Stressed Spaces - Mental Health and Architecture

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Stressed Spaces: Mental Health and Architecture
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MENTAL HEALTH AND ARCHITECTURE LITERATURE REVIEW
Stressed Spaces:
Mental Health and Architecture
Kathleen Connellan, PhD; Mads Gaardboe, MA; Damien Riggs, PhD;
Clemence Due, PhD; Amanda Reinschmidt; and Lauren Mustillo
ABSTRACT
OBJECTIVE: To present a comprehensive review of the research litera- RESULTS: Key themes that emerged were nursing stations, light, ther-
ture on the effects of the architectural designs of mental health facilities apeutic milieu, security, privacy, designing for the adolescent, forensic
on the users. facilities, interior detail, patients’ rooms, art, dementia, model of care,
gardens, post-occupancy evaluation, and user engagement in design
BACKGROUND: Using a team of cross-disciplinary researchers, this process. Of the 165 articles (including conference proceedings, books,
review builds upon previous reviews on general and geriatric healthcare and theses), 25 contained numerical data from empirical studies and
design in order to focus on research undertaken for mental health care 7 were review articles.
facility design.
CONCLUSIONS: Based on the review results, especially the growing evi-
METHODS: Sources were gathered in 2010 and 2011. In 2010 a broad dence of the beneits of therapeutic design on patient and staff well-being
search was undertaken across health and architecture; in 2011, using and client length of stay, additional research questions are suggested
keywords and 13 databases, researchers conducted a systematic search concerning optimal design considerations, designs to be avoided, and the
of peer reviewed literature addressing mental health care and architec- involvement of major stakeholders in the design process.
tural design published between 2005 to 2012, as well as a systemat-
ic search for academic theses for the period 2000 to 2012. Recurrent KEYWORDS: Evidence-based design, hospital, interdisciplinary, litera-
themes and subthemes were identiied and numerical data that emerged ture review, post-occupancy
from quantitative studies was tabulated.
AUTHOR AFFILIATIONS: Kathleen Connellan, PhD, is a Senior Lecturer in the CORRESPONDING AUTHOR: Kathleen Connellan, PhD, Division of Education,
Division of Education, Arts and Social Sciences in the School of Art, Architec- Arts and Social Sciences; School of Art, Architecture and Design; University of
ture and Design at the University of South Australia in Adelaide, South Austra- South Australia, City West Campus, Adelaide, South Australia 5001, Australia;
lia, Australia. Mads Gaardboe, MA, is the Head of School for the School of Art, Kathleen.Connellan@unisa.edu.au; +61 8 830 20355.
Architecture and Design at the University of South Australia in Adelaide, South
Australia, Australia. Damien Riggs, PhD, is a Senior Lecturer in Social Work PREFERRED CITATION: Connellan, K., Gaardboe, M., Riggs, D., Due,
and Social Planning in Social and Behavioural Sciences at Flinders University C., Reinschmidt, A., & Mustillo L. (2013). Stressed spaces: Mental health
in Adelaide, South Australia, Australia. Clemence Due, PhD, is an Associate and architecture. Health Environments Research & Design Journal, 6(4),
Lecturer and Research Associate in the School of Psychology at the University pp. 127–168
of Adelaide in Adelaide, South Australia, Australia. Amanda Reinschmidt and
Lauren Mustillo are Research Assistants at the University of South Australia in
Adelaide, South Australia, Australia.
© 2013 VENDOME GROUP LLC HEALTH ENVIRONMENTS RESEARCH & DESIGN JOURNAL 127
LITERATURE REVIEW SUMMER 2013 • VOL. 6 NO. 4, pp. 127–168
Introduction
he research question identiied for this literature review was: How does the
intersection of mental health care and architecture contribute to positive mental
health outcomes? We arrived at this research question because it is suiciently
focused but still broad enough to incorporate important variables such as difer-
ent models of care.
he University of South Australia’s Mental Health Research Group was the cata-
lyst for the formation of an interdisciplinary team of researchers across architec-
ture, design, mental health practice, and psychology. he team, called “Stressed
Spaces: Mental Health and Architecture,” won two consecutive university fund-
ing grants to conduct research in purpose-built mental health facilities in 2010
and 2011. As part of that collaboration, a survey on the existing literature on the
crossover of mental health and architectural research was conducted. he scar-
city of research literature dealing with both mental health and architecture along
with the speciic lack of evidenced-based research was noted, prompting the
team to conduct additional research. In the process, the team wrote this review
article building upon the most recent literature review publications, from Ulrich
et al. (2008) in general healthcare, to Dobrohotof and Llewellyn-Jones (2010)
on geriatric healthcare.
he objective of this article is to present an updated review of the literature across

health and architecture, but with a speciic focus on mental health care and
design in order to make a contribution to this ield and assist other researchers,
architects, and clinical practitioners in their quest for improved mental health
outcomes. he multiple considerations in the complex crossover of architectural
design and mental health require multidisciplinary collaboration, as is evidenced
by our team of researchers, policy makers, advisors, and partners. he team com-
prises two architectural irms that specialize in healthcare design, one based in
Australia and the other in the United Kingdom; one experienced architect now
heading the School of Art, Architecture and Design at the University of South
Australia; two social scientists with backgrounds in psychology; one senior men-
tal health nurse; one professor in mental health nursing at the University of
South Australia; and one senior lecturer in design theory at the University of
South Australia, specializing in design and well-being. Such collaborations have
been indicated as an essential aspect of the development of nine more eicacious
designs.
he broad socio-economic and political context factors present at the time this
article was written included the social context of an aging population in most
Western and “developed” countries; the “modern” diseases frequently associated
with those countries (such as depression and mental illness, substance abuse,
diabetes, obesity, heart disease); the political power held by aging baby boomers
(who form a large and comparatively wealthy demographic) to demand compre-
hensive health services; the technological impacts of extending life at all costs;
the costs of providing the expected standards of healthcare; and the attendant
hospital facility construction boom. With these contexts and issues in mind, we
observed the emergence of the following themes from the current body of litera-
ture: nursing stations, light, therapeutic milieu, security, privacy, designing for
128 WWW.HERDJOURNAL.COM © 2013 VENDOME GROUP LLC

the adolescent, forensic facilities, interior detail, patients’ rooms, art, dementia,
model of care, gardens, post-occupancy evaluation, and user engagement in the
design process. From these key themes, we learned that only some (25 of the 165)
research articles generated evidence-based numerical data. From this data, we
also know that the key themes also represent the areas that require more research
as they are identiied as crucial to improved mental health outcomes. here is no
question that the old institutional model of care with its associated asylum-style
architectural design is anathema to mental health practice; however, with the
construction of new facilities, we question the extent to which seemingly inno-
vative designs match contemporary mental health models of care. he gaps in
research represent the lack of reliable post-occupancy reviews of facilities. here-
fore, this review also questions why that gap exists. Do, for example, ethical pro-
tocols and concerns with qualitative methods on vulnerable populations present
too much of an obstacle for researchers and hospitals?
Of the 165 research articles, seven were literature review articles, published
between 2000 and 2010. he primary reason for writing any literature review is,
of course, to share the state of research on a particular subject with the commu-
nity. However, this is not the sole reason for doing so, and each of the seven liter-
ature review fulills its own perceived need. Two concentrate upon aged care and
design (Day, Carreon, & Stump, 2000; Dobrohotof & Llewellyn Jones, 2010),
and the remaining ive center on design with diferent foci: light and lighting
(Anjali, 2006); art (Daykin, Byrne, Soterious, & O’Connor, 2008); safety (Reil-
ing, Hughes, & Murphy, 2008); patient rooms and well-being (Lorenz, 2007);
and evidenced-based design (Ulrich et al., 2008). Each of the review articles
summarizes the recommendations based on previous indings; however, the
indings of these predominantly systematic reviews emphasized to us that this
area of research runs the risk of losing itself in disparate detail. Consequently,
there is a need for more frequent comprehensive reviews of the broad ield of
mental health and architecture crossovers in the research literature so as to form
a platform for other more focused and detailed studies.
Methodology
For this article we combined comprehensive and systematic reviews of the litera-
ture on mental health and architecture. he reason for this lies in the two sepa-
rate time periods dedicated to the literature surveys. he irst time period (2010)
involved a scoping study, which included architecture and health websites and
did not set dates or tight exclusions for the searches. In the second time period
(2011) we utilized selected databases, set dates, and utilized a deined keyword
search criteria (see Table 1). he initial scoping study resulted in 78 articles, of
which 19 were annotated according to their mental health focus and empiri-
cal/numerical data. On the basis of these indings, we developed a systematic
approach to build upon the irst literature search, retaining the articles that pre-
dated the set start dates for the second literature search.
he dates set for searching the literature in the second (systematic stage) were
2000–2011. he keywords used for the searches are listed in Table 1 and the
databases searched are listed in Table 2. he keywords were chosen based on
Table 1. List of Keywords Used in Searches
Mental health Psychiatry unit Built environment Evidence-based design

Mental illness Psychiatric hospital Therapeutic environments Post-occupancy evaluation
Mental health care Psychiatry Therapeutic gardens Facility design
Mental health facilities Wayinding Healing gardens Interior design
Healthcare facilities Architecture Architectural design
our 2010 scoping study as well as those used by other literature review articles
(included for discussion in this article).
In addition to peer-reviewed articles, the team inspected the bibliographical ref-

erences of selected papers, and identiied key sources that could be added to
the literature. Other than the search parameters already mentioned, addition-
al exclusions for the searches were (a) government reports and (b) non-English
language texts. Reasons for these exclusions were that government reports had
been included in the initial scoping study and we subsequently found that sig-
niicant indings of such reports were reconstituted into journal articles, and the
language was restricted to English to facilitate understanding in an English-
speaking research team.
Once the literature was collated and annotated, we identiied key themes (Table
3); peaks and troughs in publication dates (Figure 1); and expertise and loca-
tion of studies. he 13 major themes which emerged from the literature were
security/privacy; light; therapeutic milieu; gardens; impact of architecture on
mental health outcomes; interior detail/patients’ rooms; psychogeriatric demen-
tia; post-occupancy evaluation; user engagement in design process; nursing sta-
tions; model of care; art; designing for the adolescent; and forensic facilities.
For the purposes of this review article, we have combined and summarized the
themes based on refereed articles and empirical indings; consequently, books,
book reviews, theses, and theoretical papers contribute to the discussion but do
not constitute the core material. We discuss the themes in an order that approxi-
mates (with some exceptions) the signiicance and visibility of the theme in the
literature. Table 3 details the number of key articles for each theme and whether
those include literature review articles.
Table 2. List of Databases
PsycINFO MEDLINE
MEDLINE Plus Ovid Nursing Database
ProQuest, nursing and allied health source ProQuest, theses
PsycArticles Psychology a SAGE full text collection
SAGE Health Sciences EBSCOhost
JSTOR Arts and Sciences I-X Collection Wiley Online Library
Google Scholar

Table 3. Key Themes Found in the Literature

THEME NO. OF ARTICLES LIT. REVIEW
1. Security 38 yes
2. Light 24 yes
3. Therapeutic milieu 34 no
4. Gardens 21 no
5. Impact of architecture on health outcomes 15 yes
6. Interior design 11 yes
7. Psychogeriatric 7 yes (x 2)
8. Post-occupancy evaluations 11 no
9. Nursing stations 12 no
10. Model of care 7 no
11. Art 5 yes
12. Adolescents 6 no
13. Forensic psychiatric facilities 2 no
Figure 1 shows that there has been an increase in research in the last 10 years, and
particularly in the past 5 years. he x-axis includes the years when articles that
included architectural design/space in addition to one of the 13 themes listed
on the y-axis. he y-axis illustrates of the amount of articles published on those
themes during those years and not a precise igure. hemes have been patterned
diferently for visual recognition. Much of this research has concentrated on gar-
dens, interior design, and nursing stations, together with the overall impact of
architecture. he professional and academic expertise of lead authors contribut-
ing to this body of literature is concentrated in the ields of psychiatry (17 arti-
cles) and psychology (16 articles); there are also 17 articles with lead authors from
the ield of architecture and 4 from interior architecture. he remaining areas of
expertise show single igures in the number of articles represented for this study
but they include public health, public administration, sociology, nursing, neuro-
science, medical anthropology, health design, forensic psychiatry, engineering,
medicine, arts, and animal behavior. We also noted that research across mental
health and architecture is more concentrated in the United States—California in
particular—Canada, Australia, the United Kingdom, and to a lesser extent Swe-
den, Norway, India, and Israel. he reason for less representation from Europe
in this review may be that we only looked at English language publications for
ease of comprehension.
Security
he theme of security stretches across literature concerning all users of facilities,
including patients, all staf, and visitors. he subthemes emerging from the lit-
erature are spatial analysis and spatial mapping; it for purpose; violence; crowd-
ing; environmental stress; quality of care; stigma; risk management; nurse safety;
safe practice; and prevention strategies and assessment.
Figure 1. Peaks and troughs of publication dates, grouped by theme.

