psychiatric hospital architecture case study

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Vejle Psychiatric Hospital / Arkitema Architects

Curated by María Francisca González
Architects: Arkitema Architects
Area Area of this architecture project Area: 17000 m²
Year Completion year of this architecture project Year: 2017
Photographs Photographs: Niels Nygaard
Manufacturers Brands with products used in this architecture project Manufacturers: Troldtekt , Artigo , Fjelsø , HAI , Protec , Skandi-Bo , Södra
Lead Architect: Wilhelm Berner-Nielsen
Landscape : Arkitema
Contractor : MT Højgaard
Engineer: MT Højgaard and MOE
Client: Region of South Denmark
Artwork: Signe Guttormsen
City: Vejle
Country: Denmark
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Text description provided by the architects. In February 2017 a new psychiatric hospital opened in the Danish city of Vejle . Since the opening, the hospital has registered a 50 percent decrease in physical restraint and it is widely acknowledged for its healing architecture. This was underlined in mid-June when the hospital won the Mental Health Design category at the European Healthcare Design Awards 2018 in competition with mental health buildings from all over the world.

The building is designed by Arkitema Architects as part of a Public-Private Partnership, where the PPP team designs, build and run the building. The idea of the hospital was to create a visionary mental health hospital with 91 beds, children’s ambulatory, psychiatric ER and ECT. The background for the project is a regional focus on outpatient treatment. Thus, the new hospital supports treatment of patients with intensive and complex behavioral conditions which require hospitalization.

In the layout extroverted functions such as ER reception and children’s psychiatry are located as inviting units upon arrival, while wards are withdrawn within the building. The enclosed First-floor links administration and discreet patient transport in a ring structure which expresses a spatial division and forms a clear hierarchical façade.

Green access and plenty of light The hospital is gently placed at the bottom of a forest covered hillside. The plan layout is made up of smaller square masonry building units that twist from another, which makes room for prolonging the surrounding nature into the spaces between the buildings. The building breaks down the scale, merge with the landscape and thereby match the surroundings.

To ensure the full outcome of lights healing effect on psychiatric patients the architects have designed the building with a special focus on both natural and artificial light. Glass panels and interior courtyards bring ample daylight into the building. Withdrawn ceilings and interior glass help light extend even further through the building. Furthermore, 24 hours of colored light therapy is integrated into the wards for calming recovery, sleep support, elimination of depression and preservation of a natural circadian rhythm for staff and patients.

Vejle Psychiatric Hospital is run by the Region of Southern Denmark and built in cooperation with the PPP-company formed by Sampension, Pension DK, MTH and DEAS as investors, owners, builders and maintenance providers, where the region has committed to using the facilities in the following 25 years.

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Project location

Address: nordbanen 5, 7100 vejle, denmark.

Materials and Tags

Sustainability

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Vejle 精神医院治愈效果显著，宁静严谨的空间是心理患者的良药 / Arkitema Architects

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NCBI Bookshelf. A service of the National Library of Medicine, National Institutes of Health.

Kritsotaki D, Long V, Smith M, editors. Preventing Mental Illness: Past, Present and Future [Internet]. Cham (CH): Palgrave Macmillan; 2019. doi: 10.1007/978-3-319-98699-9_10

Preventing Mental Illness: Past, Present and Future [Internet].

Chapter 10 designing for mental health: psychiatry, psychology and the architectural study project.

Edmund Ramsden .

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Published online: October 17, 2018.

In 1953 the American Psychiatric Association established an Architectural Study Project in collaboration with the American Institute of Architects. The project brought together a wide range of experts from psychiatry and the behavioural sciences and the planning and design professions to provide solutions to the ailing mental hospital system in North America. They began to focus attention on various aspects of the hospital environment, such as light, colour and the creation of spaces for privacy and social contact, in ways that would go on to influence theories, methods and designs far beyond the walls of the institution. This paper will explore the contribution of the mental hospital, as both laboratory and field site, to the development of the new field of environmental psychology which attended to the function and design of a range of city spaces to prevent mental illness and promote mental health in a period of urban crisis.

Introduction

In historical reflections on the architecture of the mental hospital, there is a familiar narrative arc. 1 This runs from an optimistic era of moral treatment in the eighteenth and nineteenth centuries which informed the designs of those such as Thomas Kirkbride that the hospital should be light, spacious and connected to nature, to one of intense pessimism in the twentieth, with damning exposés and critical ethnographies of the mental hospital that used personal accounts and participant observation techniques to dramatic and disturbing effect. 2 In Albert Deutsch’s The Shame of the States , the reader is introduced to inhuman practices and conditions, and in Erving Goffman’s Asylums to the idea of the ‘total institution’ in which ‘a large number of like-situated individuals, cut off from the wider society for an appreciable period of time, together lead an enclosed, formally administered rounds of life’. 3 The mental hospital therefore becomes an intensely problematic space due, in part, to its physical features such as its geographical isolation from the world, designs for confinement and surveillance, depressing wards and crowded dormitories. It is also seen as a site of perpetual conflict between disciplines and communities, such as psychiatrists, psychoanalysts and social and behavioural scientists, the latter gaining their institutional strength and legitimacy from the university, rather than the mental hospital which was increasingly questioned as a locus of research and care. 4 Together with the emergence of new drugs and therapies, this criticism contributed to the opening-up of psychiatric services from the 1950s with the emergence of community care legislation, the growth of psychiatric units in general hospitals and the establishment of new buildings such as Community Mental Health Centres to better integrate different therapies and communities, rehabilitate patients and prevent mental illness.

This chapter will take a different tack, and, rather than seeing the mental hospital as cut off, isolated and left behind, will examine it as a physical space that served as a crucial site for cross-disciplinary communication and collaboration in the twentieth century. The architectural historian Daniel Abramson has explored how the ‘obsolescence’ of urban buildings generated innovative solutions through designs that emphasised flexibility, choice and freedom, and so too in the case of the mental hospital where architects and psychiatrists came together to provide creative solutions for a system under severe pressure. 5 We will be focusing on the short history of a collaborative project between the American Psychiatric Association (APA) and the American Institute of Architects (AIA), and the longer term influence of some of the individuals, principles and practices involved. The Architectural Study Project (ASP) began in 1953 and reflected a growing concern with the state of mental hospital facilities. Psychiatrists and architects turned their attention to various aspects of the hospital environment, such as light, colour and the creation of spaces for privacy and social contact, in ways that would go on to influence theories, methods and designs developed and applied far beyond the walls of the institution. This chapter explores the role of the mental hospital as a ‘hybrid’ place and an ‘experiment’ of nature and society that combined elements of laboratory and field. 6 As Robert Kohler argues, the adaptation of laboratory instruments and techniques to the field helped to create a ‘distinctive border culture’ or ‘zone’ which proved a richly fertile ground for modern biology. 7 Critical to its success was the reinvention of the field as a place where experiments were possible. Mary Morgan has focused on the significance of ‘Nature’s or Society’s experiments’ in which events, situations or places provide elements of isolation and control that give them value as ‘rich sites for scientists to research’. 8 Here, we will see how the mental hospital served as such a site for an emerging interdisciplinary field of environmental psychology, allowing for new methods for mapping behaviour and measuring emotional reactions and the development of concepts such as personal space to analyse the relationship between human beings and their physical environments. The work that resulted from the study of the mental hospital would play a critical role in the study, planning and designing of the wider territories of the city to prevent mental illness and promote mental health and psychosocial well-being in the United States in a period of urban crisis.

The Architectural Study Project

In a paper read before the American Hospital Association (AHA), Daniel Blain, Medical Director of the APA, declared 1953 to have been an ‘epochal year’ for mental health. Events had demonstrated ‘that we have come to the end of one era and are at the beginning of another’. 9 Not to be overlooked among the congressional hearings and the ‘outstanding’ treatments by the World Health Organization (WHO) and National Institute of Mental Health (NIMH), was the APA’s comprehensive report on manpower and the move to standardise training. With these contributions, the mental health field was moving from ‘vague and subjective planning efforts to a more scientific quantitative approach’. It was also embracing a wider range of preventative measures and treatments that recognised the relevance of psychological, socio-economic and political conditions. Blain interpreted this reorientation through scientific planning as contributing to a shift from the ‘mere adding of hospitals’ to the ‘provision for multitudinous other services’. 10 It had not come soon enough in North America, with its ‘enormous’ hospital system of which 714,000 beds of the total 1.5 million were filled by mental patients, and another 300,000 were required. It was expensive and dangerously short staffed, with recruitment crippled by the damning revelations of ‘inhuman conditions’ in large state mental hospitals. 11 In this regard, Blain observed that 1953 was also the year that the APA had secured a large grant from the Rockefeller Foundation and the Division Fund of Chicago for a ‘first project on design, construction and equipment of mental hospitals’. 12 The ASP reflected both a determination to fix the ailing hospital system and a growing interest in designing and building for new philosophies of prevention and treatment that moved away from long-term custodial care.

The ASP grew out of a conference in April 1952 organised by the APA to develop solutions for a system suffering ‘extreme overcrowding’ in buildings ‘obsolete, deteriorated, and sometimes condemned’. 13 While new treatment strategies might reduce the hospital population of the future, they still had a ‘vast backlog’ of patients who were so damaged that they required long-term custodial care in buildings that needed to be rehabilitated or replaced. Many buildings, even new projects, failed to properly consider patient and staff needs, and, as a consequence, lacked the ‘optimism’ and ‘atmosphere of peace and comfort’ of a truly ‘therapeutic milieu’. Environment was of critical importance because mental patients were unusually sensitive, and this was compounded by the fact that their stay would last for months, even years; it could not afford to be ‘dingy, forbidding or bleak’. While the two days of discussion did not contribute any new design solutions, it did confirm an awareness of the need for the exchange of information between those who designed and constructed the buildings and those who worked in them. It was decided that the fundamental cause of the failure of hospitals was the ‘lack of mutual understanding between doctors and designers of each other’s needs and problems’. 14

To realise what the architect Isadore Rosenfield described as the ‘humanization of mental hospitals’, they needed some form of central agency where hospital planners, administrators, architects, engineers and psychiatrists could contribute ideas and access the latest information, criteria and standards. 15 Architects expressed their frustration at not having fully explained to them the function of a ward or treatment and on the absence of a comprehensive source of reliable answers to a wide range of questions. Therefore they were hindered in their attempts to realise functional design, the precepts of which are central to modern architecture. Psychiatrists, in turn, were disappointed by how poorly medical needs were met by designers. 16 Seeking to solicit funds to launch such a project, the conference proceedings were published and circulated in pamphlet form as ‘Design for Therapy’. Included was a proposal for an organisation to collect, analyse and disseminate the ‘best information’ on design, construction and equipment, and an introduction written by Blain which declared: ‘With close collaboration between architecture and psychiatry once established, mental hospital design for modern treatment can become a reality. Buildings yet to be blueprinted will help instead of hinder the task of those who will work in them for the ultimate recovery or easement of the patient.’ 17

The ASP was directed by the APA with a strong input from the AIA who helped to provide a series of architectural consultants. Alston Guttersen, an architect with experience in hospital design with the US Public Health Service, was employed full time as the Project’s Assistant Director. A wide range of experts were called upon to give evidence on various technical elements of design and equipment, such as colour and furnishings, to help humanise hospital architecture by making it ‘more home-like’. 18 Through correspondence, conferences and hospital visits, the ASP began to collect vast amounts of material relating to elements of design, such as blueprints for new buildings, wards or recreation facilities or information on materials for walls, windows or doors. This was then organised and shared as the ASP offices became a clearing house of information, inundated with requests from administrators, planners and designers seeking to build or refurbish. They established a consultancy service, organising expert interventions on request (for a small fee) and served clients across North America. They also put local architects and psychiatrists in contact with one another, establishing joint teams to aid with the collection of data regarding good and bad design practices. To help share information and generate publicity, examples of good design—consisting of descriptions, sketches and blueprints—were published in a new architectural section in the monthly magazine Mental Hospitals , which some 700 hospitals subscribed to. 19 The object, as psychiatrist and ASP Director Charles Goshen, declared, was to provide ‘little notes on various innovations’ and ‘ingenious little ideas from various people’. 20

ASP members saw their role as working to dispel the fog of ‘ignorance and prejudice’ surrounding mental hospitals in the minds of architects who, through design, ended up making ‘many of the major decisions on the subject’. 21 Patient sensitivities were described, and design implications suggested, such as countering the common tendency to withdraw by means of environmental innovations that could ‘draw and hold human interest’. 22 Colour, long associated with emotion, was explored as a means of making the hospital atmosphere seem softer, less institutional and, where needed, as an ‘attention-getting’ measure. 23 But ASP members were also concerned to influence the field of psychiatry, to encourage it to move beyond the mental hospital as the site for psychiatric care. This was an issue that emerged early in the debates regarding the Project’s direction, and with subsequent changes in leadership, it became increasingly central. With the final two directors, Lucy Ozarin and Charles Goshen, in 1956 and 1957 respectively, a greater proportion of Project work became oriented towards alternatives to large state mental hospitals such as the day hospital, clinics, community centres and psychiatric services or units in general hospitals. 24 In their correspondence, Goshen and Ozarin questioned building for the ‘sole purpose of housing more patients’ and argued that future needs for rehabilitation would be met by smaller and more flexible installations, providing ‘more personal and… a better type of psychiatric care’. 25

The travels of Guttersen in Europe, in part funded by the WHO, helped to popularise the opening-up of psychiatric units to the community. His accounts of visits to facilities abroad were published in Mental Hospitals , complete with detailed descriptions, sketches and photographs, and made the point that the US in particular was falling behind. New advances in treatment, most notably the new range of tranquilising drugs, allowed and indeed required new kinds of psychiatric spaces. For example, Goshen observed that the ‘elaborate facilities’ needed for insulin and electric shock therapies were no longer necessary, and that the ‘old-fashioned hydro-therapy units have become storage rooms’. 26 The ASP was also building on the conclusions of the Joint Commission on Mental Illness and Health which, by bringing a wide range of health and service organisations together from 1955, had sought ‘solutions outside of the traditional framework of the mental hospital’. 27 Goshen went so far as to describe the mental hospital as having a ‘built-in obsolescence’ due to the fact that all but the most difficult patients sought alternatives to the closed institution. 28 In the place of custodial isolation, the ASP promoted two alternative psychiatric spaces, the day hospital and psychiatric services in general hospitals. The latter was a means of better integrating psychiatry with general medicine, thereby connecting more successfully with the public and taking advantage of the federal funds spent on hospital construction following the Hill-Burton Act of 1946, of which psychiatric services had received little. The day hospital provided intensive treatment while allowing the patient to retain and rebuild important connections to family and community. The psychiatrist Bernard Robbins argued that with the range of activities on offer and an atmosphere that was more like a ‘school, club or workshop’, they could make a ‘clean break with the undesirable aspects of the tradition surrounding the usual psychiatric hospital’. 29 These new kinds of environments would, in turn, drive innovation in psychiatry as, by bringing together diverse groups of mental health researchers and professionals around psychiatric places, rather than theories, it would be possible to build common therapeutic practices. 30

However, there were tensions between ASP members. Some wanted a much broader focus on mental health programming and community services from child guidance centres to clinics for the treatment of addiction. Others wanted to continue restricting the attention of the ASP to hospitals, private and public. In meetings, they spoke of the need for a ‘manual’ for hospital design, with Blain hoping for ‘a sort of textbook on mental hospital architecture for the use of the people doing the building’. 31 But Guttersen was noticing a growing ‘preference for the first activity on the part of some of the Consultants’. 32 The architect Moreland Griffith Smith was forthright, declaring that as ‘pressing’ as the problems of institutional facilities may have been, the ASP was in an ‘ideal position to do more’; the promotion of psychiatric facilities in general hospitals could, he suggested, be the Project’s ‘finest contribution’. 33 The ASP was being pulled in two directions, one towards improving conditions for the huge majority of psychiatric patients still being treated in large mental hospitals, and the other, away from the total institution in an effort to keep pace with a field that was changing rapidly. It was proving difficult to reconcile these approaches and establish coherence. The psychiatrist Addison Duval expressed his concern early in the Project, that with ‘such a diversity of opinion… the Study will come up with nothing’. 34 With this continuous broadening of the Project’s base, the end goal of the ASP was also shifting. The idea of a ‘manual’ or ‘textbook’ of standards and plans was being displaced by a more flexible and universal series of ‘principles’ of design that could travel across these increasingly varied sites of psychiatric treatment and satisfy concerns with both hospital improvement and more diverse psychiatric services. As Goshen argued, ‘There is no single set of model blueprints which could be reasonably recommended as a guide to design any psychiatric unit.’ 35 To generate these principles, as well as plan more effectively for the future, the ASP needed to conduct its own studies rather than merely rely upon information and opinion offered by others.

The Mental Hospital as an Investigative Space

When Goshen assumed the directorship of the ASP in 1957, he described the dissipation of early optimism that ‘new and progressive ideas, as well as standards, for mental hospitals might be developed’. As psychiatric care had been changing so quickly, the ‘Project never really came up with anything of value’. 36 Goshen was seeking ways to make the project ‘perform’. The ASP would move beyond its early attempts to match building types with demographics or therapies and better appreciate the environment from an architectural perspective, as one architect demanded: ‘We do not want standards, we want principles and philosophy’. 37 This meant understanding how space was experienced and used in the day-to-day life of a hospital, space being, it was argued, ‘the essence of mental hospital design’. 38 Here, Goshen was building on the direction established by his predecessor, Lucy Ozarin, who saw the development of ‘principles’ of design as dependent upon a programme of investigation. 39 Research was not new to the ASP and in late 1954, they had begun the laborious process of sifting through thousands of hospital admissions to secure ‘basic data’ to aid planning in accordance with changing patient needs. 40 But as the ASP adopted broad survey methods to mirror its widening focus, some were driven to question: ‘is this an architectural approach?’ 41 Ozarin’s work was more directly tied to architectural concerns with the use and function of space. Her studies sought to improve design through the application of observational techniques used in the social, biological and behavioural sciences, thereby complementing the quantitative approaches applied for the benefits of planning.

