it was lacking depth. Saying that, here are some useful things...

People's personalities have an effect on how they perceive a space - for example, more extrovert people will appreciate spaces with more complicated sensory detail while less introverted people tend to find these spaces sometimes too overwhelming/not relaxing.

A well designed space (ie. one which encourages the main objectives of that space)  has the following attributes:

1. It complies with the activity intended in that space - eg. has all the right equipment/tools present, and is the 'usability' component of a space. Ideally the space will also encourage the mood you want to be in to carry out these tasks.
2. Communication - it communicates information about the people who use it and also provides opportunities to socialise (or not, as appropriate). For example a hospital room may have different areas/spaces which allow rest/solitude (bed, the bathroom), work/healing (a work station) and socialising (balcony, couch area). Nonverbal clues are fairly powerful - nonverbal communication carries more weight than verbal when the two are saying conflicting things. Patients can feel more comfortable if they are allowed to customise their room to reflect who they are (or the version they want to portray). Socialising with others is important for our mental health, but so is privacy (audio and visual) - the physical environment should allow this.
3. It's comforting - meets psychological needs for perceived control over the environment (including whether to be alone or not) allowing concentration, or relaxation, or recharging as appropriate. However, the desirable level of control will change depending on the person - a person who feels they are not as capable of making good choices for control (eg. by age or mental capacity) may not want to exercise as much control.
4. It can change or evolve over time depending on how people need to use it

(Author also mentioned 'Challenging' but the definition of this sounded close to 1. (comply) so have left this out)

Restorative spaces

Characteristics of restorative spaces: (1) somewhere/something you can glance at to take you out of a mentally demanding situation (reading a novel/watching a movie does the same thing), (2) they need to hold your attention, be fascinating - pleasurable and effortless to think about, (3) they must allow us to easily do whatever we are trying to do, (4) they're always places we feel safe. This could be a quiet space with a comfortable chair and a fish tank/view out into a garden/etc. We tend to like seeing places with some sign of human tending eg. a mowed lawn, a well kept garden.

Scents

Smell was talked about quite a bit - see previous blog on this - nothing new really learnt here (just reinforced the importance of smell to alter mood/memory etc). However, points to note relating to health:

• people smelling lemon are more likely to report they are in better health
• smelling peppermint improves physical tasks plus makes tasks seem less rushed, less of a hassle
• lemon & cinnamon/vanilla are strongly associated with improved moods
• smelling lavendar or cedar reduces tension
• floral scents in general reduce anxiety, also orange, lime, marjoram, rose, lavendar, bergamot, cypress
• relaxing scents include lavendar, rose, almond, cedar/pine, sandalwood, vanilla, spiced apple
• smelling jasmine while already sleeping improves the quality of sleep

Sounds

This covered soundscapes and again, no significant new information compared with the acoustics projects I covered last year. However, points to note relating to health:

• predictable rhythms and simple harmonies are relaxing (unpredictable/complex are invigorating)
• annoying noises are more bearable if they're predictable

Colour & pattern

We find it soothing to look at patterns that are mathematically similar to ones which occur in nature (natural fractals): fields of grass, moving clouds, water, fish tank ripples, dappled light. Around the world, blue is generally the most preferred hue but after that, there are different cultural preferences.

Complexity & order

Things that are more complex are more interesting to us, but too much complexity creates tension. Curvilenear forms and smooth transitions (as seen in nature) enhance visual quality of a space, as to plants and water (even if they make it more complex). Order is desirable in complex spaces (eg. a library).
Rhythm leads people though a space visually and adds to its order (beams, textures etc)

Light

Low light intensity makes a space feel relaxing and more private and intimate, generally higher light levels are psychologically and physically stimulating.
More brightly lit spaces make us feel more cheerful, particularly if it's sunlight and indirect lighting.

Under warm white light, we: take more risks; perform better using short term memory, and problem solving skills; are more likely to resolve disputes by collaborating; are more likely to be in a better mood (if female)

Under cool white light, we: don't recall new material in our long term memory as well; experience more stress generally but; are more likely to be in a better mood (if male)

Healthcare facilities - specific notes

(pp232-)

Research (232) has shown that patients who stay in rooms with artwork on the walls, chairs for visitors and generally 'less institutional' have more positive impressions about their stay. Waiting areas which are also less institutional (have lamps, plants, artwork, comfortable domestic seating) ease users into a more positive mood. However, if they are too different from other waiting rooms they have experienced, patients become concerned - generally people are more comfortable with places and things similar to stereotypes they have developed for them.

Patients, caregivers and the designers all experience the space in different ways. Patients spend more time looking at things the caregivers and designers to not (eg. ceilings, machines, one particular wall etc).

Research notes:

• patients in rooms with more daylight need less pain medication after surgery; sunlight also helps to synchronise patient circadian rhthyms which improves sleep quality
• likewise, patients recover more quickly from surgery and require less pain medication if they can look out onto nature
• if no view is possible, pictures or virtual screens of nature experiences also help
• mirrors on the ceiling which reflect the view from a window could be a good idea where patients cannot sit up, ditto for artwork
• caregivers and visitors also benefit from views of nature
• artwork will produce differing results depending on type - abstract or ambiguous paintings or sculptures are not good choices for healthcare settings - but images that are reassuring and comforting are ideal (meadows, gardens, quiet water scenes, dappled forests etc).
• people with depression or senile dementia show improvements in their condition when exposed to morning light (related to our circadian rhythms, exposure to light in general).
• moderately intense pink (the colour of Pepto Bismol) has been shown to quickly calm people

