"Mood Board"

Mood boards showing main precedents and atmospheres for the final design

snapshots - 'walkthrough'

Floor plans

More thoughts on sensory design

Sight and touch are the senses most obviously affected in a built environment, but patients often talk about what they hear and smell in a hospital setting. Masking these effects has been the most common way of dealing with adverse sounds and smells but another option is to be more active and enhance positive sounds and smells. This also helps to overcome the 'sterile' atmosphere present in many clinical interiors.

Examples of positively engaging the senses in a hospital (or other healthcare environment) may include:

• large graphics of nature scenes or motifs accompanied by associated scents via diffusers such as lemongrass which is associated with reducing mental tension (it's important to use natural essences rather than artificial scents otherwise it may end up smelling like a public toilet)
• place scent diffusers in strategic places such as near rubbish bins
• natural materials often have a scent, such as untreated wood (eg. cedar, pine), bamboo, 
• natural lighting that changes during the day - provide lots of skylights, windows, wherever possible. Ideally have light filtered through something that responds to the weather eg. trees moving in the wind etc.
• artwork - realistic images of nature that show a savannah-like image conducive to evolutionary wellbeing, and supported by Biophilic theory, can potentially lower patient agitation levels (Nanda U, Eisen S, Zadeh RS, Owen D. Effect of Visual Art on Patient Anxiety in a Mental Health Facility and Implications for the Business Case" Journal of psychiatric and mental health nursing, 2011, Vol.18(5), pp.386-93)

Mid century psychiatric units were all about seclusion, security and safety. No artwork, no colour, often no interesting details.
However, on my second site visit to Kingseat, I was struck by the remaining traces in the original 1930's building details - the richness of these compared with the modern additions. The tiles, cornices, wood panelling. 

Janet Frame quotes

Of course I started rereading the Janet Frame autobiographies after I started this thesis research...
Here are a few quotes from her books.

 “Both formality and dinner forgotten we sat on the floor of the little library, choosing. Sometimes Dr Portman read passages aloud and turned his own memories with their dark side to face the light. And it was late afternoon when, with a headache of happiness, I returned to the ward. And from that day I felt in myself a reserve of warmth from which I could help myself, like coal from the cellar on a winter’s day, if the snow came or if the frost fell in the night to blacken the flowers and wither the new fruit.”

The floor of the little library - informal, intimate, forming connections with others by this shared experience.


Istina (the narrator in 'Faces in the Water') is obsessed by the way that the worst wards have a smell about them: "a temple where a mixture of loneliness and despair was burned in place of interest".

“Much of living is an attempt to preserve oneself by annexing and occupying others.”  

“For your own good” is a persuasive argument that will eventually make man agree to his own destruction.”    

 At one point Istina's aunt gives her a present of a bag..

"That bag was like my final entry paper into the land of the lost people. I was no longer looking from the outside on the people of Four-Five-and-One [the ward where the worst cases were kept] and their frightening care for their slight store of possessions; I was now an established citizen with little hope of returning across the frontier; I was in the crazy world, separated now by more than locked doors and barred windows from the people who called themselves sane."

And from 'Scented Gardens for the Blind',

“People dread silence because it is transparent; like clear water, which reveals every obstacle—the used, the dead, the drowned, silence reveals the cast-off words and thoughts dropped in to obscure its clear stream. And when people stare too close to silence they sometimes face their own reflections, their magnified shadows in the depths, and that frightens them. I know; I know.”

  

Brief conversation with Jan Golembiewski - 'it's NOT a placebo'

One of the best papers I'd found recently relating to my thesis was one by a researcher in Sydney - Jan Golembiewski. After sending him a brief note about how useful I'd found his paper (see earlier links), he then said 'but it's not a placebo' - meaning that it's far more than just a placebo as it does have 'active ingredients'.
The environment for mental health patients is not a true placebo in that sense as it does have an active, definable therapeutic effect. This is where this differs from, for example, cancer patients. The brain of  many mental health patients is altered to be more susceptible to environmental effects in general, there is neurological rationale behind this.

Placebo definition

The concept of the 'architectural placebo' is now more a matter of definition. I need to define more carefully what I mean by this. In a very literal sense, the building itself still is a placebo in that it does not have any pharmacological ingredients, no 'active' substances that work directly on the patient's mind. However, it does have an active effect.

