Designing Wellbeing

Introduction

The body and its intricacies are beautiful but unfathomable, its secrets infinite despite our constant progress and understanding. The untouchable knowledge of the microscopic world of cells and proteins in biomedicine stands in sharp relief compared to the extreme corporeality of the clinical domain. The living body represents a complicated and idiosyncratic world of constant change, flux and balance. Cells, tissues, organs and viscera work in concert to facilitate our physical capabilities. Digesting, dancing, dying - the opportunities are endless. The sum of these processes makes up our human lives. But there is more.

Pain, courage, suffering, hope, desire, connection… What makes us individual and unique is not restricted to our physical abilities. Our personalities and mental processes each represent a constantly changing recipe of varied ingredients. As diverse as bodies can be, so too are minds - the spaces where these values inhabit, grow and develop, fed and inspired by our senses. We are all influenced by our environments, a power which has been recognised and utilised for various means throughout the history of medicine and design. This project aims to evaluate the historical application of these beliefs to see how they have - and continue to - affect psychiatric healthcare provision. Presented here as a series of miniature essays combined with graphics and imagery inspired by this time, I will take a multidisciplinary approach to the topics of environments, design and healthcare. After providing a philosophical context through a brief explanation of philosophy of mind, I will delve first into the history of the asylum, then the history of psychiatry. I will then use these dual contexts to form the basis of my spatial reading of the Victorian asylum before discussing the environmental and spatial aspects of modern psychiatric care.

Process

During my three-week elective, based in London, I explored the concepts of mental healthcare, design and architecture, history and philosophy through literature review, media and visits to local galleries and museums. By reviewing philosophical, historical and environmental aspects separately, the hope is that greater contextual understanding is achieved, to add to the increasing understanding that multidisciplinary action and teamwork could supply us with more optimal and harmonious solutions for future mental healthcare spaces.

Philosophy of Mind

Western medicine has always had a difficult relationship with the mind, in health and pathology. To understand this relationship, we must first look to its roots, examining the dominant philosophies that have impacted their contemporary psychiatric practices.

Philosophy of mind considers the relationship of the mind and the body, grappling with issues such as the mind-body problem, consciousness, thought and free will. While ancient philosophy took a monist view that mind and body were inseparable continuous entities, this perspective was largely withdrawn after the pioneering dualist philosophy of René Descartes (1596-1650). His theory of substance realism, the notion that the physical and the mental were ontologically separate, had an immeasurable impact on subsequent Western philosophy (Thibaut, 2018). It also had a critical influence on early modern medical specialties, manifesting a deep split of psychiatry from other areas such as neurology. Biological definitions of illness were deemed objective while the psychological was considered subjective, altering the ethos of the specialty and facilitating reduced diagnostic understanding and questionable treatment methods throughout the eighteenth and nineteenth centuries (Raese, 2014). Treating the physical and the mental as a binary also stigmatised mental illness, in part because conditions were largely invisible and often externally characterised by disturbing and unexplainable symptoms. Unfortunately, these issues are not a thing of the past - Cartesian duality continues to have implications for how patients’ illnesses are considered, diagnosed and treated today (Raese, 2014).

The Enlightenment era (1685-1815) saw a new wave of philosophical ideas through the work of philosophers such as John Locke, Immanuel Kant and David Hume. Arguing against Cartesian ideas of duality, John Locke postulated ideas around selfhood and accumulation of knowledge throughout life. Considered to be the originator of the concept of identity, a fundamental of psychology, Locke suggested that the self - our own experience of consciousness - developed throughout life (Nimbalkar, 2011). In Lockean philosophy, we start life with a mind devoid of any innate knowledge, a ‘tabula rasa’. As we go through life, we pick up knowledge and ideas from external sources, through sensory experiences and perception. These are the fundamentals of empiricism, which is completely antagonistic to Descartes’ rationalist philosophy (Markie, 2021).