Aided by a clinical psychologist, Abdul Tuma, Ozarin’s studies consisted of ‘direct observation’ of patient and staff movements and activities. 42 In a study of patients in seven psychiatric wards in five general hospitals, movement was recorded for a total of 18 hours over several days. Every 15 minutes in 3-hour blocks of time, the patients were checked to see where they were and what they were doing. Observation generated specific information on space requirements and allowed Ozarin to make a series of recommendations: few patients needed to be housed in secure wards; open wards which allowed patients to use the kitchen generated an ‘active social center’; lots of small semi-private spaces were better for activities than large day rooms; the option of single bedrooms was critical for patients in need of privacy; and spaces for occupational therapy and recreation were essential. 43 Following another study, it seemed apparent that nurses stations ‘do not suit the purposes they presently serve’. Physical barriers, such as a pane of glass, isolated staff from patients. 44 More generally, Ozarin used the evidence to criticise atmospheres that were ‘rigid’, ‘bare’ and ‘typically institutional’, and celebrate open, busy, active, comfortable and colourful wards with reduced security measures and increased patient privileges. 45

In designing her studies, Ozarin drew from a variety of sources. She credited the so-called ‘Boston experiment’ for having re-established a philosophy of ‘social treatment’. 46 At the Boston Psychopathic Hospital, psychiatrists, anthropologists and social scientists had come together to explore how the environment could be used more therapeutically. To this, the ASP could contribute the important dimension of improved physical design. 47 She drew from the sociological study of a private mental hospital by Alfred Stanton and Morris Schwartz who, in their volume The Mental Hospital of 1954, privileged highly ‘acculturated’ conditions over the cold, charmless and ‘spartan’ environments so common to institutions, as critical to patient recovery. 48 By 1957 Stanton was writing to Ozarin to request help with an ‘architectural problem’ at one of the Harvard Medical School’s psychiatric hospitals. 49 Ozarin also drew from some less obvious sources, such as the work of Heini Hediger, zoo director and author of several influential books on animal behaviour in captivity. As an ethologist, Hediger argued that it was essential to design artificial environments in accordance with the biologically determined behaviour of a species. To do otherwise resulted in pathologies comparable to those of human beings in the total institution. As Ozarin surmised, the health and well-being of animals were determined by the ‘quality and quantity of space in which they live’. 50

Ozarin had learnt of Hediger’s work from a psychiatrist, Humphry Osmond, whose ideas and methods would prove increasingly central to the work of the ASP. As director of Weyburn Hospital, Saskatchewan, Osmond had been seeking design solutions for a hospital described by his research associate as ‘cavernous, poorly lit, with long corridors, institutional colors, inadequate ventilation, and little soundproofing’. 51 The flaws of Weyburn were all too common, a ‘testimony to the failure in communication which has existed between architect and psychiatrist for much of the last century’. 52 Osmond worked with Robert Sommer, a psychologist, and architect, Kiyoshi Izumi, to design an alternative therapeutic space. But they were immediately struck with the lack of information available, Sommer later complaining: ‘More was known about the design of zoo cages and chicken coops than about the design of hospital wards.’ 53 Zoo animals were expensive, he quipped, and often the subject of greater sentiment than the mentally ill, and ‘this is sufficient reason to undertake research into conditions necessary for their survival’. 54 And so, it was Hediger’s insights that helped them to develop a methodological and analytical framework for understanding the relationship between people and the physical environment. The most important requirements for the individual were spatial. Patients needed spaces in which they could interact with others, but on their own terms. They needed their own territory and privacy. Osmond argued that Hediger had ‘shown that for many wild animals incarcerated in zoos, the presence or absence of this nest or den makes the difference between the survival or death of the creature. He has also shown that the size of this place is much less important than that it should be functionally rather than structurally equivalent to the conditions found in nature’. 55

Through their own observational studies, the Saskatchewan team argued that the quality of physical space was more important than its quantity; for psychotic people, smaller rooms, even with as little as 50 square feet of floor space, were better than overly spacious, often cavernous, dormitories, whose scale was likely to confuse and overwhelm. It was critical to avoid ambiguous, muddled and complicated designs and ensure that spaces were manageable and clearly defined to avoid making demands on the patient’s impaired perceptual apparatus. Social interaction also needed to be controlled to reduce the possibility of panic and withdrawal, while maintaining healthy and suitable social relationships. Enlarged spaces meant increased frequency of unwanted social contact due to high population numbers; ‘unpleasant even for the healthy people’, such overconcentration could ‘so damage the mentally ill that they lose all hope of recovery’. The large corridors that dominated hospitals were a particular problem as they were ‘admirably suited for keeping people on the move, but ill-suited for developing interpersonal relationships’. 56 Osmond developed a set of guidelines based on the psychological and behavioural needs of patients which included privacy, choice, the reduction of uncertainty and beneficial social relationships.

With its emphasis on principles of planning and design, the ‘Saskatchewan plan’ was becoming increasingly influential in the work of the ASP. 57 In 1954, there had been a flurry of correspondence and a sharing of information with Osmond and Izumi. 58 As the programme of modernisation progressed at Weyburn, the ASP solicited the plans of Izumi’s innovative semi-circular designs for a nursing unit that tackled the problem of corridors while providing patients with freedom of movement, stimulation and meaningful interactions with staff. 59 The ASP pushed for its publication in Mental Hospitals with a complimentary article by Osmond described as a ‘think piece’, Ozarin declaring: ‘I think architects are begging for this kind of information [on] principles and philosophy’. 60 The Saskatchewan plan was the focal point of the first mental hospital design clinic in 1958, jointly sponsored by the ASP and AIA to ‘lead to a set—not of blueprints —but of principles of good psychiatric hospital design’. 61 In their joint presentation, Izumi explained how his design had fulfilled the principle of ‘sociopetality’, as developed by Osmond, in which stable interpersonal relationships were fostered through a design that encouraged small group formation and face-to-face contact. Socio-petal space, designed to bring people together and foster communication and cooperation, was contrasted with the socio-fugal, which drives people apart, and ‘prevents or discourages the formation of stable human relationships’. This was a quality that, while necessary in some urban buildings, had been become too common in the ‘monstrous’ mental hospitals of the recent past. 62

The work at Saskatchewan embodied what Goshen described as the ‘new look’ being brought to the ASP, as they sought to ‘define more clearly what the psychiatric requirements of design are, or what we hope them to become’. 63 It helped to bring much-needed conceptual and methodological advance and encouraged a functional and research-based approach. It also showed how it was possible to translate principles into plans, blueprints, bricks and mortar. Goshen edited the ASP’s final contribution, Psychiatric Architecture , published in 1959 with the last of their funds from the NIMH, a text which collected together a selection of innovative designs and processes such as furnishing and soundproofing, and highlighted the wide range of potential facilities for rehabilitation. It was a text in which the Saskatchewan plan had a prominent place, Osmond providing two of the papers focused on the relationship between psychiatry and architecture. While the ASP had struggled in its search for coherence, Goshen now declared that its ‘most important aim [was] the development of effective communication between the two main professions concerned—psychiatry and architecture’. 64 To this, Osmond added a request for ‘the help of colleagues in other disciplines’. 65 As we shall now examine, it was this much broader interdisciplinary endeavour, focused on the relationship between the physical environment and mental health, that would continue to use psychiatric spaces as critical sites for controlled investigation. In turn, the focus on the mental hospital would help establish territory, privacy and personal space as key principles for the study and design of a wide range of institutional and urban spaces.

Principles of Privacy, Territory and Personal Space in Built Environments

Among significant changes that took place in the mental health field in the post-war era was the growing influence of the social and behavioural sciences, funded extensively through the NIMH. Andrew Scull sees sociologists and psychologists as having ‘contributed extensively to the loss of legitimacy that institutional psychiatry experienced’. Critical to this loss, Scull argues, was the pessimistic portrait of the mental hospital painted by those such as Goffman. 66 The mental hospital did, however, continue to make a more positive contribution to this very movement away from institution that gathered pace in the 1960s, with the growth of community mental health programming. It continued to serve as a site that brought different disciplines and professions together to focus on the relationship between environment and behaviour and a place where ideas, concepts and principles could be generated and tested through observation and experimentation.

The clearest realization of the connection between environmental form and human behavior is taking place in the institutional field. People… are surprised to find that decisions regarding the physical plant amounting to tens of millions of dollars are made without adequate information about user behavior. Whether it is a matter of separate or bunks beds in college dormitories, secluded or exposed nurses’ stations in hospitals, open or partitioned offices, ceilings eight or eight-and-one-half feet in apartments, it is evident that little is known as to how the alternatives affect people. 67

In this statement, Sommer moves deftly from the institution to the modern apartment building and, therefore, from the hospital to the city. While earlier attempts to humanise the mental hospital had attempted to make it more ‘homelike’ and thus more like the world outside, there was now a reversal of roles; the hospital was reinterpreted as a critical site for the development of principles that were not only relevant to all psychiatric services, but to a wide variety of urban spaces in this new era of preventative mental health.

Sommer was also identifying the demand for design information that was coming from administrators and managers of institutions which, in turn, placed pressure on architects and planners. This pressure was considerable in an era of expanding urban and suburban development, increased population density and an accelerated pace of life, and with it, growing fears of a mass society in which speed, impersonality and uniformity became the norm. Concern intensified in the 1960s with the growing fear of violence and crime in the era of ‘urban crisis’. Architects were beginning to organise in response. In the late 1950s, the AIA established a Committee on Research for Architecture to ‘contribute to the public welfare through better building in both the physical and esthetic sense’. 68 And yet, as the environmental analyst and designer Mayer Spivack noted, architecture and the design disciplines ‘offer us very little in the way of reliable and sophisticated conceptual and design tools’. 69 Advisors to the AIA such as the sociologist Robert Merton suggested a ‘clinical’ approach, in which, just like the physician, the architect drew upon a variety of sciences to solve ‘classes of recurrent problems’. 70 In order to understand the psychological impact of the environment, one AIA group declared: ‘we need the help of behavioral science skills and techniques’. 71 Psychologists reciprocated in turn, concerned to move beyond the ‘contrived settings’ of the laboratory and address social problems in the ‘real world’. 72 The result was the intensely interdisciplinary field of architectural or environmental psychology, supported largely by the NIMH, and described simply by one of its leading early figures as: ‘The psychological study of behavior as it relates to the everyday physical environment’. 73

While the field of environmental psychology emerged in the 1960s, its origins lay in the work of the 1950s. Sommer was a pioneer and Osmond’s paper published in Mental Hospitals was considered field defining. Sommer continued to work with Osmond’s concepts and apply them to a range of institutions and environments. Using naturalistic observation, experiment and interview, he examined how space was controlled by individuals and the effects on intrusions into what he defined as ‘personal space’, an area that surrounded a person’s body. These were a further advance on methods originally developed in the mental hospital, such as his studies of seating arrangements to understand user behaviour and model the right kinds of spaces on a geriatric ward. 74 The development of the invasion technique, where the researcher would sit too close to individuals and gauge their response, was made possible in the mental hospital, ‘a place where the usual sanctions of the outside world did not apply’. 75 Once refined, Sommer transferred these techniques to a wide range of spaces, from college libraries to airport terminals, and argued that the spatial principles developed had universal relevance. When he turned his attention to ‘softening’ correctional architecture, he compared, as he so often did, the ‘barren, cold, or hard’ conditions where inmates were treated ‘worse than… zoo animals’, to those of mental hospitals before their research at Saskatchewan had helped to overcome the state of inertia and neglect. 76

Sommer also drew from continuing research in the mental hospital such as the ethologically informed work of psychiatrist Aristide (Hans) Esser on a psychiatric ward in the Rockland State Hospital, New York. 77 Patients were observed according to a strict time-sample and their location, posture and interaction recorded with code on maps of the ward divided into a grid of 3 × 3 foot squares. The processed information gave them a breakdown of each patient’s movement and interactions. Esser argued that, just as in nature, ‘an ordering principle occurs’ based on territoriality and a dominance hierarchy. The way in which patients used space was related to their social rank—the more dominant moved freely around the ward, while the weaker and more withdrawn established their own restricted ‘definite territories’ which they defended aggressively. 78 The mental hospital offered a unique opportunity for understanding this very complex process of social ordering in relation to space, as the ‘chronically mentally ill… are incapable of and are not allowed to participate in most role relationships. Clearly revealed is the simplicity of their aggressive behaviour related to defence of property and rank’. 79 The mental hospital had further advantages, as not only was the territorial behaviour ‘unmasked’ or ‘undisguised’, but the ward was both a ‘closed’ setting in which variables were relatively constant and a ‘natural habitat’ unlike the artificial setting of the laboratory. 80 The ward was a hybrid space, a natural experiment that allowed them to interrogate the functions of spatial behaviour from the vantage point of the nurses’ station, Esser noting just how easy ‘systematic observation’ was in ‘our specially designed observation area’. 81 It also, of course, generated principles such as territoriality that could inform the design of environments to sustain communal living in ‘the increasingly crowded conditions in our technological world’. 82 To help achieve these aims, Esser founded and directed the Association for the Study of Man-Environment Relations in 1968 and edited the journal Man - Environment Systems , both important to the development of environmental psychology. 83

So central was research in mental hospitals that all three of the first centres for environmental psychology that emerged in the 1960s did so as a direct consequence of research in spatial behaviour and design in the psychiatric ward. The most prominent, and the first to offer graduate training, was based at the Graduate Centre of the City University New York (CUNY). It emerged through a series of NIMH grants, beginning in 1958, to a research team to study mental hospital design led by a psychologist of perception, William Ittelson, at Brooklyn College. The purpose, as one member described it, was to ‘be able to tell some architects how to build a mental hospital so the patients will get cured much faster’. 84 But of course it was not so simple. They described how ‘questionable assumptions’ were stripped away and they were forced to ‘postpone the question’ of design and turn instead to explore how the hospital environment was experienced by patients. 85 An extensive research programme was undertaken and they developed an even more sophisticated technique of ‘behavioural mapping’. This not only involved time-sampling with multiple observers recording behaviour during a predetermined period in the wards of three hospitals, but also included a more formal series of ‘behavior categories’ to establish ‘types’ such as the ‘isolated passive’, a withdrawn individual either lying in bed or sitting alone. 86 This isolation was, they suggested, a consequence of the individual’s failure to control space and establish territory and privacy and so attain ‘freedom of choice’ in behaviour. The implications for design were that single or double bedrooms were preferable, as they encouraged social interaction on the patient’s own terms and thus hastened recovery. These studies were not only relevant to the design of psychiatric facilities, but, as the researchers made clear, they also had taken a step ‘toward developing general principles applicable to a variety of settings’. 87

The CUNY research group described the mental hospital as the catalyst for the development of a field ‘born of social necessity’. 88 Lawrence Good was also funded by the NIMH to model the renovation of a ward in Topeka State Hospital, Kansas in 1962. 89 Some of the anthropologists, psychologists and sociologists brought together for the project founded the Environmental Research Foundation in 1965 which soon ‘expanded its research scope into urban problems’. 90 Finally, a doctoral programme in architectural psychology was established at the University of Utah following a series of conferences on mental hospital design. Its co-director, Roger Bailey, again emphasised how research focused on the relations between the architectural environment and patient behaviour had ‘wide application in the other fields of architecture’. 91

The wider relevance of principles of psychiatric architecture was captured by a comparative piece in the magazine Progressive Architecture in 1965. This brought together an architect and psychiatrist in an investigation of two environments—a mental hospital and a college campus. The recent appointment of architect Robert Geddes as Dean of the School of Architecture at Princeton was considered ‘significant, for it implies a new direction in architectural education, in which the study of the behavioral and social sciences will become an integral part of the curriculum’. 92 Geddes was strongly influenced by Osmond, now at Princeton, and involved him in a mental hospital study carried out by his students which included materials by the ASP. The purpose of having students design for the mentally ill, and its relevance to the hall of residence designed by Geddes, was to demonstrate how Osmond’s principles of social design were ‘in effect, applicable to all architecture that involves people, whether in office buildings, in apartment houses, or, as in their case, in a college complex’. 93 It was necessary to design spaces in ways that encouraged social interaction but also ensured that individuals were not overwhelmed by unwanted social contact, otherwise ‘friendships and social groups do not form’.

Osmond advised on many other similar projects, the majority funded by the NIMH, as the behavioural sciences became increasingly influential in architectural departments, organizations and practices in the interests of promoting mental health and social well-being. He was listed as an advisor to a project devised by Mayer Spivack and others at the Laboratory of Community Psychiatry, Harvard Medical School, which was aimed at providing evidence for improved architectural practices and design criteria ‘at a critical time’ for the NIMH and the new mental health centres. 94 But the grant application captured, once again, a much broader vision. With the acute sensitivity of the ‘emotionally disturbed individual’ to spatial factors, they could be used as ‘probes’ to explore the environment. Thus, the naturalistic studies of the ward could provide ‘optimum’ specifications for ‘architectural and urban spaces in general’ and generate a better understanding of the ‘relationship between the physical environment and its influence on the minds and movements of men’. Once again, the psychiatric facility served as an ideal, valid and intact setting for the investigation and design of functional spaces. The knowledge gained would, they anticipated, feed back into the ‘design of urban structures in general… correctly classified as preventative mental health for our increasingly urbanized population’.

