Psychological Design

Applying a Salutogenic Model to Architectural Design for Psychiatric Care

Abstract
Purpose – This paper aims to look into the significance of architectural design in psychiatric care facilities. There is a strong correlation between perceptual dysfunction and psychiatric illness, and also between the patient and his environment. As such, even minor design choices can be of great consequence in a psychiatric facility. It is of critical importance, therefore, that a psychiatric milieu is
sympathetic and does not exacerbate the psychosis.

Design/methodology/approach

This paper analyses the architectural elements that may influence mental health, using an architectural extrapolation of Antonovsky’s salutogenic theory, which states that better health results from a state of mind which has a fortified sense of coherence.) According to the theory, a sense of coherence is fostered by a patient’s ability to comprehend the environment (comprehensibility), to be effective in his actions (manageability) and to find meaning (meaningfulness).
Findings – Salutogenic theory can be extrapolated in an architectural context to inform design choices when designing for a stress sensitive client base.
Research limitations/implications – In the paper an architectural extrapolation of salutogenic theory is presented as a practical method for making design decisions (in praxis) when evidence is not available. As demonstrated, the results appear to reflect what evidence is available, but real evidence is always desirable over rationalist speculation. The method suggested here cannot prove the efficacy or appropriateness of design decisions and is not intended to do so.
Practical implications – The design of mental health facilities has long been dominated by unsubstantiated policy and normative opinions that do not always serve the client population. This method establishes a practical theoretical model for generating architectural design guidelines for mental health facilities.
Originality/value – The paper will prove to be helpful in several ways. First, salutogenic theory is a useful framework for improving health outcomes, but in the past the theory has never been applied in a methodological way. Second, there have been few insights into how the architecture itself can improve the functionality of a mental health facility other than improve the secondary functions of
hospital services.
There is growing evidence that the design of a healthcare facility will directly affect the health outcomes of patients (Ulrich, 2006). But designing a healthy psychiatric unit is a difficult task as the patients are prone to distorted perceptual systems that make them especially vulnerable to confusing building forms and layouts, or even to a lack of tactile, acoustic, temporal, olfactory or visual stimulus (Hall, 1975). This article analyses various aspects of design, ranging from apparently minor interior choices such as texture, decoration and finishes through to the enveloping architectural form. By doing this we should be able to see how design decisions may affect patients’ health outcomes. To establish these links, the analysis looks at the transactional nature of perception and applies a salutogenic framework to assess design choices (largely recommendations drawn from literature) for psychiatric health facilities. It is hoped that this methodology will be useful for making informed decisions in circumstances where there is no empirical evidence available and when architectural decisions have to be made regardless. There is a reasonable body of literature about the design of hospitals and related buildings, and even about mental healthcare facilities, but the material is severely limited when compared to the complexity of problems that an architectural team faces. Without specific studies into the specific questions that an architect has to face
hundreds of times a day, how are architects and other team members to know that the choices he or she has made are the best for the subject group? There are no studies on the psychological benefits for basic design elements that are mandatory in mental health facilities. And it is the moral obligation of all facility planners’ to question any details that may not be in the best interests of the facilities raison d’eˆtre, which is to assist patients in recovery. How do architects know how a space with cushioned vinyl
walls and floors will affect the wellbeing of patients inhabiting that space? As it happens, the architect is often given little choice about the layout and finishes of standard rooms within a programme as standards and codes have already pre-empted any decision making (Figure 1). “The Australian Health Facility Guidelines” (CHAA, 2007) for example, specifies the layout and finishes of most of the spaces within a mental healthcare unit. Facility planning teams will also have to resolve occasional contradictory findings or opinions – many of these will not be impartial. One study that observes the benefits of opening up nurses’ stations and other spaces in mental wards (Whitehead and Polsky, 1984), is contradicted by another article calling for the same wards to be “locked down” and made more secure (Sine, 2008)[1]. It is important that the lead architect is proactive and has perspective; architects have to pose a question to others on the design team; “Who are we designing for, why, and how will this decision help to do that job well?”[2]. A strong guiding theoretical hypothesis, makes rational decision-making easier where there are no relevant empirical studies to provide support. For this reason salutogenics – a theory gaining interest in recent literature reviews for linking the environment to health outcomes (Schweitzer et al., 2004; Dilani, 2008) may prove to be useful for formulating robust principles for the design of psychiatric units. 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 (Figure 2). Where treatment may be required when one is ill, a supportive environment is always required to assist and maintain good health. The primary premise of salutogenic theory is that a “sense of coherence” (SOC) is strongly linked to better resistance to illness. A strong SOC is supported by feelings of comprehensibility, manageability and meaningfulness. Ultimately, a SOC builds a dynamic feeling of confidence that one’s internal and external environments are predictable and that there is a high probability that things will work out as well as can reasonably be expected. (Antonovsky, 1987; Bahrs et al., 2003) The idea that the environment has a direct effect on health through psychology is both intuitive and well supported in research. As Ulrich (1997) writes “the concept of stress provides a credible departure point for understanding why design should affect health outcomes …”. Ulrich and others have created a model associating psychological stress to poor health outcomes; the maxim is that anything likely to increase stress levels is to be avoided in health design. The stress model is simple and