• people tend to speak more quietly in lower light so keep lights lowish where possible to reduce general noise
• using red lights to guide patients to their bathrooms at night (or using other night light options) won't disrupt their circadian rhythms as other light would.
• patients who hear music they enjoy appear to experience less pain
• caregivers and patients both need private retreats
• when patients socialise with family and friends, their health benefits - rooms should have movable chairs, spaces they can easily socialise in either in their room or outside somewhere
• patients (and caregivers) prefer rooms/spaces they can personalise in some way

Recycling Psychiatric Hospitals - Stigma & Selective Remembrance

Summarised from
Joseph, Alun E, Robin A Kearns, Graham Moon. "Recycling former psychiatric hospitals in New Zealand: Echoes of deinstitutionalisation and restructuring." Health & Place 12 (March 2009): 79-87.
((my comments in italics))

"The built environment abounds with elements that evoke memories, whether personal or collective. While other people are likely to be oblivious to places that are sites of personal significance (due, for example, to instances of trauma or celebration in times past), sites of collective memory are more likely to be kept ‘on the map’ by various means. Sites of collective remembrance may be complete buildings or ruins on the ‘heritage circuit’ travelled by tourists, or the more strategically preserved—and often politically contested—remnants of events or even purpose-built memorials (Marshall, 2004).  ...

Compared, for instance, to war memorials (McLean and Phillips, 1990), closed psychiatric hospitals are unlikely to be sufficiently prominent in the national consciousness to warrant systematic treatment or memorialisation in situ. Indeed, in the New Zealand context, the names of closed hospitals arguably loom larger in the collective memory than do the sites themselves. By way of example, names like ‘Tokanui’, ‘Sunnyside’, ‘Seacliff’, ‘Cherry Farm’, ‘Porirua’ and ‘Lake Alice’, which derive from locality names, are widely associated with now-closed facilities (see Fig. 1). Yet actually locating such abandoned sites is far from easy, with few signposts and minimal reference on maps. To an extent, therefore, we can say that institutional names are prominent markers in themselves. In cases such as the former Carrington Hospital in Auckland ... renaming (in this case from Carrington Technical Institute to Unitec) was, in effect, a re-branding that arguably attempted to sever the re-used buildings from their institutional heritage."

... While successfully rehabilitating (some) patients has not been easy, neither has rehabilitating the buildings they occupied. One explanation relates to the physical and symbolic distance of some asylums from centres of economic and social activity." 

The closure of rural psychiatric hospitals could be seen as part of a continuum of closures related to economic and social restructuring in New Zealand generally - for example, schools and banks, post offices - all just memories in many rural communities now. 

In each of these cases, the rural communities have been left with closed, yet purpose-built, infrastructure—sites which were formerly places of employment, rich symbolism and community interaction. As such, closures have been variably resisted and re-uses (e.g., a bank as a community centre; a post office as a café) have involved a preservation of heritage. 

Other examples of how former psychiatric hospitals have been used since closure:

• Chaplin and Peters (2003) surveyed 71 hospitals in six areas of England to determine the proportion of hospitals still open and the fate of those that had closed. Of the 53 (75%) closed hospitals, 14 sites included derelict buildings. Interestingly, property developers often deployed adjectives in their advertising—such as ‘seclusion’ and ‘sanctuary’—that could be applied to earlier uses. Yet explicit reference to the former psychiatric uses was only made in a small minority of cases, “possibly reflecting the stigma of their former existence”. According to the authors, “paradoxically, asylum can now be bought in an ideal self-contained community, with security to keep society out” (Chaplin and Peters, 2003, p. 228).

The distinction of a heritage appearance can possibly over-ride the stigma of direct association with psychiatric detention (Chaplin and Peters, 2003). 

Kingseat Hospital

Kingseat was a major expression of the expansion of New Zealand's mental health treatment capacity after WWII while its rural setting in part reflected the desire for seclusion reminiscent of Victorian ideals ((but also probably the idea that nature provided a healing environment)). In accordance with the standards of the time, the hospital was built as a series of villas catering to different patient groups (by sex and diagnosis, and eventually also by age). The villas were markedly larger than those built in the same period at Seaview, and the location of the hospital in a prosperous agricultural area and its large estate meant that the hospital's staff and patients produced much of their own food. By the outbreak of WW II, the hospital had eight villas and a total patient capacity of 400 and by 1946 patient numbers approached 900. Employment levels increased along with patient numbers, approaching 200 by the early 1950s, a distinctly higher staff to patient ratio than at Seaview.

After closure in 1996 and subsequent sale, it was announced in 2005 that “One of New Zealand's notorious former psychiatric hospitals will become the home of a horror show. A haunted house is set to open next week in the old nurses’ home at the former Kingseat Hospital at Karaka, south of Auckland” (New Zealand Herald, 22-10-2005). The same article went on to note that “The company is aware of the potential for accusations of bad taste by choosing a former psychiatric hospital, where many experienced mental suffering and some patients say they were mistreated. ‘That's why we’ve got it in the nurses’ home and not the actual hospital itself.’ ‘Spookers’ manager Julia Watson said ‘We also will be having absolutely nothing to do with a mental asylum’.” Other views have been aired. In her regular column in Canvas magazine, Daya Willis (2005, p. 10) wrote that “while there are undoubtedly excellent arguments for the old Kingseat Hospital grounds being put to use after all these years, there's also something creepy—something downright disrespectful, methinks—about running a fake scare-athon out of a property that saw so many people live through real horrors.”

The authors of the research paper concluded by stating that "Future work might also examine the conversion of former psychiatric hospitals into either educational facilities or luxury housing developments. We see in the former, epitomised by the Unitec students’ branding of their (former Carrington Hospital) campus as ‘Looneytec’ (McKechnie, 2004), the potential for the active re-imagining of the mental hospital."