In 1968 the social psychiatrist Leonard Duhl published a paper entitled ‘The shame of the cities’. 95 The title acknowledges Deutsch’s earlier exposé of the state mental hospital, now reworked by one of the leading promoters of preventative mental health to focus attention onto ‘failure’ in the ‘real world’ at the height of the urban crisis with American cities blighted by sickness, stress, violence, and poverty. 96 And yet, for an emerging group of environmental psychologists, mental hospitals had done much more than stimulate, through their obsolescence, a turn away from custodial care; they had played a critically important role in building, adapting and refining the tools needed to address many of the problems that now inflicted the wider urban environment, problems with which experts and policy-makers were struggling to deal. When Lucy Ozarin reflected on the rise of collaborative efforts between architects and psychologists to design for mental health, she made a point of beginning with the ASP’s early studies of patients and staff, its consultation and publications as central to an ‘intensive campaign to improve existing psychiatric facilities’. 97 Similarly, when William Ittelson considered a programme of research for architecture, he reflected on his own studies of the psychiatric ward and argued that they had ‘a vast laboratory of already completed structures for study. All we need to know is how to go about doing it.’ 98

The mental hospital was a particularly important ‘laboratory’ for the development of concepts and methods to explore the social and psychological aspects of the built environment. Kohler argues that the key characteristic of a laboratory is its ‘placelessness’; its ability to generate objective knowledge and generalisation stems from ‘stripped down-simplicity and invariability’. 99 The laboratory gives the experimenter close control over material and ‘when place affects laboratory experiments we know that something went wrong’. 100 The mental hospital, with its separation from the outside world and its ‘clearly delineated physical and social system’, offered an impressive degree of control. 101 The carefully regulated systems of time, space and function allowed behaviour patterns in the hospital’s uniquely sensitive population to be identified, controlled and manipulated, such as in Sommer’s experimental altering of furnishings, for example, or in the comparison between an original and refurbished ward. But, of course, at the same moment the complexity of place, of real and intact settings, was critically important, and many psychologists were dismissive of laboratory studies for their neglect of social and physical context of behaviour. While the mental hospital granted researchers a significant degree of control, it was also a natural setting representative of the ‘real world’ which so concerned environmental psychologists. The mental hospital was a ‘hybrid’ space that contained elements of both laboratory and field. Blain described the institution as ‘part laboratory, in part hospital in the traditional sense, in part convalescent home, in part rest-home, in part university, and overall, as has been said “an institution where we teach the patients how to live”’. 102 It was, as one environmental psychologist pointed out, ‘in many ways a microcosm’ of wider society that ‘reflects within its own organization many of the larger unsolved complexities of urban life as a whole’. 103

The credibility of the mental hospital as a site for generating principles for design was further reinforced by the interpretation of the world as a multitude of comparable spaces, the city now broken into a series of settings to which the methods and concepts for understanding the spatial behaviour of the psychiatric patient could be usefully transferred. ‘In fact’, environmental psychologists declared, ‘a large part of our lives is spent in institutional settings of one kind or another, and the qualities that make a setting institutional imply some common effects on behavior’. 104 The understanding of territorial behaviour and personal space that had been established on the psychiatric ward (and which had been informed by the zoo) could be applied to the general hospital, prison, classroom, dormitory and even family apartment. In public housing developments, an understanding of territoriality was deemed critical to building more cohesive communities that promoted mental health and prevented crime. 105 In this way, the study of psychiatric architecture fulfilled the broader ambitions of the ASP. The ‘immediate need’ of improving the therapeutic potential of psychiatric facilities had brought together, for the first time, a diverse group of psychiatrists, architects and behavioural scientists who had then worked to contribute a broader and more basic understanding of spatial behaviour in the context of mental health. 106 As the ASP turned to ‘principles’ of ‘functional design’ to address the problems of psychiatric treatment, ‘by the same token’, its members suggested, ‘psychiatric thinking can be related to architectural and community design in a general way’. 107 The principles established in the context of the mental hospital could be incorporated into ‘homes, schools, factories, public buildings and community projects’. The ASP had identified the very obsolescence of the mental hospital as offering a ‘tremendous field for the architect’s imagination, putting the architect in a position to make a significant contribution to both psychiatry and society’.

See, for example, Lawrence A. Osborn, “From Beauty to Despair: The Rise and Fall of the American State Mental Hospital,” Psychiatric Quarterly 80 (2009): 219–31.

On Kirkbride, see Carla Yanni, The Architecture of Madness: Insane Asylums in the United States (Minneapolis: University of Minnesota Press, 2007). See also Leslie Topp, James E. Moran, and Jonathan Andrews, eds., Madness, Architecture and the Built Environment: Psychiatric Spaces in Historical Context (New York: Routledge, 2007).

Albert Deutsch, The Shame of the States (New York: Harcourt, 1948), Erving Goffman, Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (New York: Doubleday, 1961), xiii.

See Andrew Scull, “Psychiatry and the Social Sciences, 1940–2009,” History of Political Economy 42 (2010): 25–52.

Daniel M. Abramson, Obsolescence: An Architectural History (Chicago: Chicago University Press, 2016).

On the value of uniting these two elements, see Thomas F. Gieryn, “City as Truth-Spot: Laboratories and Field-Sites in Urban Studies,” Social Studies of Science 36 (2006): 5–38 (7).

Robert E. Kohler, Landscapes and Labscapes: Exploring the Lab-Field Border in Biology (Chicago: University of Chicago Press, 2002), 134.

Mary Morgan, “Nature’s Experiments and Natural Experiments in the Social Sciences,” Philosophy of the Social Sciences 43 (2013): 341–57 (354).

Daniel Blain, “Mental Health Program Planning,” read at the Institute on Hospital Planning, American Hospital Association (AHA), DC, February 16, 1954, Archives of the American Psychiatric Association, Architecture Study Project (hereafter ASP Papers), Folder 122. See also Daniel Blain and Robert L. Robinson, “A New Emphasis in Mental Health Planning,” American Journal of Psychiatry 110 (1954): 702–4.

Blain, “Mental Health Program Planning.”

Memorandum: Mental Health, July 1955, Council of State Governments, Chicago, ASP Papers, Folder 106.

Blain, “Mental Health Program Planning.” They received $140,000 from the Rockefeller Foundation and 15,000 from the Division Fund.

Daniel Blain, “Heart of the Matter,” in Design for Therapy: An Investigation into The Possibilities of Collaboration Between Psychiatrists and Architects in Developing Basic Information for Mental Hospital Design, Construction and Equipment , Conference in Washington, DC, April 6–7, 1952, p. 5, APA, ASP Papers, Folder 90.

Blain, “Heart of the Matter,” 6.

Blain quoting Rosenfield in “Heart of the Matter”, p. 7.

See “Notes from Talk by Dr. Paul Haun,” 1/10/55, Consultants’ Meeting, ASP Papers, Folder 104.

Blain, “Heart of the Matter”, 8.

“Mental Hospital Architecture,” n.a., n.d., ASP Papers, Folder 91.

“Proposed Hospital Construction and Equipment Project, to be administered by APA Mental Hospital Service,” ASP Papers, Folder 92. Mental Hospitals was published by the APA’s Mental Hospital Service, which served as a clearing house for technical information.

Charles Goshen, “Summary of Year’s Progress and Projects Now Underway in the Architecture Study Project, to APA Council,” November 1957, ASP Papers, Folder 118.

“Space—The Essence of Mental Hospital Design,” n.a., n.d., ASP Papers, Folder 91.

“Mental Hospital Design—Environmental Therapy,” n.a., n.d., ASP Papers, Folder 91.

Charles Goshen, “Guidelines for the Development of Psychiatric Services in General Hospitals,” n.d., ASP Papers, Folder 90.

Both had worked in some of the most innovative sites of psychiatric work, Charles Goshen as Executive Director of the first private day hospital, the Robbins Institute in New York, and Lucy Ozarin as Chief of Hospital Psychiatry in the Veteran’s Administration. There were numerous directors over the years which did not help the Project’s coherence, and prior to Ozarin and Goshen, John L. Smalldon served as director with the beginning of the Project on September 8, 1953, and he was replaced by Charles K. Bush in May 1954. “Report to the Rockefeller Foundation of the Activities of the Mental Hospital Architectural Study Project, from June 1, 1954 to May 31, 1955,” ASP Papers, Folder 105.

Goshen to R. E. Peek, August 28, 1958, from Goshen, ASP Papers, Folder 88; Ozarin to Samuel Whitman June 25, 1956, ASP Papers, Folder 119.

Charles Goshen, “A Re-appraisal of the Architectural Study Project,” 7/15/57, ASP Papers, Folder 104.

Arthur Noyes, President of the APA, to Edwin Crosby, Director of the AHA, February 22, 1955, ASP Papers, Folder 83.

Goshen, New Concepts of Psychiatric Care with Special Reference to the Day Hospital: A Summary of the Proceedings of the First National Day Hospital Conference held in Washington D.C., March 1952, presented at the Annual Convention of the APA, May 13, 1958, ASP Papers, Folder 76.

Bernard S. Robbins, “The Theoretical Rationale for the Day Hospital,” in Proceedings of the 1958 Day Hospital Conference, A Mental Hospital Design Clinic Conducted by The Architecture Study Project and The General Practitioner Project of the APA , Washington, DC, March 28–29, pp. 6–7, 1958, ASP Papers, Folder 76.

Charles Goshen, “Day Hospitals: Physical Facilities and Equipment,” presented at the First Day Hospital Conference, Washington, DC, March 1958, ASP Papers, Folder 76.

“Minutes—Meeting of Consultants’ Committee,” ASP, April 5, 1954, ASP Papers, Folder 120.

Alston Guttersen, “Review of Designated Activities for the Architectural Study Project,” ASP Papers, Folder 93.

Moreland Griffith Smith, “RE: Proposed National Plan for Mental Health Facilities,” ASP Papers, Folder 93.

“Minutes—Meeting of Consultants’ Committee,” ASP, March 1, 1954, ASP Papers, Folder 120. Duval was an important and influential member of the ASP as he served as Chair of the Committee on Standards for Psychiatric Hospitals and Clinics of the APA, which he combined with his role at St Elizabeth’s Hospital in Washington, DC, where Goffman had carried out his studies.

Goshen, “Guidelines for the Development of Psychiatric Services”, p. 11.

Goshen to Vincent Kling, July 24, 1957, ASP Papers, Folder 88. Goshen wanted to involve Kling as a consultant as he believed that, despite Alston Guttersen’s contribution, the project lacked ‘any real architectural orientation’.

John R. Magney, “Minutes—Advisory Committee Meeting,” December 14, 1956, ASP Papers, Folder 120.

“Space—The Essence of Mental Hospital Design.”

“Proposal for a Program of Investigation and Evaluation of Psychiatric Facilities Leading to the Derivation of Principles of General Architectural Design and Equipment,” November 30, 1956, ASP Papers, Folder 120. This shift towards investigation was also driven by the failure of the psychiatrist and architect teams, few returning the prepared questionnaire.

This survey originally encompassed 10,000 case records of patients admitted to six state hospitals and two outpatient psychiatric clinics in the calendar year of 1953 and was then extended to include other facilities in accordance with the broadening focus of the ASP. The widening survey approach did not help their case when they requested an extension to their grant, and the source of funding shifted from the Rockefeller Foundation to the NIMH.

Duval in Meeting, AHA & ASP, June 30, 1954, ASP Papers, Folder 105.

“Progress Report, ASP, APA, Study of Intensive Treatment Facilities for Psychiatric Patients, USPHS Grant W-5, 1956,” ASP Papers, Folder 105. Abdul Tuma was employed by the ASP having been recommended by the VA. Ozarin to Abdul Tuma, June 7, 1956, ASP Papers, Folder 111.

Lucy Ozarin, “Patterns of Patient Movement in General Hospital Psychiatric Wards,” ASP Papers, Folder 91. Later published in American Journal of Psychiatry 114 (1958): 977–85.

“Addendum to Progress Report”, Study of Intensive Treatment Facilities for Psychiatric Patients, USPHS Grant W-5, 1956, ASP Papers, Folder 121 and Lucy Ozarin, “Functions of Nursing Stations on Psychiatric Services in General Hospitals,” ASP Papers, Folder 90.

Ozarin, “Patterns of patient movement.” See also, A. H. Tuma and Lucy B. Ozarin, “Patient ‘Privileges’ in Mental Hospitals,” American Journal of Psychiatry 114 (1958): 1104–10.

Lucy Ozarin, “New Horizons in Psychiatry,” ASP Papers, Folder 91.

The physical environment was the thinnest section of the resulting volume—Milton Greenblatt, Richard H. York, and Esther L. Brown, From Custodial to Therapeutic Patient Care in Mental Hospitals (New York: Russell Sage Foundation, 1955).

Ozarin, “New Horizons.”

Alfred Stanton to Ozarin February 13, 1957, ASP Papers, Folder 113.

Ozarin, “Patterns of Patient Movement.”

Robert Sommer, “Studies in Personal Space – This Week’s Citation Classic,” Current Contents 24 (1983): 14.

Humphry Osmond, “Function as the Basis of Psychiatric Ward Design,” Mental Hospitals 8 (1957), 23–29 (23).

Sommer, “Studies in Personal Space.”

Robert Sommer, Personal Space: The Behavioral Basis of Design (Englewood Cliffs, NJ: Prentice-Hall, 1969), 12.

Osmond, “Function as the Basis of Psychiatric Ward Design”, 25–26.

Ibid., 25, 28.

The plan involved breaking up and dispersing psychiatric facilities and had a central architectural component. For an insightful, extensive and detailed analysis of this and the work of Osmond and Izumi more generally, see the work of Erika Dyck on which this paper draws—Erika Dyck and Alexander Deighton, Managing Madness: Weyburn Mental Hospital and the Transformation of Psychiatric Care in Canada (Winnipeg: University of Manitoba Press, 2017) and Erika Dyck, “Spaced-Out in Saskatchewan: Modernism, Anti-psychiatry, and Deinstitutionalization 1950–1968,” Bulletin of the History of Medicine 84 (2010): 640–66. Dyck notes that the rapid pace of deinstitutionalisation in Canada meant that little was built.

For example, Guttersen sent Izumi reprints of type plans and suggested useful hospitals for him to visit. Guttersen to Izumi August 9, 1954, ASP Papers, Folder 54. The following year, he provided information on dormitory spaces and nursing units and suggested the need for a ‘master plan.’ Guttersen to Osmond, January 12, 1955, ASP Papers, Folder 54. Smalldon had been advising Osmond on design issues regarding security and group sizes since late 1953. Smalldon to Osmond, October 7, 1953, ASP Papers, Folder 77.

Ozarin to Izumi, November 13, 1956, ASP Papers, Folder 54.

Ozarin to Osmond, January 24, 1957, and Ozarin to Osmond, December 19, 1956 ASP Papers, Folder 54.

“New Trends in Psychiatric Architecture—The First Mental Hospital Design Clinic”, sponsored by the ASP and AIA, Washington, DC, January 16–17, 1958, ASP Papers, Folder 91. The clinic also included three further reporting teams from Ohio, Indiana, and Delaware, but it was Saskatchewan, represented by Osmond and Izumi, and recipient of the APA’s Hospital Improvement Award, that was the focal point of the discussion.

Osmond, “Function as the Basis of Psychiatric Ward Design”, 28, 23.

Charles Goshen, “Progress Report,” October 30, 1957, ASP Papers, Folder 120.

Charles Goshen, “A Review of Psychiatric Architecture and the Principles of Design,” in Psychiatric Architecture: A Review of Contemporary Developments in the Architecture of Mental Hospitals, Schools for the Mentally Retarded and Related Facilities , ed. Charles Goshen (Washington, DC: The American Psychiatric Association, 1959), 1–6 (1).

Humphry Osmond, “The Historical and Sociological Development of Mental Hospitals,” in Psychiatric Architecture , ed. Goshen, 7–9 (9).

Scull, “Psychiatry and the Social Sciences, 1940–2009,” 37.

Sommer, Personal Space , 9.

“Special Report no. 4, A Statement on Architectural Research by the AIA Committee on Research, AIA,” May 1956, Martin Allen Pond Papers, Yale University Library, Box 12, Folder 227.

Mayer Spivack, “Some Psychological Implications of Mental Health Center Architecture,” 1966, Archives of the Environmental Research and Development Foundation (hereafter ERDF Papers), Kenneth Spencer Research Library, University of Kansas, Box 58, 2600. Spivack also drew from ethologists such as Hediger.

R. K. Merton to Walter E. Campbell, AIA, November 4, 1957, Pond Papers, Folder 227.

“Report A,” in Research for Architecture, Proceedings of the AIA-NSF Conference, Ann Arbor, Michigan, 10–12 March 1959 , ed. Eugene F. Magenau (Washington, DC: AIA, 1959), 90. Attendees expressed much support for such interaction.

William H. Ittelson, H. M. Proshansky, L. G. Rivlin, and G. Winkel, An Introduction to Environmental Psychology (Oxford: Holt, Rinehart & Winston, 1974), 71; Harold M. Proshansky, “Environmental Psychology and the Real World,” American Psychologist 31 (1976): 303–10.

Kenneth Craik, “The Prospects for an Environmental Psychology,” Draft, for Journal of Environmental Design , ERDF Papers, Box 55, 2154.

For a much more detailed analysis of Sommer’s work at Weyburn, see John A. Mills and Erika Dyck, “Trust Amply Recompensed: Psychological Research at Weyburn, Saskatchewan, 1957–1961,” Journal of the History of the Behavioral Sciences 44 (2008): 199–218.

Sommer, Personal Space , 31–32.

Robert Sommer, “Final Report: Research Priorities in Correctional Architecture,” July 1, 1970–December 30, 1970, ERDF Papers, Box 28.

This was reciprocated with Esser drawing on Sommer’s seating techniques—Richard Almond and Aristide H. Esser, “Tablemate Choices of Psychiatric Patients: A Technique for Measuring Social Contact,” Journal of Nervous and Mental Disease 141 (1965): 68–82. Esser was also influenced by Osmond and Izumi—Aristide H. Esser, “Environmental Design Needs Empathy to Combat Pollution,” to appear in Matrix , 1971, ERDF Papers, Box 47, 3669.

Aristide H. Esser et al., “Territoriality of Patients on a Research Ward,” in Biological Advances in Psychiatry , ed. Joseph Wortis (New York: Plenum, 1965), 37–44 (37).

Aristide H. Esser, “Interactional Hierarchy and Power Structure on a Psychiatric Ward: Ethological Studies of Dominance Behaviour in a Total Institution,” in Behavior Studies in Psychiatry , eds. Sidney J. Hutt and Corrine Hutt (Oxford: Pergamon Press, 1970), 25–59 (42).

Esser, “Interactional Hierarchy.”

Aristide H. Esser, “Social Contact and the Use of Space in Psychiatric Patients,” Abstract, AAAS Meeting, 1965, ERDF Papers, Box 54, S.1692.

John Zeisel, “Behavioral Research and Environmental Design: A Marriage of Necessity,” Design & Environment 1 (1970): 51–66.

Proshansky, “Environmental Psychology,” 303.

Harold M. Proshansky, William H. Ittelson, and Leanne G. Rivlin, “The Influence of the Physical Environment on Behavior: Some Basic Assumptions,” in Environmental Psychology: Man and His Physical Setting , eds. Proshansky, Ittelson, and Rivlin (New York: Holt, Rinehart and Winston, 1970), 27–37 (27).

William H. Ittelson, Harold M. Proshansky, and Leanne G. Rivlin, “Bedroom Size and Social Interaction of the Psychiatric Ward,” Environment and Behavior 2 (1970): 255–70.

William H. Ittelson, Harold M. Proshansky, and Leanne G. Rivlin, “The Environmental Psychology of the Psychiatric Ward,” in Environmental Psychology , eds. Proshansky, Ittelson, and Rivlin, 419–39 (424).

Proshansky, Ittelson, and Rivlin, “The Influence of the Physical Environment on Behavior,” 27.

“The Foundation’s Work in the Area of Mental Health Care Environments,” ERDF Papers, Box 7.

