Some excellent journal articles...

Healing by Design - NEJM 

"Medical care cannot be separated from the buildings in which it is delivered. The quality of space in such buildings affects the outcomes of medical care, and architectural design is thus an important part of the healing process." 

This quote was not from an architect or designer, but a medical doctor. Nor was it published in an architecture or design magazine, but in one of the most prestigious medical journals worldwide (one of the 'top 4') - the New England Journal of Medicine which reflects the fact that design is taken seriously in this respect. However, often the complexity of these building types and budget restrictions mean that well intentioned design can be diluted and restricted.

The article is a general review of hospital design so while it didn't add significant information to my research topic, it did provide an interesting overview plus research links to follow up. For example, the unique characteristics of hospitals with respect to scale and symbolism were outlined quite well by providing a quote from architectural historian Talbot E. Hamlin in 1940:

"The hospital is not a home, nor is it a factory; its character must have a subtle balance of human scale and community scale...". 

Many modern hospitals have reflected current technological preoccupations in their clean, streamlined facades and exposed structural and mechanical elements. However, the resulting resemblance of some of these to office blocks, high tech factories and airports presents a symbolism at odds with the desired message that hospitals care about individual patients. Instead, they emphasise subordination of individual occupants (office block), materials to be processed (factory) or units to be transported (airport).

Horsburgh, CR. 'Healing by Design.' New England Journal of Medicine 333, no. 11, 1995: 735-740.

Applying a Salutogenic Model to Architectural Design for Psychiatric Care - Facilities

This article was a well documented and supported review of salient points for the design of psychiatric care facilities from a salutogenic viewpoint. This overlaps with much of the environmental psychology research I had been reading. Plus it just seemed to 'make sense'!

Salutogenic theory is a useful framework to apply to mental healthcare, particularly where rational decision making is needed but there is no relevant research to provide support.
Salutogenics is a psychosocial study of what keeps people healthy, starting from the perspective that illness and health are different points on the same continuum of life and death. The key premise is that a 'sense of coherence' (SOC) is strongly linked with a better resistance to illness. SOC is defined as the ability to identify and use one's health resources and is critical for a person's ability to gain health and have a healthy orientation in life. It's something that increases with age, implying that it is a life long healthy learning process.
Having a strong SOC means you have a sense of confidence that your internal and external environment are predictable and there is a high probability that things will turn out well.

Comprehensiblity - reducing perceptual distortion

The salutogenic model describes the relationship between the patient and the environment as transactional rather than fixed - the environment changes according to the patient's sensory and perceptual abilities. Many mental health problems occur as a result of imbalances or distortions of perception. Making sense of your experience is important, but in the case of some psychiatric patients this ability is impaired. Everyone's experience of the world is different but under normal circumstances, the gap between our own perception based on subjective experiences and that of reality is not significant and/or resolved without problems. However, with many mental illnesses, this gap is significant. So, it's important to design the environment to reduce the possibility of perceptual distortions:

• keeping spaces small and to comfortable proportions
• using textures
• horizontal courses in masonry or timber to assist linear perspective
• normal objects placed to assist with size perspective (eg. no blank rooms or outdoor spaces, minimalism is not your friend in this case)
• we understand our environment through association with familiar things so provide a typology that is not institutional but more like a cosy and safe home
• avoid sound distortions such as echo, or excessive or repetitive noise
• provide clocks, calendars, other cues to provide information about the date and time
• avoid ambiguity - a door should be 'door-like', clear distinctions between wall/floor/ceiling etc
• unambiguous materials, ideally natural materials that are found everywhere such as exposed timber, brick, stone, natural carpets, so they will resonate with a wider range of cultural backgrounds
• strong structural grids and spaces associated with traditional building methods

Manageability - ability to exercise control over their environment

The feeling that a person is in control of their environment and life in general, is ideal. For psychiatric patients, this is the thing that is lost entirely (not only a loss of control over their activity, but also a loss of trust in their own perceptions, memories, and their own selves). So it's important that their remaining shreds of control are supported. The most significant thing here is to keep the numbers of people they interact with small - the number never larger than the archetypal human community, the nuclear family. More than 5 or 6 patients should not have to come into contact if they don't wish to.