Placebo could also be interpreted to mean something that works but with no conventional scientific explanation or proof of how. Calling something a placebo does not mean that it doesn't work, it just means we don't have a completely definable way of explain how it works. Perhaps by magic...

It then comes down to communication and definition.
For example, the effects of discrete changes to the environment can be explained by environmental design research, evidence based design principles such as 'views of nature reduce number of days in hospital' or 'natural light for X% of time improves symptoms of Y by normalising patient circadian rhythms' or 'private rooms reduce infection rates' and so on.
Or these same things can be described in more poetic terms considering the whole experience, not just discrete items. For example, ((find example!!))

The placebo effect here is also relating to the way the changes to the main administration building will overcome, I believe, the adverse stigma attached to this place.

Snapshots - Gordon Cullen style

My thesis is not so much about the exterior and form but more about the experience of the building - from first sighting it, entering, walking around inside etc. So rather than focusing on plans, sections, elevations, use a series of snapshots of what it will be like to walk into this building:

1. Outside looking at the main door
2. Just inside the main door, looking down the corridor to the atrium area
3. Door to the stairs
4. Stairs
5. Landing?
6. Bedroom, private spaces
7. Communal areas

The textures, smells, colour, temparature of these spaces will be important - and lighting of course.

Suggested I look at Gordon Cullens work - he was an architect whose techniques consisted of sketchy drawings that conveyed a particularly clear understanding of his ideas, snapshots or internal perspectives - 'serial vision' which better portray the experience of a place compared with plans and sections.

However, the challenge for me is that by far the easiest way to do this is to place cameras inside my 3D model - but I haven't finished this to the point of even attempting that yet (too much time to do this even quickly at the moment, have only just finished the exterior of the existing building). So I'll have to fudge it with existing photos of Kingseat.

Design standards for mental health care units

Both NZ and Australian mental health services advocate patient-centered models of care and a focus on recovery on the person's own terms. However, the current design requirements generated by health boards, nurses and other therapists are sometimes at odds with this,with the main drivers being efficiency of staff routines (therefore, staff-centered). For example, the nurses stations still largely follow the old paradigm of security and surveillance - the nurses are behind closed doors and windows, with views down all corridors and patient areas (radial lines of sight). The wards are focused around these nurses stations rather than around patient spaces.

The current standards for nonacute inpatient mental healthcare design (Australasian Health Facilities Guidelines) updated in November 2013 do, however, support most if not all the design features previously discussed eg.

• considerations for diverse needs from special groups of patients (eg. culturally and linguistically diverse backgrounds), Maori & Pacific Islanders, those from rural/remote areas, age-related differences etc
• privacy & dignity, with appropriate control over their environment (eg. single bedrooms with ensuites, the ability to lock bedroom doors, to access quiet spaces)
• the reduction and eventual elimination of the use of seclusion is a goal both nationally and internationally, by providing adequate 'de-escalation' strategies:
• private bedrooms
• lounges furnished with heavy furniture
• rooms where patients can engage in activities that relax them (eg. music, aromatherapy etc)
• a generous number of quiet lounges and private courtyards
• each kitchen to have its own dining area for no more than 10 people to 'contribute to a more domestic atmosphere' - however, 10 is a large family group for most people!
• cluster beds for the separation in to groups of patients based on behaviours/risk/gender/age/diagnosis as appropriate
• unobtrusive observation, however, 'good sight lines from staff areas such as staff stations, to consumer areas is an important design criterion' still.
• views into surrounding gardens
• the main lounges should open out onto an outdoor area
• outdoor areas to include private courtyards, seating in landscaped gardens, active areas such as basketball courts and walking paths, fixed BBQ
• the landscaping should allow people to participate in gardening if they want to
• provide acoustic privacy, and reduction of noise in general 
• provide as much natural light as possible, ' higher levels of natural light may help people better orient themselves in the building and thus enhance wayfinding.'
• the quality of darkness should be maximised at night to enhance sleep quality
• avoid extremes of colour and pattern such as geometric designs which could disturb perception
• colour should be used to highlight doors/paths commonly walked along
• soft furnishings, artwork and plants should be used to create a homelike and calming environment
• 'it is important to allow patients to have some control of their surroundings eg. access to light switches and television remotes'.
• CCTV must not be used as an alternative to direct clinical patient observation by staff - the use of CCTV for security must be 'balanced between consumer rights for privacy and the need for observation for safety and security reasons'