Number of Articles Published
Kumar and Ng (2011) based their discussion on three background studies. he

irst is Haller and Deluty’s 1988 study of 566 psychiatric and 898 non psychi-
atric beds from 16 psychiatric and general hospitals in the U.S., which report-
ed 2.54 assaults per bed yearly among psychiatric wards, compared with 0.37
assaults per year in non-psychiatric units. he second is a 1991 British study
completed by Davis, who collected data over 15 months and reported that the
number of violent incidents in the second half of the study period constituted a
highly signiicant (240%) increase over the number in the irst half. he third
is an American study in which Reid, Bollinger, and Edwards (1985) reported a
32.9% increase in assault rates from 1978 to 1980. hese numbers make it clear
that both patients and staf are at risk from widespread and increasing violence
on psychiatric wards. Crowding appears to be emerging as one of many potential
risk factors for safety issues. Kumar and Ng explain that density, privacy, and
control are major contributing factors because “not only are patients objectively
crowded, but they also may strongly experience subjective crowding in such high
density situations” (p. 434). With density, patients lose privacy and also control
over their immediate environment. his situation can be reversed by incorpo-
rating architectural principles that enhance the therapeutic environment, and
Kumar and Ng cite Gulak (1991) in suggesting “dedicating space for social inter-
action; clearly indicating a room’s intended use; making areas visually distinct
so intended use of diferent parts can be delineated from their appearance; using

colors to enhance activities and spaces; using various materials

to provide diferent tactile and visual experiences; using light- Not only are patients objectively
ing to help deine space; and inally, making the spaces that crowded, but they also
have special meaning to patients stand out” (p. 434).
may strongly experience
None of the above elements (or the lack thereof) provide the subjective crowding in such
sole explanation for the violence associated with crowding; high density situations.
possible reasons can only come from combinations and exam-
ination of speciic sites. Kumar and Ng refer to Nijman and
Rector’s 1999 study that found providing additional space on an acute-care psy-
chiatric ward lessened episodes of aggression.
Johnstone (2004) notes that people in ward environments occupy 70% less space
than did their counterparts of 150 year ago. Johnstone drew his indings from
the National Patients Safety Agency’s (NPSA) country pilot audit that revealed
that “out of 1,367 [statutory] mental health notiications, 89% relate to unsafe
ward environments, [and within that 89%] 438 reports relate to violence and
aggression, 300 reports relate to self-harm, 107 reports relate to absconding, and
39 reports relate speciically to the environment” (p. 30). Johnstone does not pro-
vide the additional report details but emphasizes that the goals to be achieved to
ensure it for purpose are safety, privacy, dignity, and adequate areas for thera-
peutic treatment, and warns that even if a building is “big enough, clean and
beautiful to look at” (p. 1), that cannot be seen as an end unto itself. It must be
adequate in terms of both therapeutical potential and freedom of movement.
Brickell and McLean (2011) focused on patient security in terms of quality of

care, stigma and health outcomes. hey built upon existing research by soliciting
the help of Canadian, Australian, and American mental health care professionals
working in the ield of patient health and/or patient safety, which led to inter-
views with 72 participants. hese interviews revealed a diversity of perspectives
on patient safety and mental health but an absence of a clear deinition, lead-
ing to the confusion over whose safety is covered by the term. One interviewee
observed that “when you look at patient safety issues … [it’s] about keeping staf
safe from patients, and it’s not about how do we keep the patient safe” (p. 41).
hirty-two percent of those interviewed felt it necessary to balance patient safe-
ty with their rights and autonomy. Interviewees also cited such adverse events
as slip-and-fall accidents, concerns about medication and substance abuse, the
potential for self-harm or sexual assault, the issue of smoking and threat of ire,
the risk of leaving the facility without authorization, and harm resulting from
restraints as signiicant concerns.
Security concerns were also implicated in terms of issues around measures taken
to protect clients from self-harm. For example, Langan and McDonald (2008)
addressed patient dignity via the clothes they are permitted to wear in the units.
In an acute psychiatric inpatient setting in the Republic of Ireland, Langan and
McDonald used a triangulation research design to investigate the prevalence of
attitudes towards the practice of “dressing inpatients in night attire during day-
time despite the lack of evidence to support its beneit in reducing absconding
or self-harm.” Case note reviews from their study revealed a high prevalence of
this practice (57%) and its signiicant association with involuntary admission.
heir results also showed that “nursing staf believed that using night attire was
efective at reducing absconding and self-harm, and that only voluntary patients
should retain the right to choose their clothes. Most patients interviewed were
uncomfortable in night clothes and indicated that they should be entitled to
choose what to wear.” In fact, the researchers observed that, while it may run
counter to the advice of some psychiatrists, it should be noted that “patients may
perceive this as undermining their autonomy” and a diferent approach may be
“more acceptable to patients and more respectful of their dignity” (p. 223).
Jayaram and Herzog (2008) conducted a study under the auspices of the Com-
mittee on Patient Safety for the American Psychiatric Association in which they
reviewed “SAFE MD”:
• S—suicide
• A— aggressive behavior and promotion of the safe use of
seclusion and restraints
• F—falls
• E—elopement
• M—complications when dealing with medical co-morbidities
• D—drug/medication errors
In addition, this study focuses on safe practice, prevention strategies, and assess-
ment. he results deal with frequency of SAFE MD events applicable to psychi-
atric care. In an analysis of 3,548 events in 2005, the authors noted events that
included suicide (13.1%), medication errors (10.1%), patient falls (5.3%), death
or injury due to the use of restraints (3.9%), and elopement (1.9%).
Commonalities among all publications that relate to safety and security include
the acknowledgment of increased crowding and loss of privacy as a risk factor;
“violence against patients and staf in psychiatric wards is both prevalent and
increasing” (Kumar & Ng, 2001, p. 433); general recommendations are that
standardized, single variable-acuity rooms mean that patients do not have to be
moved when their condition changes, enhancing a sense of normalcy and con-
trolling the spread of infection (where applicable). In addition, visually distinct
spaces ensure that the function of the space is clear.
Light
he second distinct theme that emerged as a signiicant design feature afecting
mental health outcomes was that of light and lighting. Although we give light
and lighting a separate focus in this review article, it is also the one theme that is
common to all others. A major subtheme is that of natural light, which is linked
to the following issues in the literature: eating disorders, depression, circadian
rhythm, Alzheimer’s disease, sensory stimulation, therapeutic design, and thera-
peutic patient rooms.

Joseph’s 2006 review of the available literature focused on the impact of light on
outcomes in healthcare settings (without a speciic focus on mental health facili-
ties) and divided the indings into several categories. he irst category was the
way in which lighting enables accurate performance of visual tasks, logically,
by reducing error. he second was how light afects mood and perception. In
that case, it was noted that positive impacts included daylight and proximity to
windows; alternately, the negative impact of “glare and thermal discomfort on
mood and task performance” were evident. he third category in Joseph’s review
focused on the control of the circadian system, which included a number of ben-
eits (e.g., substantial increases in the quality of sleep and enhanced rest–activity
patterns in patients with dementia). Joseph also mentioned eleven studies that
suggested connections between exposure to bright light and depression; symp-
toms of seasonal afective disorder (SAD) and the depressive phase of bipolar
disorder were diminished through exposures “between 2,500 and 10,000 lux,”
with the greatest beneits found in the morning rather than the evening. Further,
Joseph cited Beauchim and Hays (1996) as well as Benedetti et al. (2001) as doc-
umenting a connection between exposure to light and the length of depressed
patients’ stays in the hospital.
Joseph referenced the work of Watch et al. (2005) as to bright versus shaded sides
of the hospital in stating that “patients staying on the bright side of a hospital
unit were exposed to 46% higher-intensity sunlight on average; it was found that
patients exposed to an increased intensity of sunlight experienced less perceived
stress, marginally less pain, and had 21% less pain medication costs” (p. 6). he
recommendations for adjusting light and lighting to facilitate good health out-
comes from Joseph’s review pointed to the following: provide windows for natu-
ral light in patient rooms, with provisions for control of glare and temperature;
orient patient rooms to maximize early morning sun exposure; provide high
lighting for complex visual tasks—reduce errors; provide windows in staf break
rooms (p. 9).
In a paper on healing spaces, Schweitzer, Gilpin, and Frampton (2004) noted

the diferent efects of natural versus artiicial lighting on patients, speciically in
the areas of illuminance, uniformity, difusion, color, and UV radiation. hese,
in turn, afect human chronobiology, contributing to, for example, seasonal
afective disorder (SAD), sleep disorders, and work disruptions. In addition, the
natural circadian rhythm of light regulates melatonin production, inluencing
biochemical and hormonal body rhythms. On this topic, Basinger’s (2011) thesis
says that the body’s circadian rhythms are governed by eating and regulation to
natural light cycles; therefore, because eating disorder patients cannot use food
to regulate the body, natural light is a key design consideration. Brawley’s 2001
article in Aging & Mental Health asserted that light requirements for older people
may be ive times higher than that of young people. Older adults take between
5 and 30 minutes to adapt to change when entering space with considerably
lower light level, such as entering from outside. Brawley focused on the links
between Alzheimer’s, therapeutic design, and sensory stimulants, saying that
lighting is important for more than just vision, afecting endocrine systems and
producing Vitamin D, as well as other beneits already mentioned. he positive
associations of daylight and routine activities outdoors with sensory stimulation
and interaction with nature was seen to have a beneicial efect on patients suf-
fering from Alzheimer’s; however, the problem of controlling indoor glare and
licker were also acknowledged. In a study conducted in a psychiatric hospital
in Edmonton, Canada, over a 2-year period in the late 1990s, Beauchemin and
Hays (1996) observed that patients in brightly lit rooms stayed on average 16.9
days versus19.5 days for those in dimly lit rooms, a diference of nearly 3 days
(2.6 days diference).
Commonalities for all publications related to light include the importance of