More recent philosophers such as Edmund Husserl, Martin Heidegger and Maurice Merleau-Ponty also challenged Descartes’ doctrine through the development of phenomenology which describes the perception of consciousness from a first-person experience (Woodruff Smith, 2013). In phenomenology, the body is experienced as both subject and object (Fuchs, 2009), as physical encounters feed mental and emotional processes and vice versa. On this foundation, and influenced by Lockean ideas of selfhood, theories of embodied cognition suggest that aspects of the whole body, including the brain, influence the mind, giving credibility to both objective and subjective factors in the development of mental illness and its treatment (Wilson, 2017). While many Cartesian ideas still pervade Western psychiatric doctrine, increasingly views are shifting towards an embodied perspective, drastically altering our views on mental health conditions such as anxiety and depression, as well as issues such as chronic pain and its management.

A Brief History of Asylums

Institutionalised treatment of the mentally ill is a relatively modern phenomenon. Medieval efforts to contain madness were largely restricted to religious facilities such as monasteries or priories like the Priory of St Mary of Bethlehem (later known as Bethlem), founded in 1247, which took a custodial role (Porter, 2002). Those displaying unusual or antisocial behaviours were largely kept within the domestic domain and cared for at home, or treated as possessed or criminal. Piecemeal efforts to manage mental illness would remain in place until the early eighteenth century when the Vagrancy Acts of 1714 and 1744 injected the villainous stereotype of the ‘madman’ into the British psyche (Wallis, unknown). These provided a legal basis for the violent detention of those showing signs of madness, supposedly for the protection of the public. Purpose-built facilities were not yet available so madmen would be housed alongside the criminal and the impoverished in jails and workhouses.

Despite increased intolerance, new interest was taken into madness, its origins, treatments and the potential commercial opportunities it presented. Charitable institutions such as Bethel in Norwich and St Luke’s Hospital in London were two examples of early asylums, housing the insane en masse in large hospitals, often removed from city centres (Scull, 1993). Many of these hospitals were open to a paying public, serving an eclectic experience to visitors - part cautionary tale, part spectacle. ‘Treatments’ often involved violence - beatings and restraint - justified by the Cartesian premise of mind-body duality (Wallis, unknown). If the mind was separate and governed the body, it was believed that madness was symptomatic of a pathological reversal: the body taking over the mind. Violence, it was believed, would drive the body into submission enabling the mind to regain control and the madman to regain his sanity. While initially support for these institutions was strong, it was realised that the system and those within it were highly vulnerable to abuse. Stories spread about helpless individuals being kept in filthy and undignified conditions, inspiring contemporary literature and art such as William Hogarth’s A Rake’s Progress (see opposite; Porter, 2002). Corruption was also a concern as stories of families ‘disappearing’ problematic relatives or inconvenient spouses circulated. Public concern around inappropriate detainment of sane individuals precipitated the Madhouses Act of 1774 (McBeath, unknown). Shortly after, a scandal at the well-known York Asylum fuelled a shift in therapeutic attitudes towards madness, favouring ‘moral treatments’ over violence and restraint (Edginton, 1997). The York Retreat, opened in 1796 by Quaker William Tuke, aimed to be a bastion of these new principles (Tuke, 1813). In a move away from mind-body duality, moral treatments followed Lockean philosophy, suggesting that if mad people could be exposed to an array of varied positive civilising experiences, new chains of association could be made, taming the mind and reforming the spirit (Edginton, 1997). These ideas were discussed in York Retreat governor William Battie’s Treatise on Madness (Beard, 2007) where he argued in favour of using institutional settings to manage individuals’ mental illness, instead of as detention centres for the protection of the public. While not entirely accepted by his contemporaries, Battie’s work at the Retreat was highly influential, catalysing scientific and structural changes in the treatment of madness. New asylums in large countryside homes provided the backdrop for moral treatments, and an opportunity to rectify the behaviours of the mad, bringing them in line with the social mores of middle-class Britain (Porter, 2002).