in most instances it is appropriate for healthcare design and especially for mental health. But the stress model is not comprehensive nor specific, and it does come under criticism by Antonovsky who points out that there are times when stress can have a salutogenic effect; that is when a person is subjected to stressors whilst receiving high levels of environmental support the result can be fortifying. Furthermore in the salutogenic model, stress is understood to be omnipresent and not just a feature or an absence of the environment (Antonovsky, 1987). Lawton and Nahemow (1973) support this viewpoint by observing that an environment that lacks challenges leads to atrophy, but then too much challenge can be damaging. They add that patients have a reduced capacity to adapt when they are ill or infirm. Aside from this caveat, the salutogenic model seems an appropriate broad framework in which to locate the stress model because it supports the stress model with much needed substance; effectively filling the causation gap between action and effect. Understanding the environment from a salutogenic perspective From the perspective of architectural design, the salutogenic framework is compelling, as it understands the environment as a source of meaning, as a sphere of influence[3] and for its readability[4]. From the point-of-view of mental health design, the salutogenic framework provides a direct link between architectural language and psychiatry. What is interesting about salutogenics from the psychiatric point-of-view is that in this model the relationship between a patient and the environment is understood as being transactional, not fixed (Figure 3); the environment effectively changes according to the subject’s sensory and perceptual abilities and conditioning (Hall, 1990). Perception is a complex neuro-chemical process that is highly reactive to the surrounding environment and yet it is the only channel for receiving new information of any sort[5]. It has been postulated that a great deal of mental health problems occur because of imbalances and distortions in the perceptual system, causing hallucinations, instability, unpredictability and delusions. Thus, the act of perception itself can trigger psychotic events (Osmond, 1957; Weckowicz, 1957; Osmond, 1958; Searles, 1960; Osmond, 1965; Osmond, 1966; Hall, 1975, 1990).

Comprehensibility: Reading the Environment
The importance of making sense of experience cannot be underestimated (Searles, 1960; Woodbury and Woodbury, 1969), and in the case of psychiatric patients, this may mean making sense of a living nightmare (Woodbury and Woodbury, 1969; Chadwick, 1993). It is therefore important that all decision makers in design teams for psychiatric wards understand that hallucinatory experience is very real to those who suffer from it and that the environment we create may either intensify or elevate such experiences. Hallucinations are stressful and often spiral into a vicious cycle of disorienting experience, which in turn is stressful (Searles, 1960). There may be cases when there is a well informed psychologist within the team who will take responsibility for relevant design decisions, but it cannot be assumed that those on the client side will always understand the sensitivity of this issue or the complexity of behavioural psychology (Philip, 1996). If we accept that perception (whether visual, acoustic, haptic, temporal or olfactory) is synthetic, (and we are assured it is by James Gibson and other researchers into the ecological theory of perception, (Hall, 1990)) then the relationship between comprehensibility and the environment that we draw experience from is personal. Not all people will gather the same information from the same experience (Hall, 1990). However, in normal circumstances, the “gap” between a subjective experience and the reality of the objective world is acceptable and is resolved without consideration. But with schizophrenics the disjuncture between the experiential reality and objective reality is confusing for the patient (Weckowicz, 1957; Searles, 1965). For this reason it is important that the environment is designed to reduce the possibility of perceptual distortion. Size perspective, for example, is a “natural” effect whereby the apparent size of an object reduces as it retreats into the distance. The severity of a schizophrenic episode is illustrated by just how much the patient thinks an object has shrunk rather than moved backwards in space (Weckowicz, 1957). The distortion caused by size perspective can be limited by keeping spaces small and to comfortable proportions (Osmond, 1957). There are a number of other perceptual functions that are also subject to distortion, misreading or loss. These functions include very basic skills such as the understanding of distance, relative dimensions, mass, spatial orientation, the passage of time etc. (Weckowicz, 1957). Cognitive scientists have counted at least thirteen distinct ways that people comprehend the relative depth of space visually and several other ways when we include the various tactile, thermal and acoustic perceptual systems. Whilst I shall not discuss them in any depth here[6] some provision can be embedded into the environment to assist patients in these tasks. Hall notes that where one sensory ability might fail, there are others that will provide support (Hall, 1990). Textured surfaces assist with textural perspective[7]. Horizontal courses in masonry or timber assist linear perspective[8]. Various objects (outside; the presence of trees, landscape features; and inside; pieces of
furniture, paintings, rugs, light fittings etc) assist with size perspective[9], the various perspectives of parallax[10] and other perspectives[11]. As all these perspectives support the same cognitive function, that is the measuring and comprehension of space, the more provisions for these functions the better for reducing the likelihood of misreading and hallucination (Osmond, 1957, 1958; Searles, 1960; Osmond, 1966; Hall, 1990). Comprehensibility is not only a matter of spatial cognition, however. Understanding what objects are and what they are for is also of great importance. But the purpose of a place or an object is not directly cognised. Object comprehension is manufactured through the filters of memory, culture and a pre-existing epistemology (Searles, 1965; Hall, 1990). Thus, we understand the environment through association with familiar concepts, languages, objects, forms, materials, textures, emotions and expectations. For this reason it is important, as far as possible, to provide a familiar environment for psychotic patients to increase the likelihood of comprehension and to reinforce messages that aren’t likely to increase stress levels or paranoid delusions. For this reason Osmond, Elliot and Bayes Friba recommend that the typology of a psychiatric facility is not institutional; instead it should present as something both ubiquitous and desirable; a cosy and safe home (Osmond, 1957; Elliot and Bayes Friba, 1972).