Summarised from
Kearns, Robin, Alun E Joseph, Graham Moon. "Traces of the New Zealand psychiatric hospital: Unpacking the place of stigma." New Zealand Geographer 68, Issue 3 (Dec 2012): 175-186.

In this research article, the authors investigated the 'trancendent role of stigma in shaping the cultural traces of the psychiatric hosptial...' They noted a number of factors served to influence the filter of this stigma:
(1) locality - in communities immediately adjacent to former hospitals, memories of past use are very much alive, and have a degree of affection. Developers often find allies in local communities if it's felt that the development will deal with the often derelict sites and the ill ease associated with abandoned buildings.

At sites where mental health facilities remain, it could be argued that continued psychiatric services are a graphic form of rememberance (eg. Porirua)...though reuse is often  involve a deliberate manipulation of reputation and distancing from the past. An exception is Spookers in Kingseat...

See also:
Joseph, Alun E. Robin Kearns, Graham Moon. "Re-Imagining Psychiatric Asylum Spaces through Residential Redevelopment: Strategic Forgetting and Selective Remembrance." Housing Studies 28 (Jan 2013): 135-153.

Hospitals, prisons, hotels: hide versus reveal

These have similar architectural problems and sometimes even look like each other...
They all hold a transient population that must be looked after 24 hours per day, while also housing a permanent population of people who provide this 'care'. Prisons and hospitals sometimes try and look and operate like hotels, but hotels naturally try and avoid any association with the other two building types.

Prisons are the built embodiment of the state, where the state exerts complete power over the involuntary occupants.
Hospitals are where the state manifests itself in a benevolent and curative capacity for the voluntary (but often with no other choice) occupants. Though in some instances, patients are 'paying customers'. An important point is that they may present themselves with a medical need that is so urgent that there is no other choice, so medical treatment is both involuntary and consensual - patients want it, but cannot want it.
At the other end of this spectrum, hotels operate in a free market, catering to the voluntary, paying occupants' every whim.

Architecture is a means to hide and reveal, to lock in or allow out.

Buildings invariably incorporate the social relations between the people they are designed for. That is, when we look at walls, doors, windows, stairwells and other openings, we might ask 'who are these structures supposed to lock out and who are they supposed to allow in?'. The second question may relate to hiding and revealing - what is supposed to be hidden by the walls/ceilings/floor/door and what is expected to be revealed, and for whom? There are degrees of privacy in every type of building - the most obvious examples being seen in domestic dwellings where the degree of public to private occupancy can be seen when moving from the entrance hall, the living area, the bathroom, the bedroom.

A hospital hides the sick from the healthy, but not necessarily the sick from each other (though they may choose - because of an anxiety about being exposed in an unsightly circumstance - to pay for a private room in order not to reveal themselves to others). This play of hiding and revealing is seen in shared rooms with the bedside curtain, in the examination areas. But there are also many other things hospitals want to hide like the places where body remains are stored and disposed of, where corpses are kept.

Hospitals, like homes, have areas that could be described as 'on stage' and 'back stage' areas - the former are for public display but the latter are spaces where people can collect their thoughts, relax alone. In a hospital, the staff rooms are back stage areas where nurses can complain or laugh about a particular patient - this is not meant to happen 'on stage'. Patients also have their back stage area - a place away from he gaze of others where they can hide after keeping up a facade of courage for their family, to have a few minutes alone to cry or just let their smile slip. These back stage areas are important to maintain the public presentation of self, their pride. Hospitals need to provide areas for this, for visitors and patients.

Summarised from:

de Swaan, Abram. "Constraints and Challenges in Designing Hospitals: the Sociological View" In The Architecture of Hospitals, edited by Cor Wagenaar, 88-95, Rotterdam: NAi Publishing, 2006.

So...architecture could be thought of as containers for a wide range of social interactions and relationships, providing all sorts of opportunities for encounters, but also shielding against unwanted intrusion and inspection or surveillance

'the material embodiment of human interactions in all their variability and variety.'

Past & present - reuse of early 20th century hospitals

What we lose by converting early-20th century hospitals to inappropriate new uses or demolishing them is the dignified civic presence of these institutions.

There are significant links between hospitals of the past and today's institutions:

• both intend/intended hospital spaces to look comforting and homelike, not hard edged and high tech - the  current 'arranged marriage' of domesticity and high technology is one of the paradoxes of postmodern architecture, and a central idea behind post 1980s hospital architecture. Hospitals of the 1950s and 1960s tended to look like office buildings but contemporary hospital architecture tends to draw on elements of domestic, hotel and shopping mall design. Technology (and parking) is disguised.
• the collision of architectural and medical reasoning - architecture frequently draws on precedents and case studies while modern medicine looks more towards the future (though is based on prior research)

Summarised from
Adams, Annmarie. Medicine by Design. The Architect and the Modern Hospital, 1893-1943. Minneapolis : University of Minnesota Press, 2008

Site investigations - Kingseat History

1929 - construction  began on Kingseat. It was named after a hospital in Scotland
1932 - in operation.
1939 - added a 2-storey nurses home
1930-1940 - extensions added

As per standards of the time, the hospital was built as a series of villas catering to different patient groups (by sex and diagnosis, and eventually also by age). The villas were markedly larger than those built in the same period at Seaview, and the location of the hospital in a prosperous agricultural area and its large estate meant that the hospital's staff and patients produced much of their own food. By early 1945, the hospital had eight villas and a total patient capacity of 400. By 1946 patient numbers approached 900. Employment levels increased along with patient numbers, approaching 200 by the early 1950s, a distinctly higher staff to patient ratio than at Seaview.