As idealistic and promising as moral treatments had seemed initially, over time they proved largely unsuccessful. Asylums started to become overcrowded and further scandal in the early 1800s revealed that abuse was still rife within the system. The sensationalist hearts and minds of the Georgian public were compelled by stories such as that of William Norris who had been chained to his bed at Bethlem Asylum for over thirty years due to his violent disposition (Science Museum, 2018). The subsequent County Asylums and Madhouse Act of 1828 gave local authorities the power to inspect asylums and to revoke licences if conditions were deemed unsatisfactory (McBeath, unknown). However, scandal and salacious rumours would ensure that public interest didn’t wane. In the 1830s, when Queen Victoria ascended to the throne, asylums and their reported revelations remained a staple of literature and news. The 1845 Lunacy Act, the culmination of further inspections, required all counties to build asylums safeguarded and observed by the Lunacy Commission. This era saw the rapid expansion of stereotypical Victorian mental institutions, characterised by large, imposing buildings, separated from major cities (Yanni, 2007). Furthermore, progressive treatments were evolving, such as the early development of occupational and art therapy, among attempts to reduce restraint of patients (Edginton, 1997).

The nineteenth century saw a massive increase in the number of patients housed in mental institutions, akin to a crisis. At this point, public confidence in psychiatric doctors was low, with anxiety fuelled by sensationalist fiction and exposé-style writings from former patients claiming, for example, that doctors had labelled them as insane when they were, in fact, healthy (Rondinone, 2019). Apprehension towards and demonisation of psychiatry continued into the early twentieth century. Once again, concern about the state of British asylums, which were notorious for their high levels of abuse and squalor, became a major point of criticism, eventually leading to calls for deinstitutionalisation, a process that coincided with the antipsychiatry movement. Policies to deinstitutionalise British asylums, starting in the 1950s and heavily influenced by Thatcher in the ‘80s, culminated in the National Health Service Community Care Act of 1990. Under this Act, mental health patients were able to receive treatment at home under supervision of care workers. Despite intentions to improve services for mental health patients and increase economic efficiency, the reforms were widely criticised for ineffectiveness. Moving into the 2000s and the present-day, current service provision has inherited many of these issues and faces calls to improve while remaining under extreme financial pressures.

Psychiatry and Psychology

Psychiatry as a medical specialty has largely indeterminate beginnings. Despite privately run asylums existing in Britain since Bethlem, the aim of these spaces was not to treat but to contain madness. The early 1800s saw the first advances in modern psychiatric understanding as mood disorders and delusion started gaining recognition as diagnoses. In 1883, the German doctor Emil Kraepelin (1856-1926) - a strong proponent of eugenics - published his classification of mental disorders, a decisive step towards a more scientific and biological approach. These ideas formed the foundation of several controversial medical treatments throughout the 1930s, including lobotomy, electroconvulsive therapy and insulin coma therapy. These therapies, now derided as brutal and inhumane, save for a highly adapted form of electroconvulsive therapy still in use today, would be used to ‘shock’ the body from disordered states such as schizophrenia. They would remain in use across the UK until the mid-to-late ‘50s when medical critics, including psychiatrists, argued that they were ineffective and risky.

As well as biological models, psychiatry was heavily interwoven with the psychological ideas of Sigmund Freud (1856-1939). While psychoanalysis had been popular since the early 1900s, by the 1950s it formed the basis of formal psychotherapy (Alexander, 2012). Alongside changes to psychological understanding, the ‘50s saw the development of psychopharmacology with the invention of new drugs such as chlorpromazine. These drugs, capable of calming patients, started to overtake shock therapies and were extremely popular by the mid-1960s. They also became central to much of the criticism of psychiatry, forming part of the manifesto of the antipsychiatry movement led by psychiatrists such as RD Laing and Thomas Szasz, as well as sociologists like Erving Goffman and Michel Foucault. It wasn’t until the early 1970s, with developments of understanding in neurochemistry, that the mechanisms of the drugs were fully understood. During this time, too, psychological therapies were evolving as cognitive behavioural therapy (CBT) gained popularity over old-fashioned psychoanalytic practice.