Pattern Language

According to Peter Alexander's Pattern Language:

1.  the spaces defined by patterns dealing with social and psychological needs are critical
2. a building will seem alien unless it gives to its users a direct and intuitive sense of its structure - how it is put together; buildings where the structure is hidden leave yet another gap in people's understanding of their environment.
3. when the social space incorporates the fabric of the load-bearing structure supporting that space, "...then the forces of gravity are integrated with the social forces, and one feels the resolution of all the forces which are acting in this one space. " This experience is restful and whole, like sitting under an oak tree
4. the building will only be at rest psychologically if the corners of its rooms are clearly marked and coincide with the most solid elements

In this community, provide public open land where people can relax, and renew themselves using the following patterns:

• Accessible green - green open spaces that are no more than 3 minutes walk away
• High places - the instinct to climb up to some high point, from which you can look down and survey your world, seems to be a fundamental human instinct (one which I can relate to!)
• Pools and streams - connect with the nearby estuary, add water feature to the existing internal courtyard. Running water is important. Perhaps incorporate rain gutters somehow.
• Holy ground - a church, chapel, temple, place for meditation, prayer; the place will include a form of series of nested precincts, each marked by a gateway, each one progressively more private and more sacred than the last - the innermost sanctum can only be reached by passing through all the outer ones

Then drilling down a little further, provide:

• Public outdoor room
• Still water
• Local sports
• Adventure playground
• Animals
• Street cafe

Then patterns that relate to the buildings themselves:

• Wings of light, Long thin house
• Light on two sides of every room
• Cascade of roofs, Building fronts
• Family of entrances
• Entrance transition, Entrance room, 
• Circulation realms
• Pedestrian street & density, Activity pockets
• Stair seats, Staircase as a stage
• Staircase volume
• Shape of indoor space, Ceiling height variety
• Intimacy gradient
• The flow, through rooms, Short passages
• Alcoves
• Secret place
• Corner doors
• Thick walls
•  Closets between rooms
• Window places, Windows overlooking life
• Indoor sunlight, Tapestry of light and dark
• Sunny counter
• Common areas at the heart
• The fire
• Sequence of sitting spaces, Sitting cycle
• Zen view
• Half open wall, Interior windows
• Built in seats
• Sleeping to the east, Bed cluster, A room of one's own
• Farmhouse kitchen, 
• Eating atmosphere
• Cooking layout, Open shelves, Waist high shelf

• Private terrace on the street, Street window, Opening to the street
• Six foot balcony
• Connection to the earth

For the downstairs areas:

• Communal eating
• Small work groups
• Reception welcomes you
• Settled work

Outdoors:

• North facing outdoors
• Positive outdoor space - shape the outdoor green spaces so that they form one or more positive room-like spaces and surround these with trees, or walls or buildings (but not roads)
• Half-hidden garden
• Hierarchy of open space, Courtyards which live
• Roof garden
• Arcades, Gallery surround
• Paths and goals
• Outdoor room, Garden seat
• Fruit trees, Vegetable garden
• Tree places - pay attention to old trees, look after them
• Garden wall, Trellised walk
• Garden growing wild
• Greenhouse

Investigations with form...

My challenge is to keep this a 'thesis' rather than a report of some good design...Need to have more fun with the design. So, going back to my original idea of a blanket of dwellings draped or nestled on top of the existing, here are some images of a quick model...

Seeking the real - Peter Zumthor

Taken from an article: Christopher Platt & Steven Spier (2010): Seeking the Real: The Special Case of Peter
Zumthor, Architectural Theory Review, 15:1, 30-42 (see http://dx.doi.org/10.1080/13264821003629238)


This is a rare interview with Peter Zumthor in which he outlines his design philosophy and way of working. His main influences are: memory, materials, the senses, atmospheres, drawings, details, fine art, music, clients and place. He states that his desire is in "...developing an architecture that sets out from and returns to real things."