controlling the circadian system. Natural circadian rhythms regulate melatonin
production, which inluences biochemical and hormonal body rhythms, which
have the following efects upon mental health: reduced depression, decreased
length of stay, improved sleep and circadian rhythm, lessened agitation, eased
pain, and easier adaptation to night-shift work. he interdisciplinary aspect of
light makes it a challenging theme for focused research; for example, Joseph’s
2006 literature review crossed the disciplines of architecture, medicine, psychol-
ogy, ergonomics, and lighting design.
Therapeutic Milieu
he therapeutic milieu incorporates a range of thematic features that overlap
with other key issues but which we combine into a single theme that encompasses
the social and psychological aspects of environmental design. herapeutic milieu
is a term that is also interchangeable with patient-centered design and healing
environments. Consequently, the subthemes included here are both numerous
and varied; they include rehabilitation, best practice considerations, ambient fea-
tures, social features, nursing stations, staf perceptions, program evaluation,
the Planetree approach, positive design, multidisciplinary input, architectural
change, and psychiatric intensive care units.
Novotna, Urbanoski, and Rush (2011) focused on staf perceptions and program
evaluation in client-centered design of residential addiction and mental health
care facilities. hey discussed the indings of a 3-year series of focus groups, con-
ducted both pre- and post-occupancy between 2007 and 2009, using mixed-
method evaluation of clinical programs in a large mental health and substance
abuse facility in Canada. he main priorities of their research were (a) the impact
of the physical design on clients and service delivery; and (b) the impact of physi-
cal design on the working environment. Positive outcomes and perceptions from
the focus groups made repeated reference to comfort, abundance of natural light,
freedom, reduced stigma with new spatial designs that mimicked a “normal”
community setting and an enhanced sense of well-being; however, these were
partially balanced with negative outcomes and perceptions around limited staf
space and the ability to share conidential information, and staf concerns due to
reduced sightlines to clients as a result of the changes meant to facilitate greater
movement among staf and clients.
Golembiewski (2010) looked at the signiicance of architectural design in psy-

chiatric care facilities and analyzed the architectural elements that may inluence
mental health. He explored Antonovksy’s salutogenic theory “that better health

results from a state of mind which has a fortiied sense of coherence” (p. 100)
from an architectural perspective. From a psychiatric point of view, the saluto-
genic perspective is that the relationship between a patient and environment is
understood as being transactional and not ixed. Generally salutogenic now indi-
cates a focus upon holistic human wellbeing rather than disease cause and efect.
In this way, Golembiewski notes the environment should ensure that perceptual
cues are present to assist perceptual processes; clear textures, objects and lines
should prevent the possibility of perceptual distortion and ambiguity. Object
comprehension is manufactured through ilters of memory, culture and epis-
temology; therefore, the environment should be familiar to psychotic patients
as this helps stabilize both comprehension and delusions. Such an environment
should mimic a safe and cozy home where noise is kept to a minimum; echoes,
as well as repetitive sounds, should be eliminated as much as possible as this
exacerbates delusional “voices.” In terms of control and meaningfulness, the
salutogenic approach should encourage day to day “outside”
domestic tasks (cooking, washing) and limit the number of [B]etter health results from a
people in shared spaces. he outside world should not be sepa-
rated from the patient. For that reason, access to nature, pets, state of mind which has a
and supported communication with family and friends is fortiied sense of coherence.
essential to rehabilitation. To this end, environmental stimu-
lation should provide sensory gratiication.
Stichler’s (2008) article, “Healing by Design,” reviews the Planetree approach

to architectural design. his is not dissimilar to Golembiewski’s (2010) inter-
pretation of the salutogenic model; however, Stichler’s work does not focus on
mental health as such. She states that architectural aspects of healing environ-
ments include those elements that create an optimally restful patient environ-
ment. hese components include views to the outside or, if that is not possible,
at least images of nature; adequately sized bathrooms; extra seating provided
as an alternative to the bed; reduced noise levels; a variety of lighting options;
comfortable room temperatures; and close attention paid to aesthetics. And for
“staf, designs should address: the work low process of caregiving to minimize
the steps necessary to secure supplies and equipment; safety features that reduce
employee injuries resulting from repetitive movement, patient lifting, mobiliza-
tion, and transfers; visual access of patients from nursing stations or documenta-
tion alcoves; security designs to enhance protection of staf from hostile visitors;
and staf stress reduction with the design of respite rooms (quiet, meditative envi-
ronments)” (Stichler 2008, p. 507). hese features incorporate some of the nine
Planetree elements of patient-centered care, which are:
1. Human interaction
2. Consumer and patient education
3. Healing partnerships with the patients’ family and friends
4. Nurturing through food and nutrition
5. Spirituality
6. Human touch
7. Healing arts and visual therapy
8. Integration of complementary therapies

9. Healing environments created in the architecture and design of the
healthcare setting (p. 504)
he Planetree elements and the salutogenic model are commensurate with the
aims of he Center for Healthcare Design’s Pebble Project (http://www.health-
design.org/pebble) as well as models for “new residentialism” and “critical region-
alism,” as explained in Verderber and Fine (2000). All of these approaches strive
to move away from both the bureaucratization locked into some of the architec-
tural language of modernism (Verderber & Fine, 2000) and to depart completely
from conservatism of the institution.
Karlin and Zeiss (2006) reviewed environmental and therapeutic issues in psy-
chiatric hospital design over the 50 years prior to their article and noted several
considerations for best practice, including patient-centered design; ambient fea-
tures; architectural features (physical plan, layout, size and shape of units); social
features; and nursing station design and placement. hese authors recommended
the enhanced privacy associated with single rooms and private visiting areas that
facilitate intimacy but noted that unit design should also encourage family par-
ticipation and group activities. hey mentioned that gardens and views of nature
serve as positive distractions. In terms of interior design, furnishings should be
such that they have minimal institutional connotations, and they observed that
while the studies of the optimum choices for wall color show inconsistent results,
blue tones can be calming and bland color schemes and trendy palettes should be
avoided. hey also suggested that it is important to incorporate spatial lexibility
into design and that social features are also applicable to staf, who require loung-
es and/or a garden to promote their own communication and job satisfaction.
he theme of the therapeutic milieu in healthcare design, particularly mental

health care design, is even more dependent upon multidisciplinary expertise
than other themes. his is not a recent realization, and papers from the late
1990s include research indings regarding multidisciplinary input to design,
architectural change and positive outcomes that have remained relevant. For
example, Gross, Sasson, Zarhy, and Zohar (1998) review empirical studies and,
in particular, one case study of a psychiatric hospital in Israel where design and
execution was conducted by a multidisciplinary team of architects, psychiatrists,
and other mental health professionals and administrators. he major design goal
was for the “humane, eicient containment and reduction of severe psychopa-
thology. Here it was the role of psychiatrists and other mental health workers
to redirect the focus of ward design to the patients and their families” (p. 108).
As a result, design elements included no overcrowding so that patients were not
forced to interact with too many people; provision of a variety of spaces that
supported social interaction; an abundance of “classical” daylight and fresh air;
openness of design to encourage staf to leave the nursing station and spend more
time in the day room; meticulous care of buildings and grounds to reduce van-
dalism; easy observation of patients; and segregation of staf work and rest areas.
Dix and Williams (1996) made recommendations for the design of psychiatric
intensive care units, suggesting that the sites/wards should be on the ground

loor with access to enclosed gardens with standard fencing or hedges; that they
should have a separate entrance, and corridors should be wide enough to accom-
modate four abreast; there should be a good-sized quiet recreation room away
from the day room and that numerous corners and corridors should be avoided.
hey recommended disturbance buttons, louver-type observation panels in bed-
room doors that are operable from outside, and vandal-proof light ittings, but
also advocated ixtures and ittings that provide a homely environment.
Mazuch and Stephen (2005) explained how the London-based architectural

irm, Nightingale Associates, combined psychotherapeutic methods with tra-
ditional architectural methods to create healing healthcare environments. he
authors dubbed this “humanistic architecture,” which “draws on international
research in the ields of psychology and sociology, biology and physiology into
the efects of the environment on health” (p. 48). hese architects used emotion-
al mapping based, in general, on all the senses but also on colors associated with
the predominant emotional response aroused in particular areas. For example,
they noted that blues have been indicated to subdue aggressive individuals and
“visual monotony can contribute to physiological and emotional stress” (p. 50).
In terms of touch, Mazuch and Stephen noted the important role this can have
in the recovery of patients, as surfaces help to “re-engage with the materiality
of the world” (p. 50). hey emphasized that perceptual confusion should be
avoided (e.g., a wood-grain inish on a metal door would give inaccurate sen-
sory information because a metal door will be heavier and colder than would be
expected with a real wooden door). As to sound, excessive noise has implications
for increased heart rate, blood pressure, respiration, and blood cholesterol; they
stressed that hard materials absorb less noise. he architects noted that smell can
relax muscles and aid concentration; pleasant smells help produce endorphins
and can decrease heart rate. Further, they noted the hypothesis that pleasant
smells can reduce the amount of anesthetic administered during surgery (p. 50).
In the areas of light and nature, Mazuch and Stephen observed that a lack of
windows and connection to the outside world can heighten stress and depression.
To reiterate, the commonalities across the literature on providing a therapeutic

milieu through the design of facilities for mental health care focus on the ele-
ments of light; adequate personal, communal, and work space; home-like com-
fort; and access to gardens.
Gardens
he theme of gardens includes open spaces within the precincts of the hospital.
Subthemes include therapeutic gardens, Alzheimer’s facility, historical perspec-
tive, moral therapy, landscapes, therapeutic relationships, natural environments,
directed attention, attention restoration theory, restorative experience, stress,
nurses, evidenced-based design, and environments for renewal/stress relief. he
theme of gardens is not conined to mental health care design per se because the
healing garden is emerging as a topic for mental health in the context of general
healthcare as well. It is therefore a holistic theme that, due to its very nature, is
highly relevant to mental health care.
Hartig and Marcus (2006) recognize that the concept of healing is not synony-
mous with cure; clearly, gardens are not curative and misconceptions concern-
ing this notion should be avoided. However, they note that “healing gardens …
are allied with a broad conception of health, one that recognizes that a person
can move between greater and lesser degrees of health along diverse physical,
mental and social continua” (p. S36). hey ofer several recommendations as
to the structure of such healing gardens—there should be an absence of harsh
noises and unwanted demands, landscape architects with knowledge of heal-
ing plants should be employed to translate medical approaches. Unfortunately,
as the authors note, “sadly, many opportunities to make gardens available have
been wasted” (p. S37). his is something that Connellan et al. (2011b) also found
in their ethnographic observations of a purpose built mental health unit in Aus-
tralia. he upkeep and expense of gardens are mentioned as deterrents for their
wider use.
In the subthemes of nurses, evidence-based design, and envi-