It is difficult to separate the histories of psychiatry and psychology. Ideas from both converged in 1977 with the proposal of the biopsychosocial model by psychiatrist Dr George Engel (1913-1999). This model, still used in modern psychiatry, appreciated the complex interplays that may protect against or promote mental illness. It suggested a more holistic approach beyond the assessment of the physical and biological aspects of illness by including social and psychological factors. It also represents a shift into how mental illnesses are treated in the present day. While not without continued controversy and criticism, modern psychiatry has become more respected as a medical specialty. This is critically important: in its current iteration, with the growing pressures of increased mental illness, psychiatry represents a hugely significant if largely underrated service. It is estimated that the economic burden of mental illness amounts to £105.2 billion each year in the UK, accounting for 22.8% of our total disease burden (Department of Health, 2013). With the disastrous effects of the Covid-19 pandemic on mental health, it’s becoming increasingly clear that more needs to be done to prevent and treat mental ill-health.

Today, psychiatrists are part of multidisciplinary teams, working with specialist mental health nurses, clinical psychologists and occupational therapists to provide tailored and holistic care for patients. This support can exist in multiple spaces across time, depending on the needs of the patient and their condition. The arenas in which psychiatric and psychological work are done are many and varied. Asylums, as previously described, may no longer exist but care continues to be provided in specialised spaces such as medical wards and mental health units. It is also provided within the community through GP services and treatment teams. The structures used to deliver care are multiple and it is acknowledged that a one-size-fits-all approach rarely achieves positive results for patients. Psychiatric knowledge and success of treatments are steadily increasing, with exciting developments ahead, but there is still massive scope for improving our understanding of mental illness and how to combat it. Despite the specialty’s capabilities, it is widely recognised that prevention is better than cure with research focussing on social interventions designed to support and promote the wellbeing of individuals and communities, and reduce mortality and morbidity due to mental illness while reducing the burden on existing services.

Reading the Space of Victorian Asylums

The archetypal Victorian asylum is a stock backdrop to thousands of horror stories, fictional or otherwise. A certain representation of the institution - forbidding, imposing, nightmarish - exists in both contemporary and modern media and literature. Knowing more about the history of the asylum, it is unsurprising that these spaces and the events within fuelled such dread and fear. However, the fate of Victorian asylums’ reputation was not as intended (Rondinone, 2019).

The concept of environmental determinism, the idea that individual and collective behaviour is shaped by natural and artificial structures and environments, was highly pervasive in this era. Its influence can be observed in the architecture of many institutional buildings beyond asylums, including schools and prisons (Yanni, 2007). Medical understanding of mental health recognised that insanity was a product of both biological and environmental factors. As industrialisation took hold and cities became busier and more polluted, rates of insanity increased. Some Victorian alienists - precursors to modern psychiatrists - theorised that ‘degraded environments … produced degenerate populations’ (Yanni, 2007). It was theorised that environmental determinism, whilst implicated in the onset of madness, could also supply its solution. As American alienist Luther V Bell (1806-1862) expressed, asylums were intended to be ‘an instrument of treatment,’ a foundation for civilising the insane within (Haliman, 2017). Doctors, who were heavily involved in the design process of these buildings, often published their ideas as manifestoes, meaning we can examine their intentions through their writings.

Dr John Conolly (1794-1866), in his publication of The Treatment of the Insane without Mechanical Restraints (1856), made his position clear. As superintendent of the Hanwell Asylum, he believed the ‘neglect and cruelty’ of contemporary asylums required serious revision. Heavily influenced by the work of the Tukes of the York Retreat, Conolly wrote in favour of ‘non-restraint methods’ for treating patients, suggesting that wellness could be achieved through careful redesign of asylum buildings. Through ‘order and cheerfulness … cleanliness, good food’, he believed that a ‘state of comfort and tranquility’ could be achieved in patients, reforming their sanity (Conolly, 1856). A well-designed asylum would have certain key features such as bucolic surroundings, good lighting and ventilation, open areas for patients, access to sanitary facilities, separate workshops and a chapel. Conolly was also keen to limit overcrowding of mental facilities, aiming to house no more than 400 patients in each. One of Conolly’s contemporaries Dr Maximilian Jacobi (1775-1858), in many aspects, agreed with these design parameters. In 1841 he wrote that ‘the establishment should be situated … under a mild sky, in an agreeable, fertile and sufficiently dry part of the country … to enliven the spirits of the beholder’. He suggested a degree of geographic removal of asylum buildings from local city centres, arguing that they should be close enough for inhabitants to visit local towns, but not so close that they would be regularly disturbed by the ‘intrusion’ of everyday life. Jacobi was aware that a sense of place could be a factor in patients’ recovery, favouring a design without visible parameter walls so ‘the patients are thus not so easily reminded every moment of their incarceration, and through it, of their own miseries’ (Jacobi, 1841).