Searles points out that all mental illnesses affect perceptual cognition although schizophrenia does so most dramatically (Searles, 1960). It is therefore imperative that the design team considers visual, acoustic, haptic, temporal and olfactory sensibilities in their designs, not just to avoid excessive sensory pollution (such as street sounds and kitchen smells) but to avoid distortion generally. Echoes have been found to be disturbing to patients who hear voices anyway (Osmond, 1957). Excessive or repetitive noise can also be disturbing, especially for patients with neurotic complications (Osmond, 1957). A sense of real time to treat temporal distortion can be promoted by including elements that track time such as clocks, calendars, up-to-date magazines and judicious use of TV (Osmond, 1957). Beyond perceptual distortion, facility designers need to be aware of environmental symbolism that might be amplified, de-contextualised or misunderstood by sufferers of a broad range of mental illnesses (Halpern, 1995). Though there have not been a great
deal of studies into this effect in mental institutions[12], problems have been found in how patients interpret the symbolism inherent in nurses’ uniforms, which have on occasion been found to bring back wartime memories and other paranoid delusions (Richardson, 1999). When designing a mental facility, aesthetic choices and forms need to be carefully critiqued. Is the design reminiscent of schools, prisons, courts, orphanages, religious institutions or hospitals? In order to maximise comprehensibility, ambiguity should be avoided (Osmond, 1957; Figure 4). Objects should look, sound and feel like whatever they are (except, of course for institutions, which should have charm and personality and should be the functional equivalent of a “home” (Osmond, 1957)). Thus a door should be “door-like” and should have a comfortable thud when closed (Osmond, 1958). Needless to say, there are a range of other details that have not been tested and therefore where an understanding of salutogenics becomes useful in lieu of proper evidence. Questions about whether walls have to be solid and run perpendicular to the ground or whether they should have coved skirtings can be tested against salutogenic criteria; in this case, against likely impacts on comprehensibility. If details may pose a challenge to patients’ perceptual abilities then the team might consider other available options. The choice of sliding glazed doors for example.Because sliders arewalls, doorsandwindowsall atthesametimethis could pose a problem to patients with categorisation impairments (a symptom[13] of schizophrenia (American Psychiatric Association, 1994)) Other things that could come under scrutiny for comprehensibility might be the material palette. Can the team avoid the use of ambiguous materials? Could materials appearing to be something other than what they aresuch asveneerorprintedtimberpatternsbeconfusing tosomepatients? Perhaps there are other advantages still for choosing real exposed timber, stone, natural carpet and quality pressed brick; being ubiquitous the world over, they will resonate with a wider range of cultural backgrounds. Natural materials are also replete with textures to assist with difficulties in perceptual cognition. A design team that adopts salutogenics as a guiding theory might find the framework at odds with architectural fashion. In the interests of promoting comprehensibility, some architectural mannerisms might not be appropriate. Post modern double readings, fac ̧adism, deconstructionism and tectonic expressionism are all deliberately confusing, but do not need to be abandoned altogether. These are decisions the team will have to make. Dr Sivadon found that the practice of gradually exposing schizophrenic patients to more and more complex social environments was an effective treatment (Baker and Llewelyn, 1959; Osmond, 1958). The medical specialists on the team may propose that something similar is done with the built environment. Other fashions are much clearer in terms of intentions and can also be considered with care (Figure 5); Modernist chic tends to plainness and mechanical functionality, both of which have been identified as undesirable for schizophrenic patient populations (Osmond, 1957). Woodard Smith recognises this and points out that advances in engineering have enabled plasticity of form, giving bad designers scope to extend worst practice past the restrictions of traditional construction techniques. When it comes to form, mental institutions benefit from the strong structural grid and small spaces associated with traditional building methods (Woodard Smith, 1959). Manageability; the importance of being able to make a difference Architectural form itself can amplify or deny power. If one questions the validity of this major psychological effect, then consider the effect of Albert Speer’s Reich Chancellery, related in The Edifice Complex (Sudjic, 2006). Sudjic tells how it was the
disempowering “architectural stage set” of Nazi architecture in 1939 that caused Emil Hacha, Czechoslovakia’s president, to hand over his state to Germany without even engaging the “well equipped Czech army with modern artillery, technologically advanced aircraft and Skoda tanks” that were waiting to defend Czechoslovakia’s border. From the broad architectural grammars of form and space through to minute details of door handles, architecture can work with us or against us. The second of the principles of salutogenics is manageability. The feeling that a person is in control of his or her environment and life circumstances is very fortifying. And, as illustrated by Sudjic, the feeling that you are totally out of control is absolutely disempowering. All patients are subject to loss of control in the hospital system, with those who forfeit control being seen by staff as “good patients” and those who struggle to maintain control as being “bad” (Sloan Devlin and Arneill, 2003). This is even more true for psychiatric patients than any other group; as patients are overtaken by mental illness, control (manageability) is one thing that is lost entirely, not just because of pressure from the hospital staff or the disempowering nature of the hospital environment, but also because they lose trust in their own perceptions, memories, their