“[S]adly, many opportunities ronments for renewal/stress relief, Naderi and Shin’s (2008)
to make gardens available study ofers useful information concerning the beneits of
outside spaces in a medical environment. hey conducted a
have been wasted.” two-part nursing staf survey in the United States based on a
landscape design project at a healthcare center in Texas. he
results of Naderi and Shin’s survey showed that the availability of an outside
space was important to those nurses surveyed; 88% said it was important to get
outside during their workday and nearly all of the participants felt it was import-
ant for their co-workers to get outside. Favorite activities included sitting (25%),
walking (21%), and eating (10%). Nine percent expressed the need to be close to
nature and get some sunshine and fresh air, while others went out to be social,
with 18% going outside to talk to friends and 3% to engage in people watching.
However, the survey found that 52% of nurses went outside to be alone and if
nurses did go out in a group, it was with one (26%) or two (20%) other people.
he need for some improvements in existing outdoor spaces was noted: 54%
didn’t use the courtyard when it rained; 44% didn’t use it when it was too hot
or sunny; 23% didn’t use it due to lack of seating; 16% because the entrance was
sometimes blocked; and 11% because they felt privacy was compromised. As a
result of the survey, two courtyard garden designs were proposed and, incorpo-
rating nurses’ responses to the proposals, landscape architects designed a court-
yard garden primarily for their use.
In terms of the speciic needs of psychiatric patients, the writings of Clare Hick-
man (2005, 2009) provide a particular perspective based on moral therapy and
historic associations with landscapes and gardens. In the 2009 article, Hick-
man draws upon English Romantic poetry, landscape painting, and the Pre-
Raphaelite art movement in the 19th century to develop her arguments on the
important relationship between mental health and nature. She refers to poets’
and artists’ beliefs in the “morality” of the landscape and the potential of natural
environments for the prevention of what was considered to be “immoral” behav-
ior. Hickman discusses in detail themes such as the Garden of Eden and being
in nature as providing a closeness to God, a rural work ethic, and the romantic
notion of man in and of the landscape. She refers to Louis James’s “Lines Com-

posed a Few Miles above Tintern Abbey” regarding civilization and industrial-
ization bringing about insanity because of the exodus from the rural idyll. Her
2005 article refers speciically to the large old parks and gardens of the 18th and
19th century asylums. he moral therapy that was part of those asylums’ treat-
ment protocol was focused on the placement of a patient in a carefully designed
environment and seeking to minimize physical restraints. It was believed that
viewing the landscape had positive efects on the patients and therefore buildings
were designed so the landscape could be viewed from inside the building as well.
Design features included verandas, conservatories, airing courts, ornate aviaries,
pagodas, and even a Chinese gallery; however the cost of creating complex land-
scapes restricted such designs to institutions accommodating a wealthy clientele.
he presence of the gardens can be one of the most positive aspects of psychiatric
treatment. Curtis, Gesler, Priebe, and Hickman (2009) noted that in the post-
asylum age of mental health care, long-term patients were known to return to
the asylums in which they were housed in order to walk in the gardens because
of an attachment to and their positive associations with the therapeutic beneits
of such places (citing Parr, Philo, & Burns, 2003).
In one article that emerged from the initial scoping study, “the restorative bene-
its of nature” are discussed in terms of developing an integrated framework that
concentrates on directed attention, attention restoration theory, and restorative
experiences for health outcomes (Kaplan, 1995). Kaplan included three com-
ponents that are necessary for the restorative experience: “being away,” which
implies not merely entering a new setting, but instead a change that “involves
a conceptual rather than a physical transformation” (p. 173); an environment
that is rich but that maintains coherence; and compatibility between the envi-
ronment and one’s own goals. In reference to attention restoration theory and
the natural environment, and drawing upon further empirical evidence to sup-
port nature as a restorative element, Kaplan noted that being in nature requires
less efort than being in a “civilized” environment; that intervention measures
suggest that the use of nature as a restorative method have longer term beneits
and participants were more likely to, for example, start new initiatives after the
intervention.
he area of mental health aged care and gardens has a growing body of evi-
denced-based research but Heath’s (2004) research is particularly useful for the
design of Alzheimer’s facilities. Heath looked at post-occupancy studies that
had been done to evaluate the therapeutic qualities of gardens and gardening in
an Alzheimer’s facility. It is a multilevel care facility in British Columbia, Can-
ada, which opened in 1995 and has eight courtyard gardens. he interview data
revealed that 75% of visitors reported feeling more relaxed and calmer and 25%
felt refreshed. he gardens were designed with ive major goals:
1. To provide a safe outdoor environment;
2. To provide a place for relection;
3. To provide a place for relaxation;
4. To provide a place for socialization; and
5. To provide a place for people to maintain the hobby of gardening

(2004, p. 239).
he results of the post-occupancy evaluation showed that of the respondents,

83% visited the gardens and 96.5% of those liked them. Additional information
from this study included that 80% of respondents said the aims of the gardens
were met, except for providing a place for people to maintain a gardening hobby,
as the gardens were already fully planted with no free space; and more family
members used the gardens than did patients or staf, with suggested reasons
being that some patients are not independently mobile, staf lacked the time to
do so, or family members found the gardens a relaxing way to relieve the stress
of ailing family members. here were also recommendations for improvements,
such as the use of signs, maps, and automatic doors to increase access and aware-
ness; further education of both staf and volunteers; the need for lawns where
families could gather rather than areas dominated by paths and garden beds;
leaving space for residents to create their own gardens; a lack of spontaneity in
the plantings; and a lack of lexible, multi-use spaces.
Common points of discussion across the literature include the use of the various
uses of gardens, access issues, retreats for staf, and speciically designed gardens.
The Impact of Architecture on Health Outcomes

he ifth theme is another general category and although it would be ideal to
have each theme discreet and separate, as was the case with “therapeutic milieu,”
there were too many articles that centered on one issue and merely mentioned
others. herefore, while this theme does overlap with others, its focus is largely
on the impact of architecture on health outcomes. Among other issues, this
category of publications addresses aesthetics and sensory stimulation as well as
spatial design. he subthemes include mental health services, psychiatric care,
salutogenic theory, sense sensitivities, emotional mapping, physiological respons-
es, psychological responses, design models, evidenced-based healthcare design,
and healthcare quality outcomes.
By far, the most extensive and inluential research on the impact of architecture
upon health outcomes is that of Ulrich and his colleagues, speciically, their
2008 comprehensive review of the research literature on evidence-based (gen-
eral) healthcare design published in this journal, Health Environments Research
& Design Journal (HERD). his review by Ulrich et al. expanded on a previous
(2004) review, especially in relation to the scale of hospital-acquired infections.
he keywords in Ulrich’s 2008 review were “evidence-based design, hospital
design, healthcare design, healthcare quality, outcomes, patient safety, staf safe-
ty, infection, hand washing, medical errors, falls, pain, sleep, stress, depression,
conidentiality, social support, satisfaction, single rooms, noise, nature, and day
light.” he three main areas of focus were patient safety, other patient outcomes,
and staf outcomes. Although this review was on general health, we regarded it
as a strong foundation for the work that needs to be done in the area of men-
tal health care. Ulrich et al. tabulated their indings (p. 148), showing where
empirical studies have revealed relationships between particular design factors

and healthcare outcomes. Ulrich’s table also indicates where “is especially strong
evidence (converging indings from multiple rigorous studies) indicating that a
design intervention improves a healthcare outcome” (p. 148). Single bed rooms,
natural and appropriate lighting, and nature views are the three most signiicant
design factors that contribute to positive health outcomes. For example Ulrich
et al. showed that patient privacy and conidentiality as well as communication
improves with single bed rooms; day and appropriate lighting contributed posi-
tively to 14 of the 16 health outcomes listed; and nature views contributes signii-
cantly to reduced pain and stress and also to ive other health outcomes (p. 148).
Ulrich et al. (2008) used a two-step approach to their review, and one upon
which, to some extent, we modeled our own review. For the Ulrich study,
the irst step was a 32-keyword search across the literature and then a cross-
referenced search using Ebsco Host, which enabled the search of multiple data-
bases. his was supplemented with searches through ISI Web of Knowledge and
Google Scholar to obtain additional sources from reference lists. heir second
step or stage involved screening all identiied references using two criteria: that
the study “should be empirically based and examine the inluence of environ-
mental characteristics on patient, family, or staf outcomes;” and, “that the qual-
ity of each study was evaluated in terms of its research design and methods and
whether the journal was peer-reviewed” (p. 102). heir report was organized
according to three types of outcomes:
1. Patient safety issues, such as infections, medical errors, and falls.
2. Other patient outcomes, such as pain, sleep, stress, depression, length
of stay, spatial orientation, privacy, communication, social support, and
overall patient satisfaction.
3. Scientiic research relevant to staf outcomes, such as injuries, stress, work
efectiveness, and satisfaction (p. 103).
he authors noted the increasing number of rigorous studies across design and
healthcare but also observed that, despite this, “it is also important to address
the limitations of the quality of existing evidence [because] in medical ields, a
randomized controlled trial or experiment is considered the strongest research
design for generating sound and credible empirical evidence [but Ulrich et al.’s
review] found relatively few randomized controlled trials linking speciic design
features or interventions directly to impacts on healthcare outcomes” (p. 103).
Dennard’s (1997) review of David Halpern’s book, More Than Bricks and Mor-
tar? Mental Health and the Built Environment, although written some time ago,
highlights the publication of a book that is rare in this cross disciplinary ield.
Dennard reviewed Halpern’s approach of cause-and-efect associations of the
built environment according to the following four categories: as a source of
stress; as an inluence over social networks and support; through symbolic efects
and social labeling; and through the action of the (building) planning process
itself. Creative conlict often arises in inding a balance between what is best for
the patients, how the community perceives the design, and health and building
regulations and policies. he perfect patient facility may not be feasible due to
conlicts between the these factors.
Golembiewski’s previously mentioned (2010) theoretical

It is important to allow patients study on salutogenics in architectural design for psychiatric
to control their environment care used Antonovsky’s Salutogenic perspective, and specii-
cally that the patient and environment are understood as being
through meaningfulness. transactional, to inform his analyses. Golembiewski acknowl-
edged that salutogenics do not replace evidence-based studies
but said that in the absence of evidence-based design for mental health facilities,
applying salutogenics “in a methodological way” can provide a useful framework
for informing architects regarding the functionality of facilities and improving
mental health outcomes (p. 100). Acknowledging that unwell people do not nec-
essarily adapt easily, Golembiewski suggested that “the salutogenic model seems
an appropriate broad framework in which to locate the stress model because it
supports the stress model with much needed substance; efectively illing the
causation gap between action and efect” (p. 103). herefore, although patients
might not always adjust well to innovations, if the environment can be designed
to change for and with the patient’s sensory and perceptual abilities, positive out-
comes could result. Golembiewski drew upon Hall (1975) in that “perception
is a complex neuro-chemical process that is highly reactive to the surrounding
environment and yet it is the only channel for receiving new information of any
sort” (p. 103). With this in mind, the author explained the comprehensibility
of the salutogenic model as providing perceptual cues to assist the perceptual
processes and providing an environment that is ubiquitous and desirable and is
understood through the familiar and which can help stabilize comprehension
and delusions. In terms of manageability of the model, it is important to allow
patients to control their environment though meaningfulness. his goal can be
attained by “enriching the environment with complexity, order and aesthetic
considerations” (p. 114); allowing pets and personal items on the premises; and
providing a stimulating milieu.
In their assessment of the role of environment on behaviors, actions, and inter-

actions, Schweitzer, Gilpin, and Frampton (2004) focused on physiological and
psychological responses. he authors hypothesized “a hierarchy of efect of envi-
ronmental elements ranging from simply nontoxic to safe (both physically and
psychologically) to ‘providing a positive context’ to being actively salutogenic”
(p. S71). his article, published in The Journal of Alternative Medicine, advocat-
ed design to facilitate intention and awareness; wholeness and energy; healing
relationships; health promotion; and collaborative treatments. Schweitzer et al.
presented the existing research in terms of physical parameters, and as includ-
ing the following preferences in a healthcare setting: smells, noise, temperature,
environmental complexity, fresh air and ventilation, color, nature, art/aesthetics
and entertainment, and nursing stations.
In terms of personal space, there is a preference for single rooms; patient satisfac-
tion is related to perceived pleasantness of décor, cleanliness, courtesy of house-
keepers, temperature and noise, and (citing Kaldenberg, 1999) “how well things
work” (p. S73). As with Mazuch and Stephen (2005), Schweitzer et al. noted that
existing literature reveals the importance of the sensory environment in terms
of smells, saying that pleasing aromas may reduce blood pressure, slow respira-
tion, and lower pain perception levels, while unpleasant odors stimulate anxiety,