1950s - 1970s - hospital campus was expanded and modified as expectations concerning the provision of social activities and various (traditional and innovative) therapies evolved - the change in mindset signalled in part by the change in name from ‘mental hospital’ to ‘psychiatric hospital’ in 1961. 

1973 - therapeutic pool added

1977 - swimming pool added

Patient profile

In contrast to Seaview, where the majority of patients were from distant centres, Kingseat's resident population was drawn primarily from the expanding urban area of Auckland. This meant that a full range of services had to be offered and that beds were not left empty for long. Additionally, the population was younger than at Seaview, and included intellectually handicapped children after 1943. It also included more patients under active treatment, including those for whom periodic restraint was deemed necessary. In 1967, on instructions from the Ministry of Health, the hospital gave up its 660-acre farm as part of its ‘modernisation’, thereby distancing itself from Victorian forebears and launching the hospital into its last decade of comfort and self-assurance.

1980s - a decline of resident numbers. 

1995 - capacity reduced to 110 beds (or about 10% of its peak capacity) and South Auckland Health announced that it would be closed and the site and buildings sold. 

1996 - Kingseat was sold by South Auckland Health in 1996, after the Government’s deinstitutionalisation policy insisted a move away from continuing hospitalisation of mentally ill patients in favour of community care and smaller acute and rehabilitation units, closer to their families.
1999 - (July) Kingseat Hospital was officially closed. The last patients were moved to a newly refurbished secure mental health unit on Bairds Road in Otara.
1999 - grounds initially considered as a site for a new prison (600 inmates).
2000 - legal action taken against the Tainui tribe for financial issues involving the former hosptial
2003 - Tainui's sale of Kingseat Hospital complete—almost 6 years after the deal was done.
2004 -  complaints filed by former patients against the government for claims of mistreatment and abuse during 1960s and 1970s.
2005 - Spookers opened business in the former nurses home

Sale

Soon after, the purchase of the 60-ha site by the Tainui (a Maori iwi based in the Waikato region) Development Corporation was announced. The reaction to the announced price was one of surprise: 

“The decision to sell this 60 ha psychiatric facility at a bargain-basement price of $6.8 million—soon after spending $10 million on its upgrading—ranks among the most stupid and unforgivable made by this Government” (Truth, 5-01-1996). 

Further opposition to closure crystallised around concerns voiced by the police for public safety stemming from the loss of a secure treatment site (New Zealand Herald, 10-11-1995).

Within a year, Tainui had put Kingseat back on the market: “Tainui Development Ltd. executive director Greg Parker said Tainui bought the property from South Auckland Health with the intention of establishing an Auckland-based postgraduate residential college …[but]… the college would now be in central Auckland close to the university” (Waikato Times, 31-5-1997). It was noted that “The Kingseat property contains more than 50 buildings, 14 two-level brick and tile villas, an administration complex, 107-room nurses home, lecture theatre and kitchen. Recreational facilities include sports fields, bowling green, swimming pool and tennis courts.” 

Possible uses were noted to be “as an education or health facility, retirement village, equestrian centre, horticultural centre or rural lifestyle subdivision” (Waikato Times, 31-5-1997).

Tainui accepted an offer to purchase from the The Prince Corporation (a Korean-based investment group), but the Corporation subsequently sought to set aside the agreement on the “grounds of alleged misrepresentation as to the state of the property” ( Waikato Raupatu Lands Trust, 2002). Pending the result of litigation, Tainui retained control of the property, renting part of it back to South Auckland Health until it was reported that “today, Kingseat Hospital will be officially closed. The last patients held in the former mental institution will be moved off the rural complex and transported to a newly refurbished secure mental health unit” (Scoop Auckland, 28-07-1999). 

Tainui's sale of Kingseat Hospital took almost 6 years to complete. An out-of-court settlement reached with Auckland-based Prince Corporation, which agreed to buy the 60 ha former psychiatric facility in South Auckland for an undisclosed sum in 1997 (Waikato Times, 30-01-2003). In the same article a Tainui spokesperson was quoted as saying “We are glad to see the back of this headache.” 

Reuse

In the same year the headline “Kingseat looks likely as new 600 inmate prison” (Scoop Auckland, 16-08-1999) announced another parallel with the Seaview experience. The prison proposal was dropped, in part because of opposition from nearby residents and their local governments: “Delays and uncertainty they say are stalling land sales in the area and causing suspicion between residents” (Scoop Auckland, 16-08-1999).

Oct 2005 “One of New Zealand's notorious former psychiatric hospitals will become the home of a horror show. A haunted house is set to open next week in the old nurses’ home at the former Kingseat Hospital at Karaka, south of Auckland” (New Zealand Herald, 22-10-2005). The same article went on to note that “The company is aware of the potential for accusations of bad taste by choosing a former psychiatric hospital, where many experienced mental suffering and some patients say they were mistreated. ‘That's why we’ve got it in the nurses’ home and not the actual hospital itself.’ ‘Spookers’ manager Julia Watson said ‘We also will be having absolutely nothing to do with a mental asylum’.” In her regular column in Canvas magazine, Daya Willis (2005, p. 10) wrote that “while there are undoubtedly excellent arguments for the old Kingseat Hospital grounds being put to use after all these years, there's also something creepy—something downright disrespectful, methinks—about running a fake scare-athon out of a property that saw so many people live through real horrors.” Clearly, as these comments suggest, commercial exploitation of stigma raises important questions about the ease by which selectivity in the collective memory can be fostered.