"There was a time when I experienced architecture without thinking about it...[ie. as a child before becoming an architect] Memories like these contain the deepest architectural experience that I know. They are the reservoirs of the architectural atmospheres and images that I explore in my work as an architect."

That is, the deepest memories and recollections of architectural experiences from your past are very important.

However, from this personal view, the architect must be able to identify the universal in the personal and construct principles from this. To connect with what is universal  about the human condition by recalling the personal.

"We see things not as they are but as we are."

Mood board for concept

Create a mood board-like presentation of ideas for the interior:

1. Colour, Lighting, Smells (materials, foliage), Feeling etc
2. Show a graduation of window types from photos taken, from scarey to relaxing views
3. Precedent image of Moritzburg museum & thermal baths
4. Words
5. Roof walk - the 'therapeutic walk' (precedent may include the High Line)

Examples..

The Placebo & The Therapeutic Milieu

The question was raised, what is the difference between a good example of architecture (well designed etc) and the architectural placebo?

The architectural placebo will not work without it's corresponding therapeutic setting, or milieu. This setting includes the caregivers for a patient, the disease/disorder of that patient, the history of that patient and the events leading up to being in this place. Using the example of a tablet placebo, for it to work there needs to be:

1. the need for it to work - eg. the disease/disorder being treated
2. the therapeutic setting - eg. the experience of the patient beforehand such as visiting the doctor
3. the belief both of the person administering it and the person using the placebo

The architectural placebo requires some shaping of a person's experience before entering the building, the entrance, the setting etc.

'Therapeutic milieu'

Milieu = from Old French, midst, from mi middle (from Latin medius) + lieu place, from Latin locus — more at mid, stall. The English translation of the word is surroundings or environment.
Milieu therapy = scientific planning of an environment for therapeutic purposes. Much like the architectural placebo...

The goal of milieu therapy is to manipulate the environment so that all aspects of the patient’s experience are therapeutic

See these links for more information:
http://nursingplanet.com/pn/milieu_therapy.html

The environment must be flexible and able to be adapted to patient's current needs. Patients who are regressed or who are overwhelmed need more structure and support while others need more autonomy and responsibility. Ideally there is a form of stepwise increase in responsibility.

Progressive levels of responsibility according to client’s self care capacity (according to the psychiatric nursing website listed above):

Level I: Displays a destructive behavior to self, others, or the environment.
Level II: Does not display destructive behavior.

• Knows the current time, date and place.
• Attends at least one therapeutic group daily.
• Attempts to maintain good personal hygiene 

Level III: Attends All Therapeutic Activities.

• Participates actively in the Community Meetings etc.
• Develops a self-directed behavior plan to change or resolve a personal problem.
• Knows the names of all medications and the times they are to be taken.

Level IV: Takes an active role in assisting other clients to gain level changes.

One approach to differing levels is to divide the clients into small groups according to their developmental needs. More regressed clients focus on physical and safety needs, and more advanced individuals concentrate on social, esteem and self- actualizing needs. The building spaces should support this.

Updated topic

"Good architecture can make a difference ... when the style and content of an institution are mutually supporting, they can produce the Architectural Placebo."

This quote is from Charles Jencks in reference to the Maggie Cancer Centers - the cancer care centres in Britain initiated by his late wife, Maggie. Jencks and others, such as the Dutch academic Cor Wagenaar, believe that modernism has created a rupture in the long relationship between architecture and health. Ancient Greek temple complexes were about healing the spirit as well as the body. During the Enlightenment, it was proposed that well designed buildings could do more for public health than the medical profession. While looking at a nicely detailed stair may not cure us, we do need our healthcare buildings to allow us to feel like people rather than just patients.

The most basic definition of a placebo is something that cures only because of a person’s belief in it.  You could say it’s a fake but I prefer to think of it as something that unlocks your body’s unique and fantastic ability to cure itself. You have to believe in a placebo or it won't work. It works in an indirect, indeterminable way, maybe through our immune system and/or our willpower. Extrapolating this to the effects architecture could have, you could imagine many ways in which it could actually be the placebo by providing a place to relax, belong, live and dwell. All impossible to explicitly measure in discrete terms but perhaps definable in terms of relationships and patterns.