fear, and stress. here was also some evidence that (a) excessive noise increases
patients’ length of stay as well as causing interruption of sleep and increased
stress; (b) environments with greater complexity correlate with greater cognitive
functioning and beneicial physical activity in the elderly; and (c) sensory varia-
tion in ambient conditions between spaces and over time is preferred by building
occupants. he authors’ comments on light are covered in the “Light” section of
this article, above.
he viewing of nature was dealt with separately from the experiencing of nature.
Regarding the former, Schweitzer et al. noted Ulrich’s (2008) points concern-
ing the lack of a window, which may have a negative efect by reducing positive
stimulation and aggravating the negative efects of sensory deprivation; access
to views of nature with gardens, through windows and in artwork, can reduce
stress; and patients residing in units without windows developed more symptoms
of depression. In terms of actually experiencing nature, the literature reported
evidence of “lowered stress and muscle tension” (Schwetizer et al. 2004, p. S76)
and fewer incidences of violence. Indoor plants were also shown to be beneicial.
As to the last theme, Schweitzer et al.’s literature review included a section related
to arts, aesthetics, and entertainment. Here, a preference was shown for visual art
encompassing nature images, positive facial expressions, and depiction of caring
relationships, whereas ambiguous or abstract imagery was shown to have nega-
tive outcomes. Schweitzer et al. also pointed to research that demonstrates the
positive efect of music on health and also positive distractions such as humor
and entertainment, which may lead to greater optimism, socialization, coopera-
tion, and decreased dependence on medication. hese authors also covered nurs-
ing stations (see “Nursing Stations,” below).
Commonalities in the literature on the impact of architecture on mental health

outcomes include:
• Perceptual cues assist the perceptual processes, help avoid confusion.
• Enriching the environment with complexity, order, and aesthetic consid-
erations is beneicial.
• Access to nature can have positive mental health outcomes and add com-
plexity and stimulation.
• here is a general preference for single rooms.
• Smells: pleasing aromas may reduce blood pressure, slow respiration, and
lower pain perception levels; unpleasant odors stimulate anxiety, fear,
and stress.
• Access to views of nature with gardens, through windows and in artwork,
can reduce stress.
Interior Design
his theme relates speciically to interiors; subthemes of varying importance
include interior design and furnishings, interior design and color, wayinding,
cognitive mapping, spatial organization, and type of patient room (multi-occu-
pancy, semi-private, and private). Lorenz’s (2007) integrative research review,

“he Potential of the Patient Room to Promote Healing and Well-Being in
Patients and Nurses,” addressed the issue of multi- and single-occupancy patient
bedrooms in general healthcare. Within this study, Lorenz synthesized empiri-
cal and chiely quantitative studies on patients’ rooms in the acute care hospital
in terms of “promotion, maintenance or restoration of healing and well-being
for patients” (p. 263). Lorenz also focused on patient outcomes and the ability
of nurses to provide optimal care. Studies deemed relevant fell into three general
categories related to the patient room type:
1. Clinical outcomes
2. Patient perceptions
3. Staf perceptions
Outcomes were generally measured in length of stay, utilization of narcotics, and

physiological and behavioral responses. Lorenz concluded that the gaps in the
literature related to room type and impact on patient falls and medication errors;
and how room type relates to speciic patient populations and impacts on their
clinical outcomes. She also noted that further study is required to expand the
study of room type to include the design of the patient care unit.
Vaaler, Morken, and Linaker (2005) conducted a carefully controlled study in

the acute care Østmarka Norwegian psychiatric hospital between 2000 and
2001. Vaaler et al. wrote that in the 140,000 catchment area of the city of Trond-
heim, “600 patients above 18 years sufering from acute psychiatric conditions
are admitted each year” (p. 20). he researchers conducted the study in a unit
that had been refurbished 4 years prior; the traditional interior design consist-
ed of grey colors, no window curtains, a single lamp in 4-meter-high ceilings
and tubular metal beds and chairs. In close collaboration with architects, one
of the wings was redecorated and refurnished to make it look like a standard
Norwegian home, with the goal of allowing a comparison between the symp-
toms, behaviors, treatment, and relative satisfaction of the patients staying in
the traditional area as opposed to those housed in the redecorated wing. his
involved “colorful wallpaper and paintings on the walls, lowering the ceilings
and installing multiple lighting spots, tastefully curtaining the windows, putting
wardrobes, chairs, lowers and personal items in the patient rooms and Italian
ceramic tile covered the entire bathroom” (p. 21), while the other wing was left
unchanged. he indings included “no negative efects of changing to a more
pleasant and home-like environment” (p. 22); non-signiicant tendency toward
symptom amelioration in the traditional wing; creating a pleasant environment
does not generally increase length of patient stay; and there was a “complete lack
of vandalism” (p. 23) on the new side. he authors concluded that “interior and
furnishing like an ordinary home … created an environment with comparable
treatment outcomes to the traditional dismal interior, and had positive efects
on many patients’ well-being, at least among the women” (p. 19). And although
the outcomes were not markedly diferent, the researchers emphasized that they
“… ind little to justify the often-dismal interiors of wards used to seclude severe-

ly mentally ill patients. his practice should be abandoned unless there are very
speciic reasons to introduce it for special cases” (p. 24).
Salmi’s (2008) comments on wayinding for people with disabilities, although

not focused on the hospital environment or mental disabilities speciically, threw
light on universal applications for developing better wayinding in interior design.
She concentrated on spatial organization—architectural features, destination
zones, spatial overview opportunities and overall layout—advocating landmarks
that are distinct in shape and color and with appropriate signage. For example,
signage should be properly designed and well-placed. It should be perpendicu-
lar to the line of travel and at eye level for wheelchair users; the readability must
be legible, incorporating large text and high contrast with the background; it
should designed mindful of glare and paired with a graphic image. Color should
reinforce links with the environment; directories should cluster information, be
accompanied by graphics, use simple color coding, and be placed in relation to
the speciic loor. Maps should be less cluttered—“You Are Here” designations
are of the greatest importance.
he most telling studies are possibly those that have been able to map behavior
through pre- and post-renovation data. Devlin (1992) reported on such a study
involving four psychiatric wards in New England in the late 1980s; changes were
made to interior decorating including color schemes/painting, indoor plants,
new furniture, bathroom renovations, and similar minor works. he method was
primarily an environmental design survey that involved staf rating design fea-
tures; these ratings were analyzed and combined with observations and behavior
mapping. Devlin emphasized patient population and seasonal variation (warm
weather) as a determining factor in understanding reactions and movements in
a spatially altered and renovated area; however, there was suicient data to indi-
cate a decrease in stereotypic behavior among patients and improved staf morale
after elements such as wallpaper, live plants, increased light, colored walls, and
upholstered furniture replaced the previous spaces that had green and gray walls
and “mismatched vinyl-covered chairs” (p. 71).
Psychogeriatric
Research literature on aged care is growing with the worldwide concern about
a huge aged population in the coming decades, one which will put pressure
on both the social and economic infrastructures. It is therefore not surprising
that the impact of facility design in psychogeriatrics is an area that has seen
two literature review articles within the last decade, those of Dobrohotof and
Llewellyn-Jones (2010) and Day, Carreon, and Stump (2000). Subthemes that
emerged from both include psychiatry, violence, design, dementia, and ther-
apeutic design. Dobrohotof and Llewellyn-Jones focused more on psychiatry
and violence in psychogeriatric units (PGUs), noting the historically deleteri-
ous efect of hospital environments on psychiatric patients, where depressing
environments convey regression and loss of control and present as intimidating
for patients and families. hey searched the databases of Medline (1950–2010),
psycINFO (1806–2009), EMBASE (1980–2009), and CINAHL (1982–2009)
for literature concerning PGU design, from which they reviewed 200 papers,
including some government reports and non–peer-reviewed articles. hey note

that “there are few good quality studies to guide the design of acute PGUs and
much of the existing literature is based on opinion and anecdote or, at best, based
on observational studies. Randomized controlled studies comparing diferent
designs and assessing outcomes are virtually non-existent” (p. 1). With regard to
violence, these authors show that in the literature they reviewed, 18% of demen-
tia patients were violent during admission, speciic factors relating to prevalence
of violence were not well-studied, and staf working in noisy conditions with
poor lighting were more likely to be assaulted (citing Soares, Lawoko, & Nolan,
2000). As to trauma, 34% of post-discharge patients “felt frightened, unsafe, a
sense of intrusion and lack of privacy, disgust and embarrassment, powerlessness,
and feeling undermined at some time during their hospital stay” (p. 3). here
had been no systematic research into the efect of various ward environments on
patients’ experiences; the loss of self-esteem, patients’ sense of self-worth, inten-
siied psychiatric symptoms, and a reduction in patient’s participation in their
care may be caused by “sanctuary harm” (citing Robins et al., 2005). Dohrohot-
of and Llewellyn Jones make the following recommendations for designing the
optimal physical environment:
• Optimize patient and staf safety, manage patients’ physical health,
design a productive ward environment.
• Ensure access to a psychiatric intensive care unit (PICU) or high depen-
dency unit (HDU).
• Provide space—a garden, a quiet area, a seclusion suite, an activity and
games room.
• Include separate bedrooms with louver-type observation panels, doors
that open two ways, vandal-proof dimmer light ittings, and safe ixtures
and duress alarms.
• Design an environment that is secure, structured, with minimal stimula-
tion, non-intrusive, and supportive.
• Create a design that facilitates patient observation as well as high nurse-
to-patient ratios.
• Facilitate limited use of restraints and seclusion.
• Make it possible for cognitively impaired patients to be segregated from
those who are not cognitively impaired.
• Create separate male and female sections.
• Provide direct access to usable outdoor space.
• Have clear indications for the intended use of each area or room.
• Optimize the location of nurses’ station to enable direct line of sight to
as much area as possible.
• Ensure locked doors on secure wards.
• If possible create good external visibility and access to public
transportation.