Robert B. Bechtel, Environment and Behavior: An Introduction (London: Sage, 1997), 84. See also Lawrence R. Good, Saul M. Siegel, and Alfred Paul Bay, eds., Therapy by Design: Implications of Architecture for Human Behavior (Springfield, IL: C.C. Thomas, 1965). The Environmental Research Foundation became the Environmental Research and Development Foundation (ERDF) in 1970. Of considerable importance to their philosophy was the work of Roger Barker at the Midwest Psychological Field Station in Kansas, which grew out of research into child development. Barker’s observation techniques and concepts made field studies work amenable to the production of objective data on behaviour. Also critical was the work of the anthropologist Edward Hall on proxemics which served to unite disciplines around the study of spatial behaviour and communicate ideas and methods to a broad audience—see Edward Hall, The Silent Language (Garden City: Doubleday, 1959).

Roger Bailey, “Needed: Optimum Social Design Criteria,” The Modern Hospital 106 (1966): 101–3 (103).

“The Psychological Dimension of Architectural Space,” Progressive Architecture 46 (1965): 159–67.

Ibid., 163.

“The Effects of Physical Settings on Patient Behavior,” research grant application, 1967, ERDF Papers, Box 58, 2710. Spivack was named as the proposed project’s director and the principal investigator was sociologist Harold Demone, Jr. Notably, both the application and Spivack’s work in general drew strongly from ethological ideas. For an important analysis of the architectural design and function of the Community Health Centre as a critical technology in the transition from a clinical to a public health model in psychiatry, see Joy Knoblauch, “The Permeable Institution: Community Mental Health Centers as Governmental Technology (1963 to 1974)”, in Delia Duong Ba Wendel and Fallon Samuels Aidoo, eds., Spatializing Politics: Essays on Power and Place (Cambridge: Harvard Graduate School of Design, 2015).

Leonard J. Duhl, “The Shame of the Cities,” American Journal of Psychiatry 124 (1968): 70–5.

Harold M Proshansky, “The Field of Environmental Psychology: Securing the Future,” in Handbook of Environmental Psychology , eds. Daniel Stokols and Irwin Altman, v. 2 (New York: Wiley, 1987).

Lucy Ozarin, “Notes on the Development of Collaboration Between Architects and Clinicians,” Hospital & Community Psychiatry 31 (1980): 276–77 (277).

Ittelson, Discussion in Magenau, ed., Research for Architecture , 38. To this end, the architect Walter Taylor noted, they had been working closely with the APA in their research and in their ‘clinic conferences’ for design of mental hospitals.

Kohler, Landscapes , 7.

Ittelson, Proshansky, and Rivlin, “The Environmental Psychology of the Psychiatric Ward,” 419.

Daniel Blain, “Psychiatric Facilities of the Future,” n.d., ASP Papers, Folder 98.

Roslyn Lindheim, “Factors Which Determine Hospital Design,” in Environmental Psychology , eds. Proshansky, Ittelson, and Rivlin, 573–79 (573–74).

Ittelson et al., An Introduction to Environmental Psychology , 368.

On this important application of ideas of territoriality to the design of urban spaces, see Joy Knoblauch, “The Economy of Fear: Oscar Newman Launches Crime Prevention through Urban Design (1969–197x),” Architectural Theory Review 19 (2015): 336–54.

The Psychiatric Architecture Design Contest, 1957, ASP Papers, Folder 118. This was a contest open to students of architecture to encourage interest in psychiatric architecture, and was organized around a series of ‘principles’.

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Cite this Page Ramsden E. Designing for Mental Health: Psychiatry, Psychology and the Architectural Study Project. 2018 Oct 17. In: Kritsotaki D, Long V, Smith M, editors. Preventing Mental Illness: Past, Present and Future [Internet]. Cham (CH): Palgrave Macmillan; 2019. Chapter 10. doi: 10.1007/978-3-319-98699-9_10
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Rebecca Mclaughlan 1 ,
Codey Lyon 2 ,
Dagmara Jaskolska 2
1 School of Architecture and the Built Environment , The University of Newcastle , Newcastle , New South Wales , Australia
2 NTC Architects , Melbourne , Victoria , Australia
Correspondence to Dr Rebecca Mclaughlan, School of Architecture and the Built Environment, The University of Newcastle, Newcastle, NSW 2308, Australia; rebecca.mclaughlan{at}newcastle.edu.au

History suggests that departures from accepted design practice can contribute to positive change in the delivery of mental healthcare, the daily experience of hospitalised patients and public perceptions of mental illness. Yet the question of how architecture can support the therapeutic journey of patients remains a critical one. The availability of evidence-based design literature to guide architects cannot keep pace with growing global demand for new forensic psychiatric hospital facilities. This article reports a global survey of current design practice to speculate on the potential of three new hospitals to positively improve patient experience. A desktop survey was conducted of 31 psychiatric hospitals (24 forensic, 7 non-forensic) constructed or scheduled for completion between 2006 and 2022. This was supplemented by advisory panel sessions with clinical/facilities staff, alongside architectural knowledge obtained through workshops with architects from the UK and the USA, and the inclusion of Australian architects on the research team. Data analysis draws on knowledge from architectural practice, architectural history and environmental psychology, arguing that there is a responsibility to integrate knowledge from across these disciplines in respect of such a pressing and important problem.

architecture
cultural history
mental health care

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information. The primary method undertaken for this research relied on data publicly available on the internet.

https://doi.org/10.1136/medhum-2020-011887

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Introduction

In Australia, the USA and the UK, the number of hospital beds required for forensic mental health treatment doubled between 1996 and 2016. 1 Current trends and future predictions suggest this demand will continue to grow. But, in an age where evidence-based practice is highly valued, the demand for new facilities already outpaces the availability of credible evidence to guide designers. This article reports findings from a desktop survey of current design practice across 31 psychiatric hospitals (24 forensic, 7 non-forensic) constructed or scheduled for completion between 2006 and 2022. Desktop surveys, as a form of research, are heavily relied on in architectural practice; photographs and architectural drawings are analysed to understand both typical and innovative approaches to designing a particular building type. While desktop surveys are sometimes supplemented by visits to exemplar projects (which might also be termed ‘fieldwork’), time pressures and budgetary constraints often preclude this. As the result of an academic–industry partnership, the research reported herein embraced practice-based research methods in conjunction with an academic approach. The data set available for the desktop survey was rich but incomplete. Security requirements restrict the public availability of complete floor plans and postoccupancy evaluations. To mitigate these limitations, knowledge was integrated from other disciplines, including environmental psychology, architectural history and professional practice. With regard to the latter, knowledge is specifically around the design and consultation processes that guide the construction of these facilities. This knowledge was used to identify three contemporary hospitals that challenge accepted design practice and, we argue, in doing so have the potential to act as change-agents in the delivery of forensic mental healthcare. We define innovation as variation/s to common, or typical, architectural solutions that can positively improve patients’ 2 experience of these facilities in ways that directly support one, or a number, of key values underpinning forensic mental healthcare. While this article does not provide postoccupancy data to quantify the value of these innovations, we hope to encourage both designers and researchers to more closely consider these projects—particularly the way that spaces have been designed to benefit patient well-being—and the questions these designs raise for the future of forensic mental healthcare delivery.

Now regarded as naïve is the 19th-century belief that architecture and landscape, if appropriately designed, can restore sanity. 3 Yet contemporary research from the field of evidence-based design confirms that the built environment does play a role in the therapeutic process, even if that role does not determine therapeutic outcomes. 4 Research regarding the design of forensic mental healthcare facilities remains limited. An article by Ulrich et al recommended that to reduce aggression patients should be accommodated in single rooms; communal areas should have movable furniture; wards should be designed for low social densities; and accessible gardens should be provided. 5 An earlier study by Tyson et al showed that lower ward densities can also positively improve patient–staff interactions. 6 Commonly, however, the studies referenced above compared older-style mental health units with their contemporary replacements. 7 There is little comparative research available that examines contemporary facilities for forensic mental healthcare, with the exception of one article that provided a comparative analysis of nine Swedish facilities, designed between 1990 and 2008. 8 However, this article merely described the design aspirations and physical composition of each hospital without investigating the link between design aspiration, patient well-being and the resulting physical environment.

There are two further limitations to evidence-based design research. The first is the extent to which data do not provide directly applicable design tactics. Systematic literature reviews typically provide a set of design recommendations but without suggesting to designers what the corresponding physical design tactics to achieve those recommendations might actually be. 9 This is consistent for general hospital design. For example, architects have been advised to provide spaces that are ‘psychosocially supportive’ since 2000, yet it was 2016 before a spatially focused definition of this term was provided, offering designers a more tangible understanding of what they should be aiming for. 10 The second limitation is the breadth of research currently available. While rigorous and valuable, evidence-based design often overlooks the fact that architects must design across scales, from the master-planning scale—deciding where to place buildings of various functions within a site, and how to manage the safe movement of staff and patients between those buildings—to the scale of a bathroom door. How do you design a bathroom door to meet antiligature and surveillance requirements, to maintain patient safety, while still communicating dignity and respect for patients? The available literature provides much to contemplate, but in terms of credible evidence much of this research is based on a single study, typically conducted within a single hospital context and often focused on a single aspect of design. This raises the question, is there really a compelling basis for regarding evidence-based design knowledge as more credible than knowledge generated about this building type from other disciplines? In light of the small amount of evidence available in this field, is there not a responsibility to use all the available knowledge?

While the discipline of evidence-based design has existed for three decades, 11 purpose-designed buildings for the treatment of mental illness have been constructed for over three centuries. Researchers working within the field of architectural history also understand that patient experience is partially determined—for better or worse—by the decisions that designers make, and that models of care have been used to drive design outcomes since the establishment of the York Retreat in 1796. With their focus on moral treatment, the York Retreat influenced a shift in the way asylum design was approached, from the provision of safe custody to finding architectural solutions to support the restoration of sanity. 12 Architectural historians also bring evidence to bear in respect of this design challenge, specifically knowledge of how the best architectural intentions can result in unanticipated (sometimes devastating) outcomes—and of the conditions that gave rise to those outcomes. 13 There is a third, rich source of knowledge available to guide designers that, broadly speaking, academic researchers have yet to tap into. It is the knowledge produced by practitioners themselves. Architects learn through experience, across multiple projects and through practice-based forms of enquiry that include desktop surveys (also referred to as precedent studies), user group consultations and gathering (often informal) postoccupancy data from their clients. Architects have already offered a range of tangible solutions to meet particular aspirations related to patient care. There is value in examining these existing design solutions to identify those capable of providing direct benefits to patients that might justify implementation across multiple projects. In understanding how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients, all available knowledge should be valued and integrated.

Methodology: embracing ‘mode two’ research

This research was conducted within the context of a master-planning and feasibility study, commissioned by a state government department, to investigate various international design solutions to inform future planning around forensic mental health service provisions in Victoria, Australia. The industry-led nature of this project demanded a less conventional and more inclusive methodological approach. Tight timeframes precluded employing research methods that required ethics approvals (interviewing patients was not possible), while the timeframe and budget precluded the research team from conducting fieldwork. The following obstacles further limited a conventional approach:

Postoccupancy evaluations of forensic psychiatric hospital facilities are seldom conducted and/or not made publicly available. 14

Published floor plans that would enable researchers to derive an understanding of the functional layouts and corresponding habits of occupancy within these facilities are limited owing to the security needs surrounding forensic psychiatric hospital sites.

Available literature relevant to the design of forensic psychiatric hospital facilities provides few direct architectural recommendations to offer tactics for how the built environment might support the delivery of treatment.

The team had to find a way to navigate these challenges in order to address the important question of how the physical design of forensic psychiatric hospitals can best support the therapeutic journey of patients.

‘Mode two’ is a methodological approach that draws on the strength of collaborations between academia and industry to produce ‘socially robust knowledge’ whose reliability extends ‘beyond the laboratory’ to real-world contexts. 15 It shares commonalities with a phenomenological approach that attributes value to the prolonged, firsthand exposure of the researcher with the phenomenon in question. 16 The inclusion of practising architects and academic researchers within the research team provided considerable expertise in the design, consultation and documentation of these facilities, alongside an understanding of the kinds of challenges that arise following the occupation of this building type. Mode two, as a research approach, also recognises that, while architects reference evidence-based design literature, this will not replace the processes through which practitioners have traditionally assembled knowledge about particular building types, predominantly desktop surveys.

A desktop survey was undertaken to understand contemporary design practice within this building type. Forty-four projects were identified as relevant for the period 2006–2022 (31 forensic and 13 non-forensic psychiatric hospitals). These included facilities from the UK, the USA, Canada, Denmark, Norway, Sweden, the United Arab Emirates and Ireland ( online supplementary appendix 1 ). Sufficient architectural information was not available for 13 of these projects and they were excluded from the study. For the remaining 31 facilities, 24 accommodated forensic patients and 7 did not. Non-forensic facilities were included to enable an awareness of any significant programmatic or functional differences in the design responses created for forensic versus non-forensic mental health patients. Architectural drawings and photographs were analysed to identify general trends, alongside points of departure from common practice. Borrowing methods from architectural history, the desktop survey was supplemented by other available information, including a mix of hospital-authored guidebooks (as provided to patients and visitors), architects’ statements, newspaper articles and literature from the field of evidence-based design. Available data varied for each of the 31 hospitals. Adopting a method from architectural theorist Thomas Markus, the materiality and placement of external and internal boundary lines were closely studied (assisted by Google Earth). 17 When read in conjunction with the architectural drawings, boundary placement revealed information regarding patient access to adjacent landscape spaces.

Supplemental material

A desktop survey has limitations. It cannot provide a conclusive understanding of how these spaces operate when occupied by patients and staff. While efforts were made to contact individual practices and healthcare providers to obtain missing details, such requests typically went unanswered. This is likely owing to concerns of security, alongside the realities of commercial practice, concerns around intellectual property, and complex client and stakeholder arrangements that can act to prohibit the sharing of this information. To deepen the team’s understanding, a 2-day workshop was hosted to which two international architectural practices were invited to attend, one from the UK and one from the USA. Both practices had recently completed a significant forensic psychiatric hospital project. While neither of these facilities had been occupied at the time of the workshops, the architects were able to share their experiences relative to the research, design, and client and patient consultation processes undertaken. The Australian architects who led the research team also brought extensive experience in acute mental healthcare settings, which assisted in data analysis.

To further mitigate the limitations of the desktop survey, understandings developed by the team were used as a basis for advisory panel discussions with staff. Feedback was sought from five 60 min long, advisory panel sessions, each including four to six clinical/facilities staff (who attended voluntarily during work hours) from a forensic psychiatric hospital in Australia, where several participants recounted professional experience in both the Australian and British contexts. Each advisory panel session was themed relative to various aspects of contemporary design: (1) site/hospital layout, (2) inpatient accommodation, (3) landscape design and access, (4) staff amenities, and (5) treatment hubs (referred to as ‘treatment malls’ in the American context). These sessions enabled the research team to double-check our analysis of the plans and photographs, particularly our assumptions regarding the likely use, practicality and therapeutic value of particular spaces.

Model for analysis

Within general hospital design, a range of indicators are used to measure the contribution of architecture to healing, such as the optimisation of lighting to support sleep, the minimisation of patient falls, or whether the use of single patient rooms assists with infection control. 18 In mental health, however, where the therapeutic journey is based more on psychology than physiology, what metrics should be employed to evaluate the success of one design response over another in supporting patient care? We suggest the first step is to acknowledge the values that underpin contemporary approaches to mental healthcare. The second step is to translate those treatment values into corresponding spatial values using a value-led spatial framework. 19 This provides a checklist for relating particular spatial conditions to specific values around patient care. For example, if the design intent is to optimise privacy and dignity for patients, then the design of bathrooms, relaxation and de-esculation spaces are all important spaces in respect of that therapeutic value. Highlighting this relationship can assist decision makers to more closely interrogate areas that matter most relative to achieving these values. To put this in context, optimising a bathroom design to prioritise a direct line of sight for staff might improve safety but also obstruct privacy and dignity for patients. While such decisions will always need to be carefully balanced, a value-led spatial framework can provide a touchstone for designers and stakeholders to revisit throughout the design process.

To analyse the 31 projects examined within this project, we developed a framework ( Table 1 ). It recognises that a common approach to patient care can be identified across contemporary Australian, British and Canadian models:

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Value-led spatial framework: correlating treatment values with corresponding spaces within the hospital’s physical environment

That patients be extended privacy and dignity to the broadest degree possible without impacting their personal safety or that of other patients or staff.

That patients be treated within the least restrictive environment possible relative to the severity of their illness and the legal (or security) requirements attached to their care.

That patients be afforded choice and independence relative to freedom of movement within the hospital campus (as appropriate to the individual), extending to a choice of social, recreational and treatment spaces.

That patients’ progression through their treatment journey is reflected in the way the architecture communicates to hospital users.

That opportunities for peer-led therapeutic processes and involvement of family and community-based care providers be optimised within a hospital campus. 20

Table 1 assigns a range of architectural spaces and features that are relevant to each of the five treatment values listed. Architectural decisions related to these values operate across three scales: context, hospital and individual. Context decisions are those made in respect of a hospital’s location, including proximity to allied services, connections to public transport and distances to major metropolitan hubs. Decisions of this type are important relative to staffing recruitment and retention, and opportunities for research relative to the psychiatric hospital’s proximity to general (teaching) hospitals or university precincts. Architectural decisions operating at the hospital scale include considerations of how secure site boundaries are provided; how buildings are laid out on a site; and how spatial and functional links are set up between those buildings. This is important relative to the movement of patients and staff across a site, including the location and functionality of therapeutic hubs. But it can also impact patient and community psychology. The design of external fences, in particular, can compound feelings of confinement for patients; focus community attention on the custodial role of a facility over and above its therapeutic function; and influence perceptions of safety and security for the community immediately surrounding the hospital. Architectural decisions operating at the ‘individual’ scale are those that more closely impact the daily experience of a hospital for patients and staff. These include the various arrangements for inpatient accommodation; tactics for providing patients with landscape access and views; and the question of staff spaces relative to safety, ease of communication and collaboration. Approaches to landscape, inpatient accommodation and concerns of staff supervision are closely intertwined.