own selves. With this loss goes all social support; patients frequently lose their old lives, their jobs, their sense of self and their perceptual abilities (Searles, 1960). For this reason it is imperative that the shreds of control that patients still have left are supported and not withheld (Osmond, 1958). There are a host of things facility planners and architects can do to nurture a patient’s sense of control and ability to be effective (Figure 6). Right up on top of the list is keeping unit numbers small and making arrangements so that numbers are never bigger than those of the archetypal human community; the nuclear family. More than five or six patients should not have to come into contact if they do not wish it (Osmond, 1966), The tendency of institutions to put people together in large dayrooms, dining rooms, living rooms and other spaces is well known for exacerbating psychotic symptoms, because the number of human interactions compounds with every extra person present. And at a time when the capacity to relate to one another is hampered anyway, this equates to a direct loss of control (Osmond, 1958). Consider that control in a social setting relies on an awareness of your “place”. In which case, two people will have one relationship. In other words, they only have to maintain an awareness of each other. Three people will have three dynamics. They maintain awareness of each other and of a single new dynamic, which is the relationship between the other two. Four people already have six dynamics of which to maintain an awareness, and seven people have 20. By the time there are 50 people, a setting plays host to 1,225 relationships (Osmond, 1966). Any resulting confusion is further complicated by the delusions of the patients, which will make even a simple set of relations potentially deleterious[14]. The problem of overcrowding leads to one of the classic issues that define mental health problems in the public imagination: the “madman in the cupboard” E.T. Hall (1975) relates this anecdote of Dr Woodbury: […] In one of the violent “backwards, where most of the communication was spatial… the “currency” of the ward was space. Woodbury observed that the organization of the ward was territorial rather than social. In terms of hierarchy of freedom of movement, the dominant patient could go anywhere. Below this patient were two patients, each of whom could move freely in his own half of the ward. Each of these dominated the territory of other patients who were restricted to increasingly smaller areas. At the bottom of the hierarchy was a patient who slept under a bench and was not permitted even to use the spit hole in the centre of the floor. His so-called “incontinence” was a function of the fact that the toilet was not in his territory and therefore he was not permitted to use it (Woodbury, 1958). As control of the environment is lost, psychiatric patients frequently need to be retaught everything; how to wash, how to cook, clean, or use a toilet (Osmond,1957). For this reason provisions for these basic tasks should be very simple. It should be very easy to maintain personal hygiene and for a patient to clean up if mistakes are made (Osmond, 1957). The relearning of these ordinary tasks is now generally considered as part of the therapeutic process and is both empowering and essential for life outside of an institution. For this reason one of the beneficial innovations over the last half-century in psychiatric
architecture is the reintroduction of ordinary facilities that are essential in the outside world, such as kitchens, laundries, baths, telephones[15] etc. ADL (Activities of Daily Living) facilities (as they are called,) are now a part of the normal programme for a new institution and there are recommended guidelines for their design (Osmond, 1957). Unfortunately, the ADL facilities are usually in locked rooms and don’t actually serve real-life functions; that is, they are only for structured lessons or diagnosis. Planning teams should consider placing the ADL kitchens centrally and having them open (even if the ovens etc. have to be locked to prevent accidents,) to replicate a domestic environment as recommended by Elliot and Bayes Friba (1972). In the same spirit there are many other tools that are present outside of institutions that people should be able to exercise their control over, lest patients’ abilities atrophy. Opening windows and adjustable heating and cooling are very obvious examples. Such features will assist in maintaining
successful control of the environment and will have the additional benefit of deinstitutionalizing the milieu (Osmond, 1957). It has been observed that sports such as table tennis have a salutogenic effect for mental patients, (not just for the players, but for the greater patient populations) as the events assist in structuring and re-engaging human relationships, developing coordination and perceptual abilities and tackling apathy and boredom, both of which lead to skills atrophy. There are other ways to humanise mental hospitals and make them more manageable and comprehensible. Unhomely corridors and unnecessarily enlarged spaces should be avoided as they exacerbate the worst aspects of schizophrenia (Osmond, 1957). Physical retreats must be provided (Osmond, 1957, 1958, 1966; Elliot
and Bayes Friba, 1972); Furniture should be movable, but solid enough to feel secure (Osmond, 1957). Of course there are any number of other details that will also be useful but are more simply recognised with a basic understanding of salutogenic principles rather than being listed here.