To appreciate the inner workings of an institution, we must be aware of the context of the world outside. As medical historian Charles E Rosenberg suggests, hospitals are ‘an institution that reproduce values and social relationships of the wider world and yet manage at the same time to remain isolated in [their] particular way from the society that created and supports them’ (Yanni, 2007). Sociologists such as Michel Foucault, Erving Goffman and Andrew Scull have written extensively on these relationships. Power dynamics, inherent to the institutionalisation of society’s sick and marginalised, often mirror the politics of the contemporary world outside. Foucault’s discussion of the shifting powers of nineteenth-century medical professionals explores the notion of ‘governmentality’. He suggests that with the move away from restriction-based methods, medical treatment starts to become characterised by a patient’s consent to government. By agreeing to the whims of paternalistic doctors, Foucault argues, asylum inhabitants made themselves vulnerable to a loss of self-control and autonomy. External restraints needed to be replaced by internalised boundaries, a concept amply illustrated by Foucault’s discussion of Jeremy Bentham’s Panopticon, which became associated with asylums in his 1961 publication Madness and Civilisation. Bentham theorised that if a circular prison could be built around a central observation point, only one guard would be necessary to enforce good behaviour. Prisoners would be unable to know which way the guard was facing, making them feel under constant supervision. This is critical - in Foucault’s view, the success of Bentham’s deceptively simple design was that ultimately it didn’t matter if the guard was surveilling the prisoners or not. If they believed they could be being watched at all times and altered their behaviour subsequently, they had already internalised external control and relinquished themselves to the power of the prison system.

Other historians are critical of Foucault’s theories. In her book The Architecture of Madness, Carla Yanni argues that panopticism was ‘not quite activated’ in asylum design. While control and observation of patients was necessary to stop them injuring themselves, other patients or staff, other environmental aspects like ventilation and natural lighting were prioritised in physicians’ writings. Each of the basic forms, ranging from linear buildings to radial designs, had its own benefits and drawbacks when it came to balancing these priorities (Yanni, 2007). When it came to instilling a sense of control, linear buildings, H blocks and radial designs could each be manipulated to separate and isolate patients by, for example, placing them in separate rooms or categorising them according to disease severity (Cracknell, unknown). However, radial designs and other complex arrays of buildings were found to not be conducive to their therapeutic intentions. Ventilation and visual access to outside spaces proved difficult as the buildings became more complex. Therefore, a pavilion design became the most favourable as multiple detached buildings around a central green space fulfilled the majority of therapeutic design criteria.

In terms of ‘civilising’ patients, the interior design and ornamentation of Victorian asylums were also highly considered. In trying to move as far as possible from the shocking state of their predecessors, such as Bethlem, asylum designers looked to provide a commercially viable therapeutic experience. The linguistics of medical publications is particularly important in this issue, with doctors frequently making reference to the ‘home-like’ aspects of their buildings and the ‘families’ that were formed within (Yanni, 2007). As well as extricating themselves from any associations with prisons, references to the familial and the domestic aimed to incorporate homeliness and comfort into the asylum. However, there is a tension here: given the size and grandeur of many of the asylum buildings built during this period, something more is at play. Rothman argues that asylum doctors were keen to elevate themselves by suggesting that ‘the institution itself held the secret to the cure of insanity.’ This view is echoed somewhat in the work of Andrew Scull who argues that asylums were a commercial entity and had to offer something novel or effective to make them a more attractive alternative to caring for the insane at home (Scull, 1993). The ‘home-like’ attributes of asylums were, furthermore, not representative of typical middle-class British homes. Given the aim to cultivate refinement into the minds of the insane, the activities and decoration of asylums skewed towards genteel, upper-class sensibilities. Furthermore, making these dispositions more obvious legitimised asylums in the public view, compared to their previous incarnations (Scull, 1993).