Findings: what we learnt from 31 contemporary psychiatric hospital projects

Forensic psychiatric hospitals treat patients who require mental health treatment in addition to a history of criminal offending or who are at risk of committing a criminal offence. Primarily, these include patients who are unfit to stand trial and those found not guilty on account of their illness. 21 Accommodation is typically arranged according to low, medium or high security needs, alongside clinical need, and whether an acute, subacute, extended or translational rehabilitation setting is required. Security needs are determined based on the risk a patient presents to themselves and/or others, alongside their risk of absconding from the facility. The challenge that has proven intractable for centuries is how can architects balance privacy and dignity for patients, while maintaining supervision for their own safety, alongside that of their fellow patients, the staff providing care and, in some cases, the community beyond. 22 In this section we present overall trends regarding the layout of buildings within hospital sites, including the placement of treatment hubs and the design of inpatient wards. Access to landscape is not explicitly addressed in this section but is implicit in decisions around site layout and inpatient accommodation.

Design approaches to site layout

We identified two approaches to site layout—the ‘village’ (4 from 31 hospitals) and the ‘campus’ (27 from 31 hospitals) ( figure 1 ). Similar in their functional arrangement, these are differentiated according to the degree of exterior circulation required to move between patient-occupied spaces. Village hospitals comprise a number of buildings sitting within the landscape, while campus hospitals have interconnected buildings with access provided by internal corridors that prevent the need to go outside. Neither approach is new; both follow the models first used within the 19th century. The village hospital follows the model designed by Dr Albrecht Paetz in 1878 (Alt Scherbitz, Germany), which included detached cottages accommodating patients in groups of between 24 and 100, set within gardens. 23 Paetz created this design in response to his belief that upwards of 1000 patients should not be accommodated in a single building, with security measures determined in relation to those patients whose behaviour was the least predictable. 24 The resulting monotony of the daily routine and restrictions on patient movement were believed to ‘cripple the intelligence and depress the spirit’. 25 Paetz’s model allowed doctors to classify patients into smaller groups and unlock doors to allow patients with predictable behaviour to wander freely within the secure outer boundaries of the hospital. 26 This remained the preferred approach to patient accommodation for over a century, as endorsed by the WHO in their report of 1953. 27 Broadmoor Hospital (UK, 2019) provides an example of the village model.

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The Broadmoor Hospital (left) follows a ‘village’ arrangement and includes an ‘internal’ treatment hub. The Worcester Recovery Center and Hospital (right) follows a ‘campus’ arrangement and includes an ‘on-edge’ treatment hub.

The campus model is not dissimilar to the approach propagated by Dr Henry Thomas Kirkbride, a 19th-century psychiatrist who was active in the design of asylums and whose influence saw this planning arrangement dominate asylum constructions in the USA for many decades. 28 Asylums of the ‘Kirkbride plan’ arranged patient accommodation in a series of pavilions linked by corridors. While corridors can be heavily glazed, where this action is not taken, the campus approach can compromise patient and staff connections to landscape views. Examples of campus hospitals include the Worcester Recovery Center and Hospital (USA, 2012) and the Nixon Forensic Center (USA, under construction).

Treatment hubs are a contemporary addition to forensic psychiatric hospitals. These cluster a range of shared patient spaces, including recreational, treatment and vocational training facilities, and thus drive patient movement around or through a hospital site. Two different treatment hub arrangements are in use: ‘internal’ and ‘on-edge’. Those arranged internally typically place these functions at the heart of the campus and at a significant distance from the secure boundary line. Those arranged on-edge are placed at the far end of campus-model hospitals and, in the most extreme cases, occur adjacent to one of the site’s external boundaries (refer to Figure 1 ). Both arrangements aspire to make life within the hospital resemble life beyond the hospital as closely as possible, as the daily practice of walking from an accommodation area to a treatment hub mimics the practice of travelling from home to a place of work or study.

With evidence mounting regarding the psychological benefits to patients of landscape access, it should not be assumed that the current preference for campus hospitals over the village model indicates ‘best practice’. A campus arrangement offers security benefits for the movement of patients across a hospital site, while avoiding the associated risks of contraband concealed within landscaped spaces. However, the existence of village hospitals for forensic cohorts suggests it is possible to successfully manage these challenges. Why then do we see such a strong persistence of the campus hospital? This preference may be driven by cultural expectations. From 24 forensic psychiatric hospitals surveyed, 10 were located within the USA and all employed the campus model. Yet nine of those hospitals occupied rural sites where the village model could have been used, suggesting the influence of the Kirkbride plan prevails. The four village hospitals within the broader sample of 31, spanning forensic and non-forensic settings, all occurred within the UK 3 and Ireland 1 . Paetz’s villa model had been the preferred approach to new constructions in these countries since its introduction at close of the 19th century. 29 However, a look at UK hospitals in isolation revealed a more even spread of village and campus arrangements, with two of the four UK-based campus hospitals occupying constrained urban sites that required multi-story solutions. The village model would be inappropriate for achieving this as it does not lend well to urban locations where land availability is scarce.

Design approaches to inpatient accommodation

Three approaches to inpatient accommodation were identified: ‘peninsula’, ‘race-track’ and ‘courtyard’ ( Figure 2 ). The peninsula model is characterised by rows of inpatient wings, along a single-loaded or double-loaded corridor that stretches into the surrounding landscape. This typically enables an exterior view from all patient bedrooms and is not dissimilar to the traditional ‘pavilion’ model that emerged within 19th-century hospital design. 30 In the racetrack model bedrooms are arranged around a cluster of staff-only (or service) spaces, still enabling exterior views from all patient bedrooms. The courtyard model is similar to the racetrack but includes a central landscape space. Information on the design of inpatient room layouts was available for 24 of the 31 projects analysed (15 of these 24 were forensic).

Common inpatient accommodation configurations. (1) Peninsula: single-loaded version shown (patient rooms on one side only; double-loaded versions have patient rooms on two sides of the corridor); (2) racetrack and (3) courtyard (landscaped). Staff-occupied spaces and support spaces (social space and so on) shown in grey.

Ten forensic hospitals employed a peninsula plan and five employed a courtyard plan. Of the non-forensic psychiatric hospitals five employed the courtyard, three the racetrack and only one the peninsula plan. While the sample size is too small to generalise, the peninsula plan appears to be favoured for a forensic cohort. However, cultural trends again emerge. Of the 10 peninsula plan hospitals, 6 were located within the USA, and among the broader sample of 24 (including the non-forensic facilities) none of the courtyard hospitals were located there. Courtyard layouts for forensic patients occurred within the UK, Ireland, Denmark and Sweden. However, within these countries, a mix of courtyard and peninsula plans were used, suggesting no clear preference for one plan over the other.

Each plan type has advantages and disadvantages ( Table 2 ). Courtyard accommodation provides the following benefits: greater opportunity for patient access to landscape since these are easier for staff to maintain surveillance over; additional safety for staff owing to continuous circulation (staff cannot get caught in ‘dead-ends’; however, the presence of corners which are difficult to see around is a drawback); natural light is more easily available; and ‘swing bedrooms’ can be supported (this is the ability to reconfigure the number of observable bedrooms on a nursing ward by opening and closing doors at different points within a corridor). However, courtyard accommodation requires a larger site area so is better suited to rural locations than urban and is not well suited to multi-story facilities. Peninsula accommodation enables geographical separation, giving medical teams greater opportunity to manage which patients are housed together (‘cohorting’); blind corners can be avoided to assist safety and surveillance; travel distances can be minimised; finally, the absence of continuous circulation provides greater flexibility for creating social spaces for patients with graduated degrees of (semi-)privacy.

Advantages and disadvantages of peninsula versus courtyard accommodation

Another important consideration related to inpatient accommodation is ward size: the number of bedrooms clustered together, alongside the amount of dedicated living space associated with these bedrooms. Ward size can influence patient agitation and aggression, alongside ease of supervision, staff anxiety and safety. 31 The most common ward sizes were 24 or 32 beds, further subdivided into subclusters of 8 beds. Typically, each ward was provided with one large living space that all 24 or 32 patients used together. More advanced approaches gave patients a choice of living spaces. For example, at Coalinga Hospital, patients could occupy a small living space available to only 8 patients, or a larger space that all 24 patients had access to. We describe this approach as more advanced since both 19th-century understandings alongside recent research by Ulrich et al confirm that social density (the number of persons per room) is ‘the most consistently important variable for predicting crowding stress and aggressive behaviour’. 32 Only six hospitals had plans detailed enough to calculate the square-metre provision of living space per patient, and this varied between 5 and 8 square metres.

Limitations of the desktop survey

Data from a desktop survey are insufficient to obtain a comprehensive understanding of how design contributes to patient experience. To overcome this limitation, the following sections combine knowledge about how people use space from environmental psychology, knowledge about the design and consultation processes that guide the construction of these facilities, and understandings from architectural history. History suggests that seemingly small changes to typical design practice can effect significant change in the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. This integrated approach is used to identify three forensic psychiatric hospitals that challenge accepted design practice to varying degrees and, in doing so, have the potential to act as change-agents in the delivery of forensic mental healthcare. But first it is important to understand the context in which architectural innovation is able, or unable, to emerge relative to forensic mental healthcare.

Accepting the challenge: using history to help us see beyond the roadblocks to innovation

Architects tasked with designing forensic mental health facilities respond to what is called a ‘functional brief’; this documents the specific performance requirements of the hospital in question. Much consultation goes into formulating and refining a functional brief through the initial and developed design stages. Consultation is typically undertaken with a variety of different user groups, and in a sequential fashion that includes a greater cross-section of users as the design progresses, including patients, families, and clinical and security staff. Despite the focus on patient experience within contemporary models of care, functional briefs tend to prioritise safety and security, making them the basis on which most major architectural decisions are made. 33 In large part this is simply the reality of accommodating a patient cohort who pose a risk of harm towards themselves and/or others. A comment from Tom Brooks-Pilling, a member of the design team for the Nixon Forensic Center (Fulton, Missouri), provides insight into this approach and the concerns that drive it. He explained that borrowing a ‘spoked wheel’ arrangement from prison design eliminated blind spots and hiding places to enable a centrally located staff member to:

see everything that’s going on in that unit…[they are] basically watching the other staff’s back [sic] to make sure that they can focus on treatment and not worry about who might be sneaking up on them or what activities might be going on behind their backs. 34

Advisory panel feedback confirmed that when the architectural design of a facility heightens staff anxiety this has direct ramifications for the therapeutic process. For example, in spaces where staff could become isolated from one another, and where clear lines of sight were obstructed, such as ill-designed elevators or stairwells, this can lead to movement being reduced across the patient cohort to avoid putting staff in those spaces where they feel unsafe.

The architects consulted during the course of this research, including those who were part of the research team, articulated how the necessary prioritisation of safety, in turn, leads to compromises in the attainment of an ideal environment to support treatment. In the various forensic and acute psychiatric hospital projects they had been involved with, all observed a sincere commitment on the part of those engaged in project briefing to upholding ideals around privacy, dignity, autonomy and freedom of movement for patients. They reported, however, that the commitment to these ideals was increasingly obstructed as the design process progressed by the more pressing concerns of safety. Examples of the kinds of architectural implications of this prioritisation are things like spatially separated nursing stations (enclosed, often fully glazed), when a desire for less-hierarchical interactions between patients and staff had been expressed at the beginning of the briefing process; or the substitution of harder-wearing materials, with a more ‘institutional’ feel when a ‘home-like’ atmosphere had been prioritised initially. There is nothing surprising or unusual about this process since design is, by its nature, a process of seeking improvements on accepted practice while systematically checking the suitability of proposed solutions against a set of performance requirements. In the context of forensic psychiatric hospitals, safety is the performance requirement that most often frustrates the implementation of innovative design. Thus, amid the complexities of design and procurement relative to forensic psychiatric hospitals, innovation, however humble, and particularly where it can be seen to contribute positively to the patient experience, is worth a closer look.

In the historical development of the psychiatric hospital as a building type, two significant departures from accepted design practice facilitated positive change in the treatment of mental illness. The first was Paetz’s development of the village hospital which sought to replace high fences, locked doors and barred windows with ‘humane but stringent supervision’. 35 While this planning approach may not have significantly altered models of care, it was regarded as ‘an essential, vital development’, providing architectural support to the prevailing approach to treatment of the time—that of moral treatment—which aimed to extend kindness and respect to patients, in an environment that was as unrestrictive as possible. The York Retreat is worthy of acknowledgement here as a leading proponent of moral treatment whose influence shifted approaches to asylum design, from focusing on the provision of safe custody to supporting the restoration of sanity. Architecturally, however, the differences in the York Retreat’s approach were mainly focused on interior details that encouraged patients to maintain civil habits. Dining rooms had white tablecloths and flower vases adorned mantelpieces, door locks were custom-made to close quietly, and window bars fashioned to look like domestic window frames. 36 The York Retreat was originally a small institution, in line with Samuel Tuke’s preference for a maximum asylum size of 30 patients. History confirms the extent to which this approach was not scalable and thus unable to be replicated widely for asylum construction. For these reasons, it has not been considered here as a significant departure from accepted design practice.

The second significant departure from accepted design practice was the development of acute treatment hospitals, located within cities, adjacent to general hospitals and medical research facilities. The first hospital of this type was the Maudsley Hospital, led by doctors Henry Maudsley and Frederick Mott, in London. The design intent for this hospital was announced in 1908 but it was not opened until 1923. 37 In proposing this hospital, Maudsley and Mott were motivated to bring psychiatry ‘into line with the other branches of medical science’. 38 This 100-bed facility, located directly across the road from the King’s College (Teaching) Hospital, emulated the general hospital typology in offering both outpatient and short-duration inpatient care, specifically targeted at patients with recent-onset illnesses. The aspirations were threefold: to avoid the stigma associated with large public asylums; to advance the medical understanding of mental illness through research collaborations with general hospitals and medical schools and via improved teaching programmes; and to both enable and encourage patients to access early, voluntary treatment on an outpatient basis. 38 Today the Maudsley appears unremarkable, an unassuming three-storied building on a busy London street. But the significance of what this building communicated at the time it was constructed, and the extent to which it challenged accepted practice, should not be underestimated. The Maudsley sent a clear message to the public that mental illness was no longer to be regarded as different from any other illness treated within a general hospital setting; that it was no longer okay to isolate those suffering from mental illness from their families or the neighbourhoods in which they lived. 39 Following the announcement of the Maudsley, the ‘psychopathic hospital’ rose to prominence within the USA with Johns Hopkins University Hospital opening the Phipps Psychiatric Clinic, in Baltimore, in 1913. The psychopathic hospital similarly promoted urban locations and closer connections to teaching and research. The Maudsley can be seen to have played a significant role in the shift to treating acute mental illness within general hospital settings.

In any discussion of the history of institutional care, there is a responsibility to acknowledge that the aspiration to provide buildings that support care and recovery have not always manifested in ways that improved daily life for patients. The five treatment values that underpinned the analysis framework for this project are not new values. The extension of privacy and dignity to patients and the delivery of care within the least restrictive environment possible were both firmly embedded in the 19th-century approach of moral treatment. Yet the rapid growth of asylum care frustrated the delivery of those values to patients. 40 Choice and independence for patients, the desire for a patient’s recovery progress to be reflected in their environment, and opportunities for peer support and family involvement have been present in approaches to mental health treatment since the formal endorsement of the ‘therapeutic community’ approach to hospital construction and administration in the WHO’s report of 1953. 41 History reminds us, therefore, that differences can arise between the stated values on which an institution is designed and those which it is constructed and operated. The three hospitals discussed in the following section include innovative solutions that hold the promise of positive benefits for patients. Yet we acknowledge this a theoretical analysis. For concrete evidence of a positive relationship between these design outcomes and patient well-being, postoccupancy evaluations are required.

Three hospitals contributing to positive change in forensic mental healthcare

Broadmoor hospital: optimising the value of the village model for patients.

Nineteenth-century beliefs and contemporary research are in accord regarding the importance of greenspace in reducing agitation within forensic psychiatric hospital environments and in promoting positive patterns of socialisation. 42 It is surprising, therefore, that enshrining daily landscape access for patients is not widespread within current design practice. The Irish National Forensic Mental Hospital and the State Hospital at Carstairs (Scotland) both follow the model of the village hospital, but only in that they comprise a number of accommodation buildings set within the landscape, enclosed by an external boundary fence. At the Irish National Forensic Mental Hospital, the scale of the landscape—the distance between buildings and the lack of intermediate boundaries within the landscape—suggests it is highly unlikely that patients are allowed to navigate this landscape on a regular basis. By comparison, the architectural response developed for Broadmoor Hospital (2019) shows an exemplary commitment to patient views and access to landscape ( Figure 3 ).

Likely extent of landscape occupation by patients as indicated by the position of inner and outer secure boundary lines. (1) Broadmoor Hospital (rural site, UK), (2) Irish National Forensic Mental Hospital (rural site) and (3) Roseberry Hospital (suburban site, UK).

Five contemporary hospitals follow the logic of a traditional villa hospital, yet Broadmoor is the only one that optimises the benefits offered by this spatial configuration. Comprising a gateway building and a central treatment hub, with a series of patient accommodation buildings positioned around it, the landscape becomes the only available circulation route for patients travelling off-ward to the shared therapy, recreation and vocational training spaces. Most patients will thus engage with the outdoors at least twice daily on their way to and return from these shared spaces. But in addition to accessing this central landscape, landscape views from patient rooms have been prioritised, and each ward is allocated its own large greenspace. Multiple, internal boundary fences enable patient access to the adjacent landscape to the greatest possible degree (refer to Figure 3 ). This approach provides patients with a diversity of landscape experiences. This is important given the patterns of landscape use between forensic and non-forensic hospitals. In non-forensic facilities, patients are likely to have the choice of accessing multiple landscape spaces, whereas in forensic facilities access to a particular space is often restricted to one cohort, for example, a single ward group. This highlights a limitation of the courtyard model for forensic patients. Roseberry Park Hospital (2012) provides an example of how a high degree of landscape access can be similarly achieved for patients on constrained urban site, using a courtyard layout (refer to Figure 3 ).

Providing patients with daily landscape access provides challenges to maintaining safety and security. Trees with low branches can be used as weapons, while tall branches can be used for self-harm, and ground cover landscaping increases opportunities to conceal contraband. At the Australian hospital where advisory panel sessions were conducted (constructed in 2000), the landscape is occupied in a similar way and staff conveyed the constant effort required to ensure safe patient access to this greenspace. Significant costs are incurred annually by facilities staff in keeping the greenspace free from contraband and from several varieties of wild mushroom that grow seasonally on the site. Despite this cost, staff reported that both they and the patients value the opportunity to circulate through the landscaped grounds (even in inclement weather); hence, the benefits to well-being are perceived as significant enough to justify this cost. These examples make evident that placing a hospital within a landscape is not enough to ensure patients are extended the well-being benefits of ongoing access. Instead this requires that hospitals factor in the additional supervisory and maintenance requirements to maintain landscape access for patients.