2013 - property developer revealed plans to transform the site of the hospital in a countryside living estage for 450 homes, sparking debate over which buildings and their park-like ground should be retained as a reminder of its past. Also the year during which 'Asylum Paintball Park' was opened using 2 of the former hospital buildings (villa 10 & 16)

'Hauntings' The most common apparition reportedly seen at Kingseat Hospital was the 'Grey Nurse', believed to be a former staff member (seen in the old nurses home).

Wikipedia ref

Report for/by Auckland City Council

Council decisions 2013

Rezoning of Kingseat area

Josef Hoffmann's Purkersdorf Sanatorium 'Architecture for Modern Nerves'

As per the common theory that modern living (the city in particular) was the cause, or at least major factor in 'nervous imbalances', the most important treatment prescribed for patients with nervous disorders during the 19th century and early 20th century was to remove them from their usual context and isolate them from all 'unhealthy' influences from the outside world.

This was a major goal of  Josef Hoffmann's Purkersdorf Sanatorium - in the 1911 annual report for this institution, the doctors of the sanatorium emphasised the importance of removing patients from their normal unhealthy surroundings and offering them something different and more 'wholesome' in the sanatorium environment.

Architecture as a tool of medical science

The most striking thing about Hoffmann's building is that all references to history and traditional building types or architectural conventions were avoided. At the time it was built, it was unlike any other physical environment that its patients may have experienced. It was not fashioned like a house or villa as were many others before this time. The art critic Ludwig Hevesi noted that the simple harmony of the exterior was undisturbed by columns, gables, or any of the standard ornamental elements one was used to seeing. The usual window surrounds were replaced by bands of blue and white tiles, and the peaked roof was replaced by a flat roof with no softening moulding. As for the interior, 'everything is new, newer, newest'.

However, even though it was different, it was not intended to be yet another unpredictable element contributing to the constant changes of modern life. It expressed a rational order in its layout and organisation of space, in contrast to the supposedly unplanned chaos of cities. The building was intended to present as a predictable, controlled physical environment, protecting the inhabitants from spatial, visual or experiential shocks to the nerves.
The layout comprised of a tightly controlled geometric design with its 3 main functions - physical therapy, communal activities and sleeping - separated and placed on 3 different levels, each arranged symmetrically and bisected by a single corridor. The importance of an 'exact schedule' was emphasised for all patients; the tightly structured temporal division of the day was made concrete and spatial in Hoffman's building. Patients could proceed in an orderly fashion through the day and through the spaces of the building, sleeping, eating, receiving treatment, and relaxing at specific times in distinct spaces. The arrangement of the spaces also aided surveillance - the simplicity of the overall arrangement, and placement of the corridors and glass inserts made it possible to survey at a glance the entire length of each floor.

The geometric pattern of the window surrounds are mirrored throughout the building both externally and internally and in the hard and soft furnishings (the entrance floor tiling, the pattern of exposed reinforced concrete beams, the white wooden chairs (in the form of cubes) and their cushions in the hallways). A standardisation and repetition of form.

Patients were free from not only visual discordance but also physical obstacles with which they apparently struggled with in less 'modern' settings. For example, the heights of the mirrors, the design of the lamps and stairs all reflected the desire to spare patients the annoyance of bad lighting and aggravations of furniture and fittings which obstructed movement and functioned inefficiently.

Hoffman sought to create an environment free of spatial ambiguity, visual discordance and physical inconvenience and discomfort.

The design of the Purkersdorf Sanatorium was described by critics and by Hoffman himself as rational, honest, logical and based on the objective analysis of needs [this appeals to the business analyst in me!]
Hevesi described it as a 'logical organism' unencumbered by 'ornamental lies'.

Confusion of scientific rationale...

Both the Purkersdorf Sanatorium and the theories surrounding nervous ailments at the time were based not on facts shown to be empirically true, but on a set of presumptions about what a building and a life should ideally be: simple, balanced, organised and consistent.

'Hoffmann's architecture and Krafft-Ebing's medical science are not so much engaged in exposing facts as they are in designing new utopian truths.'

Leslie Topp then goes on to have a very interesting discussion of architecture versus medical 'science', and the different theories at the time, including those of Sigmund Freud.

"..In Josef Hoffmann's Purkersdorf Sanatorium we see an early example of the modernist dream of happiness through architecture built on the shifting foundations of psychiatric theory..."

Summarised from 
Topp, Leslie. "An Architecture for Modern Nerves: Josef Hoffmann's Purkersdorf Sanatorium." Journal of the Society of Architectural Historians 56, no. 4, (Dec 1996): 414-437. 

Building Details
Construction dates: 1903-1905
Function: sanatorium
Location: Purkersdorf, Wien-Umgebung, Lower Austria.

In 1926, against the will of Josef Hoffman, another floor was added to heighten the building.
Towards the end of WWII it served as a military hosptial before being requisitioned by the Russian occupying force. In 1952 it was rebuilt as a hospital and nursing home. The old pavilions were rebuilt but then fell into disrepair.

In 1995, the upper floor added in 1926 was removed and the original appearance was restored. It was used as a cultural venue then in 2003 renovated to become a senior care home.

The culture of hospitals - function versus cultural values

Hospitals are not nice places - they're where you go when you're sick and perhaps where you go to die...
You're in pain, perhaps confronting your own mortality and give control of your wellbeing to someone else, a stranger, other powers of technology or medicine or some other unknown.

"The history of hospitals is therefore one of the construction of systems of control and imprisonment, confinement and isolation, dissolved through the good offices of architects into fragments, structures that try to look like someplace other than what they are."(1)

There is a constant tension between the tendency of hospitals to expand like some cancerous growth into giant machines for healthcare or to dissolve into anonymous components throughout the city.