Meaning; A reason for Seeing
Meaning, it seems, is essential to the maintenance of life (Frankl, 1963; Antonovsky, 1987). and is therefore the most significant ingredient of a sense of coherence. And while meaning is found in the environment, it is illusive and difficult to provide for, as questions of meaning steer pretty quickly to philosophical and cultural/social debate rather than to the simple cause and effects so desirable in the physical sciences. Of all the sources of environmental meaning, there is little doubt that it is primarily found in the social environment – in love and communication, in family, friendship and in sexual relations. But the one thing that is common to all mental patients with no exceptions – is that they have experienced a rupture in interpersonal relationships resulting in alienation from the greater community and they are to a greater or lesser extent socially isolated (Osmond, 1957). Even so, good facilities for receiving social support must be considered to enable recovery The current practice of affording space meet up with family and old friends (CHAA, 2007) is very important and, in the interests of fostering meaning, might even be extended with the provision of extra
facilities for friends and family to stay over. (Osmond, 1966; Woodbury and Woodbury, 1969; Whitehead et al., 1976; Whitehead et al., 1984; Gutkowski et al., 1992) A salutogenic perspective means that affordances for pets may be considered. They have been shown to radically improve mental well-being (Searles, 1960, 1965, 1986; Wells, 2007) and while affordances for cats and dogs may be too difficult, too dangerous and raise any number of health issues including the possibility of allergies, it must be remembered that relationships with pets are often of more significance to the mentally ill than relationships with other humans and are often important stepping stones for re-establishing human relationships and other milestones for recovery such as the development of self awareness and moral conscience (Searles, 1960). When interpersonal relationships have broken down the material environment can be of life saving significance (Searles, 1960). Mental patients regularly place huge importance and feel very emotional about things and places, with schizophrenics frequently confusing their environments and themselves. Searles relates dozens of anecdotes about how the material environment waxes in importance as social relationships collapse. One patient spoke poignantly during therapy about having lost herself. During the session it emerged that the “self” she was referring to was the home she used to live in. Her identity was inextricably linked her childhood home and all it meant to her and it was when she left the house she started experiencing mental problems. Another case Searles reported was of critical melancholia; a man who preferred to spend his life in bed, not doing anything lest he should see someone caring for a garden. He was overwhelmed with grief about the loss of his closest companion; his own garden. The same man refused to leave therapy sessions. It turned out that Searles’ telephone reminded him of one that he had owned.
Whilst these fixations might sound trivial to people who do not suffer from psychosis, it must be remembered that schizophrenic patients do not speak figuratively. These experiences are very real, not poetic interpretations and they are symptomatic of a very
deep and painful ontological crisis (Searles, 1960, 1965). A designer must be aware of how meaning and its inverse (meaninglessness) may be structured into the environment. The negative effects an ugly and dehumanising space can have on such a patient cannot be underestimated (Osmond, 1966). And neither can the reassurance that comes with a space that is highly refined and aesthetically considered. As De Botton (a popular philosopher) suggests, architecture really only comes into its own when we have to plumb life’s deepest questions; when we have to deal with pain, grief and confusion, and it is at these times that no pill can help (De Botton, 2006).