Worcester Recovery Center and Hospital: spaces to support choice and a sense of control

Research in environmental psychology, conducted within residential and hospital settings, confirms that the ability to regulate social contact can have a dramatic impact on well-being. The physical layout of spaces has been linked to both the likelihood of developing socially supportive relationships and impeding this development, with direct implications for communication, concentration, aggression and a person’s resilience to irritation. 43 These problems can be more pronounced in a forensic psychiatric hospital as there is an over-representation of patients who have suffered trauma. Architects working in forensic psychiatric hospital design acknowledge that patients need space to withdraw from the busy hospital environment, spaces where they can ‘observe everything that is going on around them until they feel ready to join in’. 44 It is surprising, therefore, that many contemporary forensic psychiatric hospitals still continue to provide a single social space for all 24 or 32 patients occupying a ward. The Worcester Recovery Center, by comparison, provides patients with a choice of social spaces that are designed to enable graduated degrees of social engagement. This can support a sense of control to limit socially induced stress.

Worcester is conceptualised as three distinct zones designed to resemble life beyond the hospital: the ‘house’, ‘neighbourhood’ and ‘downtown’ ( Figure 4 ). The house zones include patient accommodation, employing a peninsula model. Each comprises 26 patient rooms, clustered into groups of 6 or 10 single bedrooms that face a collection of shared spaces dedicated to that cluster, including sitting areas, lounges and therapeutic spaces. A shared kitchen and dining room is provided for each house. Three houses feed into a neighbourhood zone that includes shared spaces for therapy and vocational training, while the downtown zone serves a total of 14 houses. The downtown zone can be accessed by patients based on a merit system and includes a café, bank and retail spaces, music room, health club, chapel, green house, library and art rooms, alongside large interior public spaces. This array of amenities does not seem distinctly different from other contemporary facilities, where therapy and vocational training happen in a mix of on-ward and off-ward (often within a central treatment hub). The difference lies in the sensitivity of how these spaces are articulated.

Details of the social spaces provided on each ward at the Worcester Recovery Center and the proximity of the ‘house’ (or ward) to the ‘neighbourhood’ and ‘downtown’.

The generosity of providing separate living spaces for every 6–10 patients and locating these directly across the corridor from the patient rooms supports a sense of control and choice for patients. Frank Pitts, an architect who worked on the Worcester project, has written that this was done to enable patients to ‘decide whether they are ready to step out and socialise or return to the privacy of their room’. 45 This approach filters throughout the facility, providing a slow graduation of social engagement opportunities for patients, from opportunities to socialise with their cluster of 6–10 individuals, to their house of 26, to their neighbourhood of 78 people, to the full downtown experience. According to the architects, the neighbourhood thus provides an intermediary zone between the quiet house and the active downtown, which can be overwhelming for some patients. 46 Importantly the scale of the architecture responds to this transition from personal to public space, providing visual indicators to reflect patients’ movement through their treatment journey; spaces become larger as they move further from the ward. This occurs because instead of providing a single, large shared living space, patients are provided a choice of smaller spaces to occupy—these are not much bigger than a patient bedroom. Dining spaces are slightly larger, while downtown spaces have a civic quality; these are double-height, providing a greater sense of light and airiness. These are arranged in a semicircle, opening onto a large veranda and greenspace. The sensitive articulation of these spaces, with regard to both their graduated physical scale and the proximity of the social spaces to the patient bedrooms, provides spatial support to these social transitions while empowering patients to control their own level of social interaction.

Margaret and Charles Juravinski Centre for Integrated Healthcare: creating opportunities for greater public engagement and supporting readjustment to the world beyond the hospital

One of the most significant barriers to mental health treatment is the stigma associated with admission to a psychiatric hospital. We know that discrimination poses an obstacle to recovery and that the media fuels public fears related to forensic mental health patients. 47 Two further challenges to mental health delivery include the disconnection patients can experience from the community, including from family and educational opportunities, and the risk of readmission in the period immediately following discharge. 48 If architecture is capable of acting as a change-agent in the delivery of mental healthcare, then it needs to show leadership, not only in the provision of a better experience for patients but more broadly in taking steps to help shift public perceptions around mental illness. The Margaret and Charles Juravinski Centre for Integrated Healthcare (MCJC) (Canada) displays several similarities with the approach taken to the Maudsley Hospital. Its appearance communicates a modern, cutting-edge healthcare facility; it does not hide on a rural site or behind walls. At five stories, and extensively glazed, MCJC communicates a strong civic presence. Its proximity to McMaster University (6 km) and to neighbouring general hospitals, including Juravinski Hospital (4 km) and Hamilton General Hospital (4 km), positions it well for research collaborations to occur, while its proximity to the Mohawk Community College, across the road, can enable patients with leave privileges to access vocational training. More importantly, it employs three innovative design tactics to target the challenges of contemporary forensic mental healthcare, providing an example for how architecture might broker positive change.

The first innovative design strategy is the co-location of support services for outpatient mental healthcare. The risk of readmission is highest immediately following discharge. A lack of collaboration between outpatient support services can result in fragmented care when patients are most vulnerable to the stresses associated with readjustment to the world beyond. 49 MCJC includes outpatient facilities allowing patients to use the hospital as a stable base, or touchstone, in adjusting to life after discharge. Bringing these services onto the same physical site can also improve opportunities for coordination between inpatient and outpatient support services which can support continuity of care. The second design strategy is the co-location of a medical ambulatory care centre which includes diagnostic imaging, educational and research facilities. This creates reasons for the general public to visit this facility, setting up the opportunity for greater public interaction. This could potentially advance understandings of the role of this facility and the patients it treats.

The third innovative design strategy was to optimise the on-edge treatment hub for public engagement. While adopted across a number of hospitals, including Hawaii State Hospital, Helix Forensic Psychiatry Clinic (Sweden) and the Worcester Recovery Center, the on-edge treatment hubs at these hospitals are buried deep inside the secure outer boundary. At MCJC, the treatment hub is placed adjacent to the public zones of the hospital—although on the second floor—and this can be viewed as extension of the public realm and enables the potential for the public to be brought right up to the secure boundary line (which occurs within the building). MCJC is divided into four zones: the public zone, the galleria (the name given to the treatment hub), the clinical corridor and inpatient accommodation ( Figure 5 ). The galleria functions similarly to the downtown at the Worcester Recovery Center; patients are given graduated access to a series of spaces that support their recovery journey. These include a gym, wellness centre, spiritual centre, library, café, beauty salon, and retail and financial services, alongside patient and family support services. While the galleria was initially intended to be accessible by the general public, this was not immediately implemented on the facilities’ opening and it is unclear whether this has now occurred. 50 Nonetheless, the potential for movement of patients outwards, and families inwards, has been built into the physical fabric of this building, meaning opportunities for social interaction and fostering greater public understanding are possible. If understanding is the antidote to discrimination, then exposing the public to the role of this facility and the patients it treats is an important step in the right direction.

Zoning configuration at the Margaret and Charles Juravinski Centre for Integrated Healthcare. The galleria zone is on the second floor (shown in black). The arrows indicate main access points to the galleria. Lifts (L) and stairwell (S) positions are indicated.

The question of how architecture can support the therapeutic journey of forensic mental health patients is a critical one. Yet the availability of evidence-based design literature to guide designers cannot keep pace with growing global demand for new forensic psychiatric hospital facilities, while limitations remain relative to the breadth and usability of this research. A narrow view of what constitutes credible evidence can overlook the value of knowledge embedded in architectural practice, alongside that held by architectural historians and lessons from environmental psychology. In respect of such a pressing and important problem, there is a responsibility to integrate knowledge from across these disciplines. Accepting the limitations of a theoretical analysis and of the desktop survey method, we also argue for its value. Architects learn through experience, across multiple projects. This gives weight to the value of examining existing, contemporary design solutions to identify architectural innovations capable of providing benefits to patients and thus perhaps worthy of implementation across multiple projects. History gives us reason to believe that small changes to typical design practice can improve the delivery of mental healthcare, the daily experience of hospitalised patients and more broadly public perceptions of mental illness. Architecture has the capacity to contribute to positive change.

Here, we have provided a nuanced way for architects and decision makers to think about the relationship between architectural space and treatment values. An institution’s model of care and the therapeutic values that underpin that model of care should be placed at the centre of architectural decision making. A survey of contemporary architectural solutions confirms that, generally speaking, innovation is lacking in this field. There will always be real obstacles to innovation, and the argument presented here does not suggest it is necessarily practical to prioritise therapeutic values at the cost of patient, staff and community safety. Instead, it challenges architects and decision makers to properly interrogate any architectural decision that compromises an initial commitment to supporting a patient’s treatment journey—to be more idealistic in the pursuit of positive change.

Tangible examples exist of architectural innovations capable of positively improving patient experience by supporting key values that underpin contemporary treatment approaches. The Broadmoor Hospital optimises the value of the village model for patients, prioritising patient needs for frequent landscape engagement to support their therapeutic journey. The Worcester Recovery Center provides a generous choice and graduation of social spaces to support the social reintegration of patients at their own pace. MCJC co-located facilities to support a patient’s readjustment to daily life postdischarge, while creating opportunities for public engagement that has the potential to foster greater public understanding of the role of these institutions and the patients they treat. In identifying these three innovative design approaches, we provide architects with tangible design tactics, while encouraging researchers to look more closely at these examples with targeted, postoccupancy studies. These projects provide hope that with a shared vision and commitment, innovation is possible in forensic psychiatric hospital design, with tangible benefits for patients.

Ethics statements

Patient consent for publication.

Not required.

Acknowledgments

The opportunity to conduct this project arose out of a multidisciplinary master-planning and feasibility study, commissioned by the Victorian Health and Human Services Building Authority, to investigate various international solutions to inform future planning and design around forensic mental health service provision. The following people contributed their time and expertise in shaping the research process that enabled this article: Neel Charitra, Stefano Scalzo, Les Potter, Margaret Grigg, Lousie Bawden, Matthew Balaam, Martin Gilbert, John MacAllister, Crystal James, Jo Ryan, Julie Anderson, Jo Wasley, Sophie Patitsas, Meagan Thompson, Judith Hemsworth, James Watson, Viviana Lazzarini, Krysti Henderson, Nadia Jaworski, Jack Kerlin and Jan Merchant.

1. Jamie O'Donahoo and Janette Graetz Simmonds (2016) , “Forensic Patients and Forensic Mental Health in Victoria: Legal Context, Clinical Pathways, and Practice Challenges,” Australian Social Work 69, no. 2: 169–80.

2. The challenge of which terminology to select when writing about psychiatric hospital design remains difficult relative to the stigmas that surround this field. The term ‘patient’ has been used throughout, instead of ‘consumer’, as this article spans both historical and contemporary developments. In the context of this timespan, consumer is a relatively recent term, introduced around 1985.

3. B Edginton (1994) , “The Well-Ordered Body: The Quest for Sanity through Nineteenth-Century Asylum Architecture,” Canadian Bulletin of Medical History 11, no. 2: 375–86; Clare Hickman (2009) , “Cheerful Prospects and Tranquil Restoration: The Visual Experience of Landscape as Part of the Therapeutic Regime of the British Asylum, 1800-60,” History of Psychiatry 20, no. 4 Pt 4: 425–41; Rebecca McLaughlan, 2012 ), “Post-Rationalisation and Misunderstanding: Mental Hospital Architecture in the New Zealand Media,” Fabrications 22, no. 2: 232–56.

4. Roger S Ulrich et al. (2008) , “A Review of the Research Literature on Evidence-Based Healthcare Design,” HERD 1, no. 3: 61–125; Jill Maben et al. (2015) , “Evaluating a Major Innovation in Hospital Design: Workforce Implications and Impact on Patient and Staff Experiences of All Single Room Hospital Accommodation,” Health Services and Delivery Research 3: 1–304; Penny Curtis and Andy Northcott (2017) , “The Impact of Single and Shared Rooms on Family-Centred Care in Children’s Hospitals,” Journal of Clinical Nursing 26, no. 11–12: 1584–96.

5. Roger S. Ulrich et al. (2018) , “Psychiatric Ward Design Can Reduce Aggressive Behavior,” Journal of Environmental Psychology 57: 53–66.

6. Graham A Tyson, Gordon Lambert, and Lyn Beattie (2002) , “The Impact of Ward Design on the Behaviour, Occupational Satisfaction and Well-Being of Psychiatric Nurses,” International Journal of Mental Health Nursing 11, no. 2: 94–102.

7. For further examples of this see Jon E. Eggert et al. (2014) , “Person-Environment Interaction in a New Secure Forensic State Psychiatric Hospital,” Behavioral Sciences & the Law 32, no. 4: 527–38; C.C. Whitehead et al. (1984) , “Objective and Subjective Evaluation of Psychiatric Ward Redesign,” The American Journal of Psychiatry 141, no. 5: 639–44; Gabriela Novotná et al. (2011) , “Client-Centered Design of Residential Addiction and Mental Health Care Facilities: Staff Perceptions of Their Work Environment,” Qualitative Health Research 21, no. 11: 1527–38.

8. Morgan Andersson et al. (2013) , “New Swedish Forensic Psychiatric Facilities: Visions and Outcomes,” Facilities 31, no 1/2: 24–88.

9. For examples see Kathleen Connellan et al. (2013) , “Stressed Spaces: Mental Health and Architecture,” HERD: Health Environments Research & Design Journal 6, no. 4: 127–168; Constantina Papoulias et al. (2014) , “The Psychiatric Ward as a Therapeutic Space: Systematic Review,” British Journal of Psychiatry 205, no. 3: 171–6.

10. R. Allen and R.G. Nairn, 1997 ; Alan Dilani, 2000 , “Psychosocially Supportive Design - Scandinavian Health Care Design,” World Hospitals and Health Services 37: 20–4; Rebecca McLaughlan (2018) , “Psychosocially Supportive Design: The Case for Greater Attention to Social Space within the Pediatric Hospital," HERD 11, no. 2: 151–62.

11. Rebecca McLaughlan (2017) , “Learning From Evidence-Based Medicine: Exclusions and Opportunities within Health Care Environments Research,” Design for Health 1: 210–28.

12. B Edginton (1997) , “Moral Architecture: The Influence of the York Retreat on Asylum Design,” Health & Place 3, no. 2: 91–9; Jeremy Taylor (1991) , Hospital and Asylum Architecture in England 1849–1914: Building for Health Care (London: Mansell Publishing Limited); Anne Digby (1985) , Madness, Morality and Medicine: A Study of the York Retreat 1796–1914 (New York: Cambridge University Press).

13. Digby, Madness, Morality and Medicine ; Erving Goffman (1961) , Asylums: Essays on the Social Situation of Mental Patients and Other Inmates (New York: Doubleday); Ivan Belknap (1956) , Human Problems of a State Mental Hospital (New York: Blakiston Division, McGraw-Hill); Andrew Scull (1979) , Museums of Madness: The Social Organization of Insanity in 19th Century England (London: Allen Lane); Leonard Smith (1999) , Cure, Comfort and Safe Custody: Public Lunatic Asylums in Early Nineteenth-Century England (London: Leicester University Press); Rebecca McLaughlan (2014) , “One Dose of Architecture, Taken Daily: Building for Mental Health in New Zealand” (PhD diss., Victoria University of Wellington, New Zealand).

14. Although not fitting a strict definition of postoccupancy evaluation, the following articles were notable exceptions to this finding: Eggert et al., “Person-Environment Interaction,” 527–38; Roger S. Ulrich et al. (2018) , “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66; Catherine Clark Ahern et al. (2016) , “A Recovery-Oriented Care Approach: Weighing the Pros and Cons of a Newly Built Mental Health Facility,” Journal of Psychosocial Nursing and Mental Health Services 54, no. 2: 39–48.

15. M Gibbons (2000) , “Mode 2 Society and the Emergence of Context-Sensitive Science,” Science and Public Policy 27: 161.

16. D Seamon, 2000 , “A Way of Seeing People and Place,” in Theoretical Perspectives in Environment-Behavior Research, ed. S. Wapner, J. Demick, T. Yamamoto and H. Minami (New York: Plenum), 157–78.

17. Thomas A Markus (1982) , Order in Space and Society: Architectural Form and Its Context in the Scottish Enlightenment (Edinburgh: Mainstream Publishing Company).

18. Ulrich et al., “A Review of the Research Literature,” 61–125.

19. This was first created by first author for use for historical analysis during her PhD and is applied here to a contemporary setting. Refer to McLaughlan, “One Dose of Architecture, Taken Daily.”

20. The following documents were referenced in compiling this list: Joint Commission Panel for Mental Health, NHS, UK (2013) , “Guidance for Commissioners of Forensic Mental Health Services,” May, https://www.jcpmh.info/resource/guidance-for-commissioners-of-forensic-mental-health-services/ ; Cannon Design (2014) , “St Joseph’s Integrated Healthcare Hamilton, Margaret and Charles Juravinski Centre for Integrated Healthcare,” Healthcare Design Showcase, September; Health Nexus Group, 2017 , “Forensicare Model of Care Report,” April, Australia (access provided by the Victorian Health and Human Services Building Authority); Donald Cant Watts Corke (2014) , “Service Plan for Forensic Mental Health Services,” July, Australia (access provided by the Victorian Health and Human Services Building Authority).

21. Sometimes this includes patients with no history of criminal behaviour but who are unable to be treated safely in a general hospital environment.

22. W.A.F Browne (1991) , "What Asylums Were, Are and Ought to Be (1837),” reprinted in The Asylum as Utopia: W.A.F. Browne and the Mid-Nineteenth Century Consolidation of Psychiatry , ed. Andrew Scull (London: Tavistock); Morgan Andersson et al. (2013) , “New Swedish Forensic Psychiatric Facilities,” 24–38; Eggert et al., “Person-Environment Interaction.”

23. Anon (1895) , “Review: The Colonization of the Insane in Connection with the Open-Door System: Its Historical Development and the Mode in Which It Is Carried Out at Alt Scherbitz Manor. By Dr. Albrecht Paetz, Director of the Provincial Institution for the Insane (Berlin: Springer, 1983),” The Journal of Mental Science 41: 697–703.