Initially, these innovations and developments were popular. A public that was used to only hearing about the horrific brutalities of restraint was intrigued by these novel practices and the outcomes they offered. However, this popularity, combined with the eventual realisation that new approaches were ultimately unsuccessful in treating madness, soon led to the failure of moral treatments. Once more, stories circulated about the filth and depravity of asylums - they started to resemble, increasingly, ‘warehouses for humans’ (Andrew Scull). As their status diminished, so too did the stature of the buildings. To maintain the appearance that cures could be found for mental illness, doctors shifted their attention towards milder cases that could be treated in the home (Yanni, 2007). Incurable patients remained institutionalised, forgotten by the public and only to be remembered through salacious gossip and horror stories. The crumbling remains of asylums started to resemble the decrepit haunted castles and manor houses of gothic literature. The Victorian asylum as we know it today was born.

Modern Psychiatric Design

Rates of mental illness continue to grow in the UK, reinforcing the importance of psychiatric treatment and care. While the majority of mild cases can be managed in the community through medication and psychotherapy, some people will need increased support in inpatient settings. For different levels of need, different clinical spaces are available. A patient undergoing a severe episode or a new illness might be treated on an acute ward. Those with more long-lasting issues or who require greater support every day may be placed in a long-term unit. These units can exist within hospitals alongside other specialties or can be separated entirely. Depending on the level of risk for the patients, different requirements and standards have to be met.

The Facility Guidelines Institute (FGI) defines a therapeutic environment as one that ‘helps make patients more receptive to the treatment by staff’. In their document Common Mistakes in Designing Psychiatric Hospitals (Hunt, 2015), they state that ‘there is no one-size-fits-all solution’ when it comes to psychiatric hospital design. Their guidance on how to improve the safety of current mental health treatment spaces suggests that there are two main design approaches depending on the priorities of an organisation. Some groups may opt for ‘a more home-like ambience,’ focusing on the wellbeing of their patients and using the space therapeutically. Others ‘have a very low tolerance for risk’ and will focus on keeping the environment as safe as possible. The FGI guidance suggests that these two factors co-exist, but tend to fall at two ends of a continuum. It is possible to ‘fall somewhere between the two extremes,’ but there are difficulties inherent to trying to achieve absolute perfection in both aspects simultaneously.

The FGI view of therapeutic environments is intriguing. It isn’t exactly contrary to Victorian definitions of environmental determinism, but instead of focusing on the clinical spaces themselves, it emphasises the importance of the staff and medical treatments held within. In terms of how this is achieved, the FGI endorse ‘creating a non-threatening environment in which patients can feel relaxed and comfortable’ to facilitate greater engagement with medication and psychotherapy (Hunt, 2015). The focus of the guidelines leans heavily into the ‘non-threatening’ side of psychiatric design. After conceding that ‘use of colour, texture and natural materials … can provide a more residential feel,’ the majority of their guidance attends to measures to improve safety by preventing self-harm and suicide. No sharp edges, no potential ligatures or places to affix them, nothing that can be dismantled to form instruments of self-harm. It is a challenging document to read, but highly valuable in its realistic assessment of the requirements of these spaces. The guidance is a sobering reminder of what can be so easily missed when trying to make an appealing space. However much an environment can seem to appear more pleasant to non-stakeholders, for those who are struggling with mental health, other - more dangerous - things may be the unfortunate priority.