The history of the hospital as a building type

The hospital has always been rather difficult to define as a building type possibly because its something we'd rather not see or know about. Even during the 18th century at the height of attempts to create a clear type, there was criticism of any architecture that tried to make the hospital 'look nobler than it really was."(2) Historically, hospitals were places to confine and control the needy and the dangerous - up until the age of Enlightenment, whether the residents were patients or paupers was irrelevant. Anyone who was not useful, was inefficient, or was not a good citizen was best isolated in hospices, almshouses, orphanages or hospitals. Both the rich and peasants were sick and died at home, not hospital. The hospitals were similar in appearance and function to places such as the military camp, monastry, cloister, orphanage or poorhouse. They were square or rectangular structures with a central open courtyard and focal points comprised of temples or chapels (these places of faith and religion were later replaced by operating theatres...religion versus science). Hospitals were (and still are) low and anonymous, with an inward focus, hiding their function and character. The ideal versions of this building type were the radial plan hospital such as that proposed by Bernard and Charles-Phillippe Coqueau after the Hotel-Dieu fire.
To counter these designs, in 1694 Christopher Wren designed the Greenwich Naval Hospital as a series of freestanding pavilions, a design with Classical roots - Ancient Greek examples of this are seen in the ascelpion which was a collection of individual buildings grouped around a temple to the god of medicine. Wards were originally small structures where the family and patient could sleep. There were separate buildings for different functions and the hospital was thus seen as a larger version of the family home, in a complex seen as an antidote to the city. This pavilion model of the hospital was lost as technology became more prominent and promoted a centralised arrangement. However, the pavilion model continued to be used for places of long term care and convalescence such as asylums, leper colonies, tuberculosis santariums and places for the elderly. A nice example of this is Otto Wagner's 1907 Steinhof Psychiatric Hospital where the architecture 'tried to reconnect its patients with both society and nature through an elaborate decorative scheme.' This is discussed by Leslie Topp in Art Bulletin.

[See also article link by Leslie Topp on the emergence of the asylum mortuary as an architectural challenge during the late 19th/early 20th century, which includes analysis of Otto Wagner's approach.]

Summarised from:
Bestky, Aaron. "Framing the Hospital: the Failure of Architecture in the Realm of Medicine." In The Architecture of Hospitals, edited by Cor Wagenaar, 68-75, Rotterdam: NAi Publishing, 2006.

(1) Aaron Bestky, "Framing the Hospital: the Failure of Architecture in the Realm of Medicine." In The Architecture of Hospitals, ed. Cor Wagenaar (Rotterdam: NAi Publishing, 2006), 68.
(2) Foucault, Michael. The Birth of the Clinic : an Archaeology of Medical Perception. Translated by A. M. Sheridan Smith. New York : Vintage Books, 1994. Also at http://solomon.soth.alexanderstreet.com.ezproxy.auckland.ac.nz/cgi-bin/asp/philo/soth/documentidx.pl?sourceid=S10021883

The culture of hospitals - cities as a parallel

Like cities, hospitals reflect life - they usually contain a representative sample of a city's population in terms of socioeconomic status, race, religion, professions and cultures. Hospitals are often divided into departments with various traffic flows connecting them and services to support them. It makes sense, then, when many hospital architects refer to the city as a model and show a desire for their project to have fundamental characteristics of a well designed city, such as the capacity to form a living community with cultural integration.
Lewis Mumford, whose books have had a major impact on town planning and architecture through his books on the culture of cities, describes the way cities are designed as a result of the deliberate choices reflecting a culture's economic, social and moral concepts, adapting to new circumstances. "Fragments of culture continue to live long after the society that originally sustained them has passed away: often long after they have ceased to be a rational response to a situation or the expression of a need." (1) This can be seen in the evolution of a hospital over time. People's choices are influenced by emotional and associative processes, and policy making is not immune to this influence. Thus, hospitals cannot be seen as distinct from their cultural context.


Summarised from:
Wagenaar, Cor. "The Culture of Hospitals." In The Architecture of Hospitals, edited by Cor Wagenaar, 24-25. Rotterdam: NAi Publishing, 2006.

(1)  Lewis Mumford, The Culture of Cities (New York, Secker & Warburg, 1944),73.

Mumford, Lewis. The Culture of Cities. London: Secker & Warburg, 1944.
Wagenaar, Cor, ed. The Architecture of Hospitals. Rotterdam: NAi Publishing, 2006.

'Space, place and patient experiences of mental healthcare' 1948-1998

Taken from a chapter in 'Madness, Architecture and the Built Environment'(1)...

Spatial metaphors, physical descriptions of the buildings and wards, and a sense of movement from place to place are common descriptions when listening to people recalling their experiences as a psychiatric patient. Research by Kerry Davies (1) used 41 oral history interviews with patients and ex patients. Her argument is that while space and place are increasingly prominent in the history of psychiatry, patients are often absent or peripheral figures in these accounts. In her definition of 'place' (versus space) she uses William Gesler's definition of a place as 'space filled with people acting out their lives'.


But I'd probably think back to Martin Heideggers' definition:
Being-in-the-world
Space (abstract) versus Place (socially experienced)

The German word for space, Raum, originates from raumen which means 'freeing of places for human dwelling'.  Dwelling - implies being at one with the world, peaceful, contented, liberating. This is related to the kind of building which is cultivating or nurturing.  Considering a dining table as a 'dwelling', then moving the table around a room or setting it for a meal is a kind of building of a sort- done in response to the needs of the people who will eat there. So dwelling is dependent on building and also vice versa. One can occupy buildings daily but not feel at home in them or near to them. The German word for building, Bauen, originally means to dwell.
Dwelling requires building and then rebuilding to respond to changing needs of dwelling [- the concept of mutability?]
So, according to Martin Heidegger in "Building Dwelling Thinking" the relation between man and space takes on the form of dwelling. A building is what allows for a sense of place in which dwelling occurs (2).