Ulrich has made some very important associations between accessibility of the natural environment and better health outcomes. Whilst it has not been explicitly noted in his papers, it is likely that the health benefits derived from access to a natural landscape
occurs because meaning is so easily found in nature (Ulrich and Parsons, 1990). It seems that meaning is fostered through environmental richness; through complexity, order and aesthetic considerations (Bachelard, 1958, 1964 (Tr.)). The more
afflicted the patient, the more significant it is that the spaces they use are truly beautiful (Osmond, 1958). Obviously, such a term raises all kinds of prickly issues, (like who is to be the final arbiter of taste) but the point (raised by Osmond) is not so much about the aesthetic of the final solution, but that the “usual’ drabness of hospital architecture is avoided. The detailing of mental facilities should be more considered (aesthetically) than a “nice” home because it is only when patients’ expectations are exceeded that they will feel a sense of ease (Edvardson et al., 2005). Currently, there is a long way to go; the surroundings in mental health wards hark back to their genealogy; as lockups, dungeons, and more recently as asylums (Osmond, 1966; Sine, 2008). These associations must be rejected entirely as there should be no sense of “punishment” embodied in health architecture. Bare, drab spaces directly affect perception(even of healthy individuals,) in a very dramatic way (Figure 7). A reduced environment causes hallucinations, delusions, confusion, the impairment of organised thinking, oppression and depression, even for healthy people (Hebb et al., 1954; Solomon et al., 1957; Searles, 1965; Osmond, 1966) and the inverse; a multi-sensory environment that is rich in complexity, has been linked to improvements in emotional, cognitive and immune system functions (Woodard Smith, 1959; Schweitzer et al., 2004). To this end, Osmond suggests that spaces for psychiatric care should be exceptionally generous in the way they are decorated and finished (Osmond, 1957; Osmond, 1958; Huntoon, 1959), even going so far as recommending fresh cut flowers in the private spaces. Any fears about patients’ scatological and
auto-erotic behaviour (presumably the reason for vinyl surfaces in the first instance,) can be largely allayed. According to Osmond, a patient is only likely to resort to “apsophilic activities, touching the staff and painting the walls with faeces” when left with no other more acceptable sensory gratification (Osmond, 1958). Although nostalgia can be a symptom of schizophrenia, Searles (1960) describes how it can also be a very important transitional fixation in the process of re-engagement with the outside world. It is very important that patients are not separated from their pre-existing lives, as this completes a disjuncture that is already a serious problem for mental health. Patients should be able to bring in photos and to stick them on their walls (Searles, 1960; Osmond, 1966). Ideally, they will have some kind of music system in their rooms also, so they can listen to their favourite tunes (Osmond, 1958). Of course these things can give rise to melancholy, but they can also be restorative as they remind a patient that there is meaning in life; be it love, desire, friendship or something else more pertinent (Searles, 1960).
Conclusion
Under normal circumstances people have a great deal of ability to adapt to new surroundings – even in stressful situations – and such changes can actually support the overall robustness of wellbeing. However, when environmental factors start to erode a general sense of coherence – when meaning, control and comprehensibility are lost – resistance to disease weakens and perceptual difficulties are exacerbated, often creating a vicious circle of increased vulnerability and anxiety. It is imperative, therefore, that health facility planning teams carefully scrutinise plans for anything that may not be in the patient’s interests. A basic understanding of what makes an environment supportive in order to assist and maintain good health will provide a useful framework for this critique. To this end, Salutogenic theory is a particularly useful tool as it is specific[16] and easily applied to an architectural application. Essentially the theory proposes that a “sense of coherence” (SOC) is an integral part of the natural healing process and that a strong SOC is supported by feelings of comprehensibility, manageability and meaningfulness, all of which have architectural ramifications. Of course the use of a salutogenic framework does not mean that no further research is required and nor does it insure that all the choices the design team makes will be the very best decisions in the given circumstances, but in providing a basis for making purposeful decisions about any aspect of the design on the fly, it means that the architectural teams are empowered to design the very best facilities they can, given restricted time and budgets and a the general paucity of useful empirical evidence. There are many things that can be done with the architecture of a facility that may alleviate mental symptoms, lessen the likelihood of future psychotic episodes, alleviate stress and assist with basic cognitive functions. These innovations can be broken into three categories in an architectural extrapolation of salutogenic theory; designing to foster a sense of coherence through:
(1) Comprehensibility: making sure that perceptual cues are present to assist perceptual processes. These include attention to texture and materiality, controlling the size of spaces and the numbers of patients and expressing environmental features in a normal way.
(2) Manageability: that is allowances for patients to exercise control of the environment, details such as opening windows and the provision of ADL and sporting facilities.
(3) Meaningfulness: enriching the environment with complexity, order and aesthetic considerations as well as providing good spaces for visitors special personal belongings and possibly even for pets. All of these approaches come together to create an architecture that really serves the needs of mental health patients, fortifying their overall sense of coherence and mental wellbeing and improving recovery.

Notes
1. Mr David Sine, the author, is president of Safety Logic Systems, a company that may well have vested interests in locking patients down.