While not considered to be as horrendous as Victorian asylums, modern mental healthcare spaces still carry much of the stigma and sensationalism of their historical counterparts. Modern mental health wards are still used as fodder for horror films and media exposé. Easy-clean linoleum floors and walls of institutional magnolia make for an easy backdrop to disturbing stories of stolen freedom, power-hungry doctors and insanity. Unfortunately, as discussed, many of these design aspects are less about visual or emotional appeal and more about safety, hygiene and convenience. Is it possible, then, or indeed useful to try to change or improve these spaces?

Evidence-based design is becoming increasingly utilised in therapeutic environments. UK policy promotes evidence-based methods in the renovation and construction of hospitals and mental health units, highlighting that they must not only meet current needs but engage with those of future stakeholders too. The UK Department of Health recommends that psychiatric areas should be ‘client-centred, with the aim of maximising wellbeing’ (Papoulias, 2014). These aims are laudable, but little research has been done to establish their outcomes. Indeed, one 2018 systematic review concluded that the ‘impacts of design on treatment outcomes are inconclusive’ (Papoulias, 2014). Perhaps, the link between design and wellbeing is not as clear as we previously believed. In the past, the work of academics such as Edward Wilson, whose biophilia model has been hugely influential, suggested that we should look to nature to enhance wellbeing in healthcare spaces (Zelenski, 2014). The parallels here to Victorian asylum design are obvious and fascinating. Ventilation and natural light are prioritised with the consensus that they are conducive to recovery alongside other measures such as protecting patients’ privacy and controlling noise levels. There are many aspects beyond control of the environment that may affect patients, however. Papoulias’ findings suggest that ‘the links between specific design features and specific health outcomes are not conclusive and, furthermore, such links are shown to vary according to the characteristics of patient populations.’ Therefore, modifying the design of environments may improve some aspects of certain patients’ mental health, but may not appeal to all.

Even if the therapeutic effects of an environment are difficult to ascertain scientifically, evidence does exist to support the use of multi-sensory experiences in psychiatric care. Multi-sensory work is already included in occupational therapies, often occurring in a dedicated space. Some groups, such as the dutch Snoezelen project and UK-based Star Wards advocate for these spaces and have been involved in their design and realisation (Haliman, 2017). Snoezelen rooms, originating in the context of care for those with learning disabilities, also have applications in psychiatric care. Stimulating the senses through aroma, sound, touch, vision and taste, they aim to engage patients in novel sensations while maintaining a sense of calm and relaxation. Activity and stimulation are hugely important to improving mental health. Given that psychiatric wards may otherwise have a focus on cleanliness and safety, dedicated sensory areas may provide a much-needed escape for patients, encouraging them to interact and engage with themselves and the space, to the benefit of their treatment.

To ascertain other ways that therapeutic environments can be improved, non-academic groups made up of stakeholders and those with lived experience have been formed. One such group, the Madlove Project, led by artist and previous patient James Leadbitter, has drawn media attention (Leadbitter, 2017). Working alongside medical professionals, artists and architects, the project asked what patients would like to see in their ideal psychiatric ward if they could design without limits. Interestingly, while some of the focus was on environmental aspects such as nature, the majority of those involved emphasised interactive elements of the space, in keeping with some of the principles described previously. They suggested washable walls where they could paint or large spaces dedicated to movement and physical activity. ‘Fluid boundaries’ between the unit and the outside world were also emphasised. Improved access for non-patients and families and the opportunity for groups to be open to the local community were floated to reduce the loss of connection experienced by many of the patients who inhabited the wards long-term.

