‘This is a great time for therapeutic architecture’

How did your interest in healthcare architecture begin?
When I read Foucault's History of Madness while studying for my Master's in Architecture. My sister was a psychology student, and Foucault was a part of their curriculum. I devoured that book. Next semester, I attended a theory module on architecture for psychiatric facilities, by Professor Fani Vavyli. Influenced by Foucault, I felt the module was not about architectural typologies, but about the people who lived and suffered in those buildings. Architecture was playing a significant role not just as the physical context, but as a mechanism of power and control.

I wanted to investigate further, so I approached the psychiatrist involved in moving people from the asylum of Leros (in Greece) back to the community [tinyurl.com/y3s5r6me]. I realised that architectural knowledge on this was very limited, and there was no literature on buildings to help these people transition back to the community. What would be the new 'home' for life after the asylum? Would it be a flat? A centre? How many people per dwelling or room? We did not know.

Fani suggested that I studied hospital design at the Medical Architecture Research Unit. I did my MSc there, and then a PhD at the Bartlett School of Graduate Studies at UCL, with Professor Julianne Hanson. Medical architecture focused more on regulations and constraints, but the seeds for patient focused care were also there thanks to my tutor Susan Francis, who was very passionate on the subject.

How did the concept of therapeutic architecture develop?
The study of the therapeutic qualities of space has developed slowly. We didn't initially use the term 'therapeutic architecture' – we said patient focused/centred design, salutogenic, evidence-based. As a discipline we were cautious about the term therapeutic architecture, and even the term 'holistic' was perceived too risky to use.

When teaching at a postgraduate program at a medical school, I came closer to the clinical community. I noticed that the medical community perceived the value of space more than we did, as built environment professionals and academics. I realised that maybe we as medical architects should consider how design could support both patients and medical professionals. This was the first time that I used the term therapeutic architecture, and I wrote a description of it in the opening paragraph of my first book. The term is now widely used.

Now, 20-something years after my first reading of Foucault's book, I realise that it was not the hospital environment that attracted me in the field, but the inequality and injustice faced by vulnerable people in such establishments.

Tell us about one of the projects you have been involved with.
Can I use the word 'sweet' to describe a project? This is the feeling that I have for a UCL Grand Challenge on Justice and Equality pilot project that we worked on a long time ago. With little money and a great idea we created something much bigger. It was a project comparing and contrasting mental health with healthcare facilities in the catchment area of Camden and Islington NHS Foundation Trust.

I had asked the Head of the Division of Psychiatry at UCL if there was something that I could do as a medical architect that would be of help. He suggested a photographic exhibition to showcase pictures of the mental health facilities next to healthcare facilities. I have visited hundreds of psychiatric facilities, and never realised the extent to which they differed. Through the UCL Grand Challenges Scheme, we started a small but flexible collaboration between the Bartlett, the Division of Psychiatry and the Slade School of Art. This proved to be an effective tool to investigate inequalities and stigma. We looked at the location of facilities in relation to the London Underground network, as well as comparing facades. The land where the mental health facilities are sitting can become a great asset to their owners, so the services tend to relocate to the periphery to capitalise on real estate gain. But then access can be compromised, and this has implications for service users, staff and carers. The aesthetics of buildings also have implications as they can generate stigma.

In what ways can staff and service users be involved in the design of a psychiatric or therapeutic space?
For my PhD I asked residents of psychiatric facilities in France and the UK to give feedback on the environment of the wards they were staying in. At the time this was very innovative, as the concept that we need to consult the patients was not established in medical architecture. I got great feedback. The feedback contradicted many of the theories and assumptions I was reading in the literature back then.

Involving patients and staff in the pre-brief consultations and keeping that dialogue open throughout is the way forward. It is also important that their voice remains clear and is not dominated by other stakeholders during these consultations. Vulnerable people can be silenced and intimidated, so it is important for facilitators to be aware of that. The project will be more meaningful and fit for purpose at the end.

What are the therapeutic benefits of good architectural design?
Architecture is about space and place. They comprise the physical context of our lives. Any obstacle in our environment requires extra energy from us. When we are well and active this is manageable: when we are ill it is more difficult to overcome such obstacles, as we need to draw on resources that are scarce or unavailable. Designing spaces according to people's perception and physiology, and therapeutic best practice, is the essence of therapeutic architecture. It involves using the environment to be restorative and support health and wellbeing.

For example, urban design that provides public toilets at regular distances might enable older people to walk further. Absence of those might restrict them to shorter walks close to home. That could affect their mental health as they become more housebound, and contribute to frailty due to limited mobility. Staircases which are hidden, too narrow, or badly lit might discourage people from using them. And certain luminaires have been associated with the disruption of our melatonin. So design can enable safe movement and natural daylight, can utilise positive and negative distractions, and can therefore support healthier lifestyles.

We designed a facility for children with autism which had a very small budget, so we had to be resourceful. I worked closely with a neuroscientist, as well as the staff. We looked at the lighting very carefully to have spectrums as close to natural light as possible. We chose colours carefully, and worked closely with the therapeutic team to create spaces compatible with treatments. We introduced elements of positive and negative distraction. We avoided areas such as cornices that would trap dust, as we were cautious of respiratory multi-morbidities. The children very quickly adjusted to using the new building, and staff said that the days they worked in that building they 'forgot' time passing.

Do you have any advice for psychologists who want to improve the setting in which they work?
Having a workspace with access to daylight is essential. In the Netherlands, all hospital offices must have direct or indirect access to daylight. In this country, there are staff working in offices which sit deep in buildings or in basements. This needs to change. Views to nature, adjustable temperature for thermal comfort – especially for women – and clean air are very important. Having a space that enables good communication with clients is also important: acoustics for privacy, suitable seating and optimal space for the chairs. One of the most critical parts of the NHS now is the difficulty in recruiting and retaining staff. Taking care of staff spaces is still a taboo. But staff need to be involved, together with patients, in decisions about their built environment.

How do you see the field of therapeutic architecture developing in the future?
This is a great time for therapeutic architecture. It is becoming more relevant as people understand the value and benefits for themselves. I was asked to create a Master's programme on therapeutic architecture at the Bartlett, which is one of the most prestigious faculties of built environment in the world. Only 20 years ago, when I was doing case studies in psychiatric facilities at the same school, I could feel a stigma around my topic. I was the odd PhD student choosing to do a non-inspiring topic of psychiatric buildings. Now, I see many young people wanting to study and work in this area.

There is also tremendous need to change our practices. Baby boomers entering old age, challenging demographics, people demanding better healthcare with less money for infrastructure, disruptive technologies, better diagnostics, healthcare moving into the community: these are all very important developments. Therapeutic architecture can play a pivotal role in all of these. This is especially so in
areas where diagnostic and interventional tools are still limited, such as mental health and dementia.

In the new MSc we involve clinicians and healthcare professionals to present and/or attend. The complexities of healthcare are such that we need to work together to identify the right questions. This is our only hope for eventually coming up with some valid answers.