• no large dayrooms, dining rooms, living rooms
• should be very easy to maintain personal hygiene
• rooms with ordinary day to day facilities - a kitchen, laundry, bathroom, telephones etc which are open and available for use anytime
• opening windows, controllable heating
• physical retreat spaces
• movable but sold feeling furniture

Meaning - enriching the environment

Mental health patients have experienced a rupture in their social relationships, a significant source of meaning. Provide other ways to introduce meaning.

• mental health patients often place huge importance on and feel very emotional about things and places
• there should be no sense of 'punishment' embodied in the architecture
• bare drab spaces directly affect perception - research has shown that such reduced environments causes hallucinations, confusion and depression even in normal healthy people - so provide generously detailed and decorated spaces
• provide good spaces for visitors, special personal belongings (including favourite music) and even pets - relationships with pets are often of more significance to these patients than relationships with other humans 

Golembiewski, Jan A. 'Start Making Sense. Applying a Salutogenic Model to Architectural Design for Psychiatric Care.' Facilities 28, no. 3/4, 2010: 100-117. doi:10.1108/02632771011023096

Stressed Spaces: Mental Health & Architecture

Another good (and very comprehensive) research review of specific design features was found in the Health Environments Research & Design Journal.

Connellan, Kathleen, Mads Gaardboe, Damien Riggs, Clemence Due, Amanad Reinschmidt and Lauren Msutillo. 'Stressed Spaces: Mental Health & Architecture' Health Environments Research & Design Journal 6, no. 4, 2013: 127-168

The research question posed in this review was: how does the intersection of mental health care and architecture contribute to positive mental health outcomes? Thirteen major themes emerged as follows (in order of prevalence):

1. security/privacy - people in ward environments occupy 70% less space than their counterparts of 150 years ago. Violence against patients and staff in psychiatric wards is prevalent and increasing. This stresses the importance of including demarcated spaces for particular activities and extra space provided where possible.
2. light - the main findings here were the importance of light for controlling the circadian rhythm in order to reduce depression and improve sleep and eating patterns. Patients in brightly lit rooms stay on average 2.6 days less in hospital than those in dimly lit rooms. A lack of natural lighting can cause seasonal affective disorder (SAD), changes to hormonal body rhythms and increased staff stress, and decreased staff satisfaction.
3. therapeutic milieu  - includes therapeutic design and environments; patient-centered design; healing environments, especially the Planetree approach; and the need for a multidisciplinary approach to healing.
4. gardens and contact with nature -extremely important for both patients and staff for renewal/restoration of attention, stress relief, and for its social aspects.
5. impact of architecture on health outcomes - architecture can enrich the environment with complexity, order, and aesthetic considerations offering perceptual cues to assist and avoid confusion. Access to nature and sensory/salutogenic considerations are important themes within this literature as is the need for privacy and a preference of single bedrooms.
6. interior design - furnishings, color, wayfinding, cognitive mapping, spatial organization, and type of patient room, the need for clear visual communication balanced with a home-like environment
7. psychogeriatric considerations - the need for quiet spaces and gardens, with an emphasis on deinstitutionalizing design features to encourage social interactions
8. post-occupancy evaluations (POEs) - deals with the lack of effective evaluations in health architecture generally and mental health particularly.
9. nursing stations - nurse-only and patient-only spaces are beneficial to both groups. Closed nursing stations often convey an image of staff inaccessibility to patients and visitors 
10. model of care - biopsychosocial approach that deals with the patient holistically, length of stay, personal visual elements in the environment, and homelessness. The literature shows the need for a balance between drug-therapy, environmental context and psychological and social therapy and interactions
11. art - as an activity but also as an aesthetic therapy; a key finding is that depression and anxiety were 34% and 20% lower, respectively, in contexts where patients were exposed to arts.
12. adolescent mental health - the need for maintaining connectedness to the outside world, including family-centered care; the role of visual preferences, including medium density gardens with water; as well as the need to keep personal items, have access to movies, and have private bathrooms
13. forensic psychiatric facilities - safety, privacy, and escapes. The literature emphasizes a pleasant domestic atmosphere that is well-lit with natural light and provides ample space for patients

This article presented the data in a fairly prescriptive manner but was useful and had a very comprehensive reference list which I will continue to scroll through!