2. Of course the diverse needs of clinical and non-clinical staff, of facility directors, local governments and other involved people are also very important, but great care must be taken that their needs do not come before those of the patients Osmond (1957). These negotiations won’t be easy, as empowering the patients will to some degree mean wrestling control from staff some of who may well be part of the planning team Gutowski et al. (1992).
3. Being able to influence the surrounding environment is the basis of manageability.
4. Readability is an architectural simile for comprehensibility.
5. It is conceivable that old information (memory) is stored and retrieved through non-perceptual means, but this is not the area of this study.
6. A handy summary is found in the appendix of Hall (1990) and in more depth in James Gibson’s original texts.
7. The density of texture appearing to increase as space recedes.
8. Parallel lines appear to converge to a vanishing point.
9. Relative size apparently decreasing with distance.
10. The angular difference as seen from one eye and the other; (binocular vision) and motion parallax where distant objects appear to move slowly, but objects up close move quickly relative to the viewer.
11. Including blur perspective, aerial perspective, relative upward location in the visual field, textural shifts when one object is placed before another, completeness of outline and changes in light and shade.
12. Halpern’s observations were in the wider community.
13. Technically a symptom is positive and refers to an unusual phenomenon. Categorisation impairment is the opposite; a sign. As it is negative – an absence of normal ability.
14. It is normal for schizophrenic patients to attribute non-human qualities to themselves or to other patients, objects or even to perceive themselves as being several disconnected entities. Searles (1965)
15. ADL (Activities of Daily Living) services are usually used as teaching and diagnostic facilities with the supervision of staff
16. A hypothesis about the specific effects of each decision can be established with relative ease.
References
American Psychiatric Association (1994), Diagnostic and Statistical Manual of Mental Disorders,
American Psychiatric Association, Washington, DC.
Antonovsky, A. (1987), Unravelling the Mystery of Health, Jossey-Bass, San Francisco, CA.
Bachelard, G. and Orion Press (1964), The Poetics of Space: The Classic Look at How We
Experience Intimate Places, Beacon Press, Boston, MA (originally published in 1958).
Bahrs, O., Heim, S., Kalitzkus, V., Matthiessen, P., Meister, P. and Mu ̈ller, H. (2003), “Salutogenesis in general practice. How to use the potential of doctor-patient-communication to promote health”, Proceedings of the 2nd Conference on Making Sense of Health, Illness and Disease, St Hilda’s College, Oxford.

Baker, A., Llewelyn, A., Davies, R. and Sivadon, P. (1959), Psychiatric Services and Architecture, WHO, Geneva. CHAA (2007), Australian Health Facilities Guidelines. Health Facility Briefing and Planning,
Centre for Health Assets Australasia (CHAA), North Ryde.
Chadwick, P. (1993), “The stepladder to the impossible: a first-hand phenomenological account of a schizoaffective psychotic crisis”, Journal of Mental Health, Vol. 2 No. 3, pp. 239-50.
De Botton, A. (2006), The Architecture of Happiness, Hamish Hamilton (the Penguin Group), London.
Dilani, A.P.D. (2008), “Psychosocially supportive design: a salutogenic approach to the design of the physical environment”, Design and Health Scientific Review, Vol. 1 No. 2, pp. 47-55.
Edvardsson, J.D., Sandman, P.O. and Rasmussen, B.H. (2005), “Sensing an atmosphere of ease; a tentative theory of supportive care settings. Nordic College of Nursing Sciences”, Scandinavian Journal of Caring Sciences, Vol. 19, pp. 344-53.
Elliot, J. (1972), Room for Improvement: A Better Environment for the Mentally Handicapped, King Edward’s Hospital Fund for London, London.
Frankl, V.E. (1963), Man’s Search for Meaning: An Introduction to Logotherapy, Pocket Books, New York, NY.
Gutkowski, S., Ginath, Y. and Guttman, F. (1992), “Improving psychiatric environments through minimal architectural change”, Hospital and Community Psychiatry, Vol. 43 No. 9.
Hall, E.T. (1975), “Mental health research and out of awareness cultural systems”, in Maretzki, T.W. and Nader, L. (Eds), Cultural Illness and Health, American Anthropological Association,
Washington, DC, pp. 97-103.
Hall, E.T. (1990), The Hidden Dimension, Anchor Books, New York, NY.
Halpern, D. (1995), Mental Health and the Built Environment: More than Bricks and Mortar, Taylor & Francis, London.
Hebb, D., Heath, E.S. and Stewart, E.A. (1954), “Experimental deafness”, Canadian Journal of Psychology, Vol. 8.
Huntoon, M. (1959), “Art for therapy’s sake”, Journal of Mental Science, Vol. 10 No. 1, p. 20.