24. Theodore Gray (1958) , The Very Error of the Moon (Ilfracombe & Devon: Arthur H. Stockwell Ltd), 64.

25. John Galt (1854) , “The Farm of St. Anne,” American Journal of Insanity II (1854): 352.

26. Galt, “The Farm of St. Anne,” 352.

27. Martin James (1948) , “Diagnostic Measures,” in Modern Trends in Psychological Medicine , ed. Noel Haris (London: Buttefwork & Co. Ltd), 146; World Health Organization (1953) , The Community Mental Hospital: Third Report of the Expert Committee on Mental Health (Geneva: WHO).

28. Carla Yanni (2007) , The Architecture of Madness: Insane Asylums in the United States. Minneapolis (London: University of Minnesota Press).

29. Key British examples included the 1923 rebuild of London’s Bethlem Hospital which followed the villa model, alongside Shenley Park Mental Hospital (Middlesex County) and Barrow Mental Hospital (Somerset), both constructed in the early 1930s.

30. Taylor, Hospital and Asylum Architecture in England .

31. Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66; O. Jenkins, S. Dye and C. Foy (2015) ( Oliver Jenkins et al., 2015 ), “A Study of Agitation, Conﬂict and Containment in Association With Change in Ward Physical Environment,” Journal of Psychiatric Intensive Care 11, no. 01: 27–35; M. Daﬀern, M.M. Mayer, and T. Martin (2004) , “Environmental Contributors to Aggression in Two Forensic Psychiatric Hospitals,” International Journal of Forensic Mental Health 3 no. 1: 105–114; Kathryn L. Brooks et al. (1994) , “Patient Overcrowding in Psychiatric Hospital Units: Effects on Seclusion and Restraint,” Administration and Policy in Mental Health 22, no. 2: 133–44; T. T Palmstierna, B Huitfeldt, and B Wistedt (1991) , “The Relationship of Crowding and Aggressive Behavior on a Psychiatric Intensive Care Unit,” Psychiatric Services 42, no. 12: 1237–40.

32. Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 57; Charles Mercier (1894) , Lunatic Asylums: Their Organisation and Management (London: Charles Griffin and Company), 135.

33. Morgan Andersson et al. (2013) , “New Swedish Forensic Psychiatric Facilities,” 24–38; Joel A Dvoskin et al. (2002) , “Architectural Design of a Secure Forensic State Psychiatric Hospital,” Behavioral Scients & the Law, 20, no. 3: 481-493; J. Enser and D. Maclnnes (1999) , “The Relationship between Building Design and Escapes from Secure Units,” Journal of the Royal Society for the Promotion of Health 119, no. 3: 170–4; Jon E. Eggert et al. (2014) , “Person-Environment Interaction,” 527–38.

34. Tom Brooks-Pilling cited in Mike Lear (2015) , “Designer: New Fulton State Hospital Will Be Better, Safer,” Missourinet, January 5, https://www.missourinet.com/2015/01/05/designer-new-fulton-state-hospital-will-be-better-safer/

35. Leslie Topp (2007) , “The Modern Mental Hospital in Late Nineteenth-Century Germany and Austria: Psychiatric Space and Images of Freedom and Control,” in Madness, Architecture and the Built Environment: Psychiatric Spaces in Historical Context, ed. Leslie Topp, James Moran and Jonathan Andrews (London and New York: Routledge), 244.

36. McLaughlan, “One Dose of Architecture, Taken Daily,” 35; Digby, Madness, Morality and Medicine .

37. Anon (1908), “Proposed New Hospital for Mental Diseases,” The Lancet 171, no. 4410: 728–9.

38. Anon, “Proposed New Hospital for Mental Diseases.”

39. McLaughlan, “One Dose of Architecture, Taken Daily.”

40. Samuel Tuke (1964) , “Description of the Retreat (1813),” reprinted in Description of the Retreat With an Introduction by Richard Hunter and Ida Macalpine (London: Dawsons of Paul Mall); Scull, Museums of Madness; Digby, Madness, Morality and Medicine; Smith, Cure, Comfort and Safe Custody .

41. World Health Organization (1953) , The Community Mental Hospital . Also refer to T.F Main (1946) , “The Hospital as a Therapeutic Institution”, Bulletin of the Menninger Clinic 10, no. 3: 66–71; David Clark (1965) , “The Therapeutic Community Concept, Practice and Future,” The Journal of Mental Science 111: 947–54.

42. Jolanda Maas et al. (2009) , “Social Contacts as a Possible Mechanism behind the Relation between Green Space and Health,” Health & Place 15, no. 2: 586–95; Gayle Souter-Brown (2015) , Landscape and Urban Design for Health and Well-Being: Using Healing, Sensory and Therapeutic Gardens (Oxon & New York: Routledge); Ulrich et al., “A Review of the Research Literature,” 61–125.

43. Leon Festinger et al. (1950) , Social Pressures in Informal Groups: A Study of Human Factors in Housing, vol. 11 (New York: Harper Bros); David Halpern (1995) , Mental Health and the Built Environment: More than Bricks and Mortar? (London: Taylor and Francis); A. Baum and G.E. Davis (1980) , “Reducing the Stress of High-Density Living: An Architectural Intervention,” Journal of Personality and Social Psychology 38, no. 3: 471–81; I. Altman and M.M. Chemers (1984) , Culture and Environment (Monterey, CA: Brooks & Cole Publishing); Gary W Evans (2003) , “The Built Environment and Mental Health,” Journal of Urban Health: Bulletin of the New York Academy of Medicine 80 no. 4: 536–55; Ulrich et al., “Psychiatric Ward Design Can Reduce Aggressive Behavior,” 53–66.

44. Stence Guldager cited in Troldtekt, “Innovative Architecture is Good for Mental Health,” https://www.troldtekt.com/News/Themes/Healing_architecture/Innovative_architecture_is_good_for_mental_health (accessed June 30, 2019); Clare Hickman and “Cheerful Prospects (2009).

45. Frank Pitts cited in Patricia Wen (2012) , “For Mentally Ill, A Design Departure,” B News, August 16, https://www.boston.com/news/local-news/2012/08/16/for-mentally-ill-a-design-departure

46. Ellenzweig with Architecture Plus, “Massachusetts Department of Mental Health, Worcester Recovery Center and Hospital – Worcester, MA,” Healthcare Design (2013) , July 30, https://www.healthcaredesignmagazine.com/architecture/massachusetts-department-mental-health-worcester-recovery-center-and-hospital-worcester-ma/

47. Sane Australia (2003) , “A Life Without Stigma,” July 25, http://apo.org.au/resource/life-without-stigma ; Otto F Wahl (2012) , “Stigma as a Barrier to Recovery from Mental Illness,” Trends in Cognitive Sciences 16, no. 1: 9–10; New Zealand Ministry of Health and Health Promotion Agency (2014) , “Like Minds, Like Mine National Plan 2014–2019: Programme to Increase Social Inclusion and Reduce Stigma and Discrimination for People with Experience of Mental Illness,” May 20, https://www.likeminds.org.nz/assets/National-Plans/like-minds-like-mine-national-plan-2014-2019-may14.pdf ; G Moon (2000) , “Risk and Protection: The Discourse of Confinement in Contemporary Mental Health Policy," Health & Place 6, no. 3: 245; R. Allen and R.G. Nairn (1997) , “Media Depictions of Mental Illness: An Analysis of the Use of Dangerousness,” Australian & New Zealand Journal of Psychiatry 31, no. 3: 375–81; Greg Philo et al. (1994) , “The Impact of the Mass Media on Public Images of Mental Illness: Media Content and Audience Belief,” Health Education Journal 53, no. 3: 271–81.

48. G Moon (2000) , “Risk and Protection,” 239–50; T.F Main (1948) , “Rehabilitation and the Individual,” in Modern Trends in Psychological Medicine , ed. Noel Haris (London: Buttefwork & Co. Ltd); D.A Fuller, E. Sinclair, and J. Snook (2016) , “Released, Relapsed, Rehospitalized: Length of Stay and Readmission Rates in State Hospitals: A Comparative State Survey,” 2016, https://www.treatmentadvocacycenter.org/storage/documents/released-relapsed-rehospitalized.pdf ; Leila Salem et al. (2015) , “Supportive Housing and Forensic Patient Outcomes,” Law and Human Behavior 39, no. 3: 311.

49. National Institute for Health and Clinical Excellence, Manchester (2016) , “Transition between Inpatient Mental Health Settings and Community or Care Home Settings: Guideline,” August, https://www.nice.org.uk/guidance/ng53/evidence/full-guideline-pdf-2606951917

50. Catherine Clark Ahern et al. (2016) , “A Recovery-Oriented Care Approach,” 47.

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Nicholls Tonia L. , and
Côté Gilles
Sane Australia
Scull Andrew
Smith Leonard
Souter-Brown Gayle
Taylor Jeremy
Topp Leslie
Tuke Samuel
Tyson Graham A ,
Lambert Gordon , and
Beattie Lyn
Ulrich Roger S ,
Zimring Craig ,
Zhu Xuemei ,
DuBose Jennifer ,
Seo Hyun-Bo ,
Choi Young-Seon ,
Quan Xiaobo , and
Joseph Anjali
Ulrich Roger S. ,
Bogren Lennart ,
Gardiner Stuart K. , and
Lundin Stefan
Wahl Otto F
Wen Patricia
Whitehead C.C. ,
Polsky R.H. ,
Crookshank C, , and
World Health Organization
Yanni Carla

Supplementary materials

Supplementary data.

This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

Data supplement 1

Contributors The research methodology was conceptualised by RM and CL. Data collection was completed by RM, CL and DJ. Analysis was completed by RM and CL, in accordance with the conceptual model developed by RM for her doctoral thesis (2014). Figures/diagrams were created by RM. The manuscript was prepared by RM.

Funding This study was funded by the Victorian Health and Human Services Building Authority (commissioned study).

Competing interests None declared.

Provenance and peer review Not commissioned; externally peer reviewed.

Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.

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Östra Hospital – Emergency Psychiatry Ward

Psychiatric care may involve the opposite to what you might think. Instead of locked doors and closed wards, the best way architecture can support patients is to emphasise continuity in everyday life; getting out into a garden unescorted, or just being able to see a tree from the window.

Architecture on the inside of life

The design of Östra Hospital’s Acute Psychiatry Ward creates a free and open environment that breaks down preconceptions formed by traditional institutional environments. Evidence-based research suggests that successful care requires the gradual increase of patients’ personal space from their room, to the garden, to the wider public realm with an eventual return to life outside.

Client: Västfastigheter Location: Göteborg, Sweden Status: Completed 2009 Area: 18,000 sqm Awards: Forum’s Healthcare Building Award 2007 Second place – WAN Healthcare Building of the Year Award Visuals: Christer Hallgren

Services: Architecture , Healthcare , Landscape architecture

The goal was to create a free and open atmosphere, to avoid any associations with force and power.

Corridor-free ward

Östra Hospital offers patients, medical staff, relatives and visitors an opportunity to benefit from a warm environment, with careful gradations of social character – from the separate rooms to seating areas inspired by the vernacular Swedish veranda. At the core of the ward are the living room, kitchen and other communal areas grouped around a small glazed conservatory. This results in a kind of ‘corridor-free ward’, a solution offering patients an opportunity to move around in ways other than through long, constrictive corridors.

Encouraging independence

The concept behind the individual rooms was to offer multiple spaces by creating rooms within the room; resting on the bed while looking out of the window, flicking through a magazine on the armchair in the reading corner, curling up in the recessed window to watch the world go by or leaving the door ajar to see the activity in the communal conservatory. This open design encourages participation while increasing the patients’ personal space, aiding them in their preparation for getting back into life outside.

Every room offers views to the world outside.

An interview on the design of new generation psychiatric facilities from the service user and the architect perspective and a conversation about the role of participatory design in increasing the therapeutic effectiveness of mental health facilities for the wider benefit of society. Stefan Lundin, partner at White Arkitekter, and service user Jan Devyr Lernbring at Östra Hospital’s Acute Psychiatry Ward.

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Architecture for Psychiatric Environments and Therapeutic Spaces

Therapeutic architecture can be described as the people-centered, evidence-based discipline of the built environment, which aims to identify and support ways of incorporating those spatial elements that interact with people physiologically and psychologically into design. Architecture is an important factor in people's lives when they are well; when they experience ill-health and are less able to cope it becomes even more important. This book explores the design of specialized residential architecture for people with mental health problems. It sets out to show how building design can support medical and health related procedures and practices, leading to better therapeutic outcomes and an enhanced quality of life. Based on almost two decades of research, it aims to understand how architectural design interacts with the therapeutic milieu, the care programs, and actually living in the spaces. The book is divided into two main parts covering theory and research. Part one consists of three chapters: a brief introduction to old practices, current medical psychosocial and architectural thinking, and alternative thinking. Part two explores the research and conclusions derived from fieldwork. This book provides a fascinating insight into the effect that architectural design can have on all of us, but particularly on those with mental health problems.

Related Papers

Evangelia Chrysikou, PhD

Medical architecture-therapeutic architecture or architecture for salutogenesis as it is also known-is an interdisciplinary field related to the evidence based, planning and design of healthcare facilities. It has been one of the first fields that addressed evidence based design and over the years becomes more and more inclusive, involving medical professionals, designers, planners, managers, carers as well as patient representatives actively in the decision making and design processes. In this paper, we report on work carried out within the project 'The social invisibility of mental health facilities: Raising awareness on social exclusion in urban environments through artwork', involving three schools at UCL, i.e., Architecture, Psychiatry and Fine Art, and describe our approach in using transdisciplinary research methods. Inequality has been reported in medical and healthcare management literature but not connected to building stock. However, the façades of mental health facilities buildings are directly visible from the community and contribute to the opinion of the public, staff and patients and convey messages on how society approaches the illness. It is also what service-users see just before crossing facility thresholds. The aim of this project is to juxtapose the exteriors of mental-health/health buildings and their urban integration, documenting this inequality from the socio-spatial perspective. We evaluate proximity of buildings to transport and analyse architectural materiality/façade using multimedia techniques to identify differences in service provision and contrast facilities of an inner-city catchment area in terms of access, condition and status compared to their surroundings. We present an attempt to develop new ways of approaching these facilities that extend beyond conventionally applied methods within traditional architectural education by adopting knowledge from the fields of psychiatry, psychology and medical architecture, on the pathology of mental illness, the stigma associated with it and the ways of social valorisation of people with mental illness and at the same time employ visual methods to support the interpretation and interrogation. That way, the

Rachel Aquino

This paper will specifically look at the impact of interior architecture on mental recovery; this being the actual structure and build of the inside of the establishment, as well as decorative and functional furnishings and components.Interior Architecture is the ‘design of a space which has been created by structural boundaries and the human interaction within these boundaries.’ The use of mental-health will cover the broad variety of issues, ranging from depression, to anger management and so forth, allowing the exploration of how approaches may differ from another in terms of effectiveness, depending on what the facility tailors to.

Kathleen A Connellan

OBJECTIVE: To present a comprehensive review of the research literature on the effects of the architectural designs of mental health facilities on the users. BACKGROUND: Using a team of cross-disciplinary researchers, this review builds upon previous reviews on general and geriatric healthcare design in order to focus on research undertaken for mental health care facility design. METHODS: Sources were gathered in 2010 and 2011. In 2010 a broad search was undertaken across health and architecture; in 2011, using keywords and 13 databases, researchers conducted a systematic search of peer reviewed literature addressing mental health care and architectural design published between 2005 to 2012, as well as a systematic search for academic theses for the period 2000 to 2012. Recurrent themes and subthemes were identified and numerical data that emerged from quantitative studies was tabulated. RESULTS: Key themes that emerged were nursing stations, light, therapeutic milieu, security, privacy, designing for the adolescent, forensic facilities, interior detail, patients’ rooms, art, dementia, model of care, gardens, post-occupancy evaluation, and user engagement in design process. Of the 165 articles (including conference proceedings, books, and theses), 25 contained numerical data from empirical studies and 7 were review articles. CONCLUSIONS: Based on the review results, especially the growing evidence of the benefits of therapeutic design on patient and staff well-being and client length of stay, additional research questions are suggested concerning optimal design considerations, designs to be avoided, and the involvement of major stakeholders in the design process. KEYWORDS: Evidence-based design, hospital, interdisciplinary, literature review, post-occupancy

Arlene De Jongh

Damien Riggs

To present a comprehensive review of the research literature on the effects of the architectural designs of mental health facilities on the users.BACKGROUND: Using a team of cross-disciplinary researchers, this review builds upon previous reviews on general and geriatric healthcare design in order to focus on research undertaken for mental health care facility design.METHODS: Sources were gathered in 2010 and 2011. In 2010 a broad search was undertaken across health and architecture; in 2011, using keywords and 13 databases, researchers conducted a systematic search of peer reviewed literature addressing mental health care and architectural design published between 2005 to 2012, as well as a systematic search for academic theses for the period 2000 to 2012. Recurrent themes and subthemes were identified and numerical data that emerged from quantitative studies was tabulated.RESULTS: Key themes that emerged were nursing stations, light, therapeutic milieu, security, privacy, designin...

Health Environments Research Design Journal

Objective: To present a comprehensive review of the research literature on the effects of the architectural designs of mental health facilities upon the users. Background: Using a team of cross disciplinary researchers, this review builds upon previous reviews on general and geriatric health care design in order to focus upon research undertaken for mental health care facility design. Methods: Sources were gathered in 2010 and 2011. In 2010 a broad search was undertaken across health and architecture; in 2011, using keywords listed below and 13 databases, researchers conducted a systematic search of peer reviewed literature addressing mental health care and architectural design published between 2005 to 2012, as well as a systematic search for academic theses for the period 2000 to 2012. Recurrent themes and sub themes were identified and numerical data that emerged from quantitative studies was tabulated. Results: Key themes that emerged were: nursing stations; light; therapeutic milieu; security; privacy; designing for the adolescent; forensic facilities; interior detail; patients’ rooms; art; dementia; model of care; gardens; post occupancy evaluation; user engagement in design process. Of the 165 articles (including conference proceedings, books and theses), 25 contain numerical data from empirical studies and 7 are review articles. Conclusions: Based on the review results, especially the growing evidence of the benefits of therapeutic design upon patient and staff well-being and client length of stay, additional research questions are suggested concerning optimal design considerations, designs to be avoided, and the involvement of major stakeholders in the design process.