In addition, design should incorporate deinstitutionalizing features such as:

• Separate living and treatment areas.
• he elimination of long echoing corridors and highly reverberant spaces.
• Residential features such as a laundry and galley kitchens.
• Reduced psychopathology among younger patients facilitated by design
solutions that encouraged social interactions: ward kitchen, an open
nursing station, and a dayroom module for crafts and other occupational
therapy activities.
he second, earlier literature review (Day et al. 2000) on psychogeriatrics focused

speciically on therapeutic design and dementia. hese authors commented on
the problem of small sample sizes in studies on design and dementia, noting
that more than 30% of the studies reviewed used samples of fewer than 30 par-
ticipants (p. 398), with many including fewer than 10. With respect to this fac-
tor, it should be noted that the majority of studies Day et al. looked at in their
600-paper review article were qualitative, where small sample sizes are accept-
able. Despite this, they mentioned the increased rate of research on design and
dementia, from 6 research reports from 1981 to 1985, to 17 research reports from
1986 to 1990, to 26 research reports from 1991 to 1995, and 21 research reports
already published since 1996 (p. 398). Day et al. provided a useful table that lists
all the papers reviewed with summaries for each. Sections include:
1. Concept and focus of study;
2. Research design;
3. Sample information;
4. Outcome measures of well-being;
5. Physical environment features; and
6. Major indings of environmental impacts on well-being.
he authors’ method for collecting papers to review stipulated empirical indings

as one of the criteria. heir indings can be summarized as the beneits of group
living for patients with dementia; the disorienting problems with changes to
their environment; the beneit of reduced use of psychotropic drugs and a decline
in behavioral disturbance in Secure Care Unit (SCU) design that showed clearly
colored wayinding, names on doors, photos of family, separate activity areas,
secure exits and closets, visual tapes across glass, and appropriate sound proof-
ing; other aspects such as the beneits of nature and natural light, recreational
activities and personal as well as gendered spaces were shown to be beneicial to
both staf and patients.
Commonalities across both of the Dobrohotof and Llwellyn Jones (2010) arti-
cles and the research of Day et al. (2000) included security issues, gender sepa-
ration, and gardens.
Post-Occupancy Evaluations
Post-occupancy evaluations (POEs) are rarely carried out, yet it is known that
architectural designs for mental health care contribute to mental health out-
comes; therefore, in order for these results to be positive for both the patients
and the community, it seems strange that evaluations are not routinely carried
out and the results disseminated. Carthey (2006), in conjunction with the Uni-
versity of New South Wales (UNSW) and the New South Wales (NSW) health
department in Australia, conducted research into the reasons for the lack of
POEs and worked toward establishing a standardized model for post-occupancy
evaluations across healthcare. Carthey ofered three diferent types of evalua-
tions, which might sometimes be confused:
1. Post-occupancy evaluations (POEs)—he process of examining and
evaluating the functioning of a building in a systematic way after com-
pletion and occupation (from 12 months to 2 years) (p. 58).
2. Post-implementation review (PIR)—“he last step in the process,” which
includes closure of the “feedback loop” that takes lessons from previous
projects (p. 59).
3. Post-completion review (PCR)—A systematic comparison of original
brief and objects with the actual outcomes (p. 62).
Although Carthey does not state this speciically, “POE” is the most commonly
used term encompassing all three.
he complexity and variables present in healthcare design evaluations give rise

to subthemes across the literature reviewed for this article: interdisciplinary
research; evidenced-based design; environment and behavior; occupant’s feed-
back/users’ needs; psychiatric unit; serious game; service planning; and ser-
vice users. Some of the publications concentrated on suitable methodologies
for conducting evaluations, and all agreed that interdisciplinary research and
input is essential (Marmot, 2002; Veitch, 2008; Vischer, 2009; Whitehead, Pol-
sky, Crookshank, & Fik, 1984). However, Veitch notes that interdisciplinary
research presents barriers such as diferent disciplinary cultures and professional
“languages” and that parties are required to challenge institutional policies that
may hinder collaboration such as the choice of journals in which to publish
results, academic publication rates, the ability to write for peer reviewed journals,
and promotion opportunities.
Marmot (2002) noted that the relative scarcity of evaluative research on build-
ings may be related to cost, fear of negative outcomes, perceived uniqueness of
buildings—lessons learned in one location for particular set of consumers may
not be applicable elsewhere—,and determining what conclusions to draw amid
many variables and inluencing factors. herefore, Marmot said that assertions
of design briefs are rarely tested properly.
he title of Liddell’s 2010 article in Health Estate, “Good Data Critical to a Suc-
cessful Outcome,” speaks for itself. Liddell examined what to look for in devel-
oping a POE process for large hospital environments, what is actually required to

perform a rigorous POE, and what can be expected from the process. he goals
of Liddell’s project on post-occupancy strategies to arrive at the best process for
critique involved documenting generic project information to enable compari-
son of similar sized projects; reviewing the planning and construction phases
of the project; reviewing the operation of the facility and the communications
strategy; and providing comment on the current NSW POE Guidelines. Liddell
detailed the reasons that POEs are not pursued more efectively, observing that
“the Government even has a manual on the subject … which itself notes that
there are a number of reasons why post-implementation review is not pursued
more efectively” (p. 26). hese include the temporary nature of teams involved;
3- to 5-year timeframes between feasibility and occupancy; the changeabili-
ty of factors such as service delivery, budgets, political climate, the economy,
unwillingness to criticize participants, budget shortfalls; and the inability of
the asset management to engage in efective critical examina-
tion and evaluation. Liddell’s recommendations included the Evidence-based design has
active involvement of key staf and stakeholders throughout
the planning process and continuing through every stage of evolved out of the precedent
the project, implementing document management systems set by evidence-based medicine.
and initiating POEs before the project team disbands.
Vischer’s (2009) review article on designing intelligently and designing intelli-

gent buildings stated that when POE studies are conducted, the “voluminous
amount of research indings lie unread on desks or are published in academic
journals that practitioners seldom read” (p. 240), also that designers frequently
go to new sites, measure in accordance with number of users, and therefore resort
to reinventing the wheel. While Vischer did not discount the usefulness of tradi-
tional POEs that ascertain the efectiveness of a building by gathering informa-
tion from users and testing hypotheses, she emphasized that “in the real world”
the newer focus on evidence-based design (EBD) is a better option. She there-
fore compared the POE process with EBD, using healthcare design as one of her
two areas of focus. Vischer cited her own 2008 research, noting that an inherent
deicit of the POE approach is that this form of measurement measures “people’s
preferences and perceived needs rather than the efectiveness of building design
and operation decisions” (p. 242); further, she argues that the traditional POE
accumulates building users’ subjective likes and dislikes, information that is not
helpful to designers who need to know exactly how aspects of the building func-
tion. In contrast, “evidence based design has evolved out of the precedent set by
evidence-based medicine” (p. 242). herefore, if both the methods and results of
EBDs are targeted, their uptake by both designers and healthcare professionals
is more purposeful and the outcomes are arguably more accurate.
In an older study (but one directed speciically at a 30-bed psychiatric unit),

Whitehead, Polsky, Crookshank, and Fik (1984) considered the “Objective and
Subjective Evaluation of Psychiatric Ward Redesign.” hey posited four psy-
choenvironmental hypotheses for evaluation:
1. Environmental alteration correlates with changes in social behavior.
2. Environmental alteration correlates with altered spatial distribution of
behavior.
3. Environmental alteration correlates with reduced psychopathology.

4. Social organizers may be used to focus the alterations in therapeutic and
socializing ways.
hese authors assessed a unit that had been redesigned in accordance with psy-
choenvironmental principles as they aimed to ascertain the efectiveness of such
an approach. Using behavioral mapping derived from ethological studies among
psychiatric patients, the researchers mapped and recorded the movements and
behavior of patients in particular parts of the wards and whether they presented
pathology. he observation was detailed and noted the following behaviors in
areas such as hallways, sitting rooms, etc.: head even, looking at person, oriented
toward neighbor, sitting quietly, talking, or no pathology. heir conclusions were
positive in terms of clinical outcomes but limited; the authors noted that length
of stay was not reduced substantially by the redesign and that the results would
have been more informative if patients could be returned to the older designed
units and observed there.
A recurring theme through the literature on post-occupancy evaluations is that

of the patient/user engagement in process of design. While users have been
engaged, this happens to varying extents, and there are luctuations in the
degree to which their recommendations are applied. Fitzgerald, Kirk, and Bris-
tow (2011) described and evaluated “serious game intervention to engage low
secure service users with serious mental illness in the design and refurbishment
of their environment” (p. 316). he advantages of a serious game (deined as a
game that has a useful purpose or models real life situations) “lie in the famil-
iarity of its format, its non-threatening facilitation of communication and the
creative and fun approach to serious issues” (citing Lamey & Bristow, 2007).
his self-selecting process of engagement resulted in 25 of 30 service users par-
ticipating in the game. Feedback from participants was overwhelmingly posi-
tive. he use of the serious game format has potential for mental health services
to successfully engage service users in collaborative dialogue such as treatment
planning, illness education and recovery. “he game begins, similar to the ‘Go’
square in ‘Monopoly’ and as in real life on the ward, at the airlock square. Instead
of streets, as in Monopoly there were themes that were grouped in accordance
to questions and issues submitted by staf, architects, management, estates and
builders” (p. 318). Simple questions such as “what would you like in a dining
room” and “how would you like your medication dispensed” were some of the
questions used in the game, with prizes as is the case with most board games.
Fitzgerald et al. wrote that these service users had not been part of the original
design decisions and management wanted to know what was working or how it
could be improved; previously, the meeting and consultation style of communi-
cation to obtain feedback from users had not proved successful and the resulting
information from the game was better. he authors said that the game removed
barriers present in the meeting style consultation and recommended that these
games be used earlier and speciically in the design conceptualization stage of
projects.

Nursing Stations
In terms of physical spatial design, nursing stations (also often called “duty
stations”) emerge as the single most signiicant factor in mental health facility
design. Issues in nursing station design overlap with security and models of care;
therefore, the subthemes include nurse-patient relationships, staf safety, space
and control, and function and work environment.
Andes and Shattell (2006) explored “the meanings of space and place in acute
psychiatric settings, to discuss how these meanings afect human relationships,
nurses’ work environment and patients’ perception of care, and to present how
the design and use of nursing stations afects therapeutic relationships” (p. 699).
hese authors concluded that the generally positive features of nursing stations
and space control include the fact that nurse-only and patient-only spaces are
beneicial to both groups and positive nurse-patient interactions “increased dra-
matically” after redesigns that “include more private areas for nurses” (p. 702).
And in terms of negative design outcomes of nursing station design and space
control, Andes and Shattell determined that, in the minds of both patients and
nurses, psychiatric patients cannot and will not respect the nursing station as
a work area. he physical barriers used in the design of nursing stations rein-
force the idea that they are of-limits to patients and impede the development
of interactions. Andes and Shattell airmed that psychiatric
nurses had few meaningful interactions with patients because They found signiicant positive
of interpersonal barriers (e.g., an impoverished view of person-
al eicacy) and organizational barriers (e.g., short lengths of psychological, behavioral, and
hospitalization and high patient acuity). hese authors stressed social effects after the removal
the “hospital should be designed in such a way as not only to of glass partitions from
serve as a temporary home [for psychiatric patients], but its
environment should aid recovery” (citing Shrivastava, Kumar, psychiatric unit nursing stations.
& Jacobson, 1999, p. 703).
Brown (2009) noted that, while the objectives of the nursing station is to make
staf feel safe, open areas are essential to “encourage interactions between patients
and staf” but that “staf must have a private space where they can retreat and
conduct administrative tasks” (p. 22). his reiterates Connellan, Due, and Riggs’
(2011b) note that, in an ethnographic observational study of a recently complet-
ed purpose built mental health unit, the design of the nursing station combined
intense administrative activity with patient interaction with the result inade-
quate patient-staf communication. Brown identiied that the optimal design
of the nursing station needed to incorporate appropriate seating, stimulants,
acoustics, and size to suit the intended function of the space and to place thera-
py spaces close to nurse stations. A sense of boundary to the patient is necessary
but there still needs to be high visibility.
Karlin and Zeiss (2006) noted that open nursing stations have been recommend-
ed by several sources; they refer to Edwards and Hutts (1970) indings of “sig-
niicant positive psychological, behavioral, and social efects after the removal of
glass partitions from psychiatric unit nursing stations. Patient requests of nurs-
es at nursing stations were dramatically reduced, as were the negative beliefs of
those patients, and improvements in ward milieu and patient-staf communica-
tion were also noted” (p. 1378). Karlin and Zeiss wrote that “available reports of
experiences with open nursing stations do not support concerns of patient abuse
of increased access to nurses, although additional empirical research on this issue
is needed. Contiguous, secure, closed to patients, is recommended to maintain
conidentiality of patient records” (p. 1378). hese authors observed that, prior
to the dawn of efective psychoactive medications, closed nursing stations were
the norm, but they fostered a perception that the staf members were inaccessible
and welcomed neither patients nor visitors to their environs.
Schweitzer, Gilpin, and Frampton (2004) reported that large centralized nursing
stations separated from patients by half-walls or glass partitions that are located
some distance from the rooms of the patients “clearly distance staf members
from patients, sending the message that they are busy and inaccessible” (p. S78).
hese authors stated that “a decentralized nursing work station that is small,
open and located outside clusters of 4–6 patient rooms, with the main nursing
station completely open to patients, suggest[s] that healing is a collaborative pro-
cess and not something exclusively under the purview of ‘professionals’” (p. S78).
he above research, published in the last 6 years, difers from some of the ear-
lier studies, which did not use ethnographic observational studies or include the
views of the patients and their families. For example, a study that came out of our
original scoping of the literature asserted that the positioning of the nursing sta-
tion should allow observation of all patients, use one-way mirrors, and surround
the nursing station with Plexiglas. In that study, a survey of nurses’ attitudes pro-
posed strengthening of windows for the station and improved sound-prooing of
quiet rooms (Dix & Williams, 1996).
he commonalities for all publications which relate to nursing stations include