Lawton, M.P. and Nahemow, L. (1973), “Ecology and the aging process”, in Eisdorfer, C. and Lawton, M.P. (Eds), Social Environment of Aging, American Psychological Association, Washington, DC, pp. 619-73.

Osmond, D.H. (1957), “Function as the basis of psychiatric ward design”, Mental Hospitals, Vol. 8, pp. 23-7.
Osmond, D.H. (1958), “The seclusion room-cell or sanctuary?”, Mental Hospitals, Vol. 9, pp. 18-19.
Osmond, D.H. (1965), “The psychological dimension of architectural space”, Progressive Architecture, Vol. 46 No. 4, pp. 159-68.
Osmond, D.H. (1966), Some Psychiatric Aspects of Design. Who Designs America?, Anchor Books, New York, NY.
Philip, D. (1996), “Essay: the practical failure of architectural psychology”, Journal of Environmental Psychology, Vol. 16 No. 3, pp. 277-84.
Richardson, M. (1999), “The symbolism of the nurse’s uniform”, British Journal of Nursing, Vol. 8 No. 3, pp. 169-75.
Schweitzer, M. (2004), “Healing spaces: elements of environmental design that make an impact on health. Toward optimal healing environments in health care”, Journal of Alternative & Complementary Medicine, Vol. 10, pp. S-71-S-83.

Searles, D.H.F. (1960), The Non-human Environment, International Universities Press, New York, NY.
Searles, D.H.F. (1965), Collected Papers on Schizophrenia and Related Subjects, Maresfield Library, London.
Searles, D.H.F. (1986), My Work with Borderline Patients, Aronson, Northvale, NJ.
Sine, D.M. (2008), “The architecture of madness and the good paternalism”, Psychiatric Services, Vol. 59 No. 9, pp. 1160-2.
Sloan Devlin, A. and Arneill, A.B. (2003), “Healthcare environments and patient outcomes: a review of the literature”, Environment and Behavior, Vol. 35 No. 5, p. 665.
Solomon, P. and Leiderman, P.H. (1957), “Sensory deprivation”, American Journal of Psychiatry, Vol. 114 No. 4, pp. 357-63.
Sudjic, D. (2006), The Edifice Complex: How the Rich and Powerful and Their Architects Shape the World, Penguin, New York, NY.
Ulrich, R.S. (1997), “Pre-symposium workshop: a theory of supportive design for healthcare
facilities”, Journal of Healthcare Design, Vol. 9, pp. 3-9.
Ulrich, R.S. (2006), “Evidence-based health-care architecture”, The Lancet, Vol. 36, B, pp. 538-9.
Ulrich, R.S. and Parsons, R. (1990), “Influences on passive plants in individual wellbeing and health”, Proceedings of the National Symposium on the Role of Horticulture in Wellbeing and Social Development, Arlington, VA, 19-21 April. Weckowicz, T.E. (1957), “Notes on the perceptual world of schizophrenic patients”, Mental Hospitals (Architectural Supplement), Vol. 8.
Wells, D.L. (2007), “Domestic dogs and human health: an overview”, British Journal of Health Psychology, Vol. 12 No. 1, pp. 145-56.
Whitehead, C. and Ellison, G. (1976), “The aging psychiatric hospital: an approach to humanistic redesign”, Hospital Community Psychiatry, Vol. 27 No. 11, pp. 781-8.

Whitehead, C. and Polsky, R.H. (1984), “Objective and subjective evaluation of psychiatric ward redesign”, American Journal of Psychiatry, Vol. 141 No. 5.
Woodard Smith, C. (1959), “Architectural research and the construction of mental hospitals”,
Mental Hospitals, Vol. 9 No. 6, pp. 39-42.
Woodbury, M. and Woodbury, M. (1969), “Community-centered psychiatric intervention: a pilot project in the 13th Arrondissement, Paris”, American Journal of Psychiatry, Vol. 126 No. 5,pp. 619-25.
Woodbury, M.A. (1958), “Ward dynamics and the formation of a therapeutic group”, mimeo, Chestnut Lodge Symposium, Rockville, MD.
Further reading
Lang, J. (1987), Creating Architectural Theory, Van Nostrand Reinhold, New York, NY.
Corresponding author
Jan A. Golembiewski can be contacted at: greenmanarch@gmail.com

Note- Dr Osmond writes that the seclusion room must not be merely pleasant, but the best room of any ward (Osmond 1958). The rooms he describe have hardly changed since 1958 and are better suited for storing dangerous chemicals than treating distressed and vulnerable patients. This room was designed according to all the recommendations of the 2007 Australasian Health Facilities Guidelines (CHAA, 2007). Spaces not dissimilar from this has been shown in repeated tasks to cause hallucinations even among people with “normal” perpetual abilities. Scatological, violent or apsophilic behaviour in such an environment is a violence against psychosis. Source Author.

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