As well as interaction and engagement with others, research suggests that psychiatric spaces benefit from incorporating elements of privacy into their design. The 2020 systematic review How to design psychiatric facilities to foster positive social interaction (Jovanović, 2020) suggests several ways to improve the design of mental healthcare environments. The review found that units comprised of individual bedrooms around a mix of communal areas fostered the greatest amount of positive social interaction. Giving patients their own rooms, as opposed to housing them in large dormitory-style wards, allowed them to retain their sense of self and gave them some personal freedoms. Patients ‘tend to decorate and personalise their rooms’ and ‘determine their own rhythm of activities’ (Jovanović, 2020). In this sense, they can retain a greater degree of autonomy, a small step to preventing them from becoming institutionalised. It can also reduce ward crowding, which has been associated with increased aggression and violent behaviours (Ulrich, 2018). The question of how to approach violent and risky patients remains challenging, posing numerous ethical discussions around restraint and freedom, so efforts to reduce these needs are highly valuable. Surveillance and observation are also problematic. A sense of observation, even if it is for safety purposes, is not conducive to a therapeutic environment. It undermines feelings of freedom and can further lead to institutionalisation as behaviours are curbed and contained to conform to the standards of the organisation (Goffman, 1961). Dignity and respect for patients remain critical, even if this is hard to achieve within safe and highly boundaried environments.

Conclusion and Reflection

On the first page of this project, I included a schematic which I had whimsically drawn towards the end of my first week of elective. Attempting to resemble a tube map, a triumph of classic design, I wanted to represent the complex interplay between some of the aspects of mental health design I had already come across. Even at that early point, it was abundantly clear that designing for mental health and wellbeing is extremely complicated. There will always be questions to be addressed, and often their answers can generate further tensions and problems. Mental healthcare spaces are unique from other hospital wards and zones due to their varied and often shocking history and the degree of safety that has to be infused into their design. When designing psychiatric spaces, this history has to be addressed, after all we must learn from our mistakes. It is often the case, however, that we are unable to predict the outcomes of new design approaches. These spaces often have a life of their own and we’ve seen the dreaded fate that can befall well-intentioned design.

In researching and writing this project, I recognised that throughout the history of mental health spaces, it is often the doctors and their critics who are given the loudest voices. Patients, at best deemed incompetent and at worst actively silenced, are not heard or well-represented. Reading about new approaches involving patients in the design of their own spaces, including the Madlove Project injects some new hope. By listening to stakeholders we will get a greater sense of needs and concerns that may otherwise go unaddressed. As ever, greater communication is critical. I would have loved to have had more time to complete the project and delve deeper, but the material is far from finite. There are so many things left to cover and many questions left to answer. What is the best way to encourage multidisciplinary work? How can we use our knowledge to prevent rather than cure? How can we make wellbeing spaces work for everyone? The list goes on and the work has only just begun.

Ethical Questions

Writing about mental health, especially its history, will always be distinctly challenging. While we have come a long way in our abilities to prevent and treat, mental illness remains a huge societal issue. Stigma and prejudice remain intractable forces, and a huge part of their power comes from the language we use to talk about mental health. In writing these pieces, I was aware that the use of terms such as ‘madness’ and ‘insanity’, even terms like ‘asylum’, can be harmful to those with experience of mental illness. However, they are historically relevant and, as such, form the convention of medical historians. Following the example of Carla Yanni, I have attempted to phase phrases in and out based on what would have been used contemporaneously, but with the recognition that these terms are not only antiquated but are also distasteful and damaging.

Another ethical issue is that of representation. While visiting museums such as the Wellcome Collection and the Bethlem Museum, I was aware that patient images and records were on display. However, due to issues around capacity and consent, I have chosen to omit photographic representations of patients. Patient records are not included.

References

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Conolly, J. (1856). The Treatment of the Insane Without Mechanical Restraints. Available from: https://wellcomecollection.org/works/tqhdd7kg/items?canvas=2

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Department of Health (2013). Health Building Note 03-01: Adult acute mental health units. Available from: https://www.england.nhs.uk/wp-content/uploads/2021/05/HBN_03-01_Final.pdf [Accessed 21/4/22].

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Acknowledgements and Thanks

Special thanks to Dr Ro Spankie at Westminster University for her support throughout my elective. Thanks also to Elise Billings-Evans, my architectural counterpart at Westminster for her enthusiastic involvement. I would also like to thank my old BSc MedHumans, including Dr Wing May Kong for helping to organise this opportunity and Dr Jennifer Wallis whose encouragement and ability to whip up reading materials in an instant will always be appreciated.