the need for discreet and separate spaces for nurses and other staf to relax and
also for spaces away from patients where they can attend to administrative tasks.
In addition, open areas are necessary to encourage interactions between patients
and staf because closed nursing stations often convey an image of staf inacces-
sibility and are not welcoming to patients and visitors.
Model of Care
he literature shows that the numerous types of models of care are one of the
chief reasons for the complexity in designing for mental health care (Cleary,
Hunt, O’Connor, & Snars, 2010; Costello, 2007; Killpsy, Ritchie, Grerr, &
Robinson, 2004). Subthemes emerging from the literature include phase of ill-
ness model of care, therapeutic space, inpatient care, bio-psycho-social approach,
built environment, length of stay, homelessness, and engagement.
Cleary, Hunt, O’Connor, and Snars (2010) shared their indings on the Concord
Centre for Mental Health’s new “phase of illness” model of care, asking wheth-
er this is the direction in which we should be moving. he professionals at the
Centre had come to question their traditional approach to mental health treat-
ment, “rehabilitation and acute psychiatry were perceived as dichotomous … [i]
npatient rehabilitation was something to which a person was referred … after all
other avenues had been exhausted” (p. 247). heir main points included attempts

to integrate “early intervention” approaches into the philosophy of a large insti-

tution to provide services responsive to the diferent phases of a patient’s illness;
the need to combine management of risk and vulnerability with an emphasis on
the patient’s experience and “journey” to recovery; to acknowledge the prevalent
levels and ranges of disability; and to discount the perception “that ‘rehabilita-
tion’ should be targeted at only those with severe levels of disability” (p. 247).
Costello’s (2007) thesis advocated for an architecture that balances supervision,

treatment, freedom, and community integration, and noted the problems with
current models of mental health care facilities, hospitals, independent living situ-
ations, and group homes include being insuicient as a continuum of care model
for mentally ill patients; hospitals disregard therapeutic qualities of long-term
care centers (focus on stabilizing and releasing); other options such as living
alone or in a group home eliminate medical stability and enhance patient inde-
pendence, but without suicient connection to therapy; and group homes can
be problematic as they can act as small isolated islands within the community.
Key design principles recommended were:

• Balance between connection with the community and retreat.
• Retail as a bufer between life in the facility and life in the
larger community.
• Integrated building form (its into the existing urban landscape).
• Interactive wayinding.
• Facility design should support multiple levels of interaction.
Fitzpatrick’s (2007) study addressed mental health care from a bio-psycho-social

perspective, one that aims to treat the patient holistically, using psychological
therapy including individual therapy and spirituality as well as social network-
ing, and which includes group and family therapy in a community. Fitzpatrick
noted that personal visual elements may ground a person’s sense of self, and a
sense of self can add to the experience of space. In addition, being able to with-
draw is important as well as aiding a person with self discovery.
Length of stay in healthcare is a signiicant factor in terms of demand for beds

and economic factors but short lengths of stay do not necessarily equate with
recovery or a stable condition, and this is particularly signiicant in mental health
care. Frank and Lave (1986) provided an analysis that showed that the treat-
ment of psychiatric patients and their length of stay responds strongly to inan-
cial incentives. heir analysis focused on the U.S. Medicaid program, a federally
supported, state-administered program that pays for medical care provided to
eligible low-income individuals and families.
Aligned to economic issues and length of stay in mental health care is that of
homelessness, Killapsy, Ritchie, Grerr, and Robinson’s article was aimed at the
assessment of “whether admission to a designated ward for the homeless men-
tally ill improves outcomes 12 months after discharge in terms of housing sta-
bility and engagement with services” (2004, p. 593). hey found that, although
the idea of a designated ward seemed the best alternative for a population that
was both mobile and resistant to services, those admitted were no more likely to
be discharged or to move on to or remain in stable housing than were those in
the control group, although this might be explained by the patients’ compara-
tive degree of ingrained homelessness. However, there was an improvement seen
in engagement with services for those who were admitted as well as diminished
issues with medication non-compliance.
Art
his theme includes a systematic literature review article by Daykin, Byrne, Sote-
rious and O’Connor (2008) on the impact of art, design and the environment on
mental health care. Daykin et al. reviewed over 600 papers published between
1985 and 2005, including discussions of contextual and policy literature, as
well as 19 reports of quantitative and qualitative studies. heir inclusion criteria
were international papers on arts, architecture or design initiatives in healthcare;
papers on participatory arts in healthcare; artists in residence; and intervention
studies. Exclusion criteria were not relevant to arts or design initiatives in health-
care; not relevant to participatory arts in healthcare; art forms (music, drama,
play, dance); art therapy where art was a purely diagnostic intervention; patient
arts; not English language; and pre-1985.
he authors revealed that there are few studies that directly examine arts inter-
ventions and a notable absence of evidence-based studies. Of these studies, two
are reviews, one does include art therapy but speciically its efect upon schizo-
phrenia; Daykin et al. explained that the “methodological challenges of evaluat-
ing the clinical efects of art, design and environment are illustrated in a report
[that of Ruddy and Miles, 2005] of a systematic review of art therapy for schizo-
phrenia” (p. 87). he other review mentioned is that of White and Angus (2003),
“Arts and Adult Mental Health Literature Review.” hey also noted small sample
sizes, which make it diicult to detect signiicant results. However, a key inding
of one empirical study by Staricof and Loppert (2003), who measured psychoso-
cial efects after art interventions, was that “depression and anxiety were respec-
tively 34% and 20% lower where intervention had taken place than with groups
not exposed to arts” (p. 88). Eight studies examined the impact of environmental
conditions, sometimes taking into account aesthetics as well as functional con-
siderations; two studies used structured assessment tools to evaluate healthcare
facilities (Daykin et al. 2008, p. 88).
he authors pointed out the issue of difering perspectives regarding art among
the various stakeholders in mental health care, stating the “[w]hile there is some
convergence of agendas, the growth of the arts for health agenda has raised chal-
lenges. First, there is a need to identify the respective contributions of the var-
ied disciplines involved in arts for health. As well as art therapists, an increasing
number of stakeholders are involved in projects, such as arts agencies, artists,
community arts workers and designers. hese groups may draw on diferent
perspectives when it comes to artworks and environments in healthcare” (p.
86). hese authors acknowledged the limitations of their own study, notwith-

standing their eforts to make the selection transparent through software such
as REFworks.
Nanda, Eisen, Zadeh, and Owen (2011) published a paper focusing on the
“Efect of Visual Art on Patient Anxiety and Agitation in a Mental Health Facil-
ity and Implications for the Business Case,” which was aimed at investigating
“the impact of diferent visual art conditions on agitation and anxiety levels of
patients by measuring the rate of pro re nata (PRN) incidents and collecting
nurse feedback” (p. 386). he results did indeed show a substantial efect of the
nature of the displayed art work on the amount of PRN medication dispensed for
anxiety and agitation, being signiicantly higher when abstract art was featured
than when the patients viewed a realistic landscape. hese results were comple-
mentary to those of a 2008 study conducted by Nanda, Eisen, and Baladan-
dayuthapani at St. Luke’s Episcopal Hospital in Houston, Texas, in which
“[i]mages selected covered a wide range: pure, contemporary abstract with non-
representational graphic forms; classic works of art from grandmasters such as
Van Gogh, Chagall, and Klimt, which used representational forms; and inal-
ly, stylized nature images. Only one of the seven images was a realistic image
of nature” (p. 276). Patients were encouraged to comment on their subjective
experience of the art works rather than judge them. Two questions were asked:
“How does this painting make you feel?” and “Would you hang this picture in
your room?” (p. 285), with answers on a Likert scale. “Hospital in-patients con-
sistently preferred images of realistic art with nature content over images that
were stylized or abstract” (p. 295), as opposed to the students from a neighbor-
ing university who rated stylized and abstract images highly. Patients rated the
autumn waterfall image as their highest preference overall.
he subthemes coming out of all the literature are art in a healthcare setting,
design, environment, visual art, and nature. Commonalities across the literature
relate to the therapeutic beneits of visual art in healthcare environments.
The Adolescent
Many mental health and other health facilities focus on a speciic population,
usually children, adults, or the aged. herefore, the needs of young people who
are subject to extreme bodily changes in their bodies and their lives during their
adolescent period are a crucial category for study, particularly in terms of treat-
ment for mental illness.
Subthemes emerging from the literature include hospital design, family-centered

care, visual preferences, and evidenced based design.
In his 2010 article in Behavioral Healthcare, Hufcut asks if design can actually
promote healing, and then answers that question through the use of research in
evidence-based design (EBD) and how its principles can be utilized to “sculpt
the space within long-term facilities to better meet the needs of adolescents”
(p. 33). Hufcut cites surveys of adolescent inpatients conducted by an architec-
ture design team concerning their preferences in the design of the facility. heir
suggestions, which included “calm down” spaces with in-depth, lifelike imagery;
the use of cool colors (blue and purple); increased daylight; and varied seating
options (with males in favor of seating placed around the television), coincided
with features suggested by previous EBD research.
In Blumberg and Devlin’s (2006) study, they observed that the needs of a sick
child are quite diferent from those of adults, and to meet those needs, “the
design of pediatric therapeutic settings difers greatly from those in adult or
general care facilities” (p. 296). hey too made use of a survey to ascertain the
preferences of adolescents, should they require hospitalization. According to the
majority of the young participants, access to a television (97%), music (96%),
and a telephone (95%) was of utmost importance. To explain these choices,
the authors cited the research of Brown, O’Keefe, Sanders, and Baker (1986),
which demonstrated that, for young people, the most common coping measure
in stressful situations is attention distraction, which can be provided easily by
television, music, and conversations with friends.
In terms of spaces beyond their rooms, Blumberg and Devlin’s research revealed
that an area in which to visit with friends was of a high priority; “a gym or exer-
cise room to work out in was selected by 82% of participants, and an accessible
kitchen was selected by 79% of participants” (p. 310). hey also addressed ado-
lescent need for privacy, stating that [t]he speciic developmental traits of ado-
lescents seem to call for distinct amenities, such as private bathrooms, single
rooms, and comfortable full-coverage pajamas, to provide for the expression of
identity” (p. 315).
In the thesis, “View Out of a Window: Visual Preferences of Dually Diagnosed

Adolescents Residing in Group Homes,” Boggavarapu (2002) observed that the
adolescents surveyed had very distinct preferences in terms of what they saw
every day from the windows of the facility in which they resided: medium veg-
etation was preferred over dense or sparse vegetation; they wanted variety—
plants, trees, bushes, shrubs, vegetation with fruits, lowers, vegetables, and
greens; some form of body of water was a favorite, with a pool the most preferred
choice; “houses” were the most preferred kind of building, beating stores, play-
grounds, schools, roads, and oices. Almost two-thirds (62.2%) of participants
wanted equal proportions of vegetation and buildings. Research from previous
studies showed nature was always preferred over man-made; this study indicated
they were desired equally.
It should be kept in mind that it is possible that results of this study are not
consistent with earlier studies. here are two plausible reasons for this: irst, the
earlier studies were conducted on mentally normal people and this sample of
population would not be considered “mentally normal.” Second, familiarity and
preference can be both positive and negative, depending on the context. It’s pos-
sible that dually diagnosed adolescents whose group homes are generally built
away from residential communities may prefer man-made settings.
Commonalities for all publications relating to designing for adolescents relate to

the need for connection with the outside world.