Place & Time

A quote from a patient ('Christopher') emphasises the change from space to place requiring time:

"And I liked Littlemore to start with, but when they got the new building, I didn't like it. I was very depressed when I went there. And it had only just opened, you could smell the paint. You know, the ward - a ward has to have some time to get an atmosphere. It didn't have one, but it has now."

The change in the space was both physical (the newness, the smell of paint) and social (expressed as a lack of atmosphere).

Imagery

Another quote from a day patient:

"...it was the drab atmosphere when I was walking over the bridge - when I used to get off the bus and walk ... it was the hospital grounds, the grey buildings. The look of it as I was walking over it was quite dismal, you know, and I thought I want more from this in my life and that's ... the reason why I packed it in..."

The dramatic physical presence of large institutions, their place in local myths, the large number of people who work and live there, all serve to maintain the central and almost physical place in the histories of mental health. People's recollections of their time in mental healthcare facilities usually include vivid descriptions of the physical surroundings, the building, moving around within the buildings but also internal details such as taps, lampshades, the state of the paintwork.

[NB. I intend to investigate ceilings as a forgotten but significant internal detail since we often spend a lot of time starting at it when we're ill...]

Spatial ownership & surveillance

(See also previous blog entry on this)
There is often a sense of a public and private face of the hospital - the 'good' wards being more publicly visible compared with spaces in the further reaches of the hospital - back wards, tops of stairs, underground pathways and rooms, adding to the 'depth' of the building.
There was a common concern at having to enter 'staff space' (eg. the central nurses area, the glass box) in order to seek support. There is/was a definite line between patient and staff spaces. The central glass area was also described as a goldfish bowl - confusing the issue as to who is watching whom...
Themes of being under surveillance in specific (small) spaces, occupied by patients but 'owned' by staff, were common. However, when being watched, patients do interact and return both the gaze and the glance. This gaze is both mediated and reciprocal.

"...they've got these little windows, with these, its not blinds, you wouldn't call it a blind, like a shutter, you can lift up and look in? So they can check on you at night ... And they put me in a room on my own, right away from everyone ... And they put you on ... obs, which is fifteen minute observations just to make sure you're [okay] but, when you're trying to get to sleep at night and they're shining a torch - 'are you still there?", yeah, yeah, go away I'm trying to get some sleep..."

Observation is portrayed as comic and ridiculous, particularly night time surveillance, the lack of control over space, the images of torches, but was intrusive, shocking, and frustrating.

The grounds...

The most significant patient spaces have tended to be the hospital grounds - there is less 'observation', and the spaces are more flexible (informal or formal, work areas, exercise areas) and less regulated. Areas that could be used for illicit activity. Places of escape - from the wards, staff surveillance, other patients - and rest.

(1) Davies, Kerry. "'A Small Corner that's for Myself': Space, Place and Patients' experiences of Mental Healthcare, 1948-98." In Madness, Architecture and the Built Environment. Psychiatric Spaces in Historical Context, edited by Leslie Topp, James E Moran and Jonathan Andrews, 305-320. New York: Routledge, 2007.

(2) Sharr, Adam. Heidegger for architects. London, New York: Routledge, 2007.

(3) Gittens, Diana. Madness in its Place. Narratives of Severalls Hospital, 1913-1997. London: Routledge, 1998.
http://site.ebrary.com.ezproxy.auckland.ac.nz/lib/auckland/docDetail.action?docID=5001600

Rural vs urban sites

Different models of care in different countries ultimately led to different designs and locations for public asylums.
Geographic differences were seen in the location of the hospitals, whether they were set in an urban or rural site. A central urban location was essential for the way in which Dutch asylums functioned (1), and in Britain they were initially sited in urban locations usually next to general infirmaries (2) . It was only after about 1820 that the location of asylums shifted to the outskirts of cities and then later to rural locations.
Particularly in Britain, city living was seen as the cause of some madness. Ebenezer Howard's Garden City designs showed hospitals and asylums sited in the outer layers of the garden city near farms and pastures.
In Germany and Austria, the large monolithic asylum building set on a hilltop in an empty countryside gave way to the late nineteenth century smaller scale buildings scattered over the site. This was the 'villa system' of design which reflected the thought that the normalising image of the home should be built into the design. Small scale buildings embodying the architectural features of the home were designed. These also split the large patient population into more manageable groups according to diagnosis.
However, even where they were built specifically to be on the outskirts of cities or in rural locations, the fast pace of urbanisation subverted this intention, particularly in countries like India (3).
Furthermore, a rural location did not necessarily mean being cut off from other human contact, nor did an urban location ensure better integration into society.
Patients do commonly refer to extensive hospital grounds as places of relative freedom and autonomy but also such grounds reinforce the impression of the hospital as a separate place away from the surrounding city (4)

 
(1) Kromm, Jane. "Site and Vantage: Sculptural Decoration and Spatial Experience in Early Modern Dutch Asylums." In Madness, Architecture and the Built Environment. Psychiatric Spaces in Historical Context, edited by Leslie Topp, James E Moran and Jonathan Andrews, 19-40. New York: Routledge, 2007.
(2) Smith, Leonard. "The Architecture of Confinement: Urban Public Asylums in England, 1750-1820." In Madness, Architecture and the Built Environment. Psychiatric Spaces in Historical Context, edited by Leslie Topp, James E Moran and Jonathan Andrews, 41-62. New York: Routledge, 2007.
(3) Ernst, Waltraud. "Madness and Colonial Spaces - British India, c. 180-1947." In Madness, Architecture and the Built Environment. Psychiatric Spaces in Historical Context, edited by Leslie Topp, James E Moran and Jonathan Andrews, 215-238. New York: Routledge, 2007.
(4) Davies, Kerry. "'A Small Corner that's for Myself': Space, Place and Patients' experiences of Mental Healthcare, 1948-98." In Madness, Architecture and the Built Environment. Psychiatric Spaces in Historical Context, edited by Leslie Topp, James E Moran and Jonathan Andrews, 305-320. New York: Routledge, 2007.