There is nothing mysterious in the success of the Maggie Center designs. They all share the similar  positive qualities of  light, space, openness, intimacy, views, connectedness to nature. They  have a domestic scale, centred around the kitchen, a place where you can make yourself a cup of tea and chat - almost the opposite of many standard hospital environments. In Jencks's words,

“...they are buildings that hug you, but don't pat you on the head.”

It's  about providing relief, psychological and emotional support – things that contribute to the urge to go on living and being part of a community. There are no sets of instructions for architects as to how to achieve these goals but perhaps this thesis will provide clues in the form of a set of patterns  which may, along with other therapeutic measures, support and help restore psychological wellbeing.

The Thesis:  Science + Magic = Architectural Placebo

 Any ‘architectural placebo’ design for restoring sanity will inevitably involve science plus a little magic. The science will be represented by a healthy dose of evidence-based design while the ‘magic’ refers to the haptic, philosophical, and spiritual qualities of architecture that often cannot be defined by words but rather by experiencing it.

Patterns of evidence-based design applied in combination with the more intuitive 'magic' of sensory and phenomenological design to create places which restore psychological wellbeing.

Science + magic = the architectural placebo.

The goal of this thesis is to define these patterns as qualities and relationships that can potentially be applied to any building to enable an 'architectural placebo for mental health', using an old abandoned psychiatric hospital as a case study.

The Site

The Kingseat administration building will be the test site for this thesis. Kingseat hospital is a site of celebrity, infamous for bad memories of psychiatric care. To overcome the stigma of the ghosts of mistreatment will be no mean feat so these patterns will be robust if they prove to work here.

The building will be restored to a use similar to that for which it was first designed; its genetic code will be restored and repaired..

The Programme

The users of this space will primarily be the 'lost' population of patients with mental illness - those for whom there is no architecture, only the streets or a revolving door at the acute wards of psychiatric hospitals. The new insertion will treat these occupants like fragile humans rather than dangerous animals, people rather than patients, family rather than boarders. An architecture of normality and domesticity, but also an architecture of restoration and safety. A place to dwell.

It will not be a hospital, but will provide therapy. It will not be a chapel, but will provide space to contemplate life. It will not be a dormitory, but will provide a place to live with others.

In order for the architecture to function fully as a placebo, it will also support and care for those providing support and care: the therapists and caregivers, the support staff and caretakers. The existing fabric of the building will be restored to similar functions of the original but with important improvements to enhance and support the therapeutic aspect of the building. The existing lower levels will be used for administration, support, therapy and communal/occupational therapy activities.

 The Design Concept

The Kingseat administration building will be covered lightly with a new 'blanket' of dwellings. The ‘blanket’ will be clad with zinc or similar, so that on gray days the new structure merges into the sky and is perhaps invisible when first entering the site. Nestling up high in the rooftops, similar to the generations of pigeons nesting in the nearby palms.

The existing building below will be carefully restored to provide a contrast between the existing and the new. An exploration of phenomenology and architecture of the senses, particularly those forgotten by architecture such as smell and touch,  will emphasise the interior experience. Cultural elements will also be significant. In particular,  considerations of different cultural requirements for privacy (visual, acoustic), a sense of place or feeling of comfort in being in a particular environment.

The History

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. Several large psychiatric hospitals were built in New Zealand during this time. All were imposing, prominent buildings with precedents from Britain. Most were self sufficient with productive gardens and farmed land out in the countryside, isolated from the cities.  They had benign names like Cherry Farm, Seaview and Sunnyside. They housed thousands of long term residents and were a culture unto themselves.

During the 1990s psychiatric hospitals gave way to community-based care for the treatment of mental illness; almost all psychiatric hospitals were closed or run down during this time which caused problems for patients who did not have appropriate community support. These patients either found themselves on the street, in prison or in a cycle of admission and discharge from acute psychiatric wards.

 The stigma of these former asylums have been enhanced by the recounting of experiences as residents by famous patients such as Janet Frame. This shadow of stigma is seen in suggestions that the former hospitals be used as prisons and in the partial redevelopment of Kingseat hospital as a horror theme park ('Spookers').

Critical Question

Using phenomenological and salutogenic design frameworks to define a set of patterns for restoring mental health,  can the stigma of an old ‘insane asylum’ be overcome and/or used to advantage to create an ‘architectural placebo’ for mental healthcare?