Journal of Healthcare Engineering

The pluralism that characterized the development of psychiatric services around the world created a variety of policies, care models and building types, and fostered experimental approaches. Increased complexities of care, institutional remnants, stigma, and the limited diagnostic and interventional accuracy of psychiatric treatments resulted in institutional behaviors surviving, even in newly built facilities. This was raised by research on awarded psychiatric buildings. The locus of the research comprised two acute psychiatric wards in London. Each was evaluated using the SCP model, a tool specifically developed for the evaluation of mental health facilities, identifying the relation between policy, care regime, and patient-focused environment. Data were derived from plans, visits, and staff and patient interviews. Findings were juxtaposed to those of an earlier study using the same methodology. Also, a syntactic analysis was conducted, to identify the social logic of ward layouts...

smriti dhingra

The door handle is the handshake of the building"Juhani Pallassma Architecture today revolves around aesthetics and imageability, rather it should be more about the feeling that the user imbibes while using that space. A space should have the potential to attract more than just the vision. Scale, colour, natural light, textures, landscapes are the aids through which a space can have a dialogue with the emotions in a human body by creating mental images of it which we commonly call as perception. This study focusses on the factors which could lend experiential quality to spaces and also strives to answer this one question can spaces heal? Diving in the psychology of architecture effort has been made to observe and document the mental asylums, their current flaws and their corresponding rectifications. This study will also throw light on the social stigmas that persist when it comes to mental illness and also tries to weave a relation between the psychology of patients and spaces...

DOI: 10.1108/02632771311324981

Jan A Golembiewski

"Purpose: Psychological and epidemiological literature suggests that the built environment plays both causal and therapeutic roles in schizophrenia, but what are the implications for designers? Methodology: A translational exploration of the dynamics between the built environment and psychotic illness, using primary research from disciplines as diverse as epidemiology, neurology and psychology. Findings: The built environment is conceived as being both an agonist and as an antagonist for the underlying processes that present as psychosis. The built environment is implicated through several means: Through the opportunities it provides. These may be physical, narrative, emotional, hedonic or personal. Some opportunities may be negative, and others positive. The built environment is also an important source of unexpected aesthetic stimulation, yet in psychotic illnesses, aesthetic sensibilities characteristically suffer from deterioration. This paper focuses on the role the built environment plays in psycho-environmental dynamics, in order that negative effects can be avoided and beneficial effects emphasised in architectural design. Limitations and implications: The findings presented are based on research that is largely translated from very different fields of enquiry. Whilst findings are cogent and logical, much of the support is correlational rather than empirical. Social implications: The WHO claims that schizophrenia destroys 24 million lives worldwide, with an exponential effect on human and financial capital. Because evidence implicates the built environment, architectural and urban designers may have a role to play in reducing the human costs wrought by the illness. Originality/value: Never before has architecture been so explicitly implicated as a cause of mental illness. This paper was presented to the Symposium of Mental Health Facility Design, and is essential reading for anyone involved in designing for improved mental health. Keywords: Mental Health, Facilities, Design, Urban, Psychosis, Schizophrenia. Acknowledgements: This work was supported by the Schizophrenia Research Institute, utilising infrastructure funding from the NSW Department of Health. ""

"Purpose: Perhaps nowhere is the significance of architectural design greater than for psychiatric care facilities. There’s 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 highly consequent in a psychiatric facility. It’s of critical importance, therefore, that a psychiatric milieu is sympathetic and doesn’t exacerbate the psychosis. Design methodology: To analyse 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 find meaning, to comprehend the environment (comprehensibility) and to be effective in his actions (manageability). Findings: Saltogenic theory can be extrapolated in an architectural context to inform design choices when designing for a stress sensitive client base. Practical implications: The design of mental health facilities has long been dominated by unsubstantiated policy and normative opinions that don’t always serve the client population. This method establishes a practical theoretical model for generating architectural design guidelines for health mental health facilities. Originality/value: Firstly, salutogenic theory is a useful framework for improving health outcomes, but in the past the theory has never been applied in a methodological way. Secondly 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."

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Vejle Psychiatric Hospital | Arkitema Architects

In February 2017 a new psychiatric hospital opened in the Danish city of Vejle. Since the opening, the hospital has registered a 50 percent decrease in physical restraint and it is widely acknowledged for its healing architecture. This was underlined in mid-June when the hospital won the Mental Health Design category at the European Healthcare Design Awards 2018 in competition with mental health buildings from all over the world.

photography by Niels Nygaard

Vejle Psychiatric Hospital is designed by Arkitema Architects as part of a Public-Private Partnership, where the PPP team designs, build and run the building. The idea of the hospital was to create a visionary mental health hospital with 91 beds, children’s ambulatory, psychiatric ER and ECT. The background for the project is a regional focus on outpatient treatment. Thus, the new hospital supports the treatment of patients with intensive and complex behavioral conditions which require hospitalization.

Floor Plans

A primary design focus has been on a visionary healthcare design which encourages physical activity and minimalizes forceful intervention. During the design process, the focus was to create the best possible surroundings for patients as well as employees. This is done by ensuring ample light throughout the building, easy access to nature and outdoor spaces, transparent wards with easy overviews, and a well thought layout. In the layout extroverted functions such as ER reception and children’s psychiatry are located as inviting units upon arrival, while wards are withdrawn within the building. The enclosed First-floor links administration and discreet patient transport in a ring structure which expresses a spatial division and forms a clear hierarchical façade.

Green access and plenty of light

The hospital is gently placed at the bottom of a forest covered hillside. The plan layout is made up of smaller square masonry building units that twist from another, which makes room for prolonging the surrounding nature into the spaces between the buildings. The building breaks down the scale, merge with the landscape and thereby match the surroundings. To ensure the full outcome of lights healing effect on psychiatric patients the architects have designed the building with a special focus on both natural and artificial light. Glass panels and interior courtyards bring ample daylight into the building. Withdrawn ceilings and interior glass help light extend even further through the building. Furthermore, 24 hours of colored light therapy is integrated into the wards for calming recovery, sleep support, elimination of depression and the preservation of a natural circadian rhythm for staff and patients.

Project Info: Architects: Arkitema Architects Location: Nordbanen 5, 7100 Vejle, Denmark Lead Architect: Wilhelm Berner-Nielsen Area: 17000.0 m2 Project Year: 2017 Photographs: Niels Nygaard Manufacturers: Troldtekt, Skandi-Bo, Protec Project Name: Vejle Psychiatric Hospital

Tags: Arkitema Architects Brick Courtyard Denmark Glass Niels Nygaard Steel Structure Vejle Psychiatric Hospital Wood

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Psychiatric Hospital, Helsingør

Typologies Health Hospital
Date 2002 - 2005
City Elsinor
Country Denmark
Photographer Dragor Luftfoto Peter Sorensen Esben Bruun

The Psychiatric Hospital in Helsingør, a port city in Denmark, is halfway between the suggestive forms generated by the new digital technologies and the rigorous geometries that characterize the more functional structures. In the research prior to the project design, an exhaustive analysis of the program and the needs of the client was done, as well as interviews with the daily users of the clinic, both medical staff and patients. The different inputs did not give any clear answers regarding what the psychiatric hospital should be like. Rather, they pointed out several paradoxes and ambiguities that were brought into the program: open and closed, centralized and decentralized, freedom and control, privacy and sociability. These conflicting qualities became part of the project design, generating a building that is and is not a psychiatric hospital.

As is known, a safe and welcoming atmosphere is essential for the good development of pyschiatric treatment and the well-being of patients. Modern treatment and therapies require a new type of architecture combining a rational and efficient program with homely and private spaces that help patients feel secure and comfortable. From the beginning, the hospital design avoided clinical stereotypes: hallways without windows and rooms on both sides with artificial, easy-cleaning materials such as plastic or linoleum in cold, grey colors. In this project, all materials have their natural surfaces: wood, glass and concrete in lively colors to create spaces that are far from the typical sad and dull image of hospitals.

Functionally the program reconciles residential use and healthcare services, public and private areas, and also defines spaces for different types of users. The star-shaped hybrid building gathers communal areas in a central node and organizes the rooms of patients, the offices and medical staff areas in a snowflake structure, separated by plant-filled triangular sections. In this way, two sets of rooms face the lake and one set of rooms faces the surrounding hills, all of them with direct access to the exterior. Organized in two levels, the building blends into the hilly landscape, with courtyards resembling cuts on the terrain. One of the galleries in the treatment program stretches out like a bridge that links up with the existing hospital and becomes a flexible structure for expansion due to future development and needs. [+] [+]

Cliente Client Frederiksborg County, Helsingør Hospital

Arquitectos Architects BIG-Bjarke Ingels Group Socios responsables Partners in charge: Bjarke Ingels, Julien De Smedt Jefe de proyecto Project leader: Jakob Eggen Jefe de obras Project architect: David Zahle Mánager de proyecto Project manager: Leif Andersen Equipo de proyecto Project team: Anders Drescher, Anna Manosa, Annette Jensen, Ask Hvas, Casper Larsen, Christian Finderup, Dennis Rasmussen, Finn Nørkjær, Hanne Halvorsen, Henrik Juel Nielsen, Ida Marie Nissen, Jakob Møller, Jamie Meunier, Jesper Bo Jensen, Jesper Wichmann, Jørn Jensen, Kasper Brøndum Larsen, Lene Nørgaard, Louise Steffensen, Nanna Gyldholm Møller, Simon Irgens-Møller, Thomas Christoffersen, Xavier Pavia Pages

Colaboradores Collaborators Moe & Brødsgaard (ingeniería engineers ); Ncc Construction Denmark (construcción construction ); JDS Architects

Fotos Photos Dragør Luftfoto; BIG; Peter Sørensen; Esben Bruun

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Vermont Psychiatric Care Hospital

Location : Berlin, VT Project Type : Healthcare Area Supplied : Corridors, Bathrooms, Lobby Products : Mosa Greys, Light Warm Grey | 24″ x 24″; 12″ x 12″, Mosa Beige & Brown, Grey Brown | 6″ x 6″, Mosa Murals Lines, Dark Anthracite | 6″ x 12″, Mosa Global Turquoise | 6″ x 6″, Mosa Terra Maestricht Cool Porcelain White | 2″ x 24″; 4″ x 24″ Quantity : 15,000 Square Feet (SF) Design Firms : Prime Architect: Architecture + | Associated Architect: Black River Design Tile Installer : Tri-State Flooring, Inc.

Awards Interior Design Project, Overall Winner, Design & Health International Academy Awards, 2015 Mental Health Project, Finalist, Design & Health International Academy Awards, 2015 World Architecture News (WAN) Healthcare Awards Shortlist, 2015 Merit Award, American Institute of Architects, Eastern New York Chapter, 2014

At the Vermont State Hospital in Waterbury, VT, 50 patients were displaced by the storm, and the hospital had to be closed permanently due to the resulting damage. Many viewed this as a “blessing in disguise” as the facility, originally constructed in the early 1900s, did not have air conditioning, proper fire safety, adequate treatment facilities, or access to outdoor space for the patients.

Hurricane Irene forced that solution. Most of the 54 beds available at the hospital were replaced by the new 25-bed, state-of-the-art Vermont Psychiatric Care Hospital in Berlin. The new hospital draws upon the findings of cutting-edge research in order to promote healing and reduce aggression in psychiatric facilities. The two facilities couldn’t be more drastically different.

Challenge Architecture+ was tasked with creating the design that would turn the facility around. The time had come for the hospital to be given a fresh start. Architecture+ sought an interior design concept that would pull elements from the Vermont landscape as inspiration. The finish materials and color selections needed to create a soothing and restorative environment.

When Architecture+ approached Creative Materials, the designer shared that the project needed to be fast-tracked, and the preference would be to use Mosa tile for its clean look and high quality. Mosa offers a vast array of color and finish options, and all tile is rectified to precise tolerances which allow for the achievement of tight grout joints while minimizing the risk of lippage.

Solution Creative Materials has strong knowledge of Mosa’s vast collections and recommended the options that would suit the space and desired aesthetic. The designer went with soothing browns and greys that would complement the healing design, and a turquoise and brown mosaic-look for the lobby.

The Creative Materials project team closely monitored the progress of the project and coordinated the successful production and supply of material to ensure that no circumstances would compromise the Mosa material selection originally made by the design team.

The facility now houses patients with diverse diagnoses in a secure, updated environment and provides a safe and therapeutic setting with the aesthetics of traditional Vermont design. Creative Materials is proud to have contributed to this project which won several awards including overall winner at the Design & Health International Academy Awards in 2015 and was described as a space that “commences with grace and proceeds with serenity and respect.”

Download Vermont Psychiatric Care Hospital Case Study

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Architecture for psychiatric treatment by Livia Wicki
Al Wakrah Psychiatric Hospital
Mental health facility design: The case for person-centred care
Kronstad Psychiatric Hospital / Origo Arkitektgruppe
architecture norway
New Psychiatric Hospital in Slagelse, Denmark, by Karlsson and VLA

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COMMENTS

Vejle Psychiatric Hospital / Arkitema Architects
Text description provided by the architects. In February 2017 a new psychiatric hospital opened in the Danish city of Vejle. Since the opening, the hospital has registered a 50 percent decrease in ...
PDF ÖSTRA HOSPITAL
www.terrapinbg.com Östra Hospital Psychiatric Facility Above: Each care unit has a visual connection to nature in the department heart. P1 P2 P6 P8 Work Cited: Architecture as Medicine - the Importance of Architecture for Treatment Outcomes in Psychiatry. ... This case study explores the strategies used to establish a biophilic experience ...
Designing for Mental Health: Psychiatry, Psychology and the
In 1953 the American Psychiatric Association established an Architectural Study Project in collaboration with the American Institute of Architects. The project brought together a wide range of experts from psychiatry and the behavioural sciences and the planning and design professions to provide solutions to the ailing mental hospital system in North America. They began to focus attention on ...
Architectural Design Qualities of an Adolescent Psychiatric Hospital to
There are major differences between the needs of adolescent and children or adults in a psychiatric hospital. Although individuals under the age of 18 are considered children and may all share the need of parental support, adolescents require more control and peer socialization (Borg-Laufs, 2013).While previous studies have proven the impact of the built environment of a psychiatric hospital ...
Architecture for psychiatric treatment by Livia Wicki
Report gives a broad overview of architecture for the psychiatric treatment. Historical point of view up to modern psychiatric institutions. Master Thesis for Master of Science in Architecture.
Östra Psychiatry Hospital
2006. BUDGET. $50M - 100M. Closed psychiatric departments have locked doors. But it does not mean that the indoor environments need to have a heavy, institutional feel. The opposite is actually a precondition for achieving a healing environment. An overall desire at Östra Hospital was to break the stigmatisation associated with psychiatric care.
A Secure Unit for Psychiatric Treatment and Rehabilitation
LIST OF CASE STUDIES. 16. 2.2. NIMHANS. 17. 2.3. VSIMH. 21. 2.4. BROADMOOR. 25. 2.5. ... Modelled based on Morstley Hospital, London. ... ARCHITECTURE FOR PSYCHIATRIC TREATMENT EPFL - École ...
(PDF) DESIGN FOR PSYCHIATRIC PATIENTS: THE COMPLEXITIES ...
The origins of Community Mental Health Architecture Baker and Sivadon [5] proposed to WHO a system of psychiatric care that included design guidance for a hospital integrated with satellite ...
Architecture as change-agent? Looking for innovation in contemporary
Introduction. In Australia, the USA and the UK, the number of hospital beds required for forensic mental health treatment doubled between 1996 and 2016.1 Current trends and future predictions suggest this demand will continue to grow. But, in an age where evidence-based practice is highly valued, the demand for new facilities already outpaces the availability of credible evidence to guide ...
Östra Hospital Acute Psychiatry Ward
Architecture on the inside of life. The design of Östra Hospital's Acute Psychiatry Ward creates a free and open environment that breaks down preconceptions formed by traditional institutional environments. Evidence-based research suggests that successful care requires the gradual increase of patients' personal space from their room, to ...
Architecture for Psychiatric Environments and Therapeutic Spaces
To present a comprehensive review of the research literature on the effects of the architectural designs of mental health facilities on the users.BACKGROUND: Using a team of cross-disciplinary researchers, this review builds upon previous reviews on general and geriatric healthcare design in order to focus on research undertaken for mental health care facility design.METHODS: Sources were ...
Psychiatric Hospital Ballerup by RUBOW Arkitekter
25,000 sqft - 100,000 sqft. Healing architecture in a suburban park. The project is based on the vision of Healing Architecture, latest research and the client's vision for future psychiatric treatment. Visions that place the patient in the center of their own treatment, with focus on good working conditions and use of the built environment ...
Vejle Psychiatric Hospital
The idea of the hospital was to create a visionary mental health hospital with 91 beds, children's ambulatory, psychiatric ER and ECT. The background for the project is a regional focus on outpatient treatment. Thus, the new hospital supports the treatment of patients with intensive and complex behavioral conditions which require hospitalization.
RIT Scholar Works
RIT Scholar Works | Rochester Institute of Technology Research
Building for Change: Comparative Case Study of Hospital Architecture
Methods: The study compares two hospital buildings with a very similar configuration and medical program but with significantly different architectural design strategies: One was designed for an unknown future medical function, and the second was designed for a specific medical function. The study analyses the two hospital buildings by their ...
Psychiatric Hospital, Helsingør
The Psychiatric Hospital in Helsingør, a port city in Denmark, is halfway between the suggestive forms generated by the new digital technologies and the rigorous geometries that characterize the more functional structures. In the research prior to the project design, an exhaustive analysis of the program and the needs of the client was done ...
Vermont Psychiatric Care Hospital Case
Hurricane Irene forced that solution. Most of the 54 beds available at the hospital were replaced by the new 25-bed, state-of-the-art Vermont Psychiatric Care Hospital in Berlin. The new hospital draws upon the findings of cutting-edge research in order to promote healing and reduce aggression in psychiatric facilities.
PDF DESIGN DILEMMAS IN MENTAL HOSPITAL ARCHITECTURE
provides a description of the themes and topics that are often mentioned in the literature about mental hospital architecture. Finally, it makes a case for studying hospital environment through dilemmas - pairs of contradicting characteristics, rather than through single elements. The dilemmas are illustrated with the examples of contradictory
PDF Architecture for specific patients (Case study of psychiatric patients
Architecture for specific patients…. Khajehpasha, Saeidi H & Khanmohammadi 48 Journal of Studies in Social Sciences and Humanities,2022,8(1), 45-53, E-ISSN: 2413-9270 A Brief Look into the World of Schizophrenia Schizophrenia is a chronic and debilitating illness affected one percent of population (Sadock, , Sadock