Architecture - deception & surveillance

The manipulation by designers of asylums of the visual appearance of these buildings was used to create a particular influence on a patients mental state. In the nineteenth century this included creating an impression of middle class domestic normality via seemingly small gestures - hanging pictures on the walls, using comfortable furnishings. The thought was that this could, through a version of osmosis, bring 'insane residents back to reason', based on the Quaker idea of mind-body unity. Other deceptions included the visual impression that residents were not confined at all by providing open views of the countryside and designing the layout like a rural village or suburban residential neighbourhood.

German alienist* Friedrich Wilhelm Roller saw the asylum as an 'architecture of visual transparency', to be created through total supervision and spatial organisation. With these things in place, the asylum could function as a giant surveillance system, extricating madness by bringing it into plain view, and exposing it to those committed to its cure...however, this idea was shown as ineffective after exposure of covert violence against the residents by nursing staff (2).
The purpose of surveillance then shifted from the reform of the patient through close long term observation to the classification of disease characteristics through short term observation made possible by Emil Kraepelin's changes to asylums in which increased the scale of scrutiny and surveillance under the guise of scientific symptom classification (3).

To be finished....(surveillance)

(1) Moran, James and Leslie Topp, "Introduction. Interpreting Psychiatric Spaces." In Madness, Architecture and the Built Environment. Psychiatric Spaces in Historical Context, edited by Leslie Topp, James E. Moran and Jonathan Andrews, 1-16. New York: Routledge, 2007.

(2) Sammet, Kai, "Controlling Space, Transforming Visibility: Psychiatrists, Nursing Staff, Violence, and the Case of Haematoma Auris in German Psychiatry c. 1830 to 1870." In Madness, Architecture and the Built Environment. Psychiatric Spaces in Historical Context, edited by Leslie Topp, James E. Moran and Jonathan Andrews, 287-304. New York: Routledge, 2007.
(3) Engstrom, Eric J, "Placing Psychiatric Practices: on the Spatial Configurations and Contests of Professional Labour in Late-Nineteenth Century Germany." In Madness, Architecture and the Built Environment. Psychiatric Spaces in Historical Context, edited by Leslie Topp, James E. Moran and Jonathan Andrews, 63-82. New York: Routledge, 2007.

Design Brief - Topic Description (Milestone 3)

[Complete the first & second pages of the Design Brief, with an image]

'Hospital Green'

RGB 129, 201, 159

Psychiatric hospitals have a chequered past in New Zealand. Childhood threats to be 'sent off to Sunnyside/Tokanui/Carrington' conjure up images of places filled with madmen, insanity. Haunted places.

During the nineteenth century there was a move to institutionalise those who 'deviated from social norms' leading to increased construction of buildings to house these people - prisons, hospitals and asylums. Many psychiatric hospitals were built in New Zealand during this time. All were imposing, prominent buildings based on similar institutions in Britain. Most were self sufficient with productive gardens and farmed land out in the countryside, isolated from the cities.  The institutions had benign names like Cherry Farm, Seaview and Sunnyside. They housed thousands of long term residents and were a culture unto themselves, a world of ‘back wards’, ‘ECT trolleys’ and ‘seclusion rooms’.

Planning for new psychiatric hospitals ended in 1963 and no extra beds were provided from 1973. During the 1990s psychiatric hospitals finally gave way to community-based care for the treatment of mental illness in New Zealand; almost all psychiatric hospitals were closed or run down during this time. This caused many problems for patients who did not have appropriate support and many local initiatives for the mentally ill did not survive the reorganisation of the entire health sector in this period.

 The former asylums were seen as sites of celebrity, with famous patients such as Janet Frame recounting their experiences there. The shadow of stigma is prominent, seen directly in suggestions that the former hospitals be used as prisons and in the partial redevelopment of one as a ‘horror theme park’ ('Spookers' at Kingseat). Should or could this stigma be overcome in the repurposing of these buildings into the modern concept of mental healthcare?

 An exploration of phenomenology and architecture of the senses, particularly those ‘forgotten’ by architecture (smell, touch) will be a strong focus of the resulting design, emphasising the interior experience. Cultural elements are hugely important for some groups of society in aiding recovery from mental illness. These may include considerations of different cultural requirements for privacy (visual, acoustic, sensory), a sense of place or feeling of comfort in being in that environment – all associated with phenomenological attributes. A more pragmatic research component will involve how to best represent these elements and ensure they don’t get lost in translation during the actual building process.

 Critical Questions

Is the stigma of the old 'insane asylums' too strong to successfully repurpose these buildings into modern mental healthcare facilities?

Do phenomenological considerations, when used in the design of mental healthcare buildings, have the potential to overcome this stigma and also enhance recovery from acute mental illness?

How can these sometimes esoteric design components be translated with minimal dilution into pragmatic but enduring design?