Forensic Psychiatric Facilities

he last key theme in this literature review is that of designing for forensic psy-
chiatric facilities. Key themes emerging here are architectural design, safety, pri-
vacy, and escapes. Commonalities for all publications relating to the designing
of forensic psychiatric facilities include a comfortable domestic scale and ambi-
ence; security; a pleasant, domestic atmosphere that is well-lit by natural light;
and ample space for the patients.
In their study, Dvoskin et al. (2002) addressed the requirement for a secure
forensic psychiatric hospital as derived from the preferences of professionals in
that ield. According to those surveyed, design considerations should include
ambience and a comfortable domestic scale, the use of good lighting, bright
colors and subdivided spaces, and a safe environment that promotes both pri-
vacy and observability and fosters the acquisition of skills. In addition, designers
should be mindful of the fact that one of the most signiicant stressors in prisons
or psychiatric hospitals is the virtually constant level of noise; anything that can
be done to bufer excessive noise would be very helpful. In terms of organization
of space, the best design would ofer “a compromise between staf eiciency and
a reasonable therapeutic milieu;” it was believed that this could be “achieved
with relatively smaller social units” that aforded a reasonable degree of freedom
to the patients (p. 490).
Enser and MacInnes (1999) examined a serious issue concerning secure facili-
ties: the link between building designs and escape. heir research revealed that
the primary areas mentioned when discussing escapes are perimeter fencing,
roofs, and internal and external windows. hey found that security breaches
and building design correlated, in that units with design problems are units that
experience a greater number of escapes, and escapes becomes much less likely the
higher the garden fence. Design features that add security without compromis-
ing patient care include secure bedrooms overlooking an inner courtyard, any
covering of that courtyard modiied by a feature that cannot be climbed, fencing
with a double overhand, the installation of closed circuit television, airlocks and
alarms on exit doors, and new and secure window ittings.
Conclusion
he research question that led us to review the literature was, How does the
intersection of mental health care and architecture contribute to positive mental
health outcomes? Our combined comprehensive and systematic review of the
literature revealed 13 major themes. In order of prevalence these are (1) security/
privacy; (2) light; (3) therapeutic milieu; (4) gardens; (5) impact of architecture
on mental health outcomes; (6) interior design; (7) psychogeriatric; (8) post-oc-
cupancy evaluation,; (9) nursing stations; (10) model of care; (11) art; (12) design-
ing for the adolescent; and (13) forensic psychiatric facilities.
he themes overlap and some statistics apply to several themes. However, for the
purpose of some clarity, we will summarize according to themes. he irst theme
comprises security, violence, privacy, and overcrowding, showing that people in
ward environments occupy 70% less space than their counterparts of 150 years
ago (Johnstone, 2004). Violence against patients and staf in psychiatric wards is
widely prevalent and increasing (Kumar et al., 2011). his has important impli-
cations for the architectural design of psychiatric units, including the impor-
tance of demarcated spaces for particular activities and extra space provided
where possible.
he second theme, light, includes natural light and artiicial lighting. he pri-
mary indings here were the importance of light for controlling the circadian
system thus reducing depression, agitation, sleep, eating patterns and also easing
pain in some instances. Patients in brightly lit rooms stay on average 2.6 days less
in hospital than those in dimly lit rooms (Beauchemin and Hays, 1996). Signii-
cant diferences were found between natural and artiicial lighting including for
both staf and patients, for example, a lack of natural lighting can cause seasonal
afective disorder (SAD), changes to hormonal body rhythms, glare and licker,
work disruptions, increased staf stress, and decreased staf satisfaction (Ulrich
et al., 2008; Schweitzer et al., 2004).
he third theme of the therapeutic milieu includes therapeutic design and

environments; patient-centered design; healing environments, especially the
Planetree approach, and positive design (Stichler, 2008); and the need for a mul-
tidisciplinary approach to healing. his theme overlapped extensively with the
fourht theme, regarding gardens and contact with nature. he fourth theme of
gardens is revealed as extremely important for both patients and staf for renew-
al/restoration of attention, stress relief, and for its social aspects, with evidenced-
based research showing high percentages to support this (Naderi & Shin, 2008).
he ifth theme, the impact of architecture on health outcomes, also overlaps

with other themes but the literature shows that architecture can enrich the envi-
ronment with complexity, order, and aesthetic considerations ofering perceptual
cues to assist and avoid confusion. Access to nature and sensory/salutogenic con-
siderations (Golembiewski, 2010) are important themes within this literature as
is the need for privacy and a preference of single bedrooms.
he sixth theme of interior design, which includes the subthemes of furnishings,

color, wayinding, cognitive mapping, spatial organization, and type of patient
room, shows the need for clear visual communication balanced with a home-like
environment (Lorenz, 2007).
he seventh theme is that of psychogeriatric considerations, which include

dementia, violence, and trauma as major subthemes that highlight the need for
quiet spaces and gardens, with an emphasis on deinstitutionalizing design fea-
tures to encourage social interactions (Dobrohotof & Llewellyn-Jones, 2010;
Day, Carreon, & Stump, 2000).
he eighth theme of post-occupancy evaluations (POEs) deals with the lack of

efective evaluations in health architecture generally and mental health partic-
ularly. he literature calls for an interdisciplinary approach to POEs, using evi-
dence-based design including building performance factors but also with the
speciic need for occupants’ feedback (Carthey, 2006; Liddell, 2010).

he ninth theme is that of nursing (duty) stations. he efectiveness of the nurs-

ing station is addressed by the literature, with nurse-only and patient-only spaces
found to be beneicial to both groups. Closed nursing stations often convey an
image of staf inaccessibility to patients and visitors (Andes & Shattell, 2006).
he tenth theme, model of care, incorporates several subthemes such as the bio-
psycho-social approach that deals with the patient holistically, length of stay,
personal visual elements in the environment, and homelessness. he literature
shows the need for a balance between drug-therapy, environmental context and
psychological and social therapy and interactions (Cleary, Hunt, O’Connor, &
Snars, 2010).
he eleventh theme is the role and importance of art, not only as an activity but
also as an aesthetic therapy. Daykin et al. (2008) note that few studies directly
examine arts interventions, however a key inding is that depression and anxiety
were 34% and 20% lower, respectively, in contexts where patients were exposed
to arts.
he twelfth theme, of designing for the adolescent mental health patient, is one
that highlights the need for maintaining connectedness to the outside world,
including family-centered care; the role of visual preferences, including medi-
um density gardens with water; as well as the need to keep personal items, have
access to movies, and have private bathrooms (Hufcut, 2010).
he thirteenth theme is forensic psychiatric facility design. Here the subthemes

include safety, privacy, and escapes. he literature emphasizes a pleasant domes-
tic atmosphere that is well-lit with natural light and provides ample space for
patients (Dvoskin et al. (2002).
Finally, the literature shows that there is a need for more research concerning
evidence-based design, and for user input into design across all themes. Despite
the noted diiculties with post-occupancy evaluations there is a need to have an
evidence base in terms of design for mental health units.
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Stressed Spaces: Mental Health and Architecture

Article in HERD · July 2013

Kathleen Connellan Damien W. Riggs

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Psychological wellbeing in acting training View project

The user has requested enhancement of the downloaded file.

he objective of this article is to present an updated review of the literature across

128 WWW.HERDJOURNAL.COM © 2013 VENDOME GROUP LLC

Table 1. List of Keywords Used in Searches

Mental health Psychiatry unit Built environment Evidence-based design

In addition to peer-reviewed articles, the team inspected the bibliographical ref-

Table 2. List of Databases

130 WWW.HERDJOURNAL.COM © 2013 VENDOME GROUP LLC

Table 3. Key Themes Found in the Literature

Figure 1. Peaks and troughs of publication dates, grouped by theme.

Kumar and Ng (2011) based their discussion on three background studies. he

132 WWW.HERDJOURNAL.COM © 2013 VENDOME GROUP LLC

colors to enhance activities and spaces; using various materials

Brickell and McLean (2011) focused on patient security in terms of quality of

134 WWW.HERDJOURNAL.COM © 2013 VENDOME GROUP LLC

In a paper on healing spaces, Schweitzer, Gilpin, and Frampton (2004) noted

Commonalities for all publications related to light include the importance of

Golembiewski (2010) looked at the signiicance of architectural design in psy-

136 WWW.HERDJOURNAL.COM © 2013 VENDOME GROUP LLC

Stichler’s (2008) article, “Healing by Design,” reviews the Planetree approach

8. Integration of complementary therapies

he theme of the therapeutic milieu in healthcare design, particularly mental

138 WWW.HERDJOURNAL.COM © 2013 VENDOME GROUP LLC

Mazuch and Stephen (2005) explained how the London-based architectural

To reiterate, the commonalities across the literature on providing a therapeutic

In the subthemes of nurses, evidence-based design, and envi-

140 WWW.HERDJOURNAL.COM © 2013 VENDOME GROUP LLC

5. To provide a place for people to maintain the hobby of gardening

he results of the post-occupancy evaluation showed that of the respondents,

The Impact of Architecture on Health Outcomes

142 WWW.HERDJOURNAL.COM © 2013 VENDOME GROUP LLC

Golembiewski’s previously mentioned (2010) theoretical

In their assessment of the role of environment on behaviors, actions, and inter-

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Commonalities in the literature on the impact of architecture on mental health

pancy, semi-private, and private). Lorenz’s (2007) integrative research review,

Outcomes were generally measured in length of stay, utilization of narcotics, and

Vaaler, Morken, and Linaker (2005) conducted a carefully controlled study in

146 WWW.HERDJOURNAL.COM © 2013 VENDOME GROUP LLC

Salmi’s (2008) comments on wayinding for people with disabilities, although

including some government reports and non–peer-reviewed articles. hey note

148 WWW.HERDJOURNAL.COM © 2013 VENDOME GROUP LLC

In addition, design should incorporate deinstitutionalizing features such as:

he second, earlier literature review (Day et al. 2000) on psychogeriatrics focused

he authors’ method for collecting papers to review stipulated empirical indings

he complexity and variables present in healthcare design evaluations give rise

150 WWW.HERDJOURNAL.COM © 2013 VENDOME GROUP LLC

Vischer’s (2009) review article on designing intelligently and designing intelli-

In an older study (but one directed speciically at a 30-bed psychiatric unit),

3. Environmental alteration correlates with reduced psychopathology.

A recurring theme through the literature on post-occupancy evaluations is that

152 WWW.HERDJOURNAL.COM © 2013 VENDOME GROUP LLC

he commonalities for all publications which relate to nursing stations include

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to integrate “early intervention” approaches into the philosophy of a large insti-

Costello’s (2007) thesis advocated for an architecture that balances supervision,

Key